Journal of Epidemiology and Global Health (2014) 4 169ndash176

http wwwelsev ier com locate

Coverage of vitamin A supplementationand deworming duringMalezi Bora in Kenya

2210-6006$ - see front matter ordf 2014 Ministry of Health Saudi Arabia Published by Elsevier Ltd All rights reservedhttpdxdoiorg101016jjegh201312005

Corresponding author Address Helen Keller International Africa Regional Office PO Box 13904-00800 Nairobi Keny+254 704 834 426

E-mail addresses palomacclohosseygmailcom (PC Clohossey) hkatcherhkiorg (HI Katcher) joruru(GO Mogonchi) mnyamwesiyahoocom (N Nyagoha) marissasoohoogmailcom (MC Isidro) kikechieveyah(E Kikechi) eonyangohkiorg (EEV Okoth) jblankenshiphkiorg (JL Blankenship)

jegh

Paloma C Clohossey a Heather I Katcher a Geoffrey O Mogonchi aNancy Nyagoha a Marissa C Isidro a Evelyn Kikechi bEdgar EV Okoth a Jessica L Blankenship a

a Helen Keller International PO Box 13904-00800 Nairobi Kenyab Ministry of Public Health and Sanitation Department of Nutrition PO Box 30016-00100 Nairobi Kenya

Received 27 August 2013 received in revised form 20 December 2013 accepted 28 December 2013Available online 6 February 2014

KEYWORDSVitamin ADewormingMalezi BoraChild health daysKenya

Abstract Twice-yearly child health weeks are an effective way of reaching chil-dren with essential child survival services in developing countries In Kenya childhealth weeks or Malezi Bora were restructured in 2007 from an outreach-baseddelivery structure to a health facility-based delivery structure to reduce deliverycosts and increase sustainability of the events Administrative data from 2007 to2011 have demonstrated a decrease in coverage of Malezi Bora services to targetedchildren A post-event coverage (PEC) survey was conducted after the May 2012Malezi Bora to validate coverage of vitamin A supplementation (VAS) and dewormingand to inform program strategy Nine hundred caregivers with children aged 6ndash59 months were interviewed using a randomized 30 middot 30 cluster design For eachcluster one facility-based health worker and one community-based health workerwere also interviewed Coverage of VAS was 310 among children aged 6ndash59 months and coverage of deworming was 196 among children aged 12ndash59 months Coverage of VAS was significantly higher for children aged 6ndash11 months(457 n = 116) than for children aged 12ndash59 months (288 n = 772) (p lt 001)Eighty-five percent (5160) of health workers reported that Malezi Bora was imple-mented in their area while 236 of primary caregivers reported that Malezi Boraoccurred in their area The results of this PEC survey indicate that the existing Male-zi Bora programmatic structure needs to be reviewed and reformed to meet WHOguidelines of 80 coverage with VASordf 2014 Ministry of Health Saudi Arabia Published by Elsevier Ltd All rightsreserved

a Tel

hkiorgoocom

170 PC Clohossey et al

1 Introduction

Vitamin A supplementation (VAS) is a widely recog-nized high-impact and cost-effective interventionfor increasing child survival [1] The World HealthOrganization recommends twice-yearly VAS inareas where vitamin A deficiency (VAD) is a publichealth concern to reduce all-cause mortality inchildren aged 6ndash59 months Robust evidence fromrandomized controlled trials has shown twice-yearly VAS can reduce all-cause mortality by 24in children 6ndash59 months of age [2] Twice-yearlydelivery of VAS through integrated Child HealthDays (CHDs) is an effective method for reachinghigh and equitable coverage of child survival inter-ventions including VAS

Throughout sub-Saharan Africa implementationof twice-yearly CHDs has been a common strategyto address the challenge of rising coverage ratesof key child survival interventions and decreasingchild mortality in a cost-effective way particularlyin areas with poor infrastructure [3] CHDs deliver apackage of high-impact child survival interventionsthat may include vitamin A supplementation(VAS) deworming immunizations and insecticide-treated mosquito nets Door-to-door distributionis effective at achieving high coverage howeverthis distribution strategy can be costly in bothmoney and human resources and alternativestrategies may be considered if funds and staffare not available [4]

In Kenya VAS and deworming services were ini-tially delivered through outreach-based twice-yearly child health campaigns with VAS coveragefrom administrative data reaching a high of 93in 2006 [5] In 2007 Kenyas child health campaignswere renamed Malezi Bora and restructured with ahealth facility-based delivery system rather thanthe previous outreach-based (door-to-door) systemin an effort to reduce implementation costs Whilethe change in delivery structure for VAS and dewor-ming reduced overall implementation costs thechange had an immediate impact on coverage withadministrative data showing only 22 coverage ofVAS in 2007 [5]

Administrative data from 2009ndash2012 indicatethat VAS coverage from Malezi Bora has steadily in-creased but coverage remains below the WorldHealth Organization (WHO) recommended 80 toreduce child mortality [1] During this period theincrease in coverage has been attributed to in-creased communication efforts surrounding MaleziBora and targeted additional distribution throughEarly Child Development Centers (ECD) to reachchildren 3ndash5 years of age

A Demographic and Health (DHS) Survey con-ducted in 2009 found coverage of VAS to be signif-icantly less than that reported throughadministrative coverage (303 vs 750 respec-tively) [6] The differences in reported coverageof the DHS and administrative data may be due tothe longer recall period for the DHS inaccuratetargeted population numbers andor errorsrecording or tallying administrative data [7]

To validate administrative data for receipt ofVAS and deworming through Malezi Bora withinan acceptable recall period a post-event coverage(PEC) survey was conducted after the May 2012Malezi Bora Secondary objectives of the surveywere to determine factors associated with VASand deworming receipt and evaluate caregiverand health worker knowledge of VAS to inform pro-gram strategy

2 Materials and methods

A PEC survey was conducted in non-arid and non-semi-arid lands (non-ASAL) of Kenya following theMay 2012 Malezi Bora in which deworming cap-sules were distributed to children 12ndash59 monthsold and VAS was distributed to children6ndash59 months old (100000 IU for children 6ndash11 months old and 200000 IU for children 12ndash59 months old) Non-ASAL areas comprise only20 of Kenyas landmass but hold 75 of the Ken-yan population and include the countrys capitalcity Nairobi [8] Data collection took place in June2012 within six weeks of the May 2012 MaleziBora to ensure accurate recall of services re-ceived Arid and semi-arid regions of Kenya wereexcluded due to a blanket supplementary feedingprogram in those areas through which VAS was dis-tributed monthly Applying standardized WHOImmunization Coverage Cluster Survey methodol-ogy [9] 30 clusters were randomly selected usingprobability proportionate to size (PPS) samplingand 2009 Kenya National Census data [10] Becausecensus data were only available at the sub-locationlevel clusters were selected at the sub-locationlevel according to census enumeration areas anda village was selected at random in each sub-location

In each cluster interviews were conducted with30 primary caregivers of children aged 6ndash59 months at the time of the May 2012 Malezi BoraHouseholds were randomly selected by identifyinga central starting point in the cluster (church mos-que communal center etc) spinning a pen todetermine a direction counting the number ofhouses from the starting point to the boundary of

Coverage of vitamin A supplementation and deworming during Malezi Bora in Kenya 171

the cluster in the determined direction and using arandom number table to select the starting house-hold from those households counted Householdswere eligible if there was a child residing in thehousehold who was 6ndash59 months of age at the timeof the May 2012 Malezi Bora and their primarycaregiver was present If there were multiple eligi-ble children in a household one child was randomlyselected by writing the names of each eligible childon separate slips of paper and selecting one at ran-dom If a primary caregiver was not present theirlocation was requested and the caretaker was vis-ited when possible If the caretaker was not inproximity the house was skipped due to time con-straints Informed oral consent was obtained fromeach caregiver interviewed

After completing the first interview enumera-tors proceeded to the next nearest house in thedetermined direction and so forth until 30 inter-views were completed Enumerators conductedsurveys in teams of two to ensure data qualityTeam leaders supervised each enumerator teamat a minimum of five interviews per cluster enter-ing responses on a second survey form and compar-ing them with enumerators responses as anadditional data assurance measure Each team car-ried deworming tablets and vitamin A capsules indosages of 50000 100000 and 200000 IU thatwere shown to caregivers to assist with recall ofservice uptake

