national vitamin A supplementation program: a study in children from the state of Alagoas 夽,夽夽,夽夽夽

www.jped.com.br

ORIGINAL ARTICLE

Coverage and educational actions related to the

national vitamin A supplementation program: a study in children from the state of Alagoas ^{夽,夽夽,夽夽夽}

Riquelane B.M. Lima

, Haroldo S. Ferreira

, Andressa L. Cavalcante

, Laíse Gabrielly M.L. Santos

, Regina Coeli S. Vieira

, Monica L. Assunc ¸ão

aUniversidadeFederaldeAlagoas(UFAL),FaculdadedeNutric¸ão,ProgramadePós-Graduac¸ãoemNutric¸ão,Maceió,AL,Brazil

bUniversidadeFederaldeAlagoas(UFAL),FaculdadedeNutric¸ão,Pós-Graduac¸ãoemEpidemiologia,Maceió,AL,Brazil

cUniversidadeFederaldoAmazonas(UFAM),InstitutodeSaúdeeBiotecnologia/Coari,CiênciasdaSaúde-CursodeNutric¸ão, Manaus,AM,Brazil

dUniversidadeFederaldeAlagoas(UFAL),FaculdadedeNutric¸ão,SaúdedaCrianc¸aedoAdolescente,Maceió,AL,Brazil

Received6May2018;accepted15August2018 Availableonline12October2018

KEYWORDS Publichealth;

VitaminA;

Supplementation;

Healthevaluation;

Brazil

Abstract

Objectives: ToestimatethecoverageoftheNationalVitaminASupplementationProgram(Pro- gramaNacionaldeSuplementac¸ãodeVitaminaA)inchildrenfromAlagoas,toidentifyfactors associatedwiththiscoverage,andtoanalyzetheadequacyofnutritioneducationactions.

Methods: Householdsurveyinvolvingarepresentativeprobabilisticsampleofchildrenaged6to 59monthsfromAlagoasandtheirmothers(n=509).Coveragewasdefinedbythepercentage ofchildrenwithsupplementation recordsinthelastsemester.Theassociationbetweenthe independentvariables(socioeconomic,demographic,andhealth)andtheNationalVitaminA SupplementationProgramcoveragewasanalyzedbasedontheprevalenceratioandits95%CI.

Themothers’knowledgeofquestionsrelatedtovitaminA wasconsideredasanindicatorof theadequacyofnutritioneducationactions.

夽 Pleasecitethisarticleas:LimaRB,FerreiraHS,CavalcanteAL,SantosLG,VieiraRC,Assunc¸ãoML.Coverageandeducationalactions relatedtothenationalvitaminAsupplementationprogram:astudyinchildrenfromthestateofAlagoas.JPediatr(RioJ).2020;96:184---92.

夽夽StudyconductedatUniversidadeFederaldeAlagoas(UFAL),FaculdadedeNutric¸ão,Maceió,AL,Brazil.

夽夽夽ArticlebasedonRiquelaneBezerraMenezesLima’sMaster’sDegreeDissertation,fromthePostgraduatePrograminNutrition,Univer- sidadeFederaldeAlagoas,Maceió,AL,Brasil.

∗Correspondingauthor.

E-mail:haroldo.ufal@gmail.com(H.S.Ferreira).

https://doi.org/10.1016/j.jped.2018.08.006

0021-7557/©2018SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Results: Programcoveragewas91.9%inchildrenaged6-11.9monthsand38.6%inchildrenaged 12-59months.Intheadjustedanalysis,thefactorsthatwereassociatedwithgreatercoverage were:agebetween6-11.9months(PR=2.50,95%CI:2.10-2.96),livinginruralareas(PR=1.45, 95%CI:1.20-1.76)andlivinginahousewith ≤4rooms(PR=1.33, 95%CI:1.09-1.63).Only 26.1%ofthemotherswereabletomentionsomefoodsourceofvitaminAandonly19.2%were awareoftheconsequencesofvitamindeficiencyforhealth.

Conclusions: TheNationalVitaminASupplementationProgramcoverageisbelowthetargets set bytheMinistryofHealth(exceptfor children<12months).Thefactorsassociatedwith greatercoverageindicateanadequatefocusoftheprogram.Thenutritioneducationactivities havenotdemonstratedsatisfactoryresults.Thisinformationshouldguideactionstoimprove theprogram.

©2018SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/

4.0/).

