An Intervention to Address Vitamin A Deficiency in Ethiopia

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Identification of the Problem

Vitamin A deficiency has been defined in different ways by different scholars. For instance, the World Health Organizations states that vitamin A deficiency is “the situation that exists when tissue levels are depleted to a level at which health consequences occur even in the absence of xerophthalmia,” (cited by Low 1997, p. 1). Vitamin A deficiency has also been defined using several terms: Xerophthalmia – if the patient exhibited any clinical signs of vitamin A deficiency in one or both eyes (Haidar & Demissie 1999); severe hyporetinolaemia – if the level of serum retinol in the patient is less than 0.35 µmol/l; mild to moderate hyporetinolaemia – if the level of serum retinol in the patient ranged between 0.35 and 0.70 µmol/l; and low vitamin A reserve – if the modified relative dose response rate is greater than or equal to 0.06 (Kassaye et al. 2003).

Irrespective of the definition adopted for vitamin A deficiency, vitamin A plays an important role in the functioning of the body. It is especially important for optimal vision and inadequate consumption of the micronutrient often leads to night blindness or total blindness. This is because vitamin A plays a key role in phototransduction. In the eyes, the cone cells play the role of the absorption of light and colour vision when there is bright light. Lack of adequate vitamin A makes it impossible for the eyes to produce visual pigments which in turn minimize the absorption of different wavelengths of light thus leading to blindness (Gropper, Smith & Groff 2005). Although vitamin A deficiency is commonly associated with visual impairments, the deficiency also causes other health problems which include: Bitot spots – Bitot spots are defined as “areas of abnormal squamous cell proliferation and keratinization of the conjunctiva,” (Semba 2007, p. 3). VAD leads to high rates of mortality among infants and children aged below 6 years. It increases the seriousness, consequences, and risk of death as a result of measles. It is linked to high rates of disease among infants, especially in the seriousness of disease episodes, for instance, diarrheal and pneumonia. It leads to the wrinkling and premature aging of skin which appears as rough and dry, as well as general skin disorders (Shils & Shike 2006). It dries up the mucous membranes found in the mouth and the respiratory and reproductive organs. VAD also causes a variety of allergic reactions (Higdon 2003).

Vitamin A deficiency is caused by two major factors: the lack of adequate consumption of vitamin A and the inability of the body to absorb or ingest vitamin A due to high rates of morbidity caused by diseases such as malaria, measles and parasitic infections (Palmer 2004). The effects of vitamin A deficiency on the sufferers and the wider community lie in the inability and difficulty to diagnose it just by observation (Kassaye et al. 2003). In most cases therefore, vitamin A deficiency is usually diagnosed clinically by trained community health workers.

Justification for Carrying Out the Intervention Strategy

Clinical and sub-clinical vitamin A deficiency is prevalent in Ethiopia among children as well as pregnant and lactating mothers in whom tremendously low levels of serum retinol are found. In general, the consumption of vitamin A is usually insufficient due to the seasonality of sources of food, the early desertion of exclusive breast feeding, high rates of morbidity, and the general practice of not feeding children with foods that are rich in vitamin A. Since the early 1990s, the key intervention strategy for dealing with VAD not only in Ethiopia but also other Sub-Saharan countries has been to hand out huge doses of vitamin A capsules to children who have been diagnosed as having vitamin A deficiency through clinical examinations. Whereas the supplementation method through vitamin A capsules to children and at-risk mothers helps to address VAD to some extent (Berger et al. 2007), the method is often subject to failure due to a number of reasons.

First, the Sub-Saharan countries are generally poor countries and often cannot afford to provide vitamin A supplements to all VAD patients. In most cases therefore, supplementation is achieved through donors who send the capsules to the affected populations. The problem of reliance on donors lies in the lack of sustainability. If the donors decide to halt their assistance, the beneficiary countries in question will not be in a position to continue with the intervention programs. Another problem of supplementation is its inability to reach all the members of the target population particularly due to corruption of government officials in charge of the distribution. It is therefore common to find that some not-so-deserving children benefitting from the supplementation program at the expense of the more deserving children. Another challenge facing supplementation programs is their costly nature which prevents them from being a long-term solution (Black, Morris & Bryce 2003).

