Rural-urban determinants of vitamin a deficiency among under 5 children in Bangladesh: Evidence from National Survey 2017–18

Vitamin A is an essential nutrient needed in small amounts and mainly required for the visual system, growth and development, maintaining epithelial cellular integrity, immune function and reproduction [1]. Inadequate intake of vitamin A is the primary root of vitamin A deficiency (VAD). Nowadays, VAD is one of the most important concerns among the public health problems since many children, and pregnant women are affected by Vitamin A deficiency disorder throughout the developing countries including Bangladesh [2, 3]. Moreover, the Vitamin A deficiency (VAD) disorders reduce the immune competence, which is responsible for increasing the morbidity and mortality associated with night blindness, corneal ulcers, keratomalacia and related ocular signs and symptoms xerophthalmia [4‐9]. Vitamin A deficiency is also associated with an increased risk of child mortality and of a range of problems, including measles, diarrhea, respiratory diseases, vision problems, and can lead to death [2, 10‐15]. The evidence above ensures that the prevalence of many childhood diseases is more common among stunted children, and on the other hand, there is a significant association between stunting and VAD [16]. Vitamin A deficiency in under-five children can also cause mortality risk up to 20–30% [17]. Also, Xerophthalmia among preschool children amounts to about 5 million cases, 10% of which can potentially lead to blindness in India [18, 19]. Globally, about 30% of children under the age of 5 years are vitamin A deficient, and about 2% of all deaths are attributable to VAD in this age group [14, 20]. The most important agenda of Sustainable Development Goal-3 is to reduce the preventable deaths of under-five children at least as low as 25 per 1000 live births within 2030 [21] and reduce the number of stunted children under five by 40% by 2025 [22]. Therefore, vitamin A supplementation was suggested to reduce child morbidity and mortality from various diseases; however, it would be treated as a cost-effective strategy for reaching SDG-3 [23].

Since the vitamin A supplementation program is a cost-effective approach to lessen the burden of VAD, it is necessary to design the community-based vitamin A supplement program considering associated factors that significantly enhance the awareness among underprivileged people and the consumption rate of vitamin A supplementation (VAS) [24‐27]. Existing literature riched by such studies that have been conducted to identify the determinants that are significantly associated with the VAS program in several countries. Abedin et al. (2019) mentioned that age, sex, religion, mother’s education, immunization status for the vaccine-preventable disease are associated with the recent receipt of VAS [21]. Mostafa et al. (2019) try to determine the factors affecting low coverage of the VAS program among the young children admitted to a diarrheal hospital of Bangladesh and age of the child, parental education, and wealth status are associated with receiving the vitamin A supplement. They also observed an increase in coverage of VAS from 61 to 76% over the last 18 years [20]. Muliyil et al. (2019) mention that the educational status of the household head was significantly associated with an increased risk of VAD among children [28]. Other studies across the world also reveal that age, sex, BMI, religion, age of mother, mother’s education, family type, occupation, income, food habits, type of residence, access to media, wealth index, and social development status of their state of residence are associated with recent receipt of VAS [2, 29‐35].

However, in light of the existing literature, a substantial research gap has been discovered in this topic, particularly in Bangladesh. Therefore, to fill this gap, the authors were motivated to conduct a study to ascertain the influential determinants of VAD in urban-rural settings of Bangladesh based on the most recent BDHS-2017/18 survey data. To assess the association between the children’s vitamin A capsule consumption status and socio-economic and demographic characteristics, we used the Chi-square test in the bivariate analysis. Moreover, the logistic regression analysis was carried out to determine the effects of the covariates on the response variable.

This section offers empirical data analysis results with descriptive interpretations. Table 1 presents the study children’s background, socioeconomic and demographic characteristics, and their distribution by the vitamin A capsule consumption status according to rural and urban areas. About 73.2 and 73.9% of children had consumed vitamin A capsules in the rural and urban areas, respectively, i.e. a less coverage of vitamin A supplementation in rural areas than in urban areas. The highest percentage (77.6%) of children consumed Vitamin A capsules in the Rangpur division and the lowest (69.6%) in the Dhaka division for rural areas. In urban areas, the highest 78.1% of children consumed Vitamin A in Mymensing and Rajshahi division and the lowest 70.2% in the Dhaka division. Thus, the division has a significant association with vitamin A consumption for Bangladesh’s urban and rural areas [Table 1].

The age of the child and religious status factors are significantly related to the consumption status of Vitamin A capsules in both urban and rural areas. Looking at the age group of 6–12 months, 70.6% of children in rural areas have consumed vitamin A capsules whereas, in the urban area, only 69.7% of children had consumed vitamin A capsules. This result indicates that the child lives in urban and rural areas are same likely to consume vitamin A supplement, however, in the previous survey, the child who lived in rural areas were more vulnerable to vitamin A deficiency-related diseases than child lived in urban areas. Parental education plays a vital role in vitamin A consumption by their child. Both in rural and urban areas, vitamin A consumption increased with the increase of wealth index. Breastfeeding children were less consuming vitamin A capsules than their counterparts [Table 1].

The prevalence of vitamin A consumption was more than 90% in the 1996–97 survey. It increased around 95% in the 1999–2000 survey for boys and girls in urban and rural areas of Bangladesh. After the year 2000, the rate of receiving the vitamin A supplement by children decreased dramatically for all groups. In 2004, the prevalence of vitamin A consumption of urban boys and girls was slightly higher than rural boys and girls. The lowest figures observed in 2011 for all categories, and then the estimates increased a bit in the 2014 survey, especially for the estimates of both boys and girls in urban areas. The vitamin A coverage again increased in 2018 compared to the previous survey year 2014, both in urban and rural areas among both sexes. In general, findings demonstrated that girls received more vitamin A capsules than boys, and the prevalence of receiving vitamin A was slightly more in urban areas than in rural areas of Bangladesh. An overall downward trend of the prevalence of vitamin A consumption is observed with some fluctuations for 1996 to 2018 by the child’s sex and rural-urban status (see Fig. 1).

The bar graph presented in Fig. 2 depicts the comparison of receiving the vitamin A supplement in the last 6 months by the urban-rural setting of different age groups of children from 1996 to 2018. In the age category of 6 months to 1 year, the prevalence was almost double in 1996–96 and 1999–2000 than the remaining years. A slight variation is observed by region as well as the age of the child. Surprisingly the overall rate of consumption of vitamin A supplements has been decreased in recent years for children aged between one and 5 years (see, Fig. 2). Also, for the age group of 6 months to 1 year, this study observed the lowest percentage of the child received vitamin A capsules in the last one and half decades in urban and rural areas of Bangladesh.

In urban areas of Bangladesh, children aged 13–24 months (OR: 2.33; CI: 1.56–3.42) and 25–36 months (OR: 0.82; CI: 0.57–1.19) were more and less likely to consume vitamin A in comparison to the age group 6–12 months respectively. The results revealed that with the increasing age of a child, consuming vitamin A supplements decreases in both urban and rural areas. Children whose mothers have secondary (OR: 1.17, CI: 0.76–1.81) and higher (OR: 1.21, CI: 0.72–2.04) education were more likely to consume vitamin A supplementation than children whose mothers were illiterate in urban areas (see in Table 2). However, in rural areas, children whose mothers have secondary education were about 24% (OR: 1.24, CI: 0.92–1.68) and higher education with 60% (OR: 1.60, CI: 1.07–2.38) more likely to consume vitamin A supplementation than children whose mothers were illiterate. Somewhat similar results were observed for the father’s education. These results depict that parents education play a vital role in the consumption of vitamin A supplement. Rural children living in different divisions received vitamin A capsules more than the Barisal division except for Dhaka and Sylhet divisions. Moreover, children with middle and upper-class families in urban and rural areas were more likely to receive vitamin A supplementation than children with low-income families. However, wealthier people are less concerned about vitamin A consumption by their children. In contrast, for the urban areas, children aged 13–24 months and 24–36 months were more likely to consume vitamin A than the age group 6–12 months [Table 2].

This study demonstrated the significance of potential socioeconomic and demographic factors associated with vitamin A supplementation among under-5 children in the settings of rural and urban areas of Bangladesh. It is found that the children residing in different divisions (administrative regions) have a varying percentage of receiving vitamin A capsules- leading the division as a significant factor for receiving vitamin A capsules. This finding is also supported by another study [21]. The authors think that this variation is due to the demographic and socio-economic diversity among divisions. In this study, urban children from middle-class families are more likely to receive vitamin A supplementation than others because Bangladeshi middle-class families are more concerned about their children. Subsequently, children from the wealthiest family have a slightly higher chance of vitamin A consumption in rural and urban areas. This finding is consistent with the result of a previous study [21, 30].

Children’s age is another contributing factor, and this study revealed that the children of age group 13–24 months are higher likely to receive vitamin A capsules. However, after 24 months, children are less likely to consume vitamin A capsules than 6–12 months aged children in urban and rural areas. These results are probably due to the assorted carrying attitudes of parents or caregivers to their offspring in different age groups. However, Janmohamed et al. (2017) and Agrawal and Agrawal (2013) found that all age groups are equally likely to consume vitamin A capsules [30, 39].

This study demonstrated that parental education was key determinants for receiving vitamin A capsule in Bangladesh’s rural and urban areas, which was a consistent finding with other [2, 29]. This study found that in rural areas, children whose mother and father having higher educational qualifications (i.e., secondary and higher) are more likely to consume vitamin A capsules. However, it observed a different result in urban areas, i.e. children whose father and mother had the primary education were more likely to consume vitamin A capsules. It could be because a higher educated parent in an urban area remains busy with other activities except for their parenting task. Therefore, parents’ awareness of their children may be more effective in reducing the VAD burden [20, 25]. The educated parents’ having enough knowledge about vitamin A-rich food also plays a crucial factor in preventing the vitamin A deficiency of their offspring. A study found a significant positive association between maternal education VAS attendance in Cambodia [40]. The families having three or more children were more likely to consume vitamin A supplementation in rural and urban areas of Bangladesh. It is because elder offspring sometimes look after their younger siblings among families having more children. The authors believe that the quality of the data ensures the acceptance of the findings.

This study depicted that vitamin A supplementation coverage for the urban and rural areas is 73.9 and 73.2%, respectively, which indicates that to achieve the SDGs target, we have to prioritise and improve the vitamin A campaign in Bangladesh. Findings also suggest that vitamin A supplementation is less in rural areas than the urban areas. Moreover, the results are varied significantly with region, religion, wealth index, children’s age, mother’s age, mother’s education, and father’s education in the rural area. This study examined the nature and determined the essential determinants of children’s vitamin A supplementation intake. The significant factors identified in this study will be helpful for the researcher to identify other related factors to reduce child mortality due to vitamin A deficiency.

Since the human body cannot produce vitamin A, it must be included in our diet. Therefore, the authors strongly recommended consuming a regular intake of vitamin A-rich foods such as liver, chicken, beef, eggs, oily fish, milk, mangoes, orange fruits, sweet potatoes, carrots, spinach, and other green vegetables. It is also suggested that mothers should breastfeed their child as it contains vitamin A which is essential for young children. Moreover, various fortified foods with vitamin A, like cereals, slices of bread, pastries, and crackers, may be used to supplement vitamin A. An improvement of dietary intake of vitamin-A may enhance the vitamin A status among under-5 children. Thus, dietary intake, including the foods mentioned earlier, will be considered an alternative approach to taking vitamin A supplements to prevent vitamin A deficiency.

Moreover, these findings would assist decision-makers to design effective policies that could improve some of the risk determinants, especially in the rural area, to increase concern for vitamin A supplementation. There may be a spatial variation in the data at local area levels, which could help developing precision policy and the most effective implementation [38]. The future study should focus on expanding the analysis to include other explanatory variables such as geospatial attributes related to child health and using the up-to-date data. Future research can also employ a multi-level modeling approach for minimizing any higher-order variations in the data [37, 41]. Finally, it may better understand the dynamics of vitamin A coverage in other Southeast Asian countries.