PALAVRAS-CHAVE Saúdepública;

VitaminaA;

Suplementac¸ão;

Avaliac¸ãoemsaúde;

Brasil

Coberturaeac¸õeseducativasnoâmbitodoprogramanacionaldesuplementac¸ãode vitaminaA:estudoemcrianc¸asdoestadodeAlagoas

Resumo

Objetivos: Estimaracoberturado Programa Nacionalde Suplementac¸ãode Vitamina A em crianc¸asdeAlagoas,identificarfatoresassociadosaessacoberturaeanalisaraadequac¸ãodas ac¸õesdasac¸õesdeeducac¸ãonutricional.

Métodos: Inquéritodomiciliarqueenvolveuamostraprobabilísticarepresentativadascrianc¸as de6a59mesesdeAlagoasesuasmães(n=509).Acoberturafoidefinidapelopercentualde crianc¸ascomregistrodesuplementac¸ãonoúltimosemestre.Aassociac¸ãoentreasvariáveis independentes(socioeconômicas,demográficasedesaúde)eacoberturadoProgramaNacional deSuplementac¸ãodeVitaminaAfoianalisadacombasenarazãodeprevalênciaeseuIC95%.O conhecimentodasmãessobrequestõesrelacionadasàvitaminaAfoiassumidocomoindicador daadequac¸ãodasac¸õesdeeducac¸ãonutricional.

Resultados: Acoberturadoprogramafoide91,9%entrecrianc¸asde6-11,9mesesede38,6%

entreasde 12-59meses. Naanáliseajustada,osfatoresque seassociaramàmaiorcober- turaforamteridade entre6-11,9meses(RP=2,50;IC95%:2,10-2,96),residirem zonarural (RP=1,45;IC95%:1,20-1,76)emoraremdomicíliocom≤4cômodos(RP=1,33;IC95%:1,09- 1,63).Somente26,1%dasmãessouberamcitaralgumalimentofontedevitaminaAeapenas 19,2%conheciamasconsequênciasdadeficiênciadessavitaminaparaasaúde.

Conclusões: AcoberturadoProgramaNacionaldeSuplementac¸ãodeVitaminaAencontra-se aquém dasmetasestabelecidaspeloMinistériodaSaúde(excetopara crianc¸as<12meses).

Os fatoresassociados àmaiorcoberturaevidenciam adequadafocalizac¸ãodo programa.As atividadesdeeducac¸ãonutricionalnãoocorremdeformasatisfatória.Essasinformac¸õesdevem nortearac¸õesdeaperfeic¸oamentodoprograma.

©2018SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Este ´eumartigo OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.

0/).

Introduction

VitaminAisanessentialmicronutrientinseveralphysiolog- icalprocessesinthehuman body,beingnecessary for the adequatefunctioningoftheimmunesystem,visualacuity, cell proliferation/differentiation, and gene expression.^1---4 Despiteuniversal susceptibility, itsdeficiencyis morefre- quent in children underfive years,pregnant women, and lactatingwomen,whichiswhythesegroupsareconsidered biologicallymorevulnerabletothisnutritionaldeficiency.⁵

VitaminAdeficiency(VAD)isamajorpublichealthprob- lem in low- and middle-income countries, affecting 190 millionchildren.⁶In2013,29%ofthechildreninthesecoun- trieshadVAD.Inthesameyear,94,500deathsfromdiarrhea

and11,200deaths frommeasleswereattributedtoVAD.⁷ InBrazil, datafrom anational surveycarried outin 2006 showedaprevalenceof17.4%inchildrenunder5yearsof age,withthis prevalence being19.0% inthe northeastof thecountry.⁸

ThemainconsequencesofVADareblindnessandimmune systemimpairment,contributingtoanincreaseinthepreva- lenceofdiarrhealand infectiousdiseases, mortalityrate, and demand for health services.⁹ Additionally, due to its participationinseveralmetabolicprocesses,VADhasbeen associatedwithotherdisorders,suchasanemia.¹⁰

In 2005, the National Vitamin A Supplementation Pro- gram (Programa Nacional de Suplementac¸ão de Vitamina A [PNVITA]) was implemented in Brazil with the aim of

reducingthe prevalenceof hypovitaminosisA in themost susceptible individuals, such as children aged 6 to 59 months. The program main action consists of bi-yearly supplementation with vitamin A megadoses. In parallel, nutrition education (NE) actions are recommended to improve vitamin A intake through food consumption.^9,10 However,nostrategiesrelatedtoprogramevaluationactiv- itieshavebeendefined,whichiswhy,perhaps,thereareso fewworksintheliterature^1,11---13thataddressthisissue.

