Exploring the relationship between maternal knowledge and age-appropriate vitamin A supplementation uptake in Nadowli-Kaleo District, Ghana, 2022

Sorengmen Amos Ziema¹, Charles Alomatu¹, Edem Kojo Amedonu², Samson Obripuo³

 

¹Department of Health Information and Records Management, Ho Teaching Hospital, P. O. Box MA 374, Ho, Ghana, ²Department of Public Health, Ho Teaching Hospital, P. O. Box MA 374, Ho, Ghana, ³Daffiama Bussie Issa District Health Directorate, Ghana Health Service, P. O. Box 03, Wa, Ghana

 

 

^&Corresponding author
Sorengmen Amos Ziema, Department of Health Information and Records Management, Ho Teaching Hospital, P. O. Box MA 374, Ho, Ghana.

 

 

 

 

Vitamin A (VA) is an important micronutrient for children under-five years and of public health importance especially in low income countries [1-3]. Children need more VA to help them grow faster, prevent and combat infections by improving immune function [4,5]. Consequently, insufficient VA intake during nutritionally demanding stages in life, such as early childhood, has serious health risk and implications [6].

 

Over a decade ago, it was projected that 190 million corresponding to 33.3% of preschool-age children worldwide suffered from VA deficiency (VAD) [1]. The estimates also showed that Africa and South-East Asia regions contained the highest proportions of preschool-age children with biochemical VAD (serum retinol concentration <0.70 µmol/l) [1]. A recent systematic review revealed that in 2019, VAD affected 146.7 million children aged 0-5 years in 165 low- and middle-income countries, corresponding to a prevalence of 19.5% [7]. The World Health Organization (WHO) African Region accounted for 61.9 million cases, corresponding to a prevalence of 30.6%. In Ghana, a randomized controlled trial among 7-9-month-old infants established that 34.9 % had a serum retinol concentration below 0.7 µmol/L, which WHO describes as a severe public health problem [8].

 

To overcome VAD, a variety of interventions are being used for its control in most high-risk countries and to improve VA status. These are dietary diversification, fortification, and VA supplementation (VAS) [1]. Amongst these interventions, WHO has categorically stated that the most widely practised approach to controlling VAD in most high-risk countries is the periodic delivery of VA supplements, which provides adequate protection for children [5]).

 

The Ministry of Health in Ghana initiated the VAS programme in 1995 through a United Nations Children´s Fund supported pilot supplementation activity in the northern regions and was later implemented nationwide [3]. The VAS intervention is currently part of the Expanded Programme on Immunization where children start the supplement at six months of age and continue at six months intervals till they reach 59 months [9]. An administrative national coverage of at least 80% is usually expected annually [9] but has not been achieved over the years.

 

Administering VA supplements to eligible children has been done mainly through routine child welfare service delivery points, school health, home visits, and mass campaigns [9]. The VAS intervention is virtually free in terms of direct cost, and mothers are to ensure their children take appropriate supplements according to their age schedules to complement VA taken from diets. However, appropriate uptake of all supplements among targeted children in Ghana is usually a problem especially when they received Measles-Rubella 2 vaccination at 18 months of age [9].

 

It is important for mothers and caregivers of these children to be knowledgeable about the VAS intervention including its benefits, starting and completion ages, and interval of uptake to inform appropriate utilization. However, previous studies assessed the knowledge of caregivers in their ability to identify colours of capsules, sources of VA rich foods, health effects of VAD, and medical effect of VA [10,11]. There exists limited studies on the specific role maternal knowledge of VAS play in its appropriate uptake among their children. This study therefore determined age-appropriate uptake of VAS and how maternal knowledge relates with its uptake among children in Nadowli-Kaleo district, Ghana. The study looked at specific aspects like mothers´ knowledge of the targeted age group of children, starting and completion ages, and the interval of supplementation.

 

 

Study design and setting

 

The study used a community-based cross-sectional design among mothers and their children. Semi-structured questionnaires were administered to mothers and data extracted from the maternal and child health records books. The questionnaire was adapted from previous related studies and modified to answer the study´s objective [8,10-12]. Data collected from mothers included sociodemographic characteristics and knowledge of VAS. Sociodemographic characteristics of children and supplementation data were extracted from the record books. This was conducted in the Nadowli-Kaleo district in the Upper West Region of Ghana. In the recent Ghana 2021 Population and Housing Census by the Ghana Statistical Service, the district´s population was estimated at 77,057, with 36,993 (48.0%) males and 40,064 (52.0%) females [13]. Population less than five years has been estimated at 9,516 and that of women in fertility age (15-49 years) at 31,950 [14].

