Vitamin A-related Nutrition Knowledge Gaps and Predictors among Caregivers of Preschool Children in Eastern Uganda: A cross-sectional study

doi:10.21203/rs.3.rs-2757739/v1

Background

Vitamin A (VA) remains one of the core micronutrients as VA Deficiency (VAD) in children has persisted as a public health problem in many parts of Africa and Asia with adverse micro and macro-level effects. Caregivers of children are essential in the control of VAD; however, there is paucity of data on their knowledge of VA, dietary sources and VAD. This study sought to assess the level of VA-related nutrition knowledge (VANK) and its predictors among caregivers of children aged 24–59 months in Eastern Uganda.

Methods

A cross-sectional analytical design was used. Both socio-demographic and knowledge and attitude (KA) data were collected using a structured questionnaire partly adapted from the FAO model Knowledge, Attitude and Practice (KAP) questionnaire. A total of 247 caregivers of children in Bukwo District in Eastern Uganda out of 256 selected using purposive and random sampling methods participated in the study. Ten knowledge questions were used to assess caregiver knowledge based on percentage scores and levels attained (≤ 40%, low; 41–69%, medium and ≥ 70%, high). Pearson’s Chi-square and correlation, and regression statistics were used to analyze the data, with p < .05 considered as significant.

Results

The caregivers were mostly female (90%) with a mean age of 30.89 years (SD = 7.69), majority were married subsistence crop farmers with at least primary level education. Just over 20% scored above 40% on VANK, with varying scores for different aspects: knowledge of VA (46.6%) and VAD (31%); VAD causes (22%), signs/symptoms of VAD (13%) and means of prevention (24%). Perceived severity of VAD among caregivers was significantly associated with their VANK. Age and level of education, were found to be significant socio-demographic predictors of VANK (p < .05).

Conclusion

Caregivers of under-fives in Eastern Uganda had inadequate VANK which was also associated with their perceptions of VAD severity. The main predictors of VANK were age and educational level of the caregiver. Efforts to enhance VANK are recommended especially among caregivers with lower education levels for effective VAD control and achievement of nutrition-related goals such as the Sustainable Development Goal (SDG) 2.

Vitamin A

caregivers

knowledge

Vitamin A deficiency

Sources

signs/symptoms

prevention

preschool children

24-59 months

Vitamin A Deficiency (VAD) is implicated in the impoverishment of many societies, especially in Sub-Saharan Africa [1]. This problem has persisted in Uganda and other low-income countries (LICs) in Africa, South Asia and the Caribbean [2, 3, 4, 5]. Between 6 and 35% of children in affected countries have sub-clinical VAD [6, 7], an estimate of over 200 million preschool age children with VAD worldwide [8] and it remains a public health problem particularly in Sub-Saharan Africa [9]. The primary effects of VAD include functional impairment of sight and debilitation of various physiological processes, including the immune response, all with wide-ranging secondary effects on health, productivity and growth of populations [4, 7].

Despite nearly three decades-long VAD control efforts including vitamin A supplementation (VAS), food fortification and bio-fortification in Uganda [10, 11, 12], VAD continues to be a problem of concern. The leading cause of VAD in preschool-age children is poor dietary vitamin A (VA) intake [13], a problem that can be solved by caregivers with the requisite knowledge, skills and material resources. Caregivers’ VA-related nutrition knowledge (VANK) facilitates the development of useful attitudes and practices that aid in alleviating the burden of VAD [4, 14].

Available data are insufficient to show the nature and extent of VANK among caregivers of preschool-age children in Uganda. This data gap hampers better planning and engagement of caregivers in endeavors to eradicate VAD. Studies examining knowledge of different aspects of VA such as its nature and sources, importance, deficiency and effects as well as control strategies, among caregivers of preschool-age children 24-59 months in Uganda are rare. But, studies conducted in Kenya [15], Dominican republic [16] and Pakistan [17] show low levels of awareness and a deficit of correct knowledge of VA and related aspects. The need to close the data gap in Uganda is compounded by the prevalence of low consumption of VA-rich fruits and vegetables among children in Eastern Uganda, particularly in the Bugisu sub-region [2].