In each cluster one community-based healthworker (community health extension worker[CHEW] or public health technician [PHT]) andone facility-based health worker (nurse clinicalofficer or nutritionist) were interviewed using con-venience sampling Criteria for selection includedworking within the selected cluster in their respec-tive field and participation in the May 2012 MaleziBora event Survey tools for both health workersand primary caretakers were structured to allowrespondents to indicate multiple responses for rel-evant questions For example when measuring pri-mary caretaker knowledge of vitamin A allresponses mentioned were recorded

21 Statistical analysis

In total 900 primary caregivers 30 facility-basedhealth workers and 30 community-based healthworkers were interviewed Of the 900 caregiversinterviewed the responses of 12 caregivers wereexcluded because their child was later determinedto be younger than six months or older than59 months at the time of Malezi Bora Due to theexclusion of these caregiver surveys certain clus-ters were represented by fewer caregivers in the

analysis To adjust for this under-representationa weight was derived for each cluster based onthe number of eligible survey forms and theseweights were used to conduct all analyses Forexample if in one cluster there were two caregiv-ers with children who were below or above the ac-cepted age range the weight used for the saidcluster was 3028 or 107

All data were entered using double data entryinto an Epi Info database compared for errorsand corrected as necessary by reviewing the origi-nal survey form Areas were categorized as urbanor rural according to their designation by the KenyaNational Bureau of Statistics Analysis was doneusing SPSS Version 20 (IBM USA) with a p-valueof lt005 considered significant In order to testfor associations Chi-square tests were conductedfor categorical variables A logistic regression anal-ysis was performed with variables showing signifi-cant associations with VAS coverage to determinethe extent of the relationship between each factorand VAS

3 Results

31 Demographic characteristics

Demographic characteristics of the caregivers andchildren surveyed are listed in Table 1 The major-ity (816) of caregivers were the selected childsmother with most (796) residing in rural areasApproximately half (455) of caregivers inter-viewed with children 3ndash5 years of age reportedthat their child did not attend an Early ChildhoodDevelopment (ECD) program even though theywere eligible for attendance

32 Vitamin A and deworming coverageduring Malezi Bora

Coverage of VAS was 310 among children aged 6ndash59 months and coverage of deworming was 196among children aged 12ndash59 months during theMay 2012 Malezi Bora (Fig 1) Coverage of VASfor children aged 6ndash11 months (456 n = 117)was significantly higher than for children aged12ndash59 months (288 n = 783) (p lt 001) Healthfacilities and dispensaries (457) were the mostfrequently reported locations of VAS delivery dur-ing Malezi Bora with VAS also received at thehome (389) at district hospitals (91) mobilehealth posts (40) and ECD (11) The primaryreasons that caregivers cited for not attendingMalezi Bora were not having heard of the event(584) and not having anyone available to takethe child (53) (Fig 2)

Table 1 Demographic characteristics of childrenselected as the focus of the interviews and their primarycaregivers

Variable n ()

Area typeRural 717 (796)Non rural 183 (204)Sex of the childMale 457 (508)Female 443 (492)

Child attends Early ChildhoodDevelopment (ECD) program

Yes 204 (545)No 171 (455)

Relationship of caregiver with childMother 734 (816)Grandmother 67 (74)Father 46 (52)Aunt 23 (26)Sibling 7 (08)Nannyhouse help 8 (09)Other relative 12 (13)

Highest level of schooling received by caregiverNone 55 (61)Primary education 560 (623)Secondary education 248 (275)University education 3 (03)College education 34 (38) Children P3 years (n = 375)

172 PC Clohossey et al

33 Malezi Bora implementation andawareness

Ninety percent of facility-based health workers and800 of community-based health workers reportedthat Malezi Bora was implemented in their areawhile only one quarter of primary caregivers(236) reported that Malezi Bora or a child health

Figure 1 Coverage of VAS to children aged 6ndash59 months amay 2012 Malezi Bora

event took place in their area in the previous twomonths Caregivers most frequently attributedtheir awareness of Malezi Bora to facility-basedhealth workers (387) radio (139) communityhealth workers (115) word of mouth (98) andcommunity leaders (98)

34 Knowledge of vitamin A

The majority of caregivers interviewed (858) hadheard of vitamin A When asked about the benefitsof VAS 267 of caregivers responded that it pro-tects against diseases 208 said it improves childhealth and one caregiver responded that it re-duces mortality (Table 2) Less than a quarter ofcaregivers knew the correct age when VAS shouldfirst be administered (221) or that childrenshould be supplemented every six months (182)

Among health workers VAS was most commonlyassociated with preventing disease and preventingblindness Very few health workers (67) recalledthat VAS reduces mortality in children

35 Health-seeking behaviors and healthcommunications

When caregivers were asked where they seekhealth services most regularly and for what rea-sons 900 of caregivers reported that they seekhealth services at government dispensaries healthfacilities or hospitals regardless of the age group(6ndash11 months vs 12ndash59 months) of their child Al-most all caregivers (964) stated that they seekhealth services when their child is sick while447 of caregivers reported that they also seekhealth services for routine visits andor immuniza-tions When stratified by age the results showedthat a significantly higher proportion of caregiverswith younger children (6ndash11 months old) tend toseek health services for routine visits andor immu-nizations (p lt 0001)

nd deworming to children aged 12ndash59 months during the

10

14

29

29

31

34

37

39

44

53

584

000 1000 2000 3000 4000 5000 6000 7000

Child was ill

Child already received vitamin A

Health facility did not have capsules

Journey was too farexpensive

Child was out of the area

Other

Too much work at home

Child finished immunizaons

Did not take child to clinic

No one available to take child

Caretaker did not hear of the event

Percent

Figure 2 Reasons reported by caregivers why children did not attend the May 2012 Malezi Bora Multiple responseswere accepted

Coverage of vitamin A supplementation and deworming during Malezi Bora in Kenya 173

36 Predictors of vas and dewormingservice uptake

Statistical analysis revealed that the recipientchilds age group (6ndash11 months and 12ndash59 months) the place where caregivers seek healthservices (district hospital versus other health insti-tutions) and methods of getting health informa-tion (through community leaders versus othermethods) are significant predictors of VAS uptakeAs shown in Table 2 after controlling for the placewhere caregivers seek health services and methodsof getting health information children aged 6ndash11 months had twice the odds of receiving VAScompared with children 12ndash59 months of age(OR = 21 p lt 001) For caregivers who regularlyseek health services in a district hospital the oddsof their children receiving VAS were 061 times(OR = 061 p lt 001) the odds of those who seekhealth services in other institutions with all otherfactors being equal After controlling for childsage and place where caregivers seek health ser-vices those caregivers getting health informationfrom their community leaders had an estimated15 times (OR = 15 p lt 005) the odds of their chil-dren receiving VAS compared with those who gethealth information from other sources

4 Discussion

Vitamin A and deworming coverage during the May2012 Malezi Bora was significantly lower than WHOrecommendations with coverage of 310 for VASand 196 for deworming which is consistent withVAS coverage measured by the 2009 DHS AccordingtoWHO and UNICEF recommendations twice-yearlyVAS coverage of at least 80 is necessary to signifi-cantly increase child survival among children aged6ndash59 months [11] Based on a 24 reduction in childmortality with universal VAS coverage an estimated16413 lives could be saved per year if universal VAScoverage is achieved in Kenya for children aged 6ndash59 months of age [HKI unpublished methodology]

Results from the current PEC survey suggest thatlow VAS and deworming coverage in Kenya is attrib-uted to lack of caregivers awareness of MaleziBora minimal knowledge of VAS as a major childsurvival intervention and low attendance of chil-dren over 12 months in health facilities for routineservice delivery Both caregiver awareness and lowhealth facility attendance need to be addressed insubsequent Malezi Bora events to increase cover-age of VAS and deworming service delivery

Low awareness of Malezi Bora among caregiversis attributed to inadequate communication of

Table 2 Caregiver community-based and facility-based health worker knowledge of vitamin A supplementation

Variable Caregivers (n = 900) Community-BasedHWs (n = 30)

Facility-basedHWs (n = 30)

n () n () n ()

Benefits of vitamin A

Protects against disease 241 (267) 22 (733) 25 (833)Improves child health 188 (208) 6 (200) 4 (133)Helps with growthbody building 114 (127) 14 (467) 10 (333)Increases appetite 89 (99) 3 (100) 1 (33)Increases energy 55 (61) 1 (33) 0 (00)Prevents blindnesshelps vision 52 (58) 22 (733) 28 (933)Reduces risk of death 1 (01) 0 (00) 2 (67)Does not knowremember 278 (310) 0 (00) 0 (00)Other 43 (47) 4 (133) 5 (167)

