Vitamin A Deficiency in Ethiopia:Magnitude, Distribution and Potential Risk Factors
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Date
2010-02
Authors
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Addis Abeba University
Abstract
Background
Based on the high vitamin A deficiency rates indicated in the reports of several pocket level
surveys, it can be concluded that vitamin A deficiency is a major public health problem exacerbating
child morbidity, mortality and disability in Ethiopia. In order to effectively address the problem, upto-date
and
comprehensive information is
imperative.
Objective
of
the
thesis
The aim of the research is to provide up-to-date and disaggregated information on the magnitude
and determinants of vitamin A deficiency in Ethiopia that are deemed important in the prevention
and control efforts.
Methods
The national survey, the major component of the research, employed cross-sectional study design
and multi-stage cluster-sampling approach. A total of 23,148 children were examined for the
clinical signs and symptoms of vitamin A deficiency. Blood was collected from 1200 children for
serum retinol analysis and a questionnaire addressing most of the potential determinants of
vitamin A deficiency was administered to 2552 households. Assessment of risk factors to
vitamin A deficiency among primary school children employed a case-control study design and
included 97 clinical cases and 194 controls. In addition, analysis of beta carotene contents of
fifteen food items, five each from common vegetables, common fruits and common staple foods
was done.
Results
The survey revealed high prevalence rates of vitamin A deficiency across the country. The
national bitot’s spot prevalence rate was 1.7% with the highest rates in the Amhara Region
(3.2%), followed by the prevalence rates in Afar (2.1%), Oromiya (1.5%), Addis Ababa (1.4%),
Harari (1.2%) and Dire Dawa (1.1%). The national maternal night blindness prevalence rate was
1.8% with the high prevalence rates in Tigray (14.1%), Benishangul-Gumuz (5.7%), Afar (1.2%)
and Amhara (1.0%). The national weighted prevalence rate of subclinical vitamin A deficiency
(<0.7µmole/lt) was 37.7% (95% CI; 35.6%-39.9%), with high prevalence rates in Afar
(57.3%) and
Oromiya regions (56.0%), moderate prevalence rates in Dire Dawa (48.0%), Amhara (40.7%)
and Harari (35.3%) regions and relatively low prevalence rates in Tigray (14.3%) and SNNP
(11.3%) regions.
Among the under-six children, male children and older children were affected more by clinical
vitamin A deficiency than female children and young children (p<0.05). The prevalence of
clinical vitamin A deficiency was significantly higher among children from predominantly rural
areas compared to that of children from predominantly urban areas (p<0.05). Being from
Muslim households (OR = 2.23), belonging to mothers who could not mention at least one fact
about vitamin A (OR = 1.80), not receiving vitamin A supplement at least once in the previous
year (OR = 1.45), belonging to mothers who have given birth to three or more children
(OR=1.46) and being sick in the two weeks preceding the survey (OR=1.42) were found to
have been associated with high levels of subclinical vitamin A deficiency among preschool age
children. Similarly, being from Muslim households (OR = 7.03), not consuming vegetables three
or more times a week (OR=3.04) and being sick in the two weeks preceding the survey
(OR=2.04) were associated with high levels of clinical vitamin A deficiency among primary
school children. In aggregate, 41.5% of the studied households did not produce/cultivate any of the common
vegetables over the year preceding the survey and the proportion was high in Addis Ababa
(99.7%), Afar (94.9%), Dire Dawa (94.2%), Tigray (86.4%) and Harari (63.1%) regions. Similarly,
75.5% of studied households did not cultivate/produce any of the common fruits over the year
preceding the survey and the proportion was high in Addis Ababa (100%), Dire Dawa (95.3%),
Afar (92.9%), Tigray (92.2%), Harari (83.3%) and Oromiya (81.8%) regions.
Overall, 38.1% of the children studied did not eat any of the common vegetables over the week
preceding the survey and the proportion was high in Afar (85.0%), Tigray (77.6%), Amhara
(61.8%) and Addis Ababa (59.3%). Similarly, 36.5% did not eat any of the common fruits over
the week preceding the survey, with the highest proportions in Tigray (88.1%) and Afar (83.5%)
regions. Over 66% of the children included in the study did not eat meat, close to 53% of the
children did not eat eggs and 33.4% of the households included in the study did not use oil over
the week preceding the survey. The situation regarding own production of fruits and vegetables
was significantly better (p<0.05) in predominantly rural areas whereas market availability and
consumption of fruits, meat, egg and oil was significantly better (p<0.05) in predominantly urban
areas.
High beta carotene content in kale (
6100.45 µg/100gm) and carrot (5800.09 µg/100gm), moderate
amounts in spinach (
800.12 µg/100gm), mango (500.54 µg/100gm) and papaw (800.86 µg/100gm)
and no or negligible amounts in injera, bread and kocho were observed.
Conclusions and recommendations
Conclusions
The study revealed that, albeit the longstanding effort to control and eradicate vitamin A
deficiency in Ethiopia, the problem is still prevailing unabated. Although the prevalence of vitamin A deficiency (clinical and subclinical) were higher than the WHO cut off points in all
regions, the extent of the problem in Amhara, Afar and Oromiya regions appears to be more
serious. Again, although vitamin A deficiency (clinical) was significantly higher in predominantly
rural areas compared to predominantly urban areas, prevalence rates in Addis Ababa, Harari
and Dire Dawa (predominantly urban areas) were found to constitute a public health concern.
The study highlighted the increased risk of Muslim preschool and school children, male and
older preschool age children to vitamin A deficiency compared to their respective
counterparts. The negative impacts of morbidity, enormous benefits of vitamin A
supplementation and the strong positive contributions of maternal awareness to vitamin A status of
children were underlined in the study. Moreover, the strong association of vegetable
consumption with vitamin A deficiency among primary school students was also underscored.
The study, however, showed that the practice of planting/cultivating and consumption of common
vegetables and fruits was suboptimal in Ethiopia.
Recommendations
Policy and strategy related recommendations
• Agricultural policies and strategies that facilitate production of fruits, vegetables and
livestock products must be developed and implemented.
• School health and nutrition policy and strategy to enhance the awareness of the
students regarding the importance of vitamin A must be developed.
Intervention related recommendations
• Continuation and intensification of the ongoing periodic vitamin A supplementation by
ensuring universal coverage, its timeliness and safety is recommended.
• Strengthening attempts aimed at enhancing the consumption of vegetables, fruits, oil and
livestock products are recommended.
• Strengthening efforts to improve women’s awareness regarding the importance of vitamin A is recommended.
• Priority and attention must be given to Amhara, Afar, Oromiya and Harari regions and
Addis Ababa and Dire Dawa city administrations.
• Interventions aimed at improving maternal vitamin A nutrition, particularly, postpartum
vitamin A supplementation is recommended.
Surveillance related recommendations
• Mechanisms to monitor vitamin A status must be established.
• Conducting serial cross-sectional surveys at national, regional and sub-regional level
periodically (e.g. in 5 years interval) using biological indicators is recommended
Research related recommendations
• The increased risk of Muslim preschool and primary school children to vitamin A
deficiency merit an in depth and well designed investigation.
• Similarly, the increased risk of male and older preschool age children to clinical vitamin A
deficiency requires further in-depth assessments to expound the reasons.
• Investigation on the reasons why Ethiopians do not adequately produce and consume
vegetables and fruits is recommended.
Description
Keywords
Clinical vitamin A deficiency; sub-clinical vitamin A deficiency; serum retinol levels;Ethiopia