Even though PNVITA has been in operation since2005, subsequent studies have found high prevalence rates of VAD.^14,15 In thestate ofAlagoas, locatedin the semi-arid regionofBrazil,therewasaprevalenceof45.4%inpreschool childrenin2007,whichsuggeststheexistenceofproblems intheprogram’sperformance.¹⁵Identifyingtheseproblems isofgreatrelevancefortheevaluationandreorganization ofPNVITAactions.

The aimof thisstudy wastoestimatethePNVITA cov- erageinchildrenfromAlagoas,identifyfactorsassociated withthiscoverage,andanalyzetheadequacyofthenutri- tioneducationactions.

Methods

Samplingplananddatacollection

This was a cross-sectional study of data from a survey called‘‘IIHealthDiagnosisoftheMaternal-ChildPopulation of the State of Alagoas,’’ in which the variable of inter- estusedin sample size calculation wasfood insecurityin Alagoas,estimated at 34.7%.The other parameterswere:

populationof841,117families,samplingerrorof2.0%,120 conglomerates(census sectors),and 1.5 for correction of the complex design effect. Thus, for a 95% CI and after including10%to coverpossible sample losses,3,696 fam- ilieswererequired.Adetaileddescriptionofthisprocedure isavailableelsewhere.¹⁶

Forthepresent study,allchildrenaged6to59months residing in the randomly selected households were eligi- ble,totaling509children.Consideringthissamplewasnot initiallyplanned,thesamplingerrorwascalculatedsubse- quently,usingtheStatCalcmoduleoftheEpiInfosoftware (Epi Info^TM, a database and statistics program for public healthprofessionals.CDC, Atlanta,GA,USA,2011).Based on the coverage rates identified in this study, the ana- lyzedsamplenumberallowedforestimationofthecoverage witherrorsrangingfrom2.3%(6-59months)to4.2%(12-59 months),dependingontheagegroupconsidered.

The fieldwork was carried out by a properly trained andsupervisedteam,fromJanuary2014toJanuary2015, throughhomevisits,usingstructuredformspre-testedina pilotstudy carried out in themunicipality of Maceióin a low-incomeneighborhood,whichwasnotpartofthecensus sectorsrandomly selected for the survey. The tools were prepared by the researchers using the PNVITA Manual of Standards¹⁷ asareferenceandcritically evaluatedbythe teamafterthepilotstudy.

The studyincluded thechildren whose mothersagreed to provide information after consenting to participate and signing the informed consent, according to the terms of the project approved by the Research Ethics

CommitteeofUniversidadeFederaldeAlagoas(processNo.

09093012.0.0000.5013).

AccordingtoDonabedian,¹⁸theevaluationofaprogram’s effectivenesscanbeperformedbyanalyzingitsstructure, itsprocesses,andtheachievedresults.Aspectsrelatedto theprogramstructurewerenotassessedinthisstudy.The coverage attained by the program was investigated as a processindicator, i.e.,the proportionofthe targetpopu- lation that receivedvitamin A supplementation according toPNVITArecommendations.Regardingtheanalysisofthe results,themothers’levelofknowledgeaboutbasicinfor- mation on adequate nutrition was considered, especially thoserelatedtotheprogramfocus:hypovitaminosisApre- vention.Theadequacyofthisknowledgewasassumedasan outcomeindicatorrelatedtoNEactivities.

To define the coverage rate, the proportion of chil- dren from the target population who had a record of vitamin A supplementation over the past six months was considered, which is specified in the Program Manual for supplementation.¹⁷ Thisinformationwasobtainedby con- sultingtherespectivechildren’s‘‘healthbooklets.’’

To analyzethe adequacy of the NEactions, the moth- ersansweredquestionsonaspectstheyshouldknowabout, if they had participated in nutrition education activities included intheprogram,consideringthatthe‘‘Promotion ofadequateandhealthynutrition,ensuringinformationto encourage the consumption of foods that are sources of vitamin A by the population’’ is partof the PNVITA Man- ualactivities,¹⁷ asoneofthemostimportantmeasuresfor VADprevention.Aimingtoavoidinformationbias,onlythe mothers(biologicalornot)wereincludedinthestudy.