The purpose of this study was to assess the VANK among caregivers of preschool-age children 24-59 months in Eastern Uganda. The objectives were to establish the levels of knowledge of VA and VAD, dietary VA sources and VAD signs/symptoms, the causes and preventive measures among caregivers of preschool children in Eastern Uganda, one of the regions with the highest levels of VAD in the country (20.5% compared to 15% national average as per [2]. Elucidation of the type and levels of VA-related knowledge possessed by caregivers will guide interventions to promote better VA status and control VAD among preschool children. Findings will also benefit implementation of VAD-related and caregiver-associated interventions targeting preschool-age children. The outcome of such improved interventions would strengthen the fight against VAD and contribute to achievement of nutrition-related goals including SDG 2 and Uganda’s Vision 2040.

Design, Setting and Participant selection

This was a cross-sectional study, involving 256 caregivers in households selected from clusters in four sub-counties of Bukwo district, Eastern Uganda. Mainly quantitative methods were used to collect data. Multi-stage sampling methodology involving purposive, simple random and probability proportional to size (PPS) sampling techniques was used to select a calculated sample of 256 caregivers. The sample size was obtained using the equation n = N/(1+N(e)² in [18], where N was the estimated population of preschool-age children in Eastern Uganda and e = 0.05, and modified for cluster randomization according to [19]. Bukwo was purposively selected because, unlike other districts, it was largely rural, remote from large food markets and had no evidence of current VA-related interventions. For this study, the entire district was geographically stratified into four regions from each of which one sub-county was selected by simple random sampling (SRS). Eight clusters/villages and eight households with children 24-59 months from each were then selected from each sub-county using PPS and SRS respectively, giving a total of 256 households and caregivers.

Data Collection

The caregivers were interviewed using a structured questionnaire developed for the study. The dependent variable was knowledge of VA as an aggregate of knowledge of: VA itself; VAD; causes, signs/symptoms of VAD and VA-rich animal and plant foods. Independent variables were the socio-demographics: gender, age, schooling, level of education attained, marital status, occupation, caregiver-household head relationship, household size, monthly household income, main household economic activity and type of health-care provider. Others were eight VA-related attitude variables.

A knowledge assessment questionnaire adapted from the Knowledge, Attitude and Practices (KAP) model questionnaire [20] and its guidelines was used. The questionnaire contained 10 mostly open-ended questions that covered the range of aspects of VA knowledge investigated. It also contained items that measured caregiver VA-related attitude based on the Health Belief model. Data for attitudinal variables were captured using a five-point Likert scale as shown in Table 1. Enumerators were trained in the study methodologies. The questionnaire was translated into the local language and then back-translated to English during training, pretested and adjusted accordingly before being used for the actual data collection. Data were collected through face-face interviews with caregivers using the local language.

Table 1 Likert Scale Values for Measurement of VA-Related Attitude Variables

Attitude Variable*	Value on Likert scale**
	1	2	3	4	5
Perceived susceptibility to VAD	Very unlikely	Unlikely	Neutral	Likely	Very likely
Perceived severity/seriousness of VAD	Not serious at all	Not serious	Neutral	Serious	Very serious
Importance of feeding child with VA-rich foods	Not important at all	Not Important	Neutral	Important	Very important
Perceived difficulty in preparing VA foods	Very difficult	Difficult	Neutral	Not difficult	Not difficult at all
Taste of VA-rich plant foods	Dislike greatly	Dislike	Neutral	Like	Like greatly

*Different aspects of VA-related attitude; **Responses ranked on a scale of 1-5

Data Analysis

Data were manually checked daily during collection to ensure completeness. Responses to knowledge questions were scored using a marking guide which was also designed to identify correct answers from arbitrary ones basing on the consistency in the pattern of responses in multiple-response questions such as food sources of VA, causes, signs/symptoms and methods of prevention of VAD. This prevented guessed answers from being scored favourably. Each correct answer was awarded 2 (two) marks, incorrect one 0 (zero) and the marks were recorded against each question. The data were then entered using MS Access database equipped with validation rules to limit errors during entry. The entered data were inspected, cleaned and exported to SPSS (Version 24) for further cleaning and analysis.

The scores for all knowledge items were summed up to obtain an individual caregiver mark which was then converted into a percentage where the maximum possible score (100%) was 20 marks. The marks (%) were used to categorize knowledge levels using criteria described in [21] where ≤40%, 41 to 69% and ≥70% were assigned low, moderate and high respectively. The individual marks (%) and corresponding knowledge level categories were used in tests of associations with other variables. Also, the mean mark (%) was computed to obtain the overall knowledge level. The SPSS (Version 24) and MS Excel were used to perform all computations and tests and generate graphics. Descriptive and inferential statistics were computed. Pearson’s correlation and Chi-square, and regression were used to test relationships between different variables.