Vitamin A deficiency usually starts to peak from the age of 2 to 4 years. At this age, however, majority of mothers tend to have stopped taking their children for monthly clinical check ups because of the completion of infant immunization at the age of 9 months. Given all these factors, the most effective intervention strategy for combating vitamin A deficiency would be a preventative one rather than a curative one. In the selection of any intervention strategy, technical feasibility, cost-effectiveness and sustainability are the three key issues that need to be addressed (Ekvall & Ekvall 2005). The intervention strategy proposed in this paper is a foods-based strategy which is achieved through agricultural production of foods rich in vitamins A, in this case orange- and yellow-fleshed sweet potatoes (Pitchford 2003). The justifications for the production of sweet potatoes as the VAD intervention strategy include: Suitability – vitamin A deficiency is the most suitable to agriculturally-based interventions among the major micronutrient deficiencies; cost – yellow- and orange-fleshed sweet potatoes are the cheapest source of dietary vitamin A that households can produce throughout the year; source of calories – among all the available major plant sources of vitamin A, sweet potato is the best source of calories (Low, Walker & Hijmans 2001); and recommended daily intake – the regular consumption of yellow- and orange-fleshed sweet potatoes can ensure the achievement of the recommended daily allowances of vitamin A (Sommer & Davidson 2002).

Aims and Objectives of the Intervention Strategy

The main goal of the proposed intervention strategy is to ensure that Ethiopian school going children have adequate intake of vitamin A in their diets. The major objectives of the intervention strategy include:

To initiate and assess the varieties of B-carotene-rich sweet potatoes among Ethiopian communities which are adversely affected by vitamin A deficiency
To educate communities on the role that Vitamin A plays in the diet for both children and adults through working directly with women’s groups, mobilizing public health workers, and using different channels of the mass media
To work with women’s groups in the production and marketing of processed sweet potato products as income-generating activities
To enhance the capacity for the women’s groups to supervise and assess their own progress regarding the suitability of different varieties of sweet potatoes as well as the feasibility of the processed products

Potential Benefits of the Proposed Intervention Strategy

The proposed intervention strategy, if successful, is likely to result in: Enhanced own production and consumption of fresh sweet potatoes as well as processed products made from sweet potatoes such as flour; an increased intake of foods that are good sources of vitamin A among children and the entire household; an extra source of income for the households which in turn translate into higher standards of living; the consumption of additional sources of vitamin A and health services through the income generated from the program; the women taking part in the program will gain more knowledge and skills in matters concerning diets and general health as well as in the production, marketing and selling of sweet potatoes; and an improved teamwork and communal spirit among the members of the community through their active participation in the programs particularly

Planned Coverage of the Program

The sweet potato-based intervention strategy will be undertaken in the Eastern zone of Tigray administrative region of Ethiopia. In this region, the prevalence of vitamin A deficiency is extremely high among children. The target population for this program will however be children aged between 5 and 9 years. This is a population of school going children suffering from VAD. The choice for this target population lies in the fact that they need good vision and generally good health to be able to undertake their studies successfully. According to Kassaye et al. (2001), the Eastern zone of Tigray administrative region has 4423 children suffering from xerophthalmia, 6406 children suffering from serum retinol levels below 0.35 µmol/l, 38,968 children suffering from serum retinol levels ranging between 0.35 and 0.70 µmol/l, and 31,266 children suffering from vitamin A reserve of greater than or equal to 0.06. All these are children aged below 9 years. The program will also target mothers with school going children. This is because it is the mothers who feed their children and therefore their involvement in the program will ensure that they benefit from the program by learning the best and healthy foods to feed their children.

