Programmatic implications of some vitamin A supplementation and deworming determinants among children aged 6-59 months in resource-poor rural Kenya

Introduction Controlling vitamin A deficiency and soil-transmitted helminth infections are public health imperatives. We aimed at revealing some caregiver and child-related determinants of uptake of vitamin A supplementation and deworming, and examine their programmatic implications in Kenyan context. Methods A cross-sectional study of randomly selected 1,177 households with infants and young children aged 6-59 months in three of the 47 counties of Kenya. The number of times a child was given vitamin A supplements and dewormed 6 months and one year preceding the study was extracted from mother-child health books. Results Coverage for age-specific deworming was considerably depressed compared to corresponding vitamin A supplementation and for both services, twice-yearly provisions were disproportionately lower than half-yearly. Univariate and multivariate analyses showed relatively younger children, of Islam-affiliated caregivers (vis a vis Christians) and those who took less time to nearest health facilities as more likely to be supplemented with vitamin A. Similar observations were made for deworming where additionally, maternal and child ages were also determinants in favour of older groups. Other studied factors were not significant determinants. Programmatic allusions of the determining factors were discussed. Conclusion Key to improving uptake of vitamin A supplementation and deworming among Kenyan 6-59 months olds are: increasing access to functional health facilities, expanding outreaches and campaigns, dispelling faith-related misconceptions and probably modulating caregiver and child age effects by complementing nutrition literacy with robust and innovative caregiver reminders. Given analogous service points and scheduling, relative lower uptake of deworming warrants further investigations.


Introduction
Vitamin A is an essential nutrient for growth and development of infants and young children due to its important function in growth and differentiation of epithelial cells [1]. Protection by breast milk against infant vitamin A deficiency symptoms needs complementation and supplementation from 6 months postpartum due to infant's increasing requirement [2]. In Kenya, latest data show the prevalence of vitamin A deficiency (retinol-binding protein <0.70 µmol/l) among pre-school children at 9.4% (CI: 7.5-11.3) -a moderate public health importance based on World Health Organisation (WHO) classification [3,4]. Vitamin A supplementation of from six months into infancy is a routine health services and is one of the cost-effective public health interventions. Worm infestation also contributes to growth retardation and hinders development of infants and young children through various mechanisms [5]. In Kenya, soil-transmitted helminth (STH) infections are common and can affect as high as 40.5% (all STH) of children aged 6-59 months [6] and this warrants mass administration of deworming drugs [7]. Deworming is one of the most feasible public health approaches to control soil-transmitted helminth infections among infants and young children [8]. IUs at an interval of 6 months -in line with WHO recommendations [9].
In Kenya, children are dewormed when they turn one year of age -

Results
General characteristics:  (Table 2). In overall, about a third of all mother were knowledgeable on standard vitamin A supplementation scheduling and one-fifth on deworming drugs. Vitamin A and deworming coverage 6 months pre-assessment were significantly different between the 3 counties; and same case for deworming twice-yearly.
For both services and in all the counties, the coverage for 6 months pre-assessment was far more depressed than the twice-yearly rates.
The proportions of children aged 12-59 months old supplemented were higher than dewormed both 6 months half-yearly and twiceyearly. A greater proportion (67.4%) were supplemented at the health facilities as compared to the health campaigns (known as malezi bora in Swahili, the Kenya national/local language) (24.9%) and Early Childhood Development Centres (7.8%) -and the differences were statistically significant (p = 0.001) (not shown in Table 2). Again for deworming, majority (37.3%) received at the health facilities and the difference with other two service points were statistically significant (p=001).

Factors associated with age-appropriate vitamin A
supplementation among children 6-59 months old:  [12]. In Sierra Leone (just like in many other countries using the campaign mode), however, high coverage rates were achieved mostly due to ample funding [14].
Similar to our study findings, access to the two health services have been found elsewhere to decline with distance to the service points [15][16][17]. The effect of distance (and by extension time taken to the service points) in accessing these services may be twofold. Consistent with the latest Kenya DHS, our finding also uncovered that the uptake of vitamin A supplementation declined with child's age [10]. Further, the Cambodian and Indian study indicated fairly same trend [18,19]. As children get older, caregivers may tend to overlook to take their children for supplementation. In Kenya, mother-child health booklets are used to record next appointment for supplementation and deworming and this is meant for prompting caregivers to demand for the services. But anecdotes indicate that the importance of these booklets tend to decline after measles vaccine which is given at about 9 months after birth -and this may partly explain the age-supplementation link. Further, the inconsistency of health workers in recording the next appointments in the booklets have been reported, albeit anecdotally and it is also common for the mothers to misplace them. It is apparent that more innovative and effective ways of caregiver reminders for vitamin A supplementation and deworming are needed to complement these commonly used ones. The efforts should however go in tandem and not replace nutrition literacy and awareness. The increased likelihood of deworming with a child's age in the present study is also comparable to latest Kenya DHS [10]. This could presumably be due to the caregiver cognizance that as a child grows older, it interacts more with its environment and thus perceived higher chances of worm infestation. Also, as children get older, they are introduced to and fed more complementary foods. Caregivers of older children are thus more sensitive to and report the apparent symptoms related to feeding such as loss of appetite, diarrhoea and weight loss, inter alia. These presentations are similar to the symptoms of worm infestation and may prompt the caregiver or the health worker to deworm the child. Older caregivers are also more likely to deworm their children and this may be due to the experience in child care. In Kenya, there have been faith-inspired concerns against immunisations and these may also adversely influence the demand for other public health services which go along together including vitamin supplementation and deworming.
In the recent years some Christian sects have been against the mass vaccination for polio and tetanus [20,21]. This may explain why in the present study, children cared for by Islam-affiliated caregivers were more likely to be supplemented and dewormedimplying dispelling religious-based misconceptions is warranted. The higher likelihood of children from Muslim household to receive health services vis a vis those from Christian households was however not demonstrated in a Ghanaian study [22].

Conclusion
The programmatic implications of our findings may also apply to alike contexts in sub-Sahara Africa. Needed to advance coverage, demand or uptake of vitamin A supplementation and deworming are: Increasing access to functional health facilities (and with capacity to conduct routine outreaches), scale-up and intensification of mass drug administration campaigns, dispelling faith-related misconceptions, improving maternal/caregiver nutrition literacy (and awareness) and modulating the influence of caregiver and child age with innovative and more effective caregivers reminders. Given akin service points and scheduling, the observed relative lower uptake of deworming compared to vitamin A supplementation is disconcerting and warrants further investigations.

Competing interests
The authors declare no competing interests.

Acknowledgments
The dedication of the data enumerators in the study is appreciated.
We also acknowledge the support provided by the Ministry of Health  Table 1: Socio-economic status of sampled households