Ethical approval

This study was approved by Mildmay Uganda Research Ethical Committee (MUREC) and registered by Uganda National Council for Science and Technology (UNCST). Permission was obtained from the District administration. All respondents provided informed consent and, confidentiality and anonymity were observed.

Socio-demographic characteristics of caregivers

A total of 247 out of the 256 selected caregivers participated in the study. The other nine respondents were not found. About 90% of the respondents were females and the mean age was 30.89 years (SD = 7.69). Other characteristics are shown in Table 2. Majority were married (94%), had ever attended formal education (94%), were engaged in subsistence crop farming as the main economic activity and earned low monthly household income (USD 14-28).

Table 2 Caregiver and Household Characteristics (N=247)

Characteristic	N	%
Marital status of Caregiver
Married (monogamous)	214	86.6
Married (polygamous)	19	7.7
Others	14	5.6
Occupation of caregiver
Housewife/stay-home	83	33.6
Subsistence crop farmer	97	39.3
Commercial crop farmer	5	2
Businessman/woman	41	16.6
Government Civil servant	10	4
Other	11	4.4
Education level of caregiver*
None	19	7.7
Primary	124	50.2
Lower secondary (“O” level	86	34.8
Upper secondary (“A” level)	3	1.2
Tertiary	15	6.1
Main economic activity
Crop farming	175	70.9
Trade in produce	12	4.9
Petty trade	34	13.8
Salaried employment	10	4
Others	16	6.4
*Average monthly Income (UGX)**
0-<50,000	40	16.2
50,000-<100,000	60	24.3
100,000-<250,000	43	17.4
250,000-<500,000	19	7.7
500,000 and above	26	10.6
Don't know	59	23.9

*Highest level of education attained by caregiver; **1 UGX ≈ USD 1/3,600

Overall Vitamin A-related knowledge

Aggregate VANK was calculated for each caregiver. The results showed that caregivers had very low levels of VANK (M = 18.91%, SD = 24.71). Even among those who had some knowledge of VA (total VA knowledge score >0), many lacked deeper knowledge of the vitamin (n =115, M = 40.6%, SD = 20.7). On categorizing the VANK scores, it was found that the caregivers that had low levels of knowledge (79.4%) far outstripped those in other categories (moderate, 15.8% and high, 4.8%).

Knowledge of Vitamin A, Sources and Deficiency

Under half of the caregivers (46.6%) were found to have knowledge of VA itself. For other aspects, responses were elicited from only those who knew VA (n = 115) and further sub-samples for VAD causes, signs/symptoms and prevention, and VA-related attitude (Figure 1).

Table 3 shows a summary of the findings on other aspects of VANK. Less than a third of all the caregivers and two thirds of those who knew VA knew VAD. It was also found that VAD was known better than VA sources and majority of caregivers who knew VAD correctly identified causes and preventive measures.

Table 3 Caregiver Knowledge of Different Aspects of VA and VAD

Knowledge aspect	n (correct response)	%
**VA sources and VAD (n =115)***
Animal foods	67	58.3
Vegetables	19	16.5
Fruits	7	6.1
Roots/tubers	3	2.6
VA-fortified foods	36	31.3
VAD	76	66.1
*VAD signs, causes, prevention (n = 76)***
Signs/symptoms of VAD	32	42.2
Causes of VAD	54	71.1
Prevention of VAD	60	78.9

VA = Vitamin A; VAD = Vitamin A Deficiency; *Only those who knew VA were asked further questions

In regard to knowledge of VA food sources, there were wide gaps. Animal-based foods were the best-known (nearly 60%), while VA-rich roots/tubers were the least (<3%). Among the other relatively less known sources, VA-fortified foods were almost twice and three times as known as the VA-rich vegetables and fruits respectively were. There were varied responses on the food sources of VA in five categories: animal-based foods, green leafy vegetables, fruits/vegetables, roots/tubers and fortified foods (Table 4). Eggs, kale and dodo (Amaranthus spp), passion fruits, potatoes and wheat-flour were the leading foods mentioned in the respective categories although among them, passion, other fruits, and potatoes were not the types with significant VA content.