Age for first administration of vitamin AAt birth 63 (70) 0 (0) 2 (67)6 months 198 (221) 24 (800) 26 (867)9 months 38 (42) 0 (00) 1 (33)Do not know 189 (210) 2 (67) 0 (00)Other 284 (316) 4 (133) 1 (33)

How often children should receive vitamin AAt each Malezi Bora 2 (02) 0 (00) 0 (00)Every six months 163 (182) 24 (800) 27 (900)Does not know 254 (283) 2 (67) 0 (00)Other 350 (389) 4 (133) 3 (100)

Vitamin A dosage for children 6ndash11 months

One blue capsule (100000 IU) NA NA 27 (900)Half of a red capsule NA NA 8 (267)One red capsule (200000 IU) NA NA 1 (33)Do not know NA NA 0 (00)Other NA NA 1 (33)Vitamin A dosage for children 12ndash59 monthsOne blue capsule (100000 IU) NA NA 2 (67)One red capsule (200000 IU) NA NA 27 (900)Do not know NA NA 0 (00)Other NA NA 0 (00) Multiple responses were accepted

174 PC Clohossey et al

Malezi Bora activities Only 236 of caregivers re-called Malezi Bora being implemented and of care-givers whose children did not receive VAS 584stated that they had never heard that Malezi Borahad taken place In the current Malezi Bora com-munication platform interpersonal communicationmethods from health workers members in thecommunity and community leaders were the mosteffective in reaching caregivers and increasingtheir awareness Additional social mobilizationand communication activities such as radio spotsposters and banners were rarely mentioned bycaregivers as sources of information on MaleziBora Increasing awareness of Malezi Bora througheffective communication methods such as inter-personal communication is recommended to in-

crease awareness and demand of Malezi Boraservices in subsequent rounds

Survey results indicate increased outreach maybe necessary to deliverMalezi Bora services Nearlyhalf of caregivers communicated that they only taketheir child to a health facility if their child is sickwhich may explain in part why the majority of care-givers did not bring their children to the health facil-ity to receive Malezi Bora services To make thereceipt of Malezi Bora services more convenientand to increase coverage to populations with pooraccess to health facilities alternate distributionsites and methods may need to be considered

Among the target population children aged6ndash11 months have twice the odds as children12ndash59 months of age to receive VAS This finding

Coverage of vitamin A supplementation and deworming during Malezi Bora in Kenya 175

is consistent with the 2009 Kenya DHS whichshowed that coverage of VAS was more than twotimes higher among children 9ndash11 months old com-pared with children 24ndash59 months old [6] Highercoverage of younger children can be explainedthrough (1) caregivers of younger children beingmore likely to visit health facilities because theyare regularly coming for routine visits and (2)younger children being more likely to be homeand available to attend Malezi Bora compared witholder children who are in school

The current outreach strategy to distributeMalezi Bora services through ECD centers may notbe the most effective method of outreach as thecurrent data suggest that ECD attendance is poorand that ECD distribution often does not occurdue to lack of funding or poor planning With poorattendance of children 3ndash5 years of age in ECD pro-grams [12] additional outreach systems for MaleziBora are needed to reach older children

One potential platform to reach older children isduring the second dose ofmeasles vaccination deliv-ered at 18 months which is planned to be intro-duced into the EPI calendar The second dose ofmeasles would bring children below 2 years of ageto the health center but would not address low cov-erage of VAS among children older than 2 years ofage Vitamin A supplementation is frequently inte-grated with polio and measles campaigns whichachieves high coverage Unfortunately polio cam-paigns are infrequent and only occur when there isan outbreak andmeasles campaigns only take placeevery 3ndash5 years Therefore integration into themeasles and polio campaigns is not a sustainablemethod to deliver VAS

Targeted delivery and communication strategiesare needed to increase coverage of VAS and dewor-ming during Malezi Bora and raise awareness ofMalezi Bora among caregivers and the wider com-munity In addition to health facility based deliveryof services a community-based approach utilizingcommunity health workers (CHW)may bewarrantedgiven that caregivers generally do not visit healthfacilities after their child turns one year aside fromwhen their child is sick A community outreach strat-egywould ideally utilize the existing systemof CHWsand CHEWs to increase awareness of the communityprior to Malezi Bora and to deliver VAS and dewor-ming at the community level during Malezi Bora Inaddition it is recommended that targeted outreachofMalezi Bora services should be expanded from theexisting ECD or school-based distribution to increasecoverage among children 3ndash5 years old

The recommendation to deliver VAS through acommunity outreach strategy is aligned with the

WHO Reaching Every District (RED) strategy whichadvocates for strengthening the linkage betweencommunities and services via CHW and re-estab-lishing outreach services to improve service deliv-ery in distant communities [13] All deliverystrategies would need to be complimented by astrong and effective communication strategy to in-crease awareness of Malezi Bora in the communityand create demand for Malezi Bora services amongcaregivers

Limitations to this study include time con-straints to complete the survey (one cluster perday per survey team) and reliance on caretaker re-call Population data were not available at the vil-lage level and thus a village was selected atrandom in each cluster to identify the first house-hold to be visited in a cluster This studys strengthsinclude data collection within six weeks of servicedelivery and multiple methods were applied to en-sure data quality In order to ensure data qualityexperienced enumerators were selected and enu-merators were required to work in pairs Duringdata collection correct recording of responseswas confirmed by supervisors who completed se-lected surveys in duplicate and double data entrywas practiced

5 Conclusion

The low coverage of VAS and deworming in Kenyaduring Malezi Bora indicate that the existing MaleziBora programmatic structure needs to be examinedand reformed to meet its original objectives atinception and address key challenges to service up-take demonstrated in these survey findings Imple-mentation of immediate changes to address poorcoverage is critical to achieve necessary levelsfor improving child survival and decrease the inci-dence of child morbidity and mortality

6 Contributions

NN HIK and JLB conceived the study PCC NNHIK and JLB supported the implementation andtrained the surveyors GOM and MCI conductedthe data analysis with support from HIK and JLBPC drafted the manuscript and JLB and HIK revisedthe manuscript All authors reviewed and approvedthe final manuscript

7 Funding

This study was made possible by the generous sup-port of the Canadian International DevelopmentAgency (CIDA) The contents are the responsibility

176 PC Clohossey et al

of the authors and do not necessarily reflect theviews of CIDA or the Canadian Government

8 Conflicts of interest

None declared

References

[1] Sommer A Tarwotjo I Djunaedi E et al Impact of vitaminA supplementation on childhood mortality A randomisedcontrolled community trial Lancet 19861(8491)1169ndash73

[2] Mayo-Wilson E Imdad A Herzer K et al Vitamin Asupplements for preventing mortality illness and blind-ness in children aged under 5 systematic review and meta-analysis BMJ 2011343d5094 httpdxdoiorg101136bmjd5094|

[3] UNICEF Multi-country evaluation of child health days inEastern and Southern Africa 2008

[4] Routh S el Arifeen S Jahan SA et al Coping with changingconditions alternative strategies for the delivery ofmaternal and child health and family planning services inDhaka Bangladesh Bull World Health Organ 200179(2)142ndash9

[5] Department of Nutrition data 2006ndash2011 Ministry of PublicHealth and Sanitation Kenya

[6] Kenya National Bureau of Statistics and ICF Macro Kenyademographic and health survey 2008ndash09 In Macro KaIeditor Calverton Maryland KNBS and ICF Macro 2010

[7] Murray CJ Shengelia B Gupta N et al Validity ofreported vaccination coverage in 45 countries Lancet2003362(9389)1022ndash7 httpdxdoiorg101016S0140-6736(03)14411-X

[8] Arid Lands Resource Management Program Arid and SemiArid Lands (ASAL) national vision and strategy Pricewater-houseCoopers 2005 [2005ndash15]

[9] World Health Organization Immunization Coverage ClusterSurvey ndash Reference Manual 2005

[10] Kenya National Bureau of Statistics Kenya National Census2009

[11] Ross DA Recommendations for vitamin A supplementationJ Nutri 2002132(Suppl 9)2902Sndash6S

[12] Ministry of Education RoK Policy framework for educationaligning education and training to the constitution ofKenya April 2012

[13] World Health Organization Evaluation of RED strategyimplementation in the Africa region June 2005

ScienceDirectAvailable online at wwwsciencedirectcom

Table 1 Demographic characteristics of childrenselected as the focus of the interviews and their primarycaregivers

Variable n ()

Area typeRural 717 (796)Non rural 183 (204)Sex of the childMale 457 (508)Female 443 (492)

Child attends Early ChildhoodDevelopment (ECD) program

Yes 204 (545)No 171 (455)

