Public Health (2008) 122, 371378

Original Research
Malnutrition and morbidity among children not
reached by the national vitamin A capsule
programme in urban slum areas of Indonesia
S.G. Berger
a
, S. de Pee
b
, M.W. Bloem
a,c
, S. Halati
d
, R.D. Semba
a,
a
Johns Hopkins School of Medicine, 550 N. Broadway, Suite 700, Baltimore, MD 21205, USA
b
Helen Keller International Asia Pacic, Singapore
c
Nutrition Service, Policy, Strategy and Programme Support Division, World Food Programme, Rome, Italy
d
Helen Keller International, Jakarta, Indonesia
Received 14 August 2006; received in revised form 22 May 2007; accepted 6 August 2007
Available online 28 January 2008
KEYWORDS
Anaemia;
Diarrhoea;
Immunization;
Malnutrition;
Morbidity;
Vitamin A;
Indonesia
Summary Objective: To determine whether vitamin A capsule programmes fail to
reach children who are at higher risk of malnutrition and morbidity. Although it has
been suggested that there are health disparities between children who are reached
or not reached by these programmes, little quantitative work has been undertaken
to characterize this relationship.
Study design: As part of a national surveillance system, nutritional status and other
factors were compared in 138,956 children, aged 1259 months, who had and had
not received vitamin A supplementation in urban slum areas in Indonesia.
Results: In total, 63.1% of children had received a vitamin A capsule within the
previous 6 months. Among children who had and had not received vitamin A
supplementation, respectively, the proportion with weight-for-age and height-for-
age Z scores o3 were 7.8% vs 8.6% (Po0.0001) and 9.4% vs 10.7% (Po0.0001), and
with a history of diarrhoea in the previous week was 8.1% vs 10.7% (Po0.0001). In
families where a child had or had not received vitamin A supplementation, the
proportion with a history of infant death o12 months was 5.2% vs 7.2% (Po0.0001)
and child death o5 years was 6.7% vs 9.2%, respectively (Po0.0001). Children who
had not received vitamin A supplementation were also signicantly more likely to be
anaemic and have diarrhoea or fever on the survey day compared with children who
had received supplementation.
Conclusions: In the urban slums of Indonesia, children who do not receive vitamin A
supplementation tend to be slightly more malnourished and ill, and are more likely
to come from families with higher child mortality than children who receive vitamin
A. Higher rates of child mortality in non-participating households suggest that
reaching preschoolers could yield a disproportionate survival benet. Importantly,
children who are not reached by the vitamin A programme are also unlikely to be
ARTICLE IN PRESS
www.elsevierhealth.com/journals/pubh
0033-3506/$ - see front matter & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.puhe.2007.08.003

Corresponding author. Tel.: +1 410 955 3572; fax: +1 410 955 0629.
E-mail address: rdsemba@jhmi.edu (R.D. Semba).
reached by vaccination and other services, emphasizing the need to identify and
extend efforts to reach non-participants.
& 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights
reserved.
Introduction
It is estimated that vitamin A deciency affects 140
million children in the developing world
1
and is a
leading cause of child morbidity, mortality and
paediatric blindness.
2
Vitamin A is essential for
normal cell differentiation, growth, maintenance
of mucosal surfaces, reproduction, immunity and
vision. Periodic high-dose vitamin A supplementa-
tion programmes have been established over the
last 25 years in many developing countries in order
to increase child survival and decrease the inci-
dence of paediatric blindness. Vitamin A supple-
mentation has proven to be a very cost-effective
intervention,
3
reducing all-cause mortality among
659-month-old children by 23%.
4
It is estimated
that if vitamin A coverage reached 99% of children
in the 42 countries with the greatest burden of
child mortality, 225,000 child deaths could be
prevented annually.
5
Vitamin A deciency has been highly prevalent in
Indonesia since at least the early 20th Century. In
the 1970s, the prevalence of xerophthalmia was
recorded at 1.33% and acute corneal disease
affected one in 1000 infants and preschool children
each year.