Table 4 Caregiver Knowledge of VA-rich Foods (n = 115)

Foods identified as rich in VA	n	% of foods^a	% of Caregivers^b
Animal foods
Liver	39	20.6	33.9
Eggs	62	32.8	53.9
Milk/Milk products	62	32.8	53.9
Others (non-VA-rich)^c	26	13.7	22.5
Green Leafy Vegetables
Kale (Brassica spp)	51	27.0	44.3
Amaranthus leaves/dodo	52	27.5	45.2
Pumpkin leaves	17	9.0	14.8
Local green vegetables (various)	43	22.7	37.4
Others (non-VA-rich vegetables e.g., cabbages)^c	26	13.8	22.6
Fruits/vegetables
Ripe mango	18	12.6	15.7
Ripe papaya	5	3.5	4.3
Pumpkin	5	3.5	4.3
Others (non-VA-rich: melons, oranges, berries, guavas, passion fruits, etc.)^c	115	80.4	100.1
Roots/tubers
Orange sweet potato	17	13.5	14.8
Carrot	11	8.7	9.6
Others (non-VA-rich potatoes, yams, etc.)^c	98	77.8	85.3
VA-fortified
Margarine	15	10.3	13.0
Cooking oil	23	15.9	20.0
Wheat Flour	23	15.9	20.0
Others (non-VA-fortified)^c	84	58.0	73.1

^aProportion of all foods mentioned;^bProportion of caregivers that mentioned the food; ^cFoods mentioned but incorrect.

Causes, Signs/symptoms and Prevention methods for VAD

Regarding the causes, 61.8% identified consumption of a poor variety of food, 6.6% a diet lacking in VA content and 6.6% infections. Others attributed VAD to various causes including eating too little food (10.5%), poor feeding (3.9%), poor fruit intake (1.3%), improper or no breastfeeding (1.3%), and inadequate medical care (5.2%). The rest confessed that they did not know (11.8%).

Less than a third of caregivers who knew VA (27.8%), about a tenth of all the caregivers (13%), knew any signs/symptoms of VAD. Most caregivers (63.2%) incorrectly associated physical body weakness to VAD. Those who linked VAD to eye problems such as night blindness (13.2%), and frequent infections (29%) were a minority. Still, a large section (21%) was honest about their lack of knowledge of signs/symptoms.

The caregivers also expressed their knowledge of the preventive measures against VAD. Most of those with knowledge of VAD mentioned increased consumption of VA–rich foods (61.8%). Others mentioned different measures including VA supplements (17.1%), nutritious and varied diet (10.4%), VA-fortified foods (2.6%) and an assortment of other measures (2.6%). Among the measures, a diet rich in VA was the most frequently cited (Figure 2).

The relationships between caregiver knowledge and VA-related attitude were also examined. The attitude aspects were perceived susceptibility/risk, severity/seriousness, value of feeding children with VA-rich foods, difficulty in preparing VA-rich foods and taste of VA-rich plant foods. For majority of those who knew VAD, their perception of its seriousness was significantly associated with their VA knowledge levels (χ²[8] = 23.278, p = .003) unlike the other aspects (p > .05).

Predictors of Vitamin A related knowledge

Several caregiver/household characteristics were examined to establish relationships with knowledge levels. For most of them, there was no statistically significant relationship (Table 5). However, as shown, level of formal education attained by caregivers was significantly associated with their VA knowledge. Spearman’s rank order test also showed a positive correlation between knowledge and education levels (r = .13, p = .035). Similarly, VA knowledge was significantly correlated with the age of caregiver (Pearson’s r =.16, p = .013).

Table 5 Relationship Between Caregiver and Household Socio-demographic Characteristics and VA-Knowledge Levels

Socio-demographic Characteristic	χ2(N = 247)	df	p
Gender	1.07	2	.587
Relationship to household head	5.70	10	.840
Marital status	13.97	8	.083
Level of education attained	26.26*	8	.001
Ever attended school?	1.06	2	.590
Main occupation	18.20	18	.442
Household size category	2.47	4	.651
Monthly household income category	7.77	12	.803
Main household economic activity	6.28	14	.958
Type of health care provider	7.10	4	.131

*Relationship significant at p < .05

Education levels were indicated according to established formal educational categories, which correspond to years of schooling, as none (0 years), primary (1-7 years), lower secondary (8-11 years), upper secondary (12-13 years) and tertiary (≥14 years). Caregivers with lower levels of education (primary and lower secondary) were more likely to have low rather than high VANK, ORs and 95% CIs: 6.73 (1.38, 32.87) and 7.67 (1.34, 43.88) for primary and lower secondary respectively.