Relationship of caregiver with childMother 734 (816)Grandmother 67 (74)Father 46 (52)Aunt 23 (26)Sibling 7 (08)Nannyhouse help 8 (09)Other relative 12 (13)

Highest level of schooling received by caregiverNone 55 (61)Primary education 560 (623)Secondary education 248 (275)University education 3 (03)College education 34 (38) Children P3 years (n = 375)

172 PC Clohossey et al

33 Malezi Bora implementation andawareness

Ninety percent of facility-based health workers and800 of community-based health workers reportedthat Malezi Bora was implemented in their areawhile only one quarter of primary caregivers(236) reported that Malezi Bora or a child health

Figure 1 Coverage of VAS to children aged 6ndash59 months amay 2012 Malezi Bora

event took place in their area in the previous twomonths Caregivers most frequently attributedtheir awareness of Malezi Bora to facility-basedhealth workers (387) radio (139) communityhealth workers (115) word of mouth (98) andcommunity leaders (98)

34 Knowledge of vitamin A

The majority of caregivers interviewed (858) hadheard of vitamin A When asked about the benefitsof VAS 267 of caregivers responded that it pro-tects against diseases 208 said it improves childhealth and one caregiver responded that it re-duces mortality (Table 2) Less than a quarter ofcaregivers knew the correct age when VAS shouldfirst be administered (221) or that childrenshould be supplemented every six months (182)

Among health workers VAS was most commonlyassociated with preventing disease and preventingblindness Very few health workers (67) recalledthat VAS reduces mortality in children

35 Health-seeking behaviors and healthcommunications

When caregivers were asked where they seekhealth services most regularly and for what rea-sons 900 of caregivers reported that they seekhealth services at government dispensaries healthfacilities or hospitals regardless of the age group(6ndash11 months vs 12ndash59 months) of their child Al-most all caregivers (964) stated that they seekhealth services when their child is sick while447 of caregivers reported that they also seekhealth services for routine visits andor immuniza-tions When stratified by age the results showedthat a significantly higher proportion of caregiverswith younger children (6ndash11 months old) tend toseek health services for routine visits andor immu-nizations (p lt 0001)

nd deworming to children aged 12ndash59 months during the

10

14

29

29

31

34

37

39

44

53

584

000 1000 2000 3000 4000 5000 6000 7000

Child was ill

Child already received vitamin A

Health facility did not have capsules

Journey was too farexpensive

Child was out of the area

Other

Too much work at home

Child finished immunizaons

Did not take child to clinic

No one available to take child

Caretaker did not hear of the event

Percent

Figure 2 Reasons reported by caregivers why children did not attend the May 2012 Malezi Bora Multiple responseswere accepted

Coverage of vitamin A supplementation and deworming during Malezi Bora in Kenya 173

36 Predictors of vas and dewormingservice uptake

Statistical analysis revealed that the recipientchilds age group (6ndash11 months and 12ndash59 months) the place where caregivers seek healthservices (district hospital versus other health insti-tutions) and methods of getting health informa-tion (through community leaders versus othermethods) are significant predictors of VAS uptakeAs shown in Table 2 after controlling for the placewhere caregivers seek health services and methodsof getting health information children aged 6ndash11 months had twice the odds of receiving VAScompared with children 12ndash59 months of age(OR = 21 p lt 001) For caregivers who regularlyseek health services in a district hospital the oddsof their children receiving VAS were 061 times(OR = 061 p lt 001) the odds of those who seekhealth services in other institutions with all otherfactors being equal After controlling for childsage and place where caregivers seek health ser-vices those caregivers getting health informationfrom their community leaders had an estimated15 times (OR = 15 p lt 005) the odds of their chil-dren receiving VAS compared with those who gethealth information from other sources

4 Discussion

Vitamin A and deworming coverage during the May2012 Malezi Bora was significantly lower than WHOrecommendations with coverage of 310 for VASand 196 for deworming which is consistent withVAS coverage measured by the 2009 DHS AccordingtoWHO and UNICEF recommendations twice-yearlyVAS coverage of at least 80 is necessary to signifi-cantly increase child survival among children aged6ndash59 months [11] Based on a 24 reduction in childmortality with universal VAS coverage an estimated16413 lives could be saved per year if universal VAScoverage is achieved in Kenya for children aged 6ndash59 months of age [HKI unpublished methodology]

Results from the current PEC survey suggest thatlow VAS and deworming coverage in Kenya is attrib-uted to lack of caregivers awareness of MaleziBora minimal knowledge of VAS as a major childsurvival intervention and low attendance of chil-dren over 12 months in health facilities for routineservice delivery Both caregiver awareness and lowhealth facility attendance need to be addressed insubsequent Malezi Bora events to increase cover-age of VAS and deworming service delivery

Low awareness of Malezi Bora among caregiversis attributed to inadequate communication of

Table 2 Caregiver community-based and facility-based health worker knowledge of vitamin A supplementation

Variable Caregivers (n = 900) Community-BasedHWs (n = 30)

Facility-basedHWs (n = 30)

n () n () n ()

Benefits of vitamin A

Protects against disease 241 (267) 22 (733) 25 (833)Improves child health 188 (208) 6 (200) 4 (133)Helps with growthbody building 114 (127) 14 (467) 10 (333)Increases appetite 89 (99) 3 (100) 1 (33)Increases energy 55 (61) 1 (33) 0 (00)Prevents blindnesshelps vision 52 (58) 22 (733) 28 (933)Reduces risk of death 1 (01) 0 (00) 2 (67)Does not knowremember 278 (310) 0 (00) 0 (00)Other 43 (47) 4 (133) 5 (167)

Age for first administration of vitamin AAt birth 63 (70) 0 (0) 2 (67)6 months 198 (221) 24 (800) 26 (867)9 months 38 (42) 0 (00) 1 (33)Do not know 189 (210) 2 (67) 0 (00)Other 284 (316) 4 (133) 1 (33)

How often children should receive vitamin AAt each Malezi Bora 2 (02) 0 (00) 0 (00)Every six months 163 (182) 24 (800) 27 (900)Does not know 254 (283) 2 (67) 0 (00)Other 350 (389) 4 (133) 3 (100)

Vitamin A dosage for children 6ndash11 months

One blue capsule (100000 IU) NA NA 27 (900)Half of a red capsule NA NA 8 (267)One red capsule (200000 IU) NA NA 1 (33)Do not know NA NA 0 (00)Other NA NA 1 (33)Vitamin A dosage for children 12ndash59 monthsOne blue capsule (100000 IU) NA NA 2 (67)One red capsule (200000 IU) NA NA 27 (900)Do not know NA NA 0 (00)Other NA NA 0 (00) Multiple responses were accepted

174 PC Clohossey et al

Malezi Bora activities Only 236 of caregivers re-called Malezi Bora being implemented and of care-givers whose children did not receive VAS 584stated that they had never heard that Malezi Borahad taken place In the current Malezi Bora com-munication platform interpersonal communicationmethods from health workers members in thecommunity and community leaders were the mosteffective in reaching caregivers and increasingtheir awareness Additional social mobilizationand communication activities such as radio spotsposters and banners were rarely mentioned bycaregivers as sources of information on MaleziBora Increasing awareness of Malezi Bora througheffective communication methods such as inter-personal communication is recommended to in-

crease awareness and demand of Malezi Boraservices in subsequent rounds

Survey results indicate increased outreach maybe necessary to deliverMalezi Bora services Nearlyhalf of caregivers communicated that they only taketheir child to a health facility if their child is sickwhich may explain in part why the majority of care-givers did not bring their children to the health facil-ity to receive Malezi Bora services To make thereceipt of Malezi Bora services more convenientand to increase coverage to populations with pooraccess to health facilities alternate distributionsites and methods may need to be considered

Among the target population children aged6ndash11 months have twice the odds as children12ndash59 months of age to receive VAS This finding

Coverage of vitamin A supplementation and deworming during Malezi Bora in Kenya 175

is consistent with the 2009 Kenya DHS whichshowed that coverage of VAS was more than twotimes higher among children 9ndash11 months old com-pared with children 24ndash59 months old [6] Highercoverage of younger children can be explainedthrough (1) caregivers of younger children beingmore likely to visit health facilities because theyare regularly coming for routine visits and (2)younger children being more likely to be homeand available to attend Malezi Bora compared witholder children who are in school

The current outreach strategy to distributeMalezi Bora services through ECD centers may notbe the most effective method of outreach as thecurrent data suggest that ECD attendance is poorand that ECD distribution often does not occurdue to lack of funding or poor planning With poorattendance of children 3ndash5 years of age in ECD pro-grams [12] additional outreach systems for MaleziBora are needed to reach older children