6
In the early 1970s, with the introduc-
tion of vitamin A capsule pilot programmes, and
later in the 1980s, with the initiation of a national
programme, the prevalence of severe vitamin A
deciency began to decrease. By 1992, the pre-
valence of xerophthalmia had fallen by approxi-
mately 750.34% and acute corneal disease to 0.05
per 1000 among infants and preschool children.
6
However, subclinical vitamin A deciency is still
common.
7
Periodic high-dose vitamin A capsule distribution
has been identied by the World Bank as one of the
most cost-effective interventions to reduce child
mortality in developing countries.
8
In addition, the
Copenhagen Consensus included vitamin A capsule
distribution as one of the most effective measures
to improve global health.
9
Indonesia has had one of
the strongest vitamin A capsule distribution pro-
grammes for child survival in the world,
10
and the
intended coverage is for all infants aged 612
months and all preschool children aged 1259
months. The programme consists of biannual dis-
tribution of oral vitamin A, 60 mg retinol equiva-
lents, to children aged 1259 months and half the
dose for infants aged 612 months.
11
The main site
for distribution of vitamin A capsules to children is
the subvillage health post (posyandu).
The effectiveness of vitamin A capsule distribu-
tion programmes for child survival is likely to be
related to the extent of programme coverage. It
has been suggested that vitamin A supplementation
in developing countries may fail to reach the
children who are at highest risk,
12
but there are
few recent quantitative data on the characteristics
of children who do not receive vitamin A supple-
mentation.
13
It is not known whether children who
are missed may actually be at greater risk of
morbidity and mortality. To gain further insight into
this issue, this study sought to characterize the
demographic and health characteristics of pre-
school children who are reached and not reached
by the national vitamin A capsule distribution
programme in Indonesia. It was hypothesized that
children who did not receive vitamin A supplemen-
tation were more likely: (i) to be stunted, wasted
and underweight; (ii) to be at higher risk of
diarrhoea, fever and anaemia; (iii) to have lower
childhood immunization coverage; and (iv) to come
from families with higher rates of infant and under-
5 child mortality than children who received
vitamin A. In order to address these hypotheses,
the characteristics of children who did and did not
receive vitamin A supplementation in urban slum
areas of Indonesia were examined.
Subjects and methods
The study subjects were children from families that
participated in a major nutritional surveillance
system (NSS) in Indonesia that was established by
the Ministry of Health, Government of Indonesia
and Helen Keller International (HKI) in 1995.
14
The
NSS included ve major urban slum areas of
Indonesia in the cities of Jakarta, Surabaya,
Semarang, Makassar and Padang. The subjects
included in this analysis were surveyed between 1
January 1999 and 27 September 2003. The NSS was
based upon UNICEFs conceptual framework on the
causes of malnutrition
15
with the underlying prin-
ciple to monitor public health problems and guide
ARTICLE IN PRESS
S.G. Berger et al. 372
policy decisions.
16
The NSS was based upon strati-
ed multistage cluster sampling of households in
subdistricts of administrative divisions of the
country and in slum areas of large cities.
14
A
purposive sampling design was used to target poor
households. Within specic slum areas, poor house-
holds were considered those in which the housing
location was along train tracks, rivers/gutters/
swamps, underneath toll roads/highways, near
waste station/dump areas, around small alleys
and/or near the beach, and where housing condi-
tions included box house (composed of cardboard,
galvanized tin, plywood and bamboo), house with
soil/uncemented oor, house attached to other
houses and house with wood oors.
The NSS in Indonesia involved the collection of
data from approximately 40,000 randomly selected
urban households every quarter. New households
were selected every round. Data were collected by
two-person eld teams. A structured coded ques-
tionnaire was used to record data on children aged
059 months, including anthropometric measure-
ments, date of birth and sex. The mother of the
child or another adult member of the household
was asked to provide information on the house-
holds composition, parental education and weekly
household expenditures, along with other socio-
economic, environmental sanitation and health
indicators. For each child over the age of 6 months,
the mother, father or guardian was asked whether
the child had received a vitamin A capsule within
the last 6 months and about receipt of diphtheria-
pertussis-tetanus (DPT), oral poliovirus vaccine
(OPV) and measles vaccine. Axillary temperature
was recorded. Haemoglobin was measured using a
HemoCue instrument (HemoCue AB, Angelholm,
Sweden). Morbidity histories were obtained for
each child, including history of diarrhoea in the
previous week and diarrhoea on the survey day.
