Malnutrition and morbidity among children not reached by the national vitamin A capsule programme in urban slum areas of Indonesia

Objective: To determine whether vitamin A capsule programmes fail to reach children who are at higher risk of malnutrition and morbidity. Although it has been suggested that there are health disparities between children who are reached or not reached by these programmes, little quantitative work has been undertaken to characterize this relationship. Study design: As part of a national surveillance system, nutritional status and other factors were compared in 138,956 children, aged 12-59 months, who had and had not received vitamin A supplementation in urban slum areas in Indonesia. Results: In total, 63.1% of children had received a vitamin A capsule within the previous 6 months. Among children who had and had not received vitamin A supplementation, respectively, the proportion with weight-for-age and height-for-age Z scores <-3 were 7.8% vs 8.6% (P<0.0001) and 9.4% vs 10.7% (P<0.0001), and with a history of diarrhoea in the previous week was 8.1% vs 10.7% (P<0.0001). In families where a child had or had not received vitamin A supplementation, the proportion with a history of infant death <12 months was 5.2% vs 7.2% (P<0.0001) and child death <5 years was 6.7% vs 9.2%, respectively (P<0.0001). Children who had not received vitamin A supplementation were also significantly more likely to be anaemic and have diarrhoea or fever on the survey day compared with children who had received supplementation. Conclusions: In the urban slums of Indonesia, children who do not receive vitamin A supplementation tend to be slightly more malnourished and ill, and are more likely to come from families with higher child mortality than children who receive vitamin A. Higher rates of child mortality in non-participating households suggest that reaching preschoolers could yield a disproportionate survival benefit. Importantly, children who are not reached by the vitamin A programme are also unlikely to be reached by vaccination and other services, emphasizing the need to identify and extend efforts to reach non-participants.