 

The Nadowli-Kaleo district has 8 sub-districts with the District Health Directorate serving as the implementing agency under the Ghana Health Service. The sub-districts include Charipong, Dapuori, Jang, Kaleo, Nadowli, Nanvilli, Sombo, and Tapko [15]. The district has 45 health facilities: two (2) hospitals (1 private), 10 health centres (including a Christian Health Association of Ghana facility) and 33 Community-based Health Planning and Services compounds [15].

 

Study population

 

The study population included mothers, and their children aged 6-59 months residing in the Nadowli-Kaleo district. The study included only mothers and their children with the maternal and child health records books. This is because the date of birth of children and the history of VAS uptake recorded in these books were important variables in this study.

 

Sample size and sampling technique

 

A sample size of 502 was used for the study (at least 125 mothers and children from each sub-district.) The sample size was calculated with OpenEpi software (open source, sample size calculator) [16] using the following parameters: estimated population of children under-five years and that of women in fertility age in the Nadowli-Kaleo district as indicated above [14]; expected frequency=50%; acceptable margin of error=5%; design effect=1; 95% confidence level. This gave a minimum sample size of 383. However, 502 children and mothers were studied to ensure adequate representation of the age groups. A multistage sampling involving a series of sampling techniques was used to select participants. Two sub-districts were pre-selected because of their urban nature while the remaining six rural sub-districts were considered for sampling.

 

Simple random sampling by balloting was used to select two of the six sub-districts. This was done by writing their names on pieces and paper and selecting at random without replacement. All communities within the sub-districts were then considered for sampling. However, five communities were randomly selected using simple random sampling from each sub-district. Names of all communities were written on pieces of paper, folded, and put in a container. The communities were then randomly selected without replacement. This was repeated for each sub-district. Taking the sample size into consideration, about 25 children and their mothers were targeted to be studied in each community. When a community did not have the targeted 25 children and mothers, the nearest communities were considered till the numbers were obtained.

 

In locating and sampling households in the communities, the centre of each community was first located with the help of a contact person. After spinning a pen, the direction of the pen represented the starting point for selecting the first house. Data collectors then moved from one house to another in a serpentine order. This was repeated in each community for all sampled communities. In the situation of a compound house with many households (household represents members of a family who eat from same pot) and more than one eligible child, simple random sampling by balloting was used to select one household with an eligible child and mother. At the household level, simple random sampling by balloting was used for more than one eligible child. Balloting implies that “No” and “Yes” were written on pieces of paper, folded, mixed in a container and selected at random. Same sampling techniques were used in all communities.

 

Data collection

 

Four trained research assistants collected the study´s data. A semi-structured non-standardized questionnaire was used. The questionnaire was developed in Kobocollect application and administered electronically using mobile phones. Using the appropriate sampling techniques from the sub-district level to the household level, a child´s maternal and child health record book was first checked in each house. The mother and child were called to voluntarily participate in the study after meeting the eligible criteria. Research assistants made sure mothers consented to the study by signing the informed consent form. Mothers also consented for their children to participant in the study. The children´s sociodemographic data were then extracted from their health record books and the questionnaires administered to mothers in private and quiet places in their homes.

 

Data analysis

 

Data was analysed using Stata/MP 17.0. Descriptive statistics was performed on sociodemographic characteristics of mothers and children, age-appropriate uptake of VAS and knowledge of schedules to produce frequencies and percentages. The outcome variable was age-appropriate uptake of VAS. This was determined by assessing whether a child took all the needed VA supplements per their age schedules. A child was assigned one (1) if he/she at any given age received the required supplements per schedules. Zero was assigned to any child that did not receive the required supplements per their age schedules irrespective the specific date. The sum of all ones gave the proportion of age-appropriate VAS uptake for all the children. Knowledge of mothers on supplementation was assessed using four variables. Reliability coefficient (Cronbach´s Alpha) of the four knowledge variables was 0.76, signifying good reliability. Binary logistic regression was used to determine associations between age-appropriate uptake of VAS and maternal knowledge of supplementation schedules. In assessing the adjusted regression model, goodness-of-fit test gave a Pearson chi of 0.79 and p-value=0.3746 indicating a good model. Statistical significance for all associations was considered at 95% confidence interval.

 

Operational definition

 

Age-appropriate uptake: means a child has taken the required VA supplements per the age schedules. Supplements are first taken by children at the age of 6 months and continued at six months interval till age 59 months. Thus, a child should have taken one supplement of VA from six to 11 months or should have taken two supplements of VA from 12 to 17 months. Accordingly, at age 59 months, a child was expected to receive nine VA supplements as complete uptake. Age-inappropriate uptake was when age-appropriate was not met.

