Baseline vitamin A coverage survey in 6 districts of Nepal.

Research Report.

SUMMARY: Background and objectives According to NDHS 2011, the vitamin A coverage is 90 percent among children aged 6-59 months. However, stratified analysis revealed that there is low coverage of vitamin A among the children age 6-8 months (70 percent) compared to the other age groups. With an objective to increase the coverage of vitamin A among children of 6-8 months in rural areas and children of 6-59 months in urban areas, the Child Health Division, Department of Health Services is planning to implement a pilot project in Jumla (mountain), Kavre (hills), and Chitwan (terai). In year 2012, Nepal Government developed a new protocol to distribute vitamin A capsule among 6-11 months children using health and nutrition service delivery platforms such as health facility and routine measles vaccination platform in addition to the National Vitamin A distribution days to 6-59 months children. Child Health Division has a plan to initiate a model programme in three districts in fiscal year 2012/2013 to implement the protocol. It is expected that the government will formulate national policy to reach hard-to-reach groups based on the results of evaluation of the pilot project. The immediate objective of this baseline coverage survey is to establish baseline status of VAS among 6-11 months children in 6 districts. Child Health Division has a request with UNICEF to make necessary arrangement in the form of survey in these three focus districts (Jumla, Kavrepalanchowk and Chitwan) and three control districts (Kalikot, Kathmandu and Bara) for the model evaluation. Therefore, the long term objective of this survey is to evaluate the proposed new vitamin A dosing model for increased vitamin A coverage among 6-11 months children and children living in urban slums through baseline and endline survey in the year 2012 and 2013 in three VAS pilot districts and three control districts. Methodology A pre-post test design with a comparison group was used to compare the vitamin A supplementation (VAS) coverage at baseline to that at end line (after one year of pilot intervention). The evaluation had two arms: intervention arm (Kavrepalanchowk, Chitwan and Jumla districts), and arm B (Kathmandu, Bara and Kalikot districts). In each district, a survey was conducted at baseline before implementing the intervention to compare coverage of vitamin A among the children of 6-11 months in rural areas and among children aged 6-59 months in urban areas. In addition to vitamin A supplementation (VAS) coverage, KAP (knowledge, attitude and practice) of service providers and care takers in relation to VAS were assessed. The sample size in rural area for each district was 90 children aged 12-17 months and 360 in each arm of the urban areas. Population proportional to size (PPS) selection of 30 wards (clusters) were undertaken for each district/domain. Mothers of children/caregivers were interviewed from selected household regarding household and respondent characteristics, knowledge of vitamin A, first dose vitamin A supplementation and supplementation in recent round. Health workers (ANM and AHW) of the health facilities of the selected cluster, female community health volunteers (FCHVs) of selected cluster, nutrition focal persons and District Public/Health Officers of the districts were also interviewed regarding vitamin A coverage, stock of vitamin A, perception on benefits of vitamin A supplementation. In addition, Local Development Officers (LDOs) of the districts, Village Development Committee (VDC) secretaries/ward secretaries of the municipalities of selected clusters were also interviewed using key informant interview. Key findings The proportion of children receiving first dose of vitamin A at earlier ages 6-8 months (56 percent in intervention districts and 50 percent in control districts) were significantly low as compared to total coverage (98 percent in intervention districts and 97 percent in control districts) in rural area. Among children receiving vitamin A within 6-8 months, 83 percent of children in intervention districts and 99 percent of children in control districts received the first dose of vitamin A in campaigns and none received during measles vaccination. The vitamin A coverage of last supplementation i.e. within six months preceding the survey was 98 percent in intervention districts and 97 percent in control districts for children aged 12-17 months in rural area.The first dose of vitamin A coverage among children 6-11 months of age in urban area was 91 percent in intervention districts and 96 percent in control districts; however, the proportions of children receiving first dose of vitamin A at ages 6-8 months were only 44 percent in intervention districts and 53 percent in control districts. The vitamin A coverage of last supplementation i.e. within six months preceding the survey was 91 percent in intervention districts and 88 percent in control districts for children aged 6-59 months in urban area. First dose of vitamin A coverage among infants 6-11 months of age in Jumla and Kalikot was 100 percent whereas the lowest coverage was observed in Chitwan (91 percent).The proportion of children receiving first dose of vitamin A at ages 6-8 months through vitamin A rounds were 78 percent in Kavre, 98 percent in Kathmandu, 84 percent in Chitwan, 100 percent in Bara, 90 percent in Jumla and 100 percent in Kalikot. Only 8 percent of mothers in intervention districts and less than 1 percent in control districts from urban area reported children were registered before the day of vitamin A distribution whereas mothers receiving message about vitamin A campaign was more than 87 percent. Similarly, 21 percent of mothers in intervention districts and 7 percent in control districts from rural area reported children were registered before the day of vitamin A distribution whereas mothers receiving message about vitamin A campaign was more than 87 percent. About half of the health workers received training on vitamin A distribution and almost of them have knowledge of age providing first dose of vitamin A and most of health facilities have sufficient vitamin A stock. Most of health workers have knowledge on vitamin A supplementation, and showed the need of monitoring and follow up of VAS. The proportion of vitamin A stock in health facilities of most of the study districts was maintained above EOP except in Jumla but proportion of FCHVs having sufficient vitamin A stock for post-partum supplementation was very low during the time of the survey. The major sources of information for vitamin A campaign were health workers and FCHVs additional source of information were radio/FMs, television, friends and relatives. Vitamin A supplementation was not noted in almost of the cards in both intervention and control districts in both area. More than 50 percent of mothers of control and intervention districts didn't know the time of next dose of vitamin A. About one tenth of FCHVs received training on vitamin A in last supplementation but all of them had knowledge of age for providing first dose of vitamin A. DHO/PHO/Nutrition Focal Person perceived that vitamin A program was a one of the successful programs to reduce night blindness and infant mortality among children. However, district level programme managers and government stakeholders pointed out that leadership and support of VDC and municipalities, micro planning, quality supervision and monitoring, sensitization of health workers and volunteers, IEC programs, strengthened recording and reporting mechanism could be important areas to be improved to strengthen and sustain vitamin A programme. Conclusion To increase the coverage of the vitamin A among children aged 6-8 months, a new strategy is needed. Leadership and support of VDC and municipalities, quality supervision and monitoring, micro planning, sensitizing of health workers and volunteers, strengthening of recording and reporting mechanism are to be improved for further success of vitamin A programme.