Ensuring the Acceptance of the Intervention Strategy by the Community

Before the implementation of the program, the program officers will convene with important figures of the communities including: the community elders, community health workers, institutions such as non-profit-making groups, schools, and churches. The involvement and support of these important figures will determine the success or failure of the intervention strategy (Sanders 1999). Once the program officers have been given the go-ahead by the community, the program officers will then meet with all women in each community who have young and school going children. This meeting will form the foundation upon which the program officers will discuss with the mothers about vitamin A deficiency, its effects on children and the entire society and the methods through which the VAD can be eliminated or prevented.

The meeting will also provide the program officers with the opportunity to justify the choice of the particular intervention strategy chosen. This will be done by educating the women on the different intervention strategies that can be used to address VAD, including their pros and cons. Without such a detailed explanation, the community may not understand why the sweet potato-based strategy has been selected instead of other seemingly easier strategies such as supplementation. The program officers will therefore have to convince the communities involved that the proposed strategy is more beneficial than others (Tontisirin & Winichagoon 1999).

Methods Used in the Intervention Strategy

The vitamin A deficiency intervention strategy will be carried out through two main methods: production and marketing of sweet potatoes, and nutritional education.

Production and marketing of sweet potatoes

The chief objective of the community intervention strategy is the extension of B-carotene-rich sweet potato varieties throughout the communities in the Eastern zone of Tigray administrative region. The program will however be facilitated through the creation of 10- or 20-member women groups. The choice of the women groups as the socialization agents is due to the fact that women still remain the key home keepers in most regions of Sub-Saharan Africa. In addition, women are more involved than men in farming and other agricultural activities. It is therefore important for the program to actively involve women. Once the women groups have been formed, an appropriate number of extension and health officers will undergo an extensive training on the role of vitamin A in the general health as well as on the methods of improving the cultivation of different varieties of sweet potatoes. The trained extension and health officers will then train the women in their groups about the same.

Once the training is done, the women will go ahead with the cultivation of different sweet potato varieties specifically the yellow- and orange-fleshed varieties in their plots. The women’s groups will act as the agents of dissemination and distribution of knowledge to the other members of the communities. The sweet potato varieties which performed well in this initial intervention phase will then be rapidly multiplied in selected primary sites throughout the communities. These varieties will then be distributed to each affected household for home gardening so that each household cultivates its own sweet potatoes both for home consumption and sale if desired. During the distribution of the sweet potato varieties to the households, a lecture will be given about the role played by vitamin A in our diets and how sweet potatoes are a good source of vitamin A (Low 1997).

The intervention strategy will also involve extensive marketing and promotion of yellow- and orange-fleshed sweet potato varieties especially among the urban communities where farming is limited due to a dense population and subsequent lack of adequate farming land. Market surveys will be conducted in these urban centres to determine the acceptance of processed products made from sweet potatoes such as flour. The promotion of sweet potatoes will not only be done to households but also to local market vendors who will be encouraged to sell sweet potatoes in lieu of other ingredients. Taking into consideration any technical or marketing challenges involved in the substitution of sweet potatoes for other ingredients, the program officers will work together with the local vendors and processors to address the challenges (World Bank 2001).

Market demonstrations will be created to reach more households in the urban centres. In addition, the mass media particularly radio programs will also be used to disseminate knowledge and to create awareness among the urban households concerning vitamin A deficiency and its adverse consequences as well as the importance of diets in addressing this deficiency (Low, Walker & Hijmans 2001).

Nutritional education

Due to the limited availability of modern channels of communication in the rural communities, the program officers will place emphasis on developing flip charts and the use of practical demonstrations to disseminate nutritional knowledge and enhance health practices among the women’s groups and the entire community (Tontisirin & Gillespie 1999). The Agricultural Information Services will help in this area by creating and testing these educational materials. The nutrition education messages will concentrate around a number of key main points including: The chief benefits of vitamin A – vitamin A is a micronutrient that is necessary in the fight against grave illnesses, and it also helps in the optimal functioning of the eyesight; how to differentiate between the major, minor, and insignificant sources of vitamin A; the role of fat in the absorption of vitamin A; the role of colostrum in promoting the health of infants; and the need for frequent feeding of children. These educative messages will put emphasis on the association between inadequate intake of vitamin A and illnesses such as measles.