ThequestionaboutfoodsthatarerichinvitaminAwas presentedopenlyandtheintervieweecouldmentionupto threefoods.Toclassifytheadequacyoftheresponses,the PNVITAManualofActivities¹⁷wasusedasreference,which includesthefollowing:

‘‘VitaminAisamicronutrientfound inanimal (retinol) andvegetable(provitaminA)foodsources.Amongthefoods ofanimalorigin,themainsourcesare:humanmilk,liver,egg yolk,andmilk.ProvitaminAisfoundingreenleafyvegeta- bles (suchas spinach,kale, purslane, Indianspinach, and mustard greens), yellowvegetables (suchaspumpkin and carrots) and yellow-orangefruits (such asmango, cashew fruit, guava, papaya, and persimmon) in addition to oils andoleaginousfruits(buritifruitoil,pupunhapalm,dende palmoil,and souarinut)which aretherichest sourcesof provitaminA’’.¹⁷

Socioeconomic,demographicandhealth assessment

Questionswereobtainedthatwererelatedtodemograph- ics (areaofresidence, child’sgender and age,number of residentsperhousehold,maternalage),socioeconomicfac- tors(maternallevelofschooling,percapitamonthlyfamily income, number of durable consumer goods, number of rooms in thehousehold,number ofrooms usedfor sleep- ing,sourceofthewaterusedfordrinking,familyenrolled inthegovernment’sincometransferprogram)andhealth- relatedfactors(whetherthechildhadhaddiarrheainthe previous15days).

Dataanalysis

Thecollecteddatawereenteredinduplicateinaformcre- atedusingtheEpiInfo3.5.4softwareand,afterreviewing possible typing errors, the statistical analyses were car- ried out using Stata software (SPSS for Windows, version 12.0.Chicago,USA).Categorical variableswerecompared basedonPearson’schi-squaredtest(␹²).Theprevalenceof coverage (dependent variable) according to the different categories of independent variables was compared based ontheprevalenceratio(PR)andits95%confidence inter- val (95% CI). The independent variables of which crude PRs indicated association with coverage witha degree of significanceofupto20%(p<0.2)weresubmittedtothemul- tivariateanalysis,graduallyexcluding thosevariableswith nostatisticalsignificance(backwardelimination).Thefinal modelincludedonlythevariablesthatreachedthesignifi- cancelevelofp<0.05.ThePRsandtheirrespective95%CIs, bothinthecrudeandadjustedanalyses,werecalculatedby Poisson regression withrobustvariance adjustment.In all situations,thestatisticalsignificancewassetatp<0.05.

Results

The analyzed sample consisted of 509 children/mothers.

Mostofthem(74.3%)livedinurbanareas,6.4%ofthemoth- ers were adolescents, 28.7% had no access to adequate drinkingwater,and12.5%ofthefamilieshadapercapita monthlyfamilyincome≤½minimumwage(theminimum wagewasR$724.00,orapproximatelyUS$272,atthetime ofthestudy).Approximately2/3ofthefamiliesparticipated in the Bolsa Família Program, the Brazilian government incometransfer program. Theseand other characteristics areshowninTable1,whichshowsthattheincidenceofdiar- rheainthechildrenwas15.8%.Regardingthisaspect,there wasnodifferencebetweenchildrensupplementedandnot supplementedwithvitaminA.

Of the509assessed children,it wasobservedthat216 ofthemhadarecordofvitaminAsupplementationatsome timeintheprevioussixmonths,correspondingtoacoverage of42.4%.

Consideringtheagegroupswithsupplementationrecom- mendationbyPNVITA,itwasverifiedthatthepercentageof coveragebytheprograminchildrenaged6to11.9months was 91.9%, whereas it was 38.6% in those aged12 to 59 months of age (Table 1). Fig. 1 shows the coverage ver- ified through the present investigation in relation to the resultspublishedfortheyear2014bytheMinistryofHealth (MoH).¹⁹

Byfurtherstratifyingtheagegroups, itwaspossibleto observeasteadydeclineinthecoveragerateoftheprogram asthechildrengrewolder;thecoveragerateintheyounger childrenwas91.9%,whereasitwas29.5%inthoseaged47-59 months(Fig.2).

The factors that were independently associated, con- tributingtoagreatercoverageofPNVITAwerebetweenage rangebetween6and11.9months(PR=2.50,95%CI:2.10- 2.96),livinginruralareas(PR=1.45,95%CI:1.20-1.76)and living ina householdwithfour or fewerrooms (PR=1.33, 95%CI:1.09-1.63),asshowninTable1.

Table2showstheresultsrelatedtothePNVITAquestions appliedto the mothers. Only 27.5% had heard about the program,andevenso,only16.5%of themknew about its purpose(curingorpreventingvitaminAdeficiency).When askediftheyhadeverreceivedinformationaboutvitaminA, 88ofthe509respondentsansweredaffirmatively(17.7%).

