Vitamin A is necessary not only for prevention of xerophthalmia but also for preserving integrity and maintaining the function of several organs in the body. Available evidence has established the role of vitamin A in preventing childhood morbidity and mortality. Vitamin A deficiency is a major cause of morbidity and mortality in India and other developing countries. An estimated 5.7% children in India suffer from eye signs of vitamin A deficiency. Although, vitamin A deficiency can occur in any age group, the most serious effects are usually seen in the preschool children. Vitamin A requirement in the fast-growing age group of two to four years is the greatest since dietary intake is precarious and illnesses such as diarrhea, acute respiratory tract infection and measles, which deplete vitamin A reserves, are common. Currently, vitamin A deficiency is considered to be a public health problem in selected geographical areas in India with superimposed wide variations within the regions.
Heartily, there is a scientific evidence of declining trends of vitamin A deficiency in the country. Under vitamin A supplementation program that is integrated through Reproductive and Child Health (RCH) program and now National Rural Health Mission (NRHM), children between nine and 36 months of age are to be provided with vitamin A solution every six months starting with 100,000 IU at nine months of age with measles vaccination and subsequently 200,000 IU every six months till 36 months of age. With rapid urbanization in India and one of the highest growth rates in the world, around 27.8% of the population is forced to reside in urban slums (Census 2001). As the slums are considered to be high-risk areas in terms of healthcare delivery, an attempt was made to determine vitamin A-first dose coverage amongst children (12–23 months) residing in slums of Delhi and to explore its association with selected variables.
Materials and Methods
The 30-cluster sampling technique based on probability proportional to size advocated by the World Health Organization (WHO) was used to assess coverage of vitamin A-first dose supplement. Out of 12 municipal zones in Delhi, one was selected randomly i.e. south municipal zone. List of all the slum clusters existing in the south municipal zone was procured from the municipal office (Annexure I). The approximate population residing in these slum clusters was 4,29,130. A cluster sampling is a two-stage random sampling technique i.e. selection of cluster and identification of children in the selected cluster. Steps involved were listing of slum clusters along with their population; calculating cumulative population for each cluster; determining sampling interval; selecting a random number which was less than or equal to sampling interval; this represented the first cluster; by adding sampling interval to the selected random number, second and then subsequent clusters were selected. A total of 30 such clusters were chosen this way. After selection of a cluster, first household was selected randomly and then subsequent household using right hand approach. From each selected slum cluster, seven eligible children were covered thus making a total sample size of 210 (30 × 7). Resident children in the age group of 12–23 months who were born between the reference period of October 1, 2003 and September 30, 2004 were enumerated from each household. Based on the documentary evidence/recall of mother regarding vitamin A-first dose received by the eligible child, data was recorded in the pre-structured proforma (Annexure II). Selected information related to religion, sex, place of birth, birth order, immunization status and education of mother was also recorded. Data was collected during October-November 2005 by a single investigator and analyzed by calculating percentages and degree of association (chi-square test) using SPSS software.
Of the total eligible subjects contacted, only one refused to participate in the study. Hence, next eligible child was contacted in the same cluster. Out of 210 study subjects, there were 175 (83%) Hindu and the rest were non-Hindu. There were 120 (57.0%) male and 90 (43.0%) female children amongst study subjects. Nearly three-fifth (126) children were born at home with the rest (84) in health institutions. The birth order of children was one, two, three (or above) as 64 (30.4%), 63 (30.0%) and 83 (39.6%) respectively. There were nearly 50.0% children fully immunized for vaccine-preventable diseases up to the age-of-one year whereas 23% were never taken for immunization. There were 74 (35%) mothers who were literate.
It was observed that only 79 (37.6%) children out of 210 had received vitamin A-first dose supplement in the community Table 1. Further analysis of 79 children was carried out with regard to selected variables. This showed that 71 (89.9%) were Hindu and eight (10.1%) were non-Hindu (P = 0.04). Nearly 44 (55.7%) males and 35 (44.3%) females had received vitamin A (P = 0.74). The proportion of children born in health institutions who received first-dose (57%) of vitamin A supplementation was significantly higher than children born at home (43%) (P < 0.001). Similarly, higher proportion of children with birth order-one (48.1%) in comparison to birth order-three or above (26.6%) had received vitamin A (P < 0.001).
The child can receive vitamin A-first dose independent of immunization status, however, from the point of view of operational feasibility, a child is administered the first dose along with measles vaccine. It was noted that 30 children though fully immunized for vaccine-preventable disease up to age-one had not received vitamin A-first dose supplement. The proportion of children receiving vitamin A was slightly higher for illiterate mothers (51.9%) than literate mothers (48.1%). However, overall relationship of literacy status and vitamin A was found to be statistically significant (P < 0.001).
India was one of the first countries in the world to have launched a vitamin A supplementation (VAS) program. In spite of this leadership role of the country in initiating the program, vitamin A-first dose supplement coverage was found to be low (37.6%) in this study. When vitamin A-first dose supplement was analyzed along with other selected variables a significant association was found amongst Hindu child, born in health institution, and with birth order one, suggestive of higher level of awareness, motivation, and/or better socioeconomic status.
A review of literature corroborated the observation of low vitamin A supplementation coverage. Rapid Household Survey (RHS) reported similar results with coverage at 35%. According to the National Family Health Survey (NFHS-3), Delhi recorded a low coverage of 17.1% of the children having received vitamin A dose in the last six months (2005–06). Taneja reported that only 37.8% children in Delhi had received vitamin A first-dose supplement. Annual report of ministry of health and family welfare, GoI (2005–06) also mentioned the coverage of vitamin A first dose as 44%. It is noted that over the years no improvement in vitamin A coverage in Delhi has been observed. Further, it was noted that even though 30 children were completely immunized for vaccine-preventable disease up to the age of one, they had not received vitamin A supplement, suggestive of missed opportunity. This further corroborates the fact that “access” to health system does not necessarily translate into delivery of quality services to beneficiaries.
A large proportion of the Indian population receives less than 50% of the recommended dietary intake of vitamin A from dietary sources. In the absence of improved dietary intake or fortification strategy, it is clear that vitamin A supplementation is a necessary intervention to compensate for the shortfall in recommended dietary allowance, especially for the community residing in slums. To conclude, the study reflects low vitamin A-first dose coverage in children residing in the slums of Delhi and requires appropriate corrective measures.
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Name of the Institute……………………………[National Institute of Health and Family Welfare, New Delhi]
- D.O.B (eligible child): Household no:
- Religion [Hindu/Non-Hindu]
- Literacy status of mother [Literate/Illiterate]:
- Place of birth [Health Institution/home]:
- Sex [M / F]:
- Birth order:
- Child taken for immunization [Yes/No]:
- Immunization status up to age-one [√]:
- Vitamin A-first dose supplement received [Yes/No]: Put [√] where applicable:
Source of Support: Nil
Conflict of Interest: None declared.