BMJ Open · 8 authors, 3 centres
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Vitamin A supplementation (VAS) coverage varies widely across 49 low/middle-income countries, with children who lack access to vitamin A-rich foods and healthcare services being less likely to receive VAS despite greater need. Significant inequities exist by geography, wealth, and caregiver education, suggesting current programs are not reaching the most vulnerable children. These findings highlight the need for targeted strategies to improve equitable VAS delivery.
**Background:** Vitamin A deficiency affects an estimated 29% of children under 5 in low/middle-income countries, contributing to mortality and infection severity. Biannual high-dose vitamin A supplementation (VAS) for children aged 6–59 months is a low-cost intervention, but global coverage has stagnated. This study aimed to evaluate equity dimensions of national VAS programs using Demographic and Health Survey (DHS) data from 49 countries, examining coverage differences by determinants of child nutrition and geography.
**Methods:** This secondary analysis used open-source DHS data from 49 countries (most recent survey since 2010). The primary outcome was VAS coverage (percentage of children 6–59 months receiving VAS in the prior 6 months). Coverage was stratified by covariates representing immediate/underlying determinants (recent consumption of vitamin A-rich foods for children 6–23 months; access to DTP1 and MCV1 vaccines as proxy for healthcare access), enabling determinants (socioeconomic position via wealth quintiles, caregiver educational attainment, caregiver social independence and decision-making autonomy via SWPER Index), and geography (urban/rural residence, administrative region). Estimates were weighted using DHS sample weights; statistically significant differences were identified by non-overlapping 95% CIs.
**Key Results:** Data from 1,465,369 women and 608,388 children aged 6–59 months were analyzed. National VAS coverage averaged 58% (range 28%–83%). Children who did not recently consume vitamin A-rich foods had significantly lower VAS coverage in 85% (41/49) of countries. Children lacking DTP1 vaccine had significantly lower VAS coverage in 47/49 countries; those lacking MCV1 had lower coverage in all 49 countries. By geography, 31% (15/49) of countries had significantly lower rural vs. urban coverage; 88% (43/49) showed significant differences between administrative regions. By wealth, 73% (36/49) of countries had significantly higher coverage in the wealthiest vs. poorest quintile (largest gaps: Nigeria 33%, Côte d'Ivoire 25%, DRC 25%). Caregiver social independence was associated with higher coverage in 37% (18/49) of countries, decision-making autonomy in 20% (10/49), and higher educational attainment in several countries.
**Clinical Implications:** VAS programs are not equitably reaching children most in need—those with poor dietary vitamin A intake and limited healthcare access. The consistent association with vaccine coverage suggests aligning VAS with routine immunization (e.g., EPI) could improve reach, though this requires system reforms (e.g., 6-month contact point, supply chain integration). For older children (12–59 months), integration with other routine programs (growth monitoring, early childhood development) may be needed. The findings support using DHS data for subnational equity monitoring to guide targeted program improvements, especially in low-coverage settings.