Inthiscase,thenursewastheprofessionalresponsiblefor providinginformationin60.2%ofcases.

Itwasverifiedthatonly18.2%oftheintervieweesmen- tionedatleastonevitaminAfoodsource,whetherofanimal orvegetableorigin,¹⁷andthat80.8%ofthemdidnotknow ofanyhealthproblemscausedbyVAD.

Discussion

ThegoalofPNVITAistoreach75%coverageforchildrenaged 6to11monthsand100%forthefirstdoseand60%forthe seconddoseinchildrenaged12to59months.²⁰ Regarding thisaspect, theresults showedthat theprogram exceeds the goal of coverage in the case of the younger children (91.9%),butfallsshortregardingchildrenaged12months or older (38.6%). In this age group, the program recom- mendssupplementationeverysixmonths.^17,21Thus,achild thatreceived 100% of the dosesaccording tothis recom- mendation,considering theperiod comprisedbetween 12 and60 months, shouldhave received eightdoses. There- fore,thisstudyadoptedtherecordofsupplementationthat occurredintheprevioussixmonthsasthecriterionfordefin- ingcoverage.Regardlessofthismethodologicaldivergence, thecoveragefoundhereinformostoftheassessedchildren demonstratesthe needfor investmentsaiming toimprove theprogram’sreach.

AsforthecriterionusedbytheMinistryofHealthwhen considering the accomplishment of a 1^st and 2^nd dose, it appears inconsistent, as the Ministry itself determines that:^{17 ‘‘}Vitamin A supplementation should be offeredto childrenaged12 to59months ofageeverysix months.’’

This recommendation is based on the assumption that megadosesaresufficient toensure agoodhepatic retinol reserveforapproximatelysixmonths,atwhichtimefurther supplementationshouldoccur. Therefore,theappropriate programimplementationshouldensurethateachchildhasa recordedsupplementationthatoccurredatmostsixmonths before.Thus,thecomparisonwiththeMoHdataisimpaired.

Nevertheless, the coverage reported herein for the assessed age group (38.6%) was lower compared to that reportedbytheMoH:70.6%and41.2%,respectively,forthe 1^stand2^nddoses.Consideringthatthis‘‘1^stdose’’mayhave occurredlongago(itsbenefitswouldnolongerbeeffective) andthatthe‘‘2^nddose’’ismorelikelytohavebeengiven morerecently,whichis closertothecriterionusedinthis article,itcanbeobservedthattheobtainedvaluesarevery similar:38.6%and41.2%.

The adequate coverage observedin children aged6 to 11months could resultfrom their morefrequent contact withthehealthcareservices.Thisagegroupcomprisesthe targetpopulation ofseveral actionsimplementedin basic health units, suchas childcareconsultations andvisits to complywiththevaccinationschedule.²²

As in the present investigation, Almeida et al.,¹² in a study carried out in the municipality of Cabedelo (state

Table1 Demographic,socioeconomic,andhealthcharacteristicsofchildren aged6to 59months, accordingtoaccess to vitaminAmegadosesupplementationinthelastsixmonths.Alagoas,Brazil,2015.

Variables Samplen(%) ReceivedvitaminAsupplementation inthelast6months

p-value AdjustedPR (95%CI) Yes(%) CrudePR(95%CI)

Children’sage(months)

6to11.9 37(7.3) 34(91.9) 2.38(2.05-2.76) 0.001^e 2.50(2.10-2.96)

12to59,9 472(92.7) 182(38.6) 1

Gender

Male 252(49.5) 102(40.5) 1.09(0.89-1.34) 0.377

Female 257(50.5) 114(44.4) 1

Childwithdiarrheainthelast15days(12mothers[2.4%]couldnotanswer)

Yes 70(15.8) 34(42.5) 1.00(0.75-1.32) 0.985

No 427(84.2) 181(42.4) 1

Maternalage(years)(28mothers[5.5%]didnotknow/didnotwanttoanswer)

≤20 31(6.4) 13(41.9) 1.01(0.65-1.55) 0.956

>20 450(93.6) 191(42.4) 1

Maternaleducation(inyearsofstudy)(32mothers[6.3%]didnotknow/didnotwanttoanswer)

≤8 238(49.9) 97(40.8) 1.07(0.86-1.32) 0.543

>8 239(50.1) 104(43.5) 1

Areaofresidence

Rural 131(25.7) 71(54.2) 1.41(1.15-1.73) 0.001^e 1.45(1.20-1.76)

