Data from the BDHS 2004 showed that the coverage of the vitamin A supplementation programme to prevent morbidity, mortality, and blindness in preschool children was relatively high in Bangladesh, exceeding the 85% coverage rate recommended by the World Bank (12
). The findings of the present study showed that the remaining 14% of preschool children who missed a vitamin A capsule in the last six months were more likely to come from families that had higher under-five child mortality. When under-five child mortality was included in a multivariate model adjusting for other covariates, the relationship between non-receipt of a capsule and previous under-five child mortality in the family was of borderline significance. Children missed by the programme may be those who could probably benefit the most, given the higher history of under-five child mortality in their families.
In the present study, children who were missed by the vitamin A capsule-distribution programme were less likely to have received DPT, OPV, and measles immunization. In the national vitamin A programme in Indonesia, there was also a similar, lower coverage among children who missed childhood immunizations (13
). The lack of immunization places children who missed vitamin A at an even higher risk of morbidity and mortality from vaccine-preventable infectious diseases. Vitamin A deficiency increases the risk of morbidity due to measles, including the severity of diarrhoeal disease, measles-related pneumonia, blindness, and mortality (14
). These findings suggest that the demographic factors that impact a child's participation in vitamin A supplementation programmes may also impact participation in other public-health interventions.
A previous report from Helen-Keller International showed that the coverage of the vitamin A supplementation programme was below 70% in the Chittagong Hill Tracts, a district within Chittagong division (15
). In the present study, the overall coverage in Chittagong division was 89.1%, and separate figures were not available for the Chittagong Hill Tracts alone.
Results of a previous study in Indonesia showed that children who were missed by the vitamin A programme were more likely to be stunted, underweight, or wasted (13
). In the present study in Bangladesh, there were significant differences in the prevalence of stunting and severe stunting between children who did and did not receive a vitamin A capsule in the last six months. Stunted children are more likely to suffer from vitamin A deficiency disorders and have higher morbidity due to infectious diseases (4
), and they represent a vulnerable group which could benefit if the coverage of the vitamin A programme could be expanded.
The national vitamin A programme was initially established by the Bangladesh Programme for the Prevention of Blindness with support from the United Nations Children's Fund in 1973 (16
). Supplementation of vitamin A has been shown to protect against clinical vitamin A deficiency, as indicated by nightblindness, among preschool children in Bangladesh (16
). In Indonesia and Viet Nam, the expanded coverage of the national vitamin A supplementation programme was also accompanied with large reductions in hospital admissions for xerophthalmia (4
). The national vitamin A supplementation programme in Ethiopia achieved a coverage of less than 50% in 2005, and children who did not receive vitamin A in the last six months were more likely to come from families with lower maternal and paternal education (18
The findings of the present study suggest that maternal education is an important factor relating to receipt of a vitamin A capsule. A higher level of formal education achieved by girls may be a key factor in breaking the intergenerational cycle of malnutrition and poverty (19
). Since younger maternal age was also associated with the lower coverage, further efforts are, thus, required by the vitamin A supplementation programmes to reach young, uneducated primigravida mothers. Also, children of households of higher socioeconomic status were more likely to have received a vitamin A capsule. The coverage ranged from 77.2% in Barisal and 78.8% in Sylhet to 89.1% in Dhaka and Chittagong divisions, and there were variations between areas within each division. Thus, it is also important for programmes to identify areas with a lower coverage and implement measures to increase the coverage and, in particular, ensure the coverage of the most vulnerable children (stunted, of lower socioeconomic background, and with uneducated and younger mothers).
Worldwide, 9.7 million children die each year; most deaths occur from preventable causes, and nearly all deaths occur in poor countries (20
). About 63% of deaths of children could be prevented with full implementation of the few known and effective interventions to reduce child mortality, such as vitamin A supplementation (5
). The reduction of under-five child mortality by two-thirds between 1990 and 2015 is one of the MDGs that was endorsed by 189 countries in September 2000 (5
). Although the coverage of the vitamin A capsule programme in Bangladesh is relatively high, efforts to reach 14% of the children missed by the programme may yield substantial benefit in reducing child deaths and nutritional blindness.