One potential platform to reach older children isduring the second dose ofmeasles vaccination deliv-ered at 18 months which is planned to be intro-duced into the EPI calendar The second dose ofmeasles would bring children below 2 years of ageto the health center but would not address low cov-erage of VAS among children older than 2 years ofage Vitamin A supplementation is frequently inte-grated with polio and measles campaigns whichachieves high coverage Unfortunately polio cam-paigns are infrequent and only occur when there isan outbreak andmeasles campaigns only take placeevery 3ndash5 years Therefore integration into themeasles and polio campaigns is not a sustainablemethod to deliver VAS

Targeted delivery and communication strategiesare needed to increase coverage of VAS and dewor-ming during Malezi Bora and raise awareness ofMalezi Bora among caregivers and the wider com-munity In addition to health facility based deliveryof services a community-based approach utilizingcommunity health workers (CHW)may bewarrantedgiven that caregivers generally do not visit healthfacilities after their child turns one year aside fromwhen their child is sick A community outreach strat-egywould ideally utilize the existing systemof CHWsand CHEWs to increase awareness of the communityprior to Malezi Bora and to deliver VAS and dewor-ming at the community level during Malezi Bora Inaddition it is recommended that targeted outreachofMalezi Bora services should be expanded from theexisting ECD or school-based distribution to increasecoverage among children 3ndash5 years old

The recommendation to deliver VAS through acommunity outreach strategy is aligned with the

WHO Reaching Every District (RED) strategy whichadvocates for strengthening the linkage betweencommunities and services via CHW and re-estab-lishing outreach services to improve service deliv-ery in distant communities [13] All deliverystrategies would need to be complimented by astrong and effective communication strategy to in-crease awareness of Malezi Bora in the communityand create demand for Malezi Bora services amongcaregivers

Limitations to this study include time con-straints to complete the survey (one cluster perday per survey team) and reliance on caretaker re-call Population data were not available at the vil-lage level and thus a village was selected atrandom in each cluster to identify the first house-hold to be visited in a cluster This studys strengthsinclude data collection within six weeks of servicedelivery and multiple methods were applied to en-sure data quality In order to ensure data qualityexperienced enumerators were selected and enu-merators were required to work in pairs Duringdata collection correct recording of responseswas confirmed by supervisors who completed se-lected surveys in duplicate and double data entrywas practiced

5 Conclusion

The low coverage of VAS and deworming in Kenyaduring Malezi Bora indicate that the existing MaleziBora programmatic structure needs to be examinedand reformed to meet its original objectives atinception and address key challenges to service up-take demonstrated in these survey findings Imple-mentation of immediate changes to address poorcoverage is critical to achieve necessary levelsfor improving child survival and decrease the inci-dence of child morbidity and mortality

6 Contributions

NN HIK and JLB conceived the study PCC NNHIK and JLB supported the implementation andtrained the surveyors GOM and MCI conductedthe data analysis with support from HIK and JLBPC drafted the manuscript and JLB and HIK revisedthe manuscript All authors reviewed and approvedthe final manuscript

7 Funding

This study was made possible by the generous sup-port of the Canadian International DevelopmentAgency (CIDA) The contents are the responsibility

176 PC Clohossey et al

of the authors and do not necessarily reflect theviews of CIDA or the Canadian Government

8 Conflicts of interest

None declared

References

[1] Sommer A Tarwotjo I Djunaedi E et al Impact of vitaminA supplementation on childhood mortality A randomisedcontrolled community trial Lancet 19861(8491)1169ndash73

[2] Mayo-Wilson E Imdad A Herzer K et al Vitamin Asupplements for preventing mortality illness and blind-ness in children aged under 5 systematic review and meta-analysis BMJ 2011343d5094 httpdxdoiorg101136bmjd5094|

[3] UNICEF Multi-country evaluation of child health days inEastern and Southern Africa 2008

[4] Routh S el Arifeen S Jahan SA et al Coping with changingconditions alternative strategies for the delivery ofmaternal and child health and family planning services inDhaka Bangladesh Bull World Health Organ 200179(2)142ndash9

[5] Department of Nutrition data 2006ndash2011 Ministry of PublicHealth and Sanitation Kenya

[6] Kenya National Bureau of Statistics and ICF Macro Kenyademographic and health survey 2008ndash09 In Macro KaIeditor Calverton Maryland KNBS and ICF Macro 2010

[7] Murray CJ Shengelia B Gupta N et al Validity ofreported vaccination coverage in 45 countries Lancet2003362(9389)1022ndash7 httpdxdoiorg101016S0140-6736(03)14411-X

[8] Arid Lands Resource Management Program Arid and SemiArid Lands (ASAL) national vision and strategy Pricewater-houseCoopers 2005 [2005ndash15]

[9] World Health Organization Immunization Coverage ClusterSurvey ndash Reference Manual 2005

[10] Kenya National Bureau of Statistics Kenya National Census2009

[11] Ross DA Recommendations for vitamin A supplementationJ Nutri 2002132(Suppl 9)2902Sndash6S

[12] Ministry of Education RoK Policy framework for educationaligning education and training to the constitution ofKenya April 2012

[13] World Health Organization Evaluation of RED strategyimplementation in the Africa region June 2005

ScienceDirectAvailable online at wwwsciencedirectcom

10

14

29

29

31

34

37

39

44

53

584

000 1000 2000 3000 4000 5000 6000 7000

Child was ill

Child already received vitamin A

Health facility did not have capsules

Journey was too farexpensive

Child was out of the area

Other

Too much work at home

Child finished immunizaons

Did not take child to clinic

No one available to take child

Caretaker did not hear of the event

Percent

Figure 2 Reasons reported by caregivers why children did not attend the May 2012 Malezi Bora Multiple responseswere accepted

Coverage of vitamin A supplementation and deworming during Malezi Bora in Kenya 173

36 Predictors of vas and dewormingservice uptake

Statistical analysis revealed that the recipientchilds age group (6ndash11 months and 12ndash59 months) the place where caregivers seek healthservices (district hospital versus other health insti-tutions) and methods of getting health informa-tion (through community leaders versus othermethods) are significant predictors of VAS uptakeAs shown in Table 2 after controlling for the placewhere caregivers seek health services and methodsof getting health information children aged 6ndash11 months had twice the odds of receiving VAScompared with children 12ndash59 months of age(OR = 21 p lt 001) For caregivers who regularlyseek health services in a district hospital the oddsof their children receiving VAS were 061 times(OR = 061 p lt 001) the odds of those who seekhealth services in other institutions with all otherfactors being equal After controlling for childsage and place where caregivers seek health ser-vices those caregivers getting health informationfrom their community leaders had an estimated15 times (OR = 15 p lt 005) the odds of their chil-dren receiving VAS compared with those who gethealth information from other sources

4 Discussion

Vitamin A and deworming coverage during the May2012 Malezi Bora was significantly lower than WHOrecommendations with coverage of 310 for VASand 196 for deworming which is consistent withVAS coverage measured by the 2009 DHS AccordingtoWHO and UNICEF recommendations twice-yearlyVAS coverage of at least 80 is necessary to signifi-cantly increase child survival among children aged6ndash59 months [11] Based on a 24 reduction in childmortality with universal VAS coverage an estimated16413 lives could be saved per year if universal VAScoverage is achieved in Kenya for children aged 6ndash59 months of age [HKI unpublished methodology]

Results from the current PEC survey suggest thatlow VAS and deworming coverage in Kenya is attrib-uted to lack of caregivers awareness of MaleziBora minimal knowledge of VAS as a major childsurvival intervention and low attendance of chil-dren over 12 months in health facilities for routineservice delivery Both caregiver awareness and lowhealth facility attendance need to be addressed insubsequent Malezi Bora events to increase cover-age of VAS and deworming service delivery

Low awareness of Malezi Bora among caregiversis attributed to inadequate communication of

Table 2 Caregiver community-based and facility-based health worker knowledge of vitamin A supplementation

Variable Caregivers (n = 900) Community-BasedHWs (n = 30)

Facility-basedHWs (n = 30)

n () n () n ()

Benefits of vitamin A

Protects against disease 241 (267) 22 (733) 25 (833)Improves child health 188 (208) 6 (200) 4 (133)Helps with growthbody building 114 (127) 14 (467) 10 (333)Increases appetite 89 (99) 3 (100) 1 (33)Increases energy 55 (61) 1 (33) 0 (00)Prevents blindnesshelps vision 52 (58) 22 (733) 28 (933)Reduces risk of death 1 (01) 0 (00) 2 (67)Does not knowremember 278 (310) 0 (00) 0 (00)Other 43 (47) 4 (133) 5 (167)