Urban 378(74.3) 145(38.4) 1

Numberoffamilymembers

≤4 312(61.3) 142(45.5) 1.21(0.97-1.50) 0.083

>4 197(38.7) 74(37.6) 1

Familyisenrolledinthegovernment’sincometransferprogram

Yes 331(65.0) 138(41.7) 1.05(0.85-1.30) 0.642

No 178(35.0) 78(43.8) 1

Percapitamonthlyfamilyincomeinnumberofminimumwages(R$)^a(39mothers[7.7%]%didnot know/didnotwanttoanswer)

≤½MW 59(12.5) 24(40.7) 1.07(0.77-1.48) 0.683

>½MW 411(87.5) 179(43.5) 1

Numberofdurableconsumergoods^b

<6 279(54.8) 116(41.6) 1.04(0.85-1.28) 0.666

≥6 230(45.2) 100(43.5) 1

Numberofroomsinthehouse

≤4 105(20.6) 56(53.3) 1.35(1.08-1.67) 0.007^e 1.33(1.09-1.63)

>4 404(79.4) 160(39.6) 1

Numberofroomsusedforsleeping

<2 340(66.8) 153(45.0) 1.22(0.97-1.53) 0.091

≥2 169(33.2) 62(36.9) 1

Originofdrinkingwater

Inadequate^c 146(28.7) 81(55.5) 1.49(1.22-1.82) 0.001^e

Adequate^d 363(71.3) 135(37.2) 1

aMinimumwagevalueatthetimeofdatacollection:R$724.00.

b TVset,radio,car,washingmachine,videocassette,refrigerator,freezer,microcomputer,dishwasher,microwaveoven,motorcycle, clothesdryer,DVDplayer.

c River,well,water-hole,etc.

d Generalwaternetworksystemormineralwater.

e Statisticallysignificantdifference(p<0.05)accordingtoPearson’schi-squaredtest.

Figure1 NationalVitaminASupplementationProgramcoverageinthestateofAlagoas,Brazil,in2014,accordingtodatafrom theMinistryofHealthandahouseholdsurveyinvolvingchildrenaged6to59months.

Source:MinistryofHealth(Brazil,2014);Householdsurvey.

TheresultsobtainedthroughthehouseholdsurveyinthestateofAlagoasfortheagegroupof12 to59 monthswereobtained usingadifferentmethod fromthosepublishedby theMinistryofHealth.Thelatterconsideredthecoverageinrelationtothe accomplishmentofa1^stand2^nddosesofvitaminAsupplementation.Inthehouseholdsurvey,coveragewasdefinedaccordingto thesupplementationrecordinthechild’s‘‘healthbooklet’’dateduptosixmonthsbeforetheinterview.

Figure2 NationalVitaminA SupplementationProgramcov- erageinthestateofAlagoas,Brazil,accordingtodifferentage rangesinchildrenfromthatstate,2015.

aStatisticallysignificant(chi-squaredforlineartrend).

of Paraíba,Brazil), alsofound greaterPNVITA coveragein youngerchildrenandadecliningtrendwithincreasingage (stratifiedbysemesters).Theadequatecoverageachieved inyoungerchildrenisaveryinterestingaspect,asitprovides vitaminAprotectionpreciselytooneofthegroupsbiologi- callymorevulnerabletomorbimortalityduetoinfections.⁹ Therefore, despite the excellent coverage observed in theagegroupof6to11months,thelowcoverageobserved in children older than 12 months is a matter of concern, whichsuggestsfailuresintheprogram’soperation.Accord- ing to Paiva,¹³ a strategy to increase coverage would be to improve the maternal level of information about the program and reinforce actions to increase adherence to scheduled health service visits. Additionally, the active searchstrategyisanalternativetoachievecoveragegoals inthisagegroup,since,unlikeyoungerchildren,thoseolder than12monthsaregenerallylessinvolvedinroutinevisits tothehealthservices.

