| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
RESEARCH AND PRACTICE |
Joanne Katz, Keith P. West Jr, Lee Wu, Elizabeth Kimbrough Pradhan, Parul Christian, and Steven C. LeClerq are with the Department of International Health, Center for Human Nutrition, Johns Hopkins School of Hygiene and Public Health, Baltimore, Md. Subarna K. Khatry and Sharada Ram Shrestha are with the Nepal Nutrition Intervention Project, Sarlahi, Kathmandu, Nepal.
Correspondence: Requests for reprints should be sent to Joanne Katz, ScD, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Room W5515, Baltimore, MD 21205–2103 (e-mail: jkatz{at}jhsph.edu).
 |
INTRODUCTION |
|---|
 TOP INTRODUCTION METHODSRESULTSDISCUSSIONReferences |
|---|
|
METHODS |
|---|
|
TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
All women who applied for employment as distributors were interviewed in regard to demographic and socioeconomic characteristics such as age, literacy, years of education, number of hours spent doing housework, occupation of head of household, land ownership, type of dwelling and sanitation, and socioeconomic status (measured in terms of ownership of animals, ox carts, radios, watches, bicycles, furniture, and kitchen utensils). Information was also gathered on whether a weekly market, health post, school, or medicine shop was located in a given ward. Two years into the trial, the hours per week that distributors spent on this work were ascertained via interviews. Number of recipients for whom each distributor was responsible was recorded throughout the trial.
On the basis of analyses of socioeconomic data from the trial population, we developed a Guttman scale to characterize respondents' socioeconomic status as reflected by land, cattle, and ox cart ownership and whether their house had an upper story.17 Scores could range from 0 (no land, cattle, or ox cart ownership and no upper story) to 4 (land, cattle, and ox cart ownership and upper story). Values below 3 denoted "lower" socioeconomic status.
For each supplement recipient, coverage was defined as the percentage of possible doses received in the trial. The overall coverage rate attained by each distributor was estimated as the mean coverage rate among all recipients for which that distributor was responsible. Low and high coverage rates were defined as less than 50% and 70% or more, respectively. This choice of cutoffs was based on the minimum coverage thought to produce beneficial health outcomes and the maximum coverage that would not lead to any improvements in community health.
Two multiple logistic regression models were fitted to the coverage data, one with low coverage and the other with high coverage as the outcome. Hours per week spent distributing supplements and doing housework and number of women for whom the distributor was responsible were entered into the model as continuous variables. Selection of variables for model inclusion was based on P values below .10 for individual associations with coverage.
|
RESULTS |
|---|
|
TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
In comparison with women from villages without a weekly market, those from villages that contained a weekly market were more likely to have low coverage rates (odds ratio [OR] = 2.32; 95% confidence interval [CI] = 1.01, 5.28), to do more housework each week (42.5 hours vs 38.2 hours), and to distribute supplements to more women (114 vs 103; Table 1
). Also, women with higher coverage rates were more likely to be illiterate (OR = 5.07; 95% CI = 0.94, 27.44). Finally, distributors with higher coverage rates spent 1 hour less per week distributing supplements, as they had fewer women to supplement.
|
|
DISCUSSION |
|---|
|
TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
The literacy rate among the recipients was 14%.15,16 Illiterate distributors may have related better to women who were more like themselves, leading to increased compliance. A similar result was seen in a vitamin A supplementation program for preschool children in Indonesia, where village-based male distributors with less education had higher coverage rates.18
As mentioned, distributors with higher coverage rates spent an average of 1 hour less per week doing their work. Amount of time spent was a function not only of the number of households to be visited but also of the amount of travel time between households. Hence, time spent on work might not mean more time spent with each recipient.
Amount of time spent distributing supplements did have an effect on coverage, but distributors with low coverage rates had an average of 13 more women to supplement than did those with high coverage rates. They also reported an average of 4 more hours of housework per week than did distributors with higher coverage rates. Thus, although there was no evidence that work conditions (hours spent and number of households visited) or competing demands (housework) were associated with high coverage, these factors did appear to be related to low coverage.