Age for first administration of vitamin AAt birth 63 (70) 0 (0) 2 (67)6 months 198 (221) 24 (800) 26 (867)9 months 38 (42) 0 (00) 1 (33)Do not know 189 (210) 2 (67) 0 (00)Other 284 (316) 4 (133) 1 (33)

How often children should receive vitamin AAt each Malezi Bora 2 (02) 0 (00) 0 (00)Every six months 163 (182) 24 (800) 27 (900)Does not know 254 (283) 2 (67) 0 (00)Other 350 (389) 4 (133) 3 (100)

Vitamin A dosage for children 6ndash11 months

One blue capsule (100000 IU) NA NA 27 (900)Half of a red capsule NA NA 8 (267)One red capsule (200000 IU) NA NA 1 (33)Do not know NA NA 0 (00)Other NA NA 1 (33)Vitamin A dosage for children 12ndash59 monthsOne blue capsule (100000 IU) NA NA 2 (67)One red capsule (200000 IU) NA NA 27 (900)Do not know NA NA 0 (00)Other NA NA 0 (00) Multiple responses were accepted

174 PC Clohossey et al

Malezi Bora activities Only 236 of caregivers re-called Malezi Bora being implemented and of care-givers whose children did not receive VAS 584stated that they had never heard that Malezi Borahad taken place In the current Malezi Bora com-munication platform interpersonal communicationmethods from health workers members in thecommunity and community leaders were the mosteffective in reaching caregivers and increasingtheir awareness Additional social mobilizationand communication activities such as radio spotsposters and banners were rarely mentioned bycaregivers as sources of information on MaleziBora Increasing awareness of Malezi Bora througheffective communication methods such as inter-personal communication is recommended to in-

crease awareness and demand of Malezi Boraservices in subsequent rounds

Survey results indicate increased outreach maybe necessary to deliverMalezi Bora services Nearlyhalf of caregivers communicated that they only taketheir child to a health facility if their child is sickwhich may explain in part why the majority of care-givers did not bring their children to the health facil-ity to receive Malezi Bora services To make thereceipt of Malezi Bora services more convenientand to increase coverage to populations with pooraccess to health facilities alternate distributionsites and methods may need to be considered

Among the target population children aged6ndash11 months have twice the odds as children12ndash59 months of age to receive VAS This finding

Coverage of vitamin A supplementation and deworming during Malezi Bora in Kenya 175

is consistent with the 2009 Kenya DHS whichshowed that coverage of VAS was more than twotimes higher among children 9ndash11 months old com-pared with children 24ndash59 months old [6] Highercoverage of younger children can be explainedthrough (1) caregivers of younger children beingmore likely to visit health facilities because theyare regularly coming for routine visits and (2)younger children being more likely to be homeand available to attend Malezi Bora compared witholder children who are in school

The current outreach strategy to distributeMalezi Bora services through ECD centers may notbe the most effective method of outreach as thecurrent data suggest that ECD attendance is poorand that ECD distribution often does not occurdue to lack of funding or poor planning With poorattendance of children 3ndash5 years of age in ECD pro-grams [12] additional outreach systems for MaleziBora are needed to reach older children

One potential platform to reach older children isduring the second dose ofmeasles vaccination deliv-ered at 18 months which is planned to be intro-duced into the EPI calendar The second dose ofmeasles would bring children below 2 years of ageto the health center but would not address low cov-erage of VAS among children older than 2 years ofage Vitamin A supplementation is frequently inte-grated with polio and measles campaigns whichachieves high coverage Unfortunately polio cam-paigns are infrequent and only occur when there isan outbreak andmeasles campaigns only take placeevery 3ndash5 years Therefore integration into themeasles and polio campaigns is not a sustainablemethod to deliver VAS

Targeted delivery and communication strategiesare needed to increase coverage of VAS and dewor-ming during Malezi Bora and raise awareness ofMalezi Bora among caregivers and the wider com-munity In addition to health facility based deliveryof services a community-based approach utilizingcommunity health workers (CHW)may bewarrantedgiven that caregivers generally do not visit healthfacilities after their child turns one year aside fromwhen their child is sick A community outreach strat-egywould ideally utilize the existing systemof CHWsand CHEWs to increase awareness of the communityprior to Malezi Bora and to deliver VAS and dewor-ming at the community level during Malezi Bora Inaddition it is recommended that targeted outreachofMalezi Bora services should be expanded from theexisting ECD or school-based distribution to increasecoverage among children 3ndash5 years old

The recommendation to deliver VAS through acommunity outreach strategy is aligned with the

WHO Reaching Every District (RED) strategy whichadvocates for strengthening the linkage betweencommunities and services via CHW and re-estab-lishing outreach services to improve service deliv-ery in distant communities [13] All deliverystrategies would need to be complimented by astrong and effective communication strategy to in-crease awareness of Malezi Bora in the communityand create demand for Malezi Bora services amongcaregivers

Limitations to this study include time con-straints to complete the survey (one cluster perday per survey team) and reliance on caretaker re-call Population data were not available at the vil-lage level and thus a village was selected atrandom in each cluster to identify the first house-hold to be visited in a cluster This studys strengthsinclude data collection within six weeks of servicedelivery and multiple methods were applied to en-sure data quality In order to ensure data qualityexperienced enumerators were selected and enu-merators were required to work in pairs Duringdata collection correct recording of responseswas confirmed by supervisors who completed se-lected surveys in duplicate and double data entrywas practiced

5 Conclusion

The low coverage of VAS and deworming in Kenyaduring Malezi Bora indicate that the existing MaleziBora programmatic structure needs to be examinedand reformed to meet its original objectives atinception and address key challenges to service up-take demonstrated in these survey findings Imple-mentation of immediate changes to address poorcoverage is critical to achieve necessary levelsfor improving child survival and decrease the inci-dence of child morbidity and mortality

6 Contributions

NN HIK and JLB conceived the study PCC NNHIK and JLB supported the implementation andtrained the surveyors GOM and MCI conductedthe data analysis with support from HIK and JLBPC drafted the manuscript and JLB and HIK revisedthe manuscript All authors reviewed and approvedthe final manuscript

7 Funding

This study was made possible by the generous sup-port of the Canadian International DevelopmentAgency (CIDA) The contents are the responsibility

176 PC Clohossey et al

of the authors and do not necessarily reflect theviews of CIDA or the Canadian Government

8 Conflicts of interest

None declared

References

[1] Sommer A Tarwotjo I Djunaedi E et al Impact of vitaminA supplementation on childhood mortality A randomisedcontrolled community trial Lancet 19861(8491)1169ndash73

[2] Mayo-Wilson E Imdad A Herzer K et al Vitamin Asupplements for preventing mortality illness and blind-ness in children aged under 5 systematic review and meta-analysis BMJ 2011343d5094 httpdxdoiorg101136bmjd5094|

[3] UNICEF Multi-country evaluation of child health days inEastern and Southern Africa 2008

[4] Routh S el Arifeen S Jahan SA et al Coping with changingconditions alternative strategies for the delivery ofmaternal and child health and family planning services inDhaka Bangladesh Bull World Health Organ 200179(2)142ndash9

[5] Department of Nutrition data 2006ndash2011 Ministry of PublicHealth and Sanitation Kenya

[6] Kenya National Bureau of Statistics and ICF Macro Kenyademographic and health survey 2008ndash09 In Macro KaIeditor Calverton Maryland KNBS and ICF Macro 2010

[7] Murray CJ Shengelia B Gupta N et al Validity ofreported vaccination coverage in 45 countries Lancet2003362(9389)1022ndash7 httpdxdoiorg101016S0140-6736(03)14411-X

[8] Arid Lands Resource Management Program Arid and SemiArid Lands (ASAL) national vision and strategy Pricewater-houseCoopers 2005 [2005ndash15]

[9] World Health Organization Immunization Coverage ClusterSurvey ndash Reference Manual 2005

[10] Kenya National Bureau of Statistics Kenya National Census2009

[11] Ross DA Recommendations for vitamin A supplementationJ Nutri 2002132(Suppl 9)2902Sndash6S

[12] Ministry of Education RoK Policy framework for educationaligning education and training to the constitution ofKenya April 2012

[13] World Health Organization Evaluation of RED strategyimplementation in the Africa region June 2005

ScienceDirectAvailable online at wwwsciencedirectcom

Table 2 Caregiver community-based and facility-based health worker knowledge of vitamin A supplementation

Variable Caregivers (n = 900) Community-BasedHWs (n = 30)