No studies were found onthe economic impact of the activesearchstrategy.However,theMinistryofHealthitself

indicatesitasawaytoincreaseprogramcoverage,asitcan beincorporatedintotheroutineofthefamilyhealthteams andallowsadjustmentsintheregularityofsupplementation andtheNEactions.^11,12,17

Thepresentstudyidentifiedgreatercoverageofthepro- gramintheruralarea,asituationthatmayberelatedtothe moreactivesearchofhealthagentsintheseareas.¹²There isagreaterproportionofhouseholdsregisteredinthefamily healthunitsinruralareasinBrazil.²³

Anothervariablethatwasassociatedwithgreatercover- ageofthePNVITAwaslivinginahouseholdwithuptofour rooms,acondition thatmayreflectunfavorablesocioeco- nomiccharacteristics of the familyand,therefore, would receive greater attention from health professionals. The adverse effect of living in a poor household can be mit- igated when individuals receive more attention from the publicauthorities.²⁴

The variables that were associated with the greater coverage of the PNVITA suggest the adequate focus of the program: children in the most biologically vulner- able age group, living in rural areas, who belong to families with unfavorable socioeconomic characteristics.

Incidentally,unfavorablesocioeconomiccharacteristicscan interfereinthechoiceoffoodsconsumedbythefamilies, eitherduetotheirpurchasingpowerorasaconsequenceof thematernalknowledgeaboutadequatefoods.Therefore, thesechildrenwouldbemoresusceptibletoaninadequate intakeofdietaryvitaminA.²⁵

It is part of the regulation that created the PNVITA that,duringitsoperationalization,NEactivitiesshouldbe reinforced,withemphasis on healthy eatingpromotion.²¹ Tosupporttheseactivities,severalmaterialsareproduced (leaflets, posters) containing information about the pro- gram, VAD and its consequences, and food sources high in vitamin A. If these resources are reaching the target

Table2 Frequencyofresponsesgivenbymothersofchildrenaged6to59monthstoquestionsrelatedtotheNationalVitamin ASupplementationProgram.Alagoas,Brazil,2015.

Questions/Answers n %

HaveyouheardabouttheNationalVitaminASupplementationProgram?

No 366 72.5

Yes 139 27.5

Inyouropinion,whatisthepurposeoftheNationalVitaminASupplementationProgram?^a

Anotheranswer/didnotknowhowtoanswer 116 83.5

Tocure/preventvitaminAdeficiency 23 16.5

HasthechildeverfailedtoreceivethedoseofvitaminAbecausetheydidnothaveitinthebasic healthunit?

Yes 181 36.3

No/doesnotremember 318 63.7

Amongotherthings,duringthisprogram,hassomeonefromHealthCarecutacapsulelikethis (SHOWIT)containingvitaminAandputitinthechild’smouth?Hasyourchildreceivedthisvitamin Ainthelast6months.?^b

No/doesnotremember 163 32.5

Yes 339 67.5

Timesincetheadministrationofthelastdose(coveragerate)^c

>6months 293 57.6

≤6months 216 42.4

HaveyoueverreceivedinformationaboutvitaminA?

No/doesnotremember 409 82.3

Yes 88 17.7

Whichprofessionalgaveyoutheinformation?^d

Nurse 53 60.2

Physician 6 6.8

Nutritionist 0 0.0

Pharmacist 2 2.3

Healthagent 25 28.4

Doesnotremember 2 2.3

WhichfoodsarerichinvitaminA?

3correctanswers 3 1.0

2correctanswers 21 6.9

1correctanswer 55 18.2

Errors/Doesnotknow 224 73.9

WhathealthproblemscanoccurwhenourbodylacksvitaminA?

3correctanswers 3 0.6

2correctanswers 15 2.9

1correctanswer 80 15.7

Errors/doesnotknow 411 80.8

Somemothersdidnotwanttoanswerquestions1,3,4,6and8,whichiswhytherespectivepercentageswerecalculatedconsidering onlythetotalanswersobtained.Thenon-responsefrequenciesforthesequestionswere,respectively:0.8%(n=4);2.0%(n=10);1.4%

(n=7);2.4%(n=12);40.5%(n=206).

aAppliedtothosewhoanswered‘‘yes’’tothepreviousitem.

b Correspondstothemothers’answer.

c Correspondstothedoseconfirmedonthechild’svaccinationcard.

d Correspondstothe17.7%whoreportedreceivinginformationonvitaminA.

audience and if the information is being transmitted, regardless of the strategies used (individual guidance, group meetings, lectures, dramatizations, videos), the mothersshouldrecognizetheexistenceofPNVITAandwhat itspurposeis.However,only27.5%ofthemreportedhaving heardoftheprogram,andofthese,only16.5%knewhowto correctlyanswerabout itspurpose.Mostofthemreported

having watched the administration of vitamin A to the child; however,theywereunaware of itsconnectionwith the PNVITA. Considering these data and comparing them withthecoveragerate observedherein,it isevident that thesupplementationactivityoccurswhiledissociatedfrom educationalguidelines,which,inadditiontobeingoutside thescopeoftheprogram,doesnotprovidesustainabilityto

theprocess,sincewithoutanadequatediet,theriskofVAD willalways existand,consequently,the need tomaintain supplementationactivities.