Time Frame

The time frame for the successful implementation of the sweet potato-based intervention strategy will be approximately fifteen months. The activities that will be carried out throughout the designated time frame are as follows:

1^st month – a qualitative assessment of the region will be done by the program officers. The officers will convene with the key figures and institutions of the community to propose and convince them of the feasibility of the program. In the same month, the program officers will also meet with the women’s groups to discuss about vitamin A deficiency and the proposed intervention strategy. Market surveys will also be carried out during this month to determine consumer behaviour regarding the new varieties of sweet potatoes. The familiarity of community health workers and extension officers about vitamin A will also be determined.
2^nd to 3^rd month – the planting of new sweet potato varieties on women’s groups’ plots will be done. The successful varieties will then be multiplied rapidly on selected primary sites. Distribution of the successful varieties from the plots of the women’s groups and the primary sites to other households will also be done in this month.
4^th month – Extension agents from non-governmental organizations will be posted full-time throughout the communities.
4^th to 6^th month – Home visits will be done to determine the child feeding practices of households in the communities
7^th month – Harvest of the planted sweet potatoes will be done. Taste evaluation of the initial round of on-farm yields will be done on all the new varieties of sweet potatoes.
5^th to 10^th month – during this time period, the nutrition education materials will be developed, and pre-tested at the community level. Marketing and promotion of the sweet potatoes will also be carried out to the urban centres.
11^th to 14^th month – A laboratory analysis for B-carotene content will be conducted on the new varieties of sweet potatoes to determine if they can provide the daily recommended amount of vitamin A.
15^th month – Finalization of the intervention strategy will be done in which the program officers will determine the success or failure of the intervention strategy in addressing vitamin A deficiency in the selected region. If successful, the strategy will be adopted by the community as a long-term solution to the problem of vitamin A deficiency.

Cost Effectiveness

The cost effectiveness of this program will be measured using the disability adjusted life year (DALY) which is a measurement that is equal to a year of healthy life that is lost as a result of a health condition. The calculation of DALY is done by “combining the years of life lost from a disease and the years of life spent with disability from the disease,” (Semba & Bloem 2008, p. 867). The cost effectiveness of this program is approximated to be $25 per every DALY saved. The program is therefore cost-effective because it will take the community only $25 to save one life that would otherwise have been lost or disabled due to the complications brought about by vitamin A deficiency (Duggan, Watkins & Walker 2008).

Agencies Involved

A number of agencies will be involved in this program, including: Non-governmental organizations – NGOs dealing with health and nutrition and agriculture will take part in the program to train local health and extension officers and to oversee the overall implementation of the program; Agricultural Information Services – this agency will assist in the development and testing of educational materials to be disseminated throughout the communities; media agencies – these agencies will assist in the dissemination of information to the communities particularly to the urban centres; and market research organizations – these organizations will conduct market surveys throughout the communities and urban centres to determine consumer behaviour regarding the new varieties of sweet potatoes.

Outcomes Assessment

The impact of the sweet potato-based intervention strategy at the community level will be evaluated through several ways: Quarterly examinations of the quantities and prices of the new varieties of sweet potatoes on the market; the rate of dissemination of planting materials to other households in the wider community; close supervision of the decline in seasonal fluctuations in the supply of sweet potatoes as well as the accessibility of sufficient amounts of planting material so as to ensure the sustainability of a year-round availability of B-carotene-rich roots; the existence of new varieties of sweet potatoes throughout the communities; and finally, child feeding patterns in the households will be assessed to ensure that children receive the recommended daily intake of vitamin A-rich foods.

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