Recipient characteristics that predicted higher coverage rates included older age and higher parity, previous history of child deaths, and lower socioeconomic status.19 This profile of the compliant recipient fits the notion that compliance is higher among distributors who are similar to recipients in terms of education level. If the results of ongoing and planned trials involving antenatal micronutrient supplementation confirm the benefits of such interventions, the success and sustainability of programs may be enhanced through a better understanding of the characteristics of distributors and recipients.
|
Acknowledgments |
|---|
|
Footnotes |
|---|
Accepted for publication October 18, 2001.
|
References |
|---|
|
TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
2. West KP Jr, Pokhrel RP, Katz J, et al. Efficacy of vitamin A in reducing preschool child mortality in Nepal. Lancet.1991;338:67–71.[Medline]
3. Daulaire NMP, Starbuck ES, Houston RM, Church MS, Stukel TA, Pandey MR. Childhood mortality after a high dose of vitamin A in a high risk population. BMJ.1992;304:207–210.
4. Ghana VAST Study Team. Vitamin A supplementation in northern Ghana: effects on clinic attendances, hospital admissions and child mortality. Lancet.1993;342:7–12.[Medline]
5. Lawless JW, Latham MC, Stephenson LS, Kinoti SN, Pertet AM. Iron supplementation improves appetite and growth in anemic Kenyan primary school children. J Nutr.1994;124:645–654.
6. Menendez C, Kahigwa E, Hirt R, et al. Randomised placebo-controlled trial of iron supplementation and malaria chemoprophylaxis for prevention of severe anemia and malaria in Tanzanian infants. Lancet.1997;350:844–850.[Medline]
7. Kolsteren P, Rahman SR, Hilderbrand K, Diniz A. Treatment for iron deficiency anaemia with a combined supplementation of iron, vitamin A and zinc in women of Dinajpur, Bangladesh. Eur J Clin Nutr.1999;53:102–106.[Medline]
8.
Osendarp SJM, van Raaij JMA, Arifee SE, Wahed MA, Baqui AH, Fuchs GJ. A randomized, placebocontrolled trial of the effect of zinc supplementation during pregnancy on pregnancy outcome in Bangladeshi urban poor. Am J Clin Nutr.2000;71:114–119.
9.
Smith JC, Makdani D, Hegar A, Rao D, Douglass LW. Vitamin A and zinc supplementation of preschool children. J Am Coll Nutr.1999;18:213–222.
10. Berger J, Dyuck JL, Galan P, et al. Effect of daily iron supplementation on iron status, cell-mediated immunity, and incidence of infections in 6–36 month old Togolese children. Eur J Clin Nutr.2000;54:29–35.[Medline]
11. Umeta M, West CE, Haidar J, Deurenberg P, Hautvast JG. Zinc supplementation and stunted infants in Ethiopia: a randomised controlled trial. Lancet.2000;355:2021–2026.[Medline]
12. Sazawal S, Black RE, Bhan MK, et al. Zinc supplementation reduces incidence of persistent diarrhea and dysentery among low socioeconomic children in India. J Nutr.1996;126:443–450.
13.
Sazawal S, Black RE, Bhan MK, Jalla S, Sinhu A, Bhandari N. Efficacy of zinc supplementation in reducing the incidence and prevalence of acute diarrhea—a community-based, double-blind, controlled trial. Am J Clin Nutr.1997;66:413–418.
14.
Sazawal S, Black RE, Jalla S, Mazumdar S, Sinha A, Bhan MK. Zinc supplementation reduces the incidence of acute lower respiratory infections in infants and preschool children: a double-blind controlled trial. Pediatrics.1998;102:1–5.
15.
West KP Jr, Katz J, Khatry SK, et al. Double blind, cluster randomised trial of low dose supplementation with vitamin A or beta-carotene on mortality related to pregnancy in Nepal. BMJ.1999;318:570–575.
16.
Katz J, West KP Jr, Khatry SK, et al. Maternal low-dose vitamin A or beta-carotene supplementation has no effect on fetal loss and early infant mortality: a randomized cluster trial in Nepal. Am J Clin Nutr.2000;71:1570–1576.
17.
Christian P, West KP Jr, Khatry SK, et al. Night blindness of pregnancy in rural Nepal—nutritional and health risks. Int J Epidemiol.1998;27:231–237.
18.
Tarwotjo I, West KP Jr, Mele L, et al. Determinants of community-based coverage: periodic vitamin A supplementation. Am J Public Health.1989;79:847–849.
19. Christian P, West KP Jr, Khatry SK, et al. Compliance to vitamin A and beta-carotene supplementation and pregnancy-related mortality in Nepali women—program implications. Paper presented at: International Vitamin A Consultative Group Meetings, February 12–15 2001, Hanoi, Vietnam.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
70%) Supplement Coverage and Adjusted Odds Ratios: Sarlahi District, Nepal, 1994–1997