In supportoftheseconsiderations isthe factthatonly 17.7%ofthemothersansweredthattheyhadreceivedinfor- mationaboutvitaminA,73.9%didnotknowanyfoodsrich in vitaminA, and80.8% didnot know at leastone conse- quenceofvitaminAdeficiency.Similarresultswerefoundin asampleof2,546childrenfrommunicipalitieslocatedinthe stateofBahia,Brazil,¹where74.6%ofthemothershadno knowledgeaboutvitaminA.Whilestudyingchildrenfroma municipalitylocatedinnortheasternBrazil,Almeidaetal.¹² observedthat only43.5% ofthe mothershadheard about PNVITA;however, of these,86.2%did notknow about the program’sactivities.Moreover,only 22.2%provideda cor- rectanswer aboutsomefunctionofvitaminA,andamong those who claimed to know the food sources of retinol (40.7%), only 33.4% correctly mentioned some food with thischaracteristic.Consideringthesefindings,theystated thatthelackofknowledgerelatedtovitaminAmayinter- ferewithadherencetoPNVITAactions,makingitdifficultto achievetheestablishedgoals.

The nutritionist is the health professional whose work aims to provide dietary care at the individual or collec- tive level.²⁶ However,of the mothers whoanswered they received some information on vitamin A, none of them reportedthisinformationwasprovidedbyanutritionist.In thisscenario, in60.2%of thecases,it wasthenursewho providedsuchinformation.Astudy includingprofessionals involved in theprogram operationalizationin ninemunic- ipalities located in the state of Paraíba identified a low participationofnursesinNEactivities,withhealthagents beingthemainperformersofthisactivity.¹³

Marques et al.¹¹ used a qualitative approach to iden- tifypracticesrelatedtoPNVITAanddisclosematernalsocial representationsaboutvitaminA,itsdeficiency,andthepro- graminamunicipalitylocatedinValedoJequitinhonha.It wasobservedthatsupplementationhasoccurredinassoci- ationwithvaccinationactions,whichmayfavoranincrease insupplementationcoverage,butalsomayresultinapas- siveparticipationinPNVITA,bothbythetargetpopulation andbytheprofessionals,consideringthatsupplementation is carriedout asa secondary action tovaccination andis unaccompanied byan educational process,leadingto the formation of distorted ideas, such as that vitamin A is a vaccine.

Themisinformationcontributestobadchoicesregarding theindividuals’selectionoffoods.Graebneretal.,²⁷ when investigatingchildren fromruralareasof theFederal Dis- trict,foundthat,evenwhentheyhadaccesstofoodsources ofcarotenoids,childrenhadahighprevalenceofVAD,which wouldnotoccurifthesefoodswereregularlyconsumed.

Rodrigues and Roncada²⁸ have stated that, since its implementation, PNVITA’s main emphasis is onthe distri- butionofvitaminAmegadosesandthatnutritioneducation activities are far behindthe expected due tothe lack of skilled human resources and the lack of effective imple- mentationstrategies. Theybelieve thatasthe NEactions develop and are consolidated as part of an intersectoral publichealth promotionpolicy, therewill beanevolution oftheproposedcontentsandmethodologies,whichwillbe incorporatedintoitspractice,promotinghealthyeatingand

preventingnotonlydiseasessuchasVAD,butalsochronic noncommunicablediseases.

TheresultsobtainedallowustoconcludethatthePNVITA coverageinchildrenaged12-59monthsisbelowtheestab- lished goals. However, the factors associated to greater coverageindicate an adequate focusregarding thetarget population. The NE activities have not demonstratedsat- isfactoryresults,jeopardizingtheprogram’seffectiveness.

Thisinformationshouldguidehealthmanagersandprofes- sionalswhenplanningimprovementactionsfortheprogram.

Funding

ThisstudyreceivedfinancialsupportfromtheBrazilianCon- selhoNacionaldeDesenvolvimentoCientíficoeTecnológico ---(NationalCouncil for ScientificandTechnological Devel- opment - CNPq) (process No. 474381 / 2011-0) and the Fundac¸ão de Amparo à Pesquisa of the state of Alagoas (AlagoasResearchSupportFoundation---FAPEAL)underpro- cessNo.60030.000716/2013.

Conflicts of interest

Theauthorsdeclarenoconflictsofinterest.

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