The results showed that the caregivers were mainly married mothers in their lower 30s, active in child feeding and therefore with sufficient maturity and experience for the study. They were slightly older than those for a similar study in Pakistan, 29 years [17], and younger compared to another one in Tanzania, 40.75 years [22]

The cut–off score of 40% for low knowledge used in this study and also by Kigaru et al. [21] to categorize knowledge levels, was higher (stricter) than 25% used by Alzaben et al. [23]. Categorization of knowledge scores into low, moderate and/or high is a common approach as shown in [24] although some studies such as Liu et al. [25] do not explicitly do so. This study investigated VA-related knowledge which is more specific than the general nutrition knowledge commonly investigated using the cut-off. Most caregivers, nonetheless, had low knowledge levels, similar to other studies which are rather few and almost outdated [16, 17].

The low aggregate VA knowledge score obtained in this study (M = 18.91%, SD = 24.71), the great majority of caregivers in the low category and the low mean total scores for those who knew at least one aspect of VA, VA itself (40.6%), all revealed that VANK among caregivers was not only very low but also shallow. This study agreed with some studies [17, 16] but differed a little with another [22] which showed higher levels but targeted urban rather than rural households.

The lack of comprehensive VA knowledge among caregivers reflects their limited cognitive exposure to the vitamin. Therefore, despite existence of decades-long VA–related programs, caregivers have not been empowered with VA knowledge. This shortcoming suggests a need for more inclusive and participatory approaches to fighting VAD, especially in rural communities.

Knowledge of different aspects of vitamin A

Less than 20% of caregivers could identify any particular VA-rich fruit, vegetable or root/tuber despite having some VA knowledge (Table 4). Some of the foods mentioned were true sources of VA but others were not. The green vegetables, kale and Amaranthus, are excellent pro-vitamin A (β-carotene) sources [16, 26]. Animal-based foods, liver, eggs (egg yolk) and milk, provide preformed VA (retinol) and are great sources of VA. In addition, whereas passion (Passiflora edulis) and citrus fruits generally, are poor VA sources, they were nonetheless mentioned by the caregivers ahead of established fruit sources such as ripe mangoes and papaya [27]. In the roots/tubers group, non-orange/yellow root crops including potatoes (Solanum tuberosum) predominated the others such as carrots and orange-fleshed sweet-potatoes which are true VA (pro-VA) sources. The poor knowledge of VA sources contributed to the low overall VANK scores.

Knowledge of Vitamin A Deficiency, signs/symptoms, causes and prevention

Knowledge of VAD can be considered as contingent on that of VA itself although this may not always be true. The substantial proportion that knew VAD (66.1%) showed a correlation between knowledge of VAD and that of VA; however, this represented less than one third of all the caregivers. Therefore, knowledge of VAD was generally poor. Other studies have also found little knowledge of VAD [16, 17]. The limitation of this finding is that it did not cater for caregivers who knew VAD irrespective of the vitamin itself.

Majority of the caregivers (62%) attributed VAD to consumption of a poor variety of food, one among many non-specific causes mentioned. Inadequate dietary intake of VA, a more direct cause, was identified by only 6.6%, although this was expected to be easily derived from the description of VAD which inevitably spells VA. A more cogent assessment of caregiver knowledge of VAD causes could therefore be obtained from the evaluation of their knowledge of VA-rich foods.

Ability of caregivers to recognize signs/symptoms of VAD in children is essential in VAD control. Eye problems are the classic manifestations of VAD including several stages of xerophthalmia that involve physical (Bitot’s spots, corneal scars) and functional (forms of blindness) defects [16, 28]. Non-specific indicators include frequent infections and variable skin conditions [29]. Infections have a vicious relationship with VA [30, 27]. Very few caregivers were able to tell the correct signs associated with VAD including only 13% who knew the cardinal VAD signs. These findings are consistent with those for a study in Ghana [31]. Together, these studies underscore the danger of sub-clinical VAD because of the high implausibility of recognition or detection despite persistent prevalence [6, 2]. Hence, caregivers of children in rural areas of LICs still need greater sensitization on shielding against the threat of latent VAD and avoiding complacency.