 

Knowledge of VAS: four variables were used to determine maternal knowledge of VAS. These included the targeted age group of children for VAS, age of first supplementation, age of completion and interval of supplementation.

 

Ethical considerations

 

The study was approved by the Research Ethics Committee of University of Health and Allied Sciences, Institute of Health Research, Ho with protocol identification number UHAS-REC A.8 (3120-21). Permission was sought from the Nadowli-Kaleo District Health Directorate through a formal letter. Mothers were assured of confidentiality and anonymity to inform their voluntary participation with their children. Informed consent was then obtained from each mother through signing the consent form. Additionally, mothers also consented for their children to participate in the study.

 

 

A total of 502 children and their mothers enrolled in this study. For the children, 96 (18.3%) were aged 6-11 months, 126 (25.1%) were 12-23 months, and 71 (14.2%) being 48-59 months old. The majority (52.8%) of the children were males. Regarding the mothers´ age, 205 (40.8%) were aged 20-29 years, 71 (14.2%) were 30-39 years and 52 (10.4%) being 40-49 years old. Only 34 (6.8%) mothers had a tertiary level of education whilst 140 (27.9%) did not have any formal education (Table 1). The majority (88.2%) of mothers were married and 39 (7.8%) were single. Also, 399 (79.5%) mothers were Christians and 76 (15.1%) were Muslims. Of the children who achieved age-appropriate uptake of VAS, 87 (27.8%) were aged 6-11 months and 21 (6.7%) 48-59 were months old. In terms of sex, 169 (54.0%) males took age-appropriate VAS. For mothers whose children attained age-appropriate uptake of VAS, 125 (39.9%) were 30-39 years old, 29 (9.3%) had tertiary education, 275 (87.9%) were married and 251 (80.2%) were Christians.

 

This study observed that overall, 313 (62.4%) of the children appropriately took the VA supplements per their age schedules while the rest did not (Figure 1). Regarding mothers´ knowledge of VAS, 328 (65.3%) knew the targeted age group of children, and 263 (52.4%) recognized the interval of VAS. Again, 396 (78.9%) knew the starting age and 341 (67.9%) were familiar with the completion age of supplementation, (Figure 2).

 

In the unadjusted logistic regression model, children whose mothers knew the starting age for VAS (COR=1.57, 95%CI: 1.02, 2.43; p=0.041), and interval of receiving VAS (COR=1.99, 95%CI: 1.38, 2.86; p<0.001) had increased odds of taking VAS appropriately compared to children whose mothers did not know. In the adjusted logistic regression model, there were increased odds of taking VAS appropriately among children whose mothers knew the interval of VAS (AOR=1.89, 95%CI: 1.27, 2.82; p=0.002) compared to children whose mothers did not know, (Table 2).

 

 

This current study revealed that about three out of five children appropriately took the VA supplements per their age schedules. While previous studies assessed VAS uptake relative to fixed periods, this current study determined the uptake of VAS in relation to age of children. A previous finding in the Ashanti region of Ghana revealed that only one in five children received the recommended supplementation of taking two supplements in the last year [10]. Another study in Kenya reported that about three out of five children received supplements once and twice in the year preceding the survey [17]. It was also found in Ethiopia that three-quarters of children had received a supplement in the past six months prior to the study [12]. Differences in study settings, methods of assessment, availability of VA supplements, health seeking behaviour and health priorities of mothers could account for the difference between this study´s finding and others. This study´s finding suggests that close to two of five children were not receiving the supplements appropriately. The Ghana Health Service (GHS) targets an administrative national coverage of 80% annually and recommends that after the routine vaccinations at 18 months, children should continue to visit the child welfare clinics for supplementation with VA to improve their immunity, increase resistance to infections and improve sight [9]. Though this study did not determine the district administrative coverage, high age-appropriate uptake of VAS should result in high administrative coverage. In terms of health, VA supplements are needed by children for growth and development and inappropriate uptake can lead to VAD. Also, if significant number of children are not receiving the supplements appropriately, it would result in low coverage in the Nadow-Kaleo district. Desirably, if all the targeted children appropriately take the supplements per their age schedules, it would always result in optimal age-appropriate uptake and contribute to high district and national coverages. It is therefore essential that factors that hinder or increase age-appropriate uptake of VAS at the district level are identified and given the needed attention by district health authorities.

 

More than half of mothers knew the targeted age group of children, starting and completion ages and interval of taking VAS among children. Notably, more than three-quarters of the mothers recognized the starting age for VAS for their children. From our literature search, previous studies did not determine maternal knowledge of VAS using variables on supplementation schedules as this current study. An earlier study which observed more than a third of caregivers having good knowledge of VA was based on capsules identification, sources of VA rich foods and the health effects of VAD [11]. Also, [10] determined mothers´ knowledge of VA based on participants identifying VA supplements, natural sources and medical effect of VAD. Our current findings imply that the health education usually given to mothers at child welfare clinics by health professionals may be lacking comprehensive information on VAS schedules. Hence, mothers should be given adequate and comprehensive education on VAS schedules at child welfare clinics by health professionals. Education should be specific and have the essential information on VAS to increase their knowledge and drive its utilization among children.

 

It was observed that children whose mothers were familiar with the interval of VAS had a significantly increased chance of receiving the supplements appropriately per their age schedules. Per our literature search, we did not find related studies to compare this finding with. Implicatively, our finding suggests that mothers who had knowledge of successive supplementation interval ensured that their children received VAS appropriately. This is a significant finding that could guide health professionals to deliver specific information about VAS to mothers and caregivers. The interval between successive supplementation is six months. To ensure appropriate VAS uptake among children, mothers need to know specific information about supplementation schedules as this study has demonstrated. Further studies should be conducted in other settings to validate our findings and contribute to knowledge of VAS in literature. This will enhance appropriate uptake of VAS among targeted children in Ghana.

 

Limitation

 

One major limitation of the study was that only four variables on VAS schedules were used to assess maternal knowledge which are not the only variables necessary to ensure appropriate VAS. Notwithstanding, sufficient knowledge of these four variables among mothers is very necessary and could help improve VAS in the Nadowli-Kaleo district and across other districts in Ghana. Also, the study focused on the relationship between only variables on maternal knowledge and age-appropriate uptake of VAS. The study didn´t assess other variables that could influence VAS uptake. This is because the focus of this current study was to find such a peculiar relationship between maternal knowledge and age-appropriate uptake of VAS only.

 

 

The study revealed that about three out of five children received VAS appropriately per their age schedules. Though this study did not determine administrative coverage in the district, high age-appropriate uptake of VAS should result in high district and national coverages. The current finding implies that a significant proportion of children in the Nadowli-Kaleo district did not receive VAS appropriately. This could adversely affect the GHS targeted administrative national coverage of 80% annually among children 6-59 months old. Consequently, if these children were not taking adequate VA from diets, they could be at risk of VAD. This should be a matter of concern to health authorities who are interested in the adequate growth and development of children in the Nadowli-Kaleo district.

 

The majority of the mothers knew about the targeted children for VAS, starting and completion ages and interval of successive supplementation. Children whose mothers were acquainted with the interval of supplementation had a high chance of taking VAS appropriately. For GHS to achieve its targeted VAS coverage among children annually, every district, including Nadowli-Kaleo must play a crucial role. Evidently, maternal knowledge of VAS is essential if children would receive the supplements appropriately. Therefore, public health practitioners at the service delivery points should provide specific information about VAS to mothers especially the interval of successive supplementation to ensure appropriate uptake among their children. Since the interval of successive supplementation is six months and children usually complete most of the childhood immunizations at 18 months, the GHS could consider using text message via mobile phones to remind mothers of VAS schedules as policy intervention to increase uptake.

 

 

The authors declare no competing interests.

 

 

Study conception: Sorengmen Amos Ziema, Design, data acquisition, analysis, and interpretation: Sorengmen Amos Ziema, Charles Alomatu, Edem Kojo Amedonu, Samson Obripuo, Drafting initial manuscript and approval of final version: Sorengmen Amos Ziema, Charles Alomatu, Edem Kojo Amedonu, Samson Obripuo.

 

 

The authors acknowledge the Nadowli-Kaleo District Health Directorate for all the support given to conduct the study. They also acknowledge the contributions of the research assistants in the conduct of the study.

 

 

Table 1: Socio-demographic characteristics of children and mothers by age-appropriate uptake of vitamin A supplementation in Nadowli-Kaleo District, 2022 (n=502).

Table 2: Association between mothers´ knowledge and uptake of vitamin A supplementation among children aged 6-59 months in Nadowli-Kaleo District, 2022 (n=502).

Figure 1: Uptake of vitamin A supplementation among children aged 6-59 months per their age schedules in the Nadowli-Kaleo District, 2022 (N=502).

Figure 2: Maternal knowledge of vitamin A supplementation schedules for children aged 6-59 months in Nadowli-Kaleo District, 2022 (N=502).

 

 

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