Vitamin A supplementation among 9-59 month old children in India: geospatial perspectives and implications for targeted coverage

Abstract

IntroductionVitamin A supplementation (VAS) is yet to reach all Indian children aged 9-59 months, despite guidelines for universal coverage. This study mapped geospatial patterns underlying VAS coverage across two policy-relevant administrative unit levels (states and districts) in India. The relationship between spatial distribution of VAS coverage and vitamin A deficiency (VAD) prevalence was also investigated.MethodsThe study draws on nationally representative cross-sectional data collected during National Family and Health Survey 4 (NFHS-4) and Comprehensive National Nutritional Survey (CNNS). VAS coverage was estimated using information obtained during NFHS-4 from mothers about whether their children (n=204 645) had received VAS within 6 months of the survey. VAD prevalence estimates were based on serum retinol measurements during CNNS in under-five children (n=9563). State-level and district-level choropleth maps of VAS coverage were constructed. Spatial patterns were probed using Moran’s statistics, scatter plots and local indicators of spatial association (LISA). Relationship between VAS coverage (as an explanatory variable) and VAD prevalence was explored using spatial autoregressive models.ResultsVAS coverage in India (overall 60.5%) ranged from 29.5% (Nagaland) to 89.5% (Goa) across the various states/union territories. Among districts, it ranged from 12.8% (Longleng district, Nagaland) to 94.5% (Kolar district, Karnataka). The coverage exhibited positive spatial autocorrelation, more prominently at the district-level (univariate Moran’s I=0.638, z-value=25.614, pseudo p value=0.001). LISA maps identified spatial clusters of high coverage and low coverage districts. No significant spatial association was observed between VAS coverage and VAD prevalence in the states during spatial error (R2=0.07, λ=0.30, p value=0.14) and spatial lag (R2=0.05, ρ=0.25, p value=0.23) regression.ConclusionTwo out of every five eligible Indian children were not supplemented with vitamin A. The coverage was geographically heterogeneous with discernible spatial patterns. Their consequences on vitamin A status and associated health effects in the community deserve close monitoring.

Sub-national estimates of vitamin A supplementation coverage in children: a geospatial analysis of 45 low and middle-income countries

“…For example, our maps point to low VAS coverage in several conflict-affected areas, such as northeastern Nigeria and southwestern Pakistan. Consistent with a previous analysis, we also found low VAS coverage in Manipur and Nagaland states in north-eastern India, which have high poverty levels and are geographically remote (Bora 2022). Nutrition and immunization programs that have been successfully implemented in lowresource and complex settings offer insight into enabling factors.…”

“…Tracking VAS coverage at a geographically granular level could inform interventions by pinpointing which communities have particularly low coverage, thus contributing to more efficient use of scarce resources. While prior studies have estimated sub-national VAS coverage in select priority countries (Bora 2022, Gilano et al 2021, Zegeye et al 2022, to our knowledge, no comprehensive analysis of VAS coverage data across priority countries has been undertaken. The present study used data from the USAID Demographic and Health Surveys (DHS) program to examine the state of VAS coverage on a granular level in priority countries with available data, an important step towards quantifying and addressing national and sub-national disparities.…”