Facility-basedHWs (n = 30)

n () n () n ()

Benefits of vitamin A

Protects against disease 241 (267) 22 (733) 25 (833)Improves child health 188 (208) 6 (200) 4 (133)Helps with growthbody building 114 (127) 14 (467) 10 (333)Increases appetite 89 (99) 3 (100) 1 (33)Increases energy 55 (61) 1 (33) 0 (00)Prevents blindnesshelps vision 52 (58) 22 (733) 28 (933)Reduces risk of death 1 (01) 0 (00) 2 (67)Does not knowremember 278 (310) 0 (00) 0 (00)Other 43 (47) 4 (133) 5 (167)

Age for first administration of vitamin AAt birth 63 (70) 0 (0) 2 (67)6 months 198 (221) 24 (800) 26 (867)9 months 38 (42) 0 (00) 1 (33)Do not know 189 (210) 2 (67) 0 (00)Other 284 (316) 4 (133) 1 (33)

How often children should receive vitamin AAt each Malezi Bora 2 (02) 0 (00) 0 (00)Every six months 163 (182) 24 (800) 27 (900)Does not know 254 (283) 2 (67) 0 (00)Other 350 (389) 4 (133) 3 (100)

Vitamin A dosage for children 6ndash11 months

One blue capsule (100000 IU) NA NA 27 (900)Half of a red capsule NA NA 8 (267)One red capsule (200000 IU) NA NA 1 (33)Do not know NA NA 0 (00)Other NA NA 1 (33)Vitamin A dosage for children 12ndash59 monthsOne blue capsule (100000 IU) NA NA 2 (67)One red capsule (200000 IU) NA NA 27 (900)Do not know NA NA 0 (00)Other NA NA 0 (00) Multiple responses were accepted

174 PC Clohossey et al

Malezi Bora activities Only 236 of caregivers re-called Malezi Bora being implemented and of care-givers whose children did not receive VAS 584stated that they had never heard that Malezi Borahad taken place In the current Malezi Bora com-munication platform interpersonal communicationmethods from health workers members in thecommunity and community leaders were the mosteffective in reaching caregivers and increasingtheir awareness Additional social mobilizationand communication activities such as radio spotsposters and banners were rarely mentioned bycaregivers as sources of information on MaleziBora Increasing awareness of Malezi Bora througheffective communication methods such as inter-personal communication is recommended to in-

crease awareness and demand of Malezi Boraservices in subsequent rounds

Survey results indicate increased outreach maybe necessary to deliverMalezi Bora services Nearlyhalf of caregivers communicated that they only taketheir child to a health facility if their child is sickwhich may explain in part why the majority of care-givers did not bring their children to the health facil-ity to receive Malezi Bora services To make thereceipt of Malezi Bora services more convenientand to increase coverage to populations with pooraccess to health facilities alternate distributionsites and methods may need to be considered

Among the target population children aged6ndash11 months have twice the odds as children12ndash59 months of age to receive VAS This finding

Coverage of vitamin A supplementation and deworming during Malezi Bora in Kenya 175

is consistent with the 2009 Kenya DHS whichshowed that coverage of VAS was more than twotimes higher among children 9ndash11 months old com-pared with children 24ndash59 months old [6] Highercoverage of younger children can be explainedthrough (1) caregivers of younger children beingmore likely to visit health facilities because theyare regularly coming for routine visits and (2)younger children being more likely to be homeand available to attend Malezi Bora compared witholder children who are in school

The current outreach strategy to distributeMalezi Bora services through ECD centers may notbe the most effective method of outreach as thecurrent data suggest that ECD attendance is poorand that ECD distribution often does not occurdue to lack of funding or poor planning With poorattendance of children 3ndash5 years of age in ECD pro-grams [12] additional outreach systems for MaleziBora are needed to reach older children

One potential platform to reach older children isduring the second dose ofmeasles vaccination deliv-ered at 18 months which is planned to be intro-duced into the EPI calendar The second dose ofmeasles would bring children below 2 years of ageto the health center but would not address low cov-erage of VAS among children older than 2 years ofage Vitamin A supplementation is frequently inte-grated with polio and measles campaigns whichachieves high coverage Unfortunately polio cam-paigns are infrequent and only occur when there isan outbreak andmeasles campaigns only take placeevery 3ndash5 years Therefore integration into themeasles and polio campaigns is not a sustainablemethod to deliver VAS

Targeted delivery and communication strategiesare needed to increase coverage of VAS and dewor-ming during Malezi Bora and raise awareness ofMalezi Bora among caregivers and the wider com-munity In addition to health facility based deliveryof services a community-based approach utilizingcommunity health workers (CHW)may bewarrantedgiven that caregivers generally do not visit healthfacilities after their child turns one year aside fromwhen their child is sick A community outreach strat-egywould ideally utilize the existing systemof CHWsand CHEWs to increase awareness of the communityprior to Malezi Bora and to deliver VAS and dewor-ming at the community level during Malezi Bora Inaddition it is recommended that targeted outreachofMalezi Bora services should be expanded from theexisting ECD or school-based distribution to increasecoverage among children 3ndash5 years old

The recommendation to deliver VAS through acommunity outreach strategy is aligned with the

WHO Reaching Every District (RED) strategy whichadvocates for strengthening the linkage betweencommunities and services via CHW and re-estab-lishing outreach services to improve service deliv-ery in distant communities [13] All deliverystrategies would need to be complimented by astrong and effective communication strategy to in-crease awareness of Malezi Bora in the communityand create demand for Malezi Bora services amongcaregivers

Limitations to this study include time con-straints to complete the survey (one cluster perday per survey team) and reliance on caretaker re-call Population data were not available at the vil-lage level and thus a village was selected atrandom in each cluster to identify the first house-hold to be visited in a cluster This studys strengthsinclude data collection within six weeks of servicedelivery and multiple methods were applied to en-sure data quality In order to ensure data qualityexperienced enumerators were selected and enu-merators were required to work in pairs Duringdata collection correct recording of responseswas confirmed by supervisors who completed se-lected surveys in duplicate and double data entrywas practiced

5 Conclusion

The low coverage of VAS and deworming in Kenyaduring Malezi Bora indicate that the existing MaleziBora programmatic structure needs to be examinedand reformed to meet its original objectives atinception and address key challenges to service up-take demonstrated in these survey findings Imple-mentation of immediate changes to address poorcoverage is critical to achieve necessary levelsfor improving child survival and decrease the inci-dence of child morbidity and mortality

6 Contributions

NN HIK and JLB conceived the study PCC NNHIK and JLB supported the implementation andtrained the surveyors GOM and MCI conductedthe data analysis with support from HIK and JLBPC drafted the manuscript and JLB and HIK revisedthe manuscript All authors reviewed and approvedthe final manuscript

7 Funding

This study was made possible by the generous sup-port of the Canadian International DevelopmentAgency (CIDA) The contents are the responsibility

176 PC Clohossey et al

of the authors and do not necessarily reflect theviews of CIDA or the Canadian Government

8 Conflicts of interest

None declared

References

[1] Sommer A Tarwotjo I Djunaedi E et al Impact of vitaminA supplementation on childhood mortality A randomisedcontrolled community trial Lancet 19861(8491)1169ndash73

[2] Mayo-Wilson E Imdad A Herzer K et al Vitamin Asupplements for preventing mortality illness and blind-ness in children aged under 5 systematic review and meta-analysis BMJ 2011343d5094 httpdxdoiorg101136bmjd5094|

[3] UNICEF Multi-country evaluation of child health days inEastern and Southern Africa 2008

[4] Routh S el Arifeen S Jahan SA et al Coping with changingconditions alternative strategies for the delivery ofmaternal and child health and family planning services inDhaka Bangladesh Bull World Health Organ 200179(2)142ndash9

[5] Department of Nutrition data 2006ndash2011 Ministry of PublicHealth and Sanitation Kenya

[6] Kenya National Bureau of Statistics and ICF Macro Kenyademographic and health survey 2008ndash09 In Macro KaIeditor Calverton Maryland KNBS and ICF Macro 2010

[7] Murray CJ Shengelia B Gupta N et al Validity ofreported vaccination coverage in 45 countries Lancet2003362(9389)1022ndash7 httpdxdoiorg101016S0140-6736(03)14411-X

[8] Arid Lands Resource Management Program Arid and SemiArid Lands (ASAL) national vision and strategy Pricewater-houseCoopers 2005 [2005ndash15]

[9] World Health Organization Immunization Coverage ClusterSurvey ndash Reference Manual 2005