The demonstrated knowledge of preventive measures against VAD among caregivers as per their correct identification of increased consumption of VA-rich foods (Figure 2) is commendable but is undercut by their limited knowledge of such foods and the generally minority status of those who knew VAD as highlighted in Table 3. This calls for mechanisms that widen knowledge of VA-rich foods. Other measures cited such as VA supplements and nutritious diet are effective but problematic because while supplements are non-food items and also unaffordable [32, 33], caregiver conception of a nutritious or balanced diet with respect to VA needs further scrutiny.

Similar studies in Kenya [34] and Ethiopia [35] showed higher levels of knowledge of VA and its sources, and signs of VAD than this study did. The variance was probably because the Kenyan and Ethiopian studies were concerned mainly with VAS and conducted after major interventions, in each case unlike this study, and the former involved urban caregivers who are usually more informed than rural dwellers, the main participants in this study. Consistent with this study, however, Hadzi et al. [31] found that very few caregivers knew the sources of VA and signs of VAD.

One aspect of VA-related attitude, perceived severity of VAD in children, was significantly associated with VANK. Compared to other constructs of the Health Belief Model (HBM), perceived severity represents a stronger feeling of threat to health and life which may be a strong intrinsic motivator to taking action [36]. The perceived magnitude of threat posed by VAD probably drove caregivers to adopt survival strategies which may include learning more about VAD and thereby increasing their VA knowledge. Elucidating on the adverse effects of VAD could be an effective way to promote VANK in VAD control.

Predictors of Vitamin A-related nutrition knowledge

There were positive correlations between VANK and caregiver age and level of formal education in agreement with reviews in [14] and [24]. Spronk et al. [14] attributed high nutrition knowledge at middle age to high education levels at that age. However, this study observed that age was independent of education because at 31 (mean age), educational cycles for most caregivers would have long been completed, and proposes that age relates to VANK through experience by caregivers. According to the 2016 UDHS [2], the mean age of first birth in Uganda is just below 20 years, and fertility rate is 5.9 implying that at 31, many married mothers, as were majority of caregivers in this study, would have had more than one cycle of child birth and care. These cycles expose them to knowledge through various avenues including antenatal health-care visits and participation in health promotion activities. Hence, the older the caregiver, the greater the experience and knowledge as well.

Concerning education, levels were correlated with those of VANK, similar to findings in [25]. These studies suggest that VANK is obtained, directly or indirectly (through availability of opportunities and enhancement of means of acquisition), during formal education. Generally, greater maternal education is linked to higher child survival due to better health care practices [37] which can be associated with greater knowledge.

Other characteristics including marital status, income and occupation were not significantly associated with VANK. Caregiver income was shown in [14] to be significantly related to nutrition knowledge but this study used household income instead and shows that it may not be as strong a predictor of knowledge as individual income. Nevertheless, this study estimated household income through interviews of the caregiver alone who was seldom the household head therefore possibly limiting the accuracy of the estimates as Fisher et al. [38] argue.

The objective of this study was to estimate the VA-related nutrition knowledge (VANK) among caregivers of preschool-age children. Generally, the caregivers possessed very low VANK, with a mean score of 19%. There was a vast proportion of caregivers who had no VANK whatsoever (53.4%). The caregivers demonstrated little knowledge of all the aspects of VA investigated, signifying shallow knowledge of the vitamin. Less than half of all caregivers (46.6%) knew VA and about two thirds of these (66.1%), also knew VAD. Majority of those who had knowledge of both VA and VAD knew the causes and measures of preventing VAD but very few of them could tell the signs/symptoms associated with it. A very small proportion of caregivers was able to identify VA-rich foods. Some could identify VA-rich animal foods but hardly any of the other types of VA/pro-VA-rich foods. The VANK was associated with the caregivers’ perception of the seriousness of VAD. The key predictors of vitamin A-related knowledge were age of the caregiver and education level attained. Knowledge appeared to increase with both age and educational level. This study highlights the need for and recommends deliberate efforts to promote knowledge of VA and related aspects among caregivers of preschoolers in rural areas of LICs where VAD is a problem of public health concern. More attention ought to be given to caregivers with little or no education. Enhanced VA-related knowledge will strengthen VAD control and contribute to achievement of SDG 2 and other nutrition-related goals. More studies are needed especially on the concept of VAD where it is defined independently of VA. In addition, the caregiver interpretation of “wide variety” and “nutritious diet” in terms of VA need further investigation and clarification.

FAO: Food & Agricultural organization; HBM: Health Belief Model; KAP: Knowledge Attitudes and Practices; LC: Local Council; LIC: Low-Income Country; MUREC: Mildmay Uