The present study aimed to analyze the policy to reduce VAD prevalence among children aged 15–23 months in Iran.
Relevance of findings
Before a policy can be launched, the “government’s attention should be drawn to the underlying issue [
16]. Our interviews confirmed that VAD prevalence in this age group is not clear to politicians; additionally, the existing policy is neither carried out constantly nor with strict supervision, but sometimes it is changed before coming to its end. Sustainable programs require political commitment regardless of any related changes [
13]. The implementation of this policy depends on ‘politicians’ perspectives in each province. Politics is done at different levels, and in several cases, budgets are spent on some other policies. Therefore, policy importance should be articulated with actors such as civil society and IRIB on politicians.
There are two national studies on micronutrients in Iran, but their results have been considered to make decisions to reduce VAD prevalence. The criteria for moderate and severe VAD in the study of 2001 were less than 30 and 20 μg/dL, respectively, which were modified to less than 20 and 10 μg/dL in 2012, based on the updated WHO guidelines, respectively. Despite this change in the criteria, there is an increase in the prevalence of VAD in this age group [
4,
5] which can be partially attributed to deteriorate the economic status of Iranian population. Based on WHO classification, VAD in these two study groups was moderate (≥10% to ≤20%) [
17]. Evidence-based decision-making has been proffered for explicitly justified decisions [
18,
19], so it is expected that physicians, as well as politicians to rely on authentic evidence when making decisions or even policies [
20]. The main purpose for so doing is to grasp the three streams together, i.e., problem, policy, politics, to develop the content based on specific policy elements which are likely to be effective, then decide on the next step; improve, expand, or terminate that policy [
21]. Schools of nutrition and scientific associations can better cooperate to find out these evidences. Scientific studies should be planned analytically rather than being descriptive.
It seems that the relevance of the knowledge provided by public health actors is not limited to the agenda-setting stage [
22]. There are many components to developing and implementing policies that should be monitored and evaluated intermittently to determine if interventions are necessary [
23]. The evaluation aimed to determine the relevance and consistency with objectives, developmental efficiency, effectiveness, impact, and sustainability [
24]. Termination of policies might be attributed to inefficiency or lack of stakeholders and elected officials who first put it on their agenda [
16].
For accurate planning and evaluation, a reliable information system is required, as the information may differ for each stage of policymaking. Accordingly, the information should be recorded correctly [
25]. However, there are some problems such as underdevelopment of the
SIB system, differences in the registration systems, and time constraints required for recording information. The workload of health providers without sufficient incentives is one of the consequences which might negatively affect policy implementation.
Although the Iranian PHC system has numerous successes, especially in health network deployment, Behavers’ role, health indicator improvement in rural areas, and the elimination of urban-rural inequality [
26], he is one of the main strengths implementing related policies such as supplementary foods and promoting education.
The role and importance of context in policy implementation are widely recognized. The main contextual factors that significantly affect the promotion and use of knowledge in policymaking have to be detected and explored [
27]. In Iran, there are various ethnic groups, cultures, climates, and social and economic situations. Socioeconomic and cultural factors significantly affect access level to vitamin resources to the population [
28]. For success, all stakeholders should be involved in decision-making and implementation processes seeking commitment, ownership, and accountability of government, civil society, combined with advocacy and assistance of international agencies [
29]. Therefore, to implement this policy properly, there is a need for inter-sectoral coordination and cooperation. For example, Imam Khomeini’s relief committee is currently distributing food packages to needy families, but these packages need to be evaluated to enrich them in terms of vitamins. The monthly food rations in a province cans consist of vegetable oil (2 L), rice (10 kg), lentil (1 kg), milk (3 L), soybean (0.5 kg), canned tuna (three cans), and spaghetti (2 k). In contrast, in another province it contained milk (2 L), cheese (0.5 kg), potato(3 kg), vegetable oil (2 L), canned tuna (five cans), rice (2 kg), wax bean 1 kg), lentils (1 kg), eggs (1 kg), and chicken (2 kg) [
30,
31]. IRIB may also have a great impact on education and cultural factors. MOHME should be responsible for organizing these efforts [
30,
31].
Supplementation and training are the major policies to reduce VAD prevalence in Iran. Success in supplementary policy depends on accurate evaluation, supplement coverage, and political commitment [
32]. In South Asian countries, VA supplement was a successful approach to overcome VAD, as these programs were well-structured and closely monitored [
33]. Effective training should start from the local knowledge in that area [
29] and can help with dietary changes. Still, there was no formal and accurate evaluation of this policy. Due to the workload of health providers and time constraints, health care providers cannot evaluate the effectiveness of learning and the amount and use of supplements. Assessment is carried out in the field by inspectors of the university’s health deputy. Therefore, accurate evaluation of the supplementary is not performed in different stages, such as estimating the required supplements, delivery of the supplement to mothers, and the amount for use and did not provide credible and useful information, enabling incorporating lessons learned into the decision-making process of both recipients and donors. It is essential to officially evaluate the outputs of this policy by engaging all interested actors.
The evidence from this study implies there is no enough political commitment and inter-organizational cooperation in this policy. Sometimes decision-making is subjective to prejudgments, rooted in ‘policymakers’ views, and without a comprehensive understanding of the problem. Based on Bangladesh’s experiences, political commitment is required for policy triumph [
29,
34]. In 1997, reducing child mortality became a political priority for the Nigerian government. Ministry of Health, Helen Keller International Foundation, and UNICEF have formed a coalition to control VAD. Since then, Nigeria became one of the first African countries to effectively supplement VA during the National Immunization Days to eradicate polio [
35]. Despite this, many countries use the mega-dose vitamin in VA deficient areas (of course, it recommended shifting judiciously from periodic VACs to increasing regular intakes) [
10]. Mega-dose has not been provided to children with VAD for a long time. Still, his supplement is given to children up to 6 months and then substituted by multivitamins for free in the amount of vitamin consumed according to the age.
Except for physical access to vitamins, geographical or economic reasons, cultural factors, and common diet type in those areas are also influential factors [
36,
37]. Accountability of society and interested people affect this policy, so cultural factors such as lifestyle, context, and marginalization which affect these people, should be deemed. Many children between the ages of 18 and 23 months, who are not vaccinated, do not visit health centers to get supplements or in some cases, not enough supplements are provided in health centers. Either they may take different types of supplements following non-specialists or in doses lower than recommended.
It is recommended that other policies be used along with supplementary to boost VAD reduction [
38]. Most VA food sources can be cultivated and accessed in developing countries [
39]. In Iran, various diets and dietary resources are very low due to various factors, such as cultural and economic factors. Dietary diversification and ensuring regular access to foods naturally rich in VA are important in the long run [
34]. Home gardens provide fresh sources of vitamins and increase women’s participation [
40]. Even in areas where water and land are scarce, using innovative approaches to home gardening can be effective for families [
41].
One of the important policies to control vitamin deficiency is breastfeeding [
29]. Breastfeeding training is given, but the key issue is the mother’s access to VA resources, which depends on various factors and needs that should be considered.
As mentioned, several factors contribute to the proper implementation of the VAD prevention policy, which makes it possible for various organizations such as the Ministry of Interior, the Ministry of Welfare, the Civil Society, and IRIB to cooperate and coordinate with the MoHME. Also, the departments of MoHME, such as Food and Drugs, the Health Deputy, and the Education Deputy, have to be coordinating with each other.
It is noteworthy that affordability and access to policy requirements dominate education and awareness concerning its content; this highlights the role of government, NGOs, and international organizations in aiding needy people in various packages of foods and supplements [
42].
Limitations/strengths
The current study had limitations. Firstly, we were unable to interview experts in the Ministry of Agriculture and the Islamic Republic of Iran Broadcasting (IRIB). Since the current study had a qualitative framework, the findings have low generalizability. According to the author’s best knowledge, the current research is the first study on the prevalence of VAD in children aged 15–23 months.
Policy recommendations
Based on our findings, we recommend that each province in Iran will identify facilitators and administrative barriers to address VAD, and through multi-sectoral collaboration, formulate evidence-based policies to tackle the problem. In addition to supplementation policy, other policies should be planned.
In particular, we recommend providing quality training on proper nutrition, supplementation through actors such as nutritionists, caregivers, doctors, media, municipalities and relief committees. In addition, accurate assessments of all stages of policy through various actors, with relevant job description is crucial for recording information and statistics and results. NGOs can also be helpful in providing food packages containing vitamin A sources at reasonable prices, full coverage of supplements in deprived areas, and increasing people’s nutritional literacy. Adopting appropriate economic policies to increase access to vitamin A sources, with special emphasis on low-income and vulnerable groups (e.g., through subsidies and incentive policies for health-supporting industries); improving the working conditions of health workers and employing more healthcare staff; monitoring the allocation of earmarked budget for reducing the prevalence of VAD; and implementing policies related to home gardens to increase growing vegetables that are rich in vitamin A; are among policies that we recommend to be implemented to tackle VAD in Iran. Fortification of infant and children foods with vitamin A is a cost-effective intervention for reducing vitamin A deficiency, especially in settings where improving dietary quality through food variety is not possible.