[10] Kenya National Bureau of Statistics Kenya National Census2009

[11] Ross DA Recommendations for vitamin A supplementationJ Nutri 2002132(Suppl 9)2902Sndash6S

[12] Ministry of Education RoK Policy framework for educationaligning education and training to the constitution ofKenya April 2012

[13] World Health Organization Evaluation of RED strategyimplementation in the Africa region June 2005

ScienceDirectAvailable online at wwwsciencedirectcom

Coverage of vitamin A supplementation and deworming during Malezi Bora in Kenya 175

is consistent with the 2009 Kenya DHS whichshowed that coverage of VAS was more than twotimes higher among children 9ndash11 months old com-pared with children 24ndash59 months old [6] Highercoverage of younger children can be explainedthrough (1) caregivers of younger children beingmore likely to visit health facilities because theyare regularly coming for routine visits and (2)younger children being more likely to be homeand available to attend Malezi Bora compared witholder children who are in school

The current outreach strategy to distributeMalezi Bora services through ECD centers may notbe the most effective method of outreach as thecurrent data suggest that ECD attendance is poorand that ECD distribution often does not occurdue to lack of funding or poor planning With poorattendance of children 3ndash5 years of age in ECD pro-grams [12] additional outreach systems for MaleziBora are needed to reach older children

One potential platform to reach older children isduring the second dose ofmeasles vaccination deliv-ered at 18 months which is planned to be intro-duced into the EPI calendar The second dose ofmeasles would bring children below 2 years of ageto the health center but would not address low cov-erage of VAS among children older than 2 years ofage Vitamin A supplementation is frequently inte-grated with polio and measles campaigns whichachieves high coverage Unfortunately polio cam-paigns are infrequent and only occur when there isan outbreak andmeasles campaigns only take placeevery 3ndash5 years Therefore integration into themeasles and polio campaigns is not a sustainablemethod to deliver VAS

Targeted delivery and communication strategiesare needed to increase coverage of VAS and dewor-ming during Malezi Bora and raise awareness ofMalezi Bora among caregivers and the wider com-munity In addition to health facility based deliveryof services a community-based approach utilizingcommunity health workers (CHW)may bewarrantedgiven that caregivers generally do not visit healthfacilities after their child turns one year aside fromwhen their child is sick A community outreach strat-egywould ideally utilize the existing systemof CHWsand CHEWs to increase awareness of the communityprior to Malezi Bora and to deliver VAS and dewor-ming at the community level during Malezi Bora Inaddition it is recommended that targeted outreachofMalezi Bora services should be expanded from theexisting ECD or school-based distribution to increasecoverage among children 3ndash5 years old

The recommendation to deliver VAS through acommunity outreach strategy is aligned with the

WHO Reaching Every District (RED) strategy whichadvocates for strengthening the linkage betweencommunities and services via CHW and re-estab-lishing outreach services to improve service deliv-ery in distant communities [13] All deliverystrategies would need to be complimented by astrong and effective communication strategy to in-crease awareness of Malezi Bora in the communityand create demand for Malezi Bora services amongcaregivers

Limitations to this study include time con-straints to complete the survey (one cluster perday per survey team) and reliance on caretaker re-call Population data were not available at the vil-lage level and thus a village was selected atrandom in each cluster to identify the first house-hold to be visited in a cluster This studys strengthsinclude data collection within six weeks of servicedelivery and multiple methods were applied to en-sure data quality In order to ensure data qualityexperienced enumerators were selected and enu-merators were required to work in pairs Duringdata collection correct recording of responseswas confirmed by supervisors who completed se-lected surveys in duplicate and double data entrywas practiced

5 Conclusion

The low coverage of VAS and deworming in Kenyaduring Malezi Bora indicate that the existing MaleziBora programmatic structure needs to be examinedand reformed to meet its original objectives atinception and address key challenges to service up-take demonstrated in these survey findings Imple-mentation of immediate changes to address poorcoverage is critical to achieve necessary levelsfor improving child survival and decrease the inci-dence of child morbidity and mortality

6 Contributions

NN HIK and JLB conceived the study PCC NNHIK and JLB supported the implementation andtrained the surveyors GOM and MCI conductedthe data analysis with support from HIK and JLBPC drafted the manuscript and JLB and HIK revisedthe manuscript All authors reviewed and approvedthe final manuscript

7 Funding

This study was made possible by the generous sup-port of the Canadian International DevelopmentAgency (CIDA) The contents are the responsibility

176 PC Clohossey et al

of the authors and do not necessarily reflect theviews of CIDA or the Canadian Government

8 Conflicts of interest

None declared

References

[1] Sommer A Tarwotjo I Djunaedi E et al Impact of vitaminA supplementation on childhood mortality A randomisedcontrolled community trial Lancet 19861(8491)1169ndash73

[2] Mayo-Wilson E Imdad A Herzer K et al Vitamin Asupplements for preventing mortality illness and blind-ness in children aged under 5 systematic review and meta-analysis BMJ 2011343d5094 httpdxdoiorg101136bmjd5094|

[3] UNICEF Multi-country evaluation of child health days inEastern and Southern Africa 2008

[4] Routh S el Arifeen S Jahan SA et al Coping with changingconditions alternative strategies for the delivery ofmaternal and child health and family planning services inDhaka Bangladesh Bull World Health Organ 200179(2)142ndash9

[5] Department of Nutrition data 2006ndash2011 Ministry of PublicHealth and Sanitation Kenya

[6] Kenya National Bureau of Statistics and ICF Macro Kenyademographic and health survey 2008ndash09 In Macro KaIeditor Calverton Maryland KNBS and ICF Macro 2010

[7] Murray CJ Shengelia B Gupta N et al Validity ofreported vaccination coverage in 45 countries Lancet2003362(9389)1022ndash7 httpdxdoiorg101016S0140-6736(03)14411-X

[8] Arid Lands Resource Management Program Arid and SemiArid Lands (ASAL) national vision and strategy Pricewater-houseCoopers 2005 [2005ndash15]

[9] World Health Organization Immunization Coverage ClusterSurvey ndash Reference Manual 2005

[10] Kenya National Bureau of Statistics Kenya National Census2009

[11] Ross DA Recommendations for vitamin A supplementationJ Nutri 2002132(Suppl 9)2902Sndash6S

[12] Ministry of Education RoK Policy framework for educationaligning education and training to the constitution ofKenya April 2012

[13] World Health Organization Evaluation of RED strategyimplementation in the Africa region June 2005

ScienceDirectAvailable online at wwwsciencedirectcom

176 PC Clohossey et al

of the authors and do not necessarily reflect theviews of CIDA or the Canadian Government

8 Conflicts of interest

None declared

References

[1] Sommer A Tarwotjo I Djunaedi E et al Impact of vitaminA supplementation on childhood mortality A randomisedcontrolled community trial Lancet 19861(8491)1169ndash73

[2] Mayo-Wilson E Imdad A Herzer K et al Vitamin Asupplements for preventing mortality illness and blind-ness in children aged under 5 systematic review and meta-analysis BMJ 2011343d5094 httpdxdoiorg101136bmjd5094|

[3] UNICEF Multi-country evaluation of child health days inEastern and Southern Africa 2008

[4] Routh S el Arifeen S Jahan SA et al Coping with changingconditions alternative strategies for the delivery ofmaternal and child health and family planning services inDhaka Bangladesh Bull World Health Organ 200179(2)142ndash9

[5] Department of Nutrition data 2006ndash2011 Ministry of PublicHealth and Sanitation Kenya

[6] Kenya National Bureau of Statistics and ICF Macro Kenyademographic and health survey 2008ndash09 In Macro KaIeditor Calverton Maryland KNBS and ICF Macro 2010

[7] Murray CJ Shengelia B Gupta N et al Validity ofreported vaccination coverage in 45 countries Lancet2003362(9389)1022ndash7 httpdxdoiorg101016S0140-6736(03)14411-X

[8] Arid Lands Resource Management Program Arid and SemiArid Lands (ASAL) national vision and strategy Pricewater-houseCoopers 2005 [2005ndash15]

[9] World Health Organization Immunization Coverage ClusterSurvey ndash Reference Manual 2005

[10] Kenya National Bureau of Statistics Kenya National Census2009

[11] Ross DA Recommendations for vitamin A supplementationJ Nutri 2002132(Suppl 9)2902Sndash6S

[12] Ministry of Education RoK Policy framework for educationaligning education and training to the constitution ofKenya April 2012

[13] World Health Organization Evaluation of RED strategyimplementation in the Africa region June 2005

ScienceDirectAvailable online at wwwsciencedirectcom