Data were collected on the history of any deaths in
the household before 1 month of age, before 12
months of age and before 5 years of age.
The eld teams measured and recorded the
weight of each child aged 059 months to a
precision of 0.1 kg and the length/height to a
precision of 0.1 cm. Birth dates of the children
were estimated using a calendar of local and
national events and converted to the Gregorian
calendar. Z-scores of weight-for-height (WHZ;
wasting), weight-for-age (WAZ; underweight) and
height-for-age (HAZ; stunting) were calculated
using EpiInfo software (Centers for Disease Control
and Prevention, Atlanta, GA, USA), which uses the
reference population of the US National Center for
Health Statistics. Children with Z-scores o2
standard deviations (SD) for WHZ, WAZ or HAZ
were considered wasted, underweight or stunted.
17
Severe wasting, underweight and stunting were
dened by Z scores o3 SD. Children who had a
mid-upper arm circumference o125 mm were
considered to be at high risk of malnutrition.
18
HKI provided training to new eld teams, eld
supervisors and assistant eld ofcers, and
refresher training prior to each new round of data
collection. During each round, a monitoring team
from HKI visited all eld sites to check and
calibrate the equipment and supervise data collec-
tion. A quality control team from HKI revisited 10%
of households without prior warning within 2 days
of data collection by the eld teams and recol-
lected data on selected indicators, including
anthropometric measurements. Data collected by
these quality control teams were later compared
with the data collected by the eld teams to check
the accuracy of the data collection.
The study protocol complied with the principles
of the Declaration of Helsinki.
19
The eld teams
were instructed to explain the purpose of the NSS
and data collection to each childs mother or
caretaker, and if present, the father and/or house-
hold head; data collection and phlebotomy pro-
ceeded only after written informed consent.
Participation was voluntary and all subjects were
free to withdraw at any stage of the interview. The
protocol was approved by the Medical Ethical
Committee of the Ministry of Health, Government
of Indonesia. The research plan was reviewed
by the Johns Hopkins School of Medicine Institu-
tional Review Board and granted an exemption on
14 July 2006 under Department of Health and
Human Services 45, Code of Federal Regulations
46.404.
Data analyses were restricted to children aged
1259 months at the start of the most recent
vitamin A capsule distribution round because these
were the children who were eligible to receive
60 mg retinol equivalents (200,000 International
Units) every 6 months in the Indonesian vitamin A
capsule programme. Children who were aged
between 6 and 12 months at the time of the last
vitamin A capsule distribution round in the local
area were not included in this analysis because
supplementation of children in this age range with
a different dose and type of capsule was being
implemented during the period of this study. For
families with more than one child, the youngest
child aged 1259 months was selected to represent
each family. Continuous variables were compared
using Students t-test, and variable transformations
were used when necessary to normalize the data.
Categorical variables were compared using Chi-
squared tests. Anaemia was dened as haemoglobin
ARTICLE IN PRESS
Malnutrition and morbidity in children without vitamin A supplementation 373
o11 g/dl, according to World Health Organization
criteria.
19
Population-based weighting was used to
account for differences in population size of the
various provinces, and population-weighted results
are reported.
Results
The study population included 138,956 children,
aged 1259 months, of whom 87,675 (63.1%) had
received a vitamin A capsule within the last 6
months. Non-respondents accounted for only 612
children (0.4%). Table 1 shows the demographic and
other characteristics of children who did and who
did not receive vitamin A supplementation. Chil-
dren who did not receive a vitamin A capsule were
signicantly more likely to be younger, male, have
WAZ and HAZo2, have WAZ, HAZ and WHZ o3,
have fever on the survey day, have diarrhoea on the
survey day, have a history of diarrhoea in the
previous week, and have anaemia compared with
children who received a vitamin A capsule. Children
who did not receive vitamin A supplementation
were signicantly more likely to have mothers who
were younger and less educated and fathers who
were less educated. The mean distance and time to
walk from the house to the posyandu were
signicantly higher for children who did not receive
a vitamin A capsule compared with children who
did receive a vitamin A capsule.
Childhood immunization coverage was compared
for children who did and did not receive vitamin A
supplementation (Table 2). Children who did not
receive a vitamin A capsule were signicantly
less likely to receive the rst, second and
third DPT immunization, the rst, second, and
third OPV immunization, and measles immuniza-
tion. A history of child mortality was compared in
households where the children did or did not
receive vitamin A supplementation (Fig. 1). In
households where the child did not receive a
vitamin A capsule, the proportions of deaths before
1 month of age, before 12 months of age and before
5 years of age were signicantly higher than in
households where the child received a vitamin A
capsule.
The general reasons given for not visiting the
posyandu are shown in Table 3. The ve main
reasons were that the child was afraid of being
weighed, that the parents usually took the child to
other health facilities, that the family had just
moved to the survey area, that the health post was
not active, and that they thought the child was too
old to attend the posyandu.
Discussion
The vitamin A capsule supplementation programme
in Indonesia has proved to be highly effective over
the last 25 years in decreasing rates of severe
vitamin A deciency and increasing overall cover-
age rates.
6,10
However, these results, based on the
most recent data from the NSS conducted in
Indonesia, show that the programme may not be
reaching the children who are at highest risk for
malnutrition and infectious disease morbidity in
urban Indonesia. The evidence shows that in urban
slum areas, children, aged 1259 months, who had
not received vitamin A supplementation in the
previous 6 months were at greater risk of under-
weight, stunting and severe wasting. They were
also more likely to be anaemic and to have higher
rates of diarrhoea on the survey day, fever on the
survey day and a history of diarrhoea in the
previous week than children who had received
vitamin A supplementation. In addition, children
who did not receive vitamin A were more likely to
be more severely underweight, stunted and wasted
(Z scores o3) compared with children who did
receive vitamin A. The difference in value of the
above indicators between children who did and did
not receive vitamin A supplementation was not
exceptionally large and the statistical signicance
of these variables was probably inuenced by the
large sample size of the study. Nevertheless,
consistent differences in anthropometric and
health characteristics in both real and statistically
signicant terms offer compelling evidence that
the children who were not reached by the vitamin A
programme were at much greater risk for malnutri-
tion and morbidity.
This analysis also shows that children who did not
receive vitamin A capsules were less likely to
receive DPT, OPV and measles vaccine, thereby
placing them at higher risk for infectious disease
morbidity and mortality from vaccine-preventable
diseases. Lack of vaccine protection as well as lack
of vitamin A supplementation may place children at
especially high risk, especially with regards to
measles. Vitamin A deciency is known to increase
the risk of measles morbidity and measles-related
pneumonia, blindness and mortality. These ndings
suggest that children who are not reached by the
vitamin A programme are unlikely to benet from
other primary care and preventive care pro-
grammes. It is clear that efforts to increase
participation in vitamin A programmes should also
emphasize participation in childhood immunization
and other primary care programmes.
Barriers to access were also examined. Mothers
reported the childs fear of getting weighed and use
ARTICLE IN PRESS
S.G. Berger et al. 374
ARTICLE IN PRESS
Table 1 Demographic and health characteristics of children, aged 1259 months, who did and did not receive a
vitamin A capsule.
Characteristic N Did not
receive
vitamin A
N Received
vitamin A
P
Child age (months) (%)
1223 19,516 38.1 31,073 35.4 0.0001
2435 14,248 27.8 26,649 30.4
3647 10,509 20.5 19,039 21.7
4859 7010 13.7 10,913 12.4
Gender, % male 27,210 53.1 44,749 51.0 0.0001
Maternal age (years) (%)
p24 9435 18.5 14,391 16.4 0.0001
2528 13,115 25.7 22,612 25.8
2932 14,465 28.3 26,427 30.2
X33 14,085 27.6 24,120 27.5
Maternal education (years) (%)
06 28,447 55.7 40,452 46.3 0.0001
79 11,339 22.2 21,418 24.5
X10 11,302 22.1 25,576 29.2
Paternal education (years) (%)
06 20,902 42.1 29,588 34.6 0.0001
79 12,556 25.3 21,325 24.9
X10 16,204 32.6 34,648 40.5
Number of children o5 years in household
1 23,944 72.2 55,564 78.5 0.0001
2 8486 25.6 14,344 20.3
3 688 2.1 797 1.1
4+ 45 0.1 73 0.1
Year in which interview was conducted
1999 17,456 34.0 16,012 18.3 0.0001
2000 18,930 36.9 28,251 32.2
2001 8833 17.2 16,676 19.0
2002 3710 7.2 15,026 17.1
2003 2353 4.6 11,711 13.4
Weight-for-age Z (WAZ) score (%)
WAZ o2 21,986 43.2 37,016 42.5 0.012
WAZ o3 4371 8.6 6791 7.8 0.0001
Height-for-age Z (HAZ) score (%)
HAZ o2 19,345 38.3 31,589 36.4 0.0001
HAZ o3 5399 10.7 8149 9.4 0.0001
Weight-for-height Z (WHZ) score (%)
WHZ o2 5786 11.4 9805 11.3 0.541
WHZ o3 603 1.2 873 1.0 0.002
MUAC o125 mm (%) 1642 3.2 2705 3.1 0.237
Diarrhoea on survey day (%) 3246 6.3 4534 5.2 0.0001
Fever on survey day (%) 1427 2.8 1618 1.9 0.0001
Diarrhoea last week (%) 5448 10.7 7036 8.1 0.0001
Anaemic (%) 5788 56.2 9622 53.9 0.0001
Distance to the posyandu
Metres
a
50,710 264.5 86,279 78.7 0.0001
(259.2270.9) (77.879.5)
Minutes
a
35,204 5.11 82,508 4.66 0.0001
(5.075.15) (4.644.69)
MUAC, mid-upper arm circumference.
a
Geometric mean (95% condence intervals).
Malnutrition and morbidity in children without vitamin A supplementation 375
of other health facilities as the main reasons why
their children did not participate in the national
vitamin A capsule programme. Other major reasons
given were that the family had moved to the area
recently and the posyandus were not active. Less
than 2% of respondents cited distance to the health
post as a reason for non-participation. Most reasons
given by the mothers suggested a lack of knowledge
about the health benets of vitamin A. Other
studies in Indonesia have shown that limited
knowledge of the importance of vitamin A is
associated with lower rates of participation in the
national vitamin A programme.
13,20
In addition, it is
clear that general lack of access to health posts,
and thus to primary care, is likely to be an
additional determinant of the increased morbidity
among children who are not reached by the vitamin
A capsule programme.
Two studies from the Philippines and Indonesia
examined the characteristics of children who did
and did not participate in vitamin A supplementa-
tion programmes. However, these studies focused
mainly on socio-economic and family characteris-
tics.
12,13
Another recent study from Bangladesh
ARTICLE IN PRESS
Table 2 Relationship of vitamin A capsule receipt with childhood vaccinations.
Characteristic N Did not
receive
vitamin A
N Received
vitamin A
P
DPT vaccine dose 1
Received, with record 7710 23.5 28,683 40.7 0.0001
Received, no record 18,309 55.8 36,439 51.7
Not received 6402 19.5 5188 7.4
Does not know 418 1.2 232 0.3
DPT vaccine dose 2
Received, with record 7072 21.5 27,579 39.1 0.0001
Received, no record 17,043 51.9 35,070 49.7
Not received 8284 25.2 7652 10.8
Does not know 448 1.3 253 0.4
DPT vaccine dose 3
Received, with record 6582 20.0 26,482 37.6 0.0001
Received, no record 16,044 48.9 33,784 47.9
Not received 9716 29.6 9868 14.0
Does not know 482 1.5 329 0.4
OPV vaccine dose 1
Received, with record 7949 24.2 29,122 41.3 0.0001
Received, no record 18,325 55.8 36,493 51.8
Not received 6235 19.0 4646 6.6
Does not know 330 1.0 233 0.3
OPV vaccine dose 2
Received, with record 7480 22.8 28,372 40.2 0.0001
Received, no record 17,210 52.4 35,355 50.1
Not received 7790 23.7 6520 9.2
Does not know 371 1.1 252 0.3
OPV vaccine dose 3
Received, with record 6993 21.3 27,392 38.9 0.0001
Received, no record 16,294 49.6 34,303 48.7
Not received 9161 27.9 8515 12.1
Does not know 398 1.2 273 0.4
Measles vaccine
Received, with record 5972 18.2 24,809 35.2 0.0001
Received, no record 14,294 43.5 31,737 45.0
Not received 12,030 36.6 13,401 19.0
Does not know 530 1.6 504 0.7
DPT, diphtheria-pertussis-tetanus; OPV, oral poliovirus vaccine.
S.G. Berger et al. 376
described disparities in vitamin A supplementation
among ethnic minorities in Bangladesh.
21
To the
authors knowledge, the present study is the rst to
examine the health and nutritional characteristics
of children who are not reached by a vitamin A
capsule supplementation programme. In addition,
the study highlights that the programme coverage
rate among children aged 1259 months living in
urban slum areas was 63.1%, falling below the
Indonesian Governments target coverage rate of
80%
10
and below the World Banks recommendation
of 85%.
8
These ndings suggest that strategies need
to be developed to reach children who do not
receive vitamin A supplementation and basic
primary preventive care programmes in Indonesia.
The study also emphasizes the substantial impact of
formal maternal and paternal education on vitamin
A supplementation in children. Further investiga-
tion is necessary to determine how coverage rates
of vitamin A supplementation may be increased
through improvements in formal and nutrition
education among parents and primary caregivers.
The International Vitamin A Consultative Group
(IVACG) recently suggested that vitamin A de-
ciency may affect a disproportionate number of the
poor who are also least likely to access public
health services.
8
IVACG recommended that vitamin
A supplementation should achieve coverage over
80%, acknowledging that the averted morbidity and
mortality would probably be greatest among the
lowest one-fth of the population.
22
Little quanti-
tative data have been available regarding those
who are not reached, and the study ndings conrm
that non-participants in urban areas suffer poorer
nutritional status and higher morbidity than parti-
cipants in the vitamin A capsule programme.
Periodic high-dose vitamin A supplementation
remains one of the most cost-effective means of
reducing child mortality in developing countries,
and unless coverage is expanded to reach the
children in greatest need, the international com-
munity will fall short of reaching the Millennium
Development Goals for reducing child mortality by
two-thirds between 1990 and 2015.
3,23
Ethical approval
Medical Ethical Committee of the Ministry of
Health, Government of Indonesia; plan for second-
ary data analysis reviewed by Johns Hopkins School
of Medicine Medical Institutional Review Board and
granted an exemption on 14 July 2006 under the US
Department of Health and Human Services 45, Code
of Federal Regulations 46.404.
Funding
Lew R. Wasserman Award from Research to Prevent
Blindness.
Competing interests
None declared.
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Table 3 Reasons given for not taking children to the
health post (posyandu).
Reason n %
Child afraid of being weighed 14,039 36.4
Usually take child to another
health facility 5319 13.8
Just moved to survey area 2525 6.5
Health clinic not active 2376 6.2
Child is too old 1879 4.9
Mother is too busy 1124 2.9
Do not know schedule 1057 2.7
Health clinic too far away 661 1.7
Immunizations are complete 552 1.4
Need to pay 118 0.3
Child is too young 94 0.2
Child is weighed at home 57 0.1
No food supplementation programme 42 0.1
Other reasons 8727 22.6
0
1
2
3
4
5
6
7
8
9
10
Infant Died <1 Month Infant Died <12
Months
Child Died <5 Years
No capsule
Capsule
*
*
*
%
Figure 1 History of infant dying before 1 month of age,
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Malnutrition and morbidity in children without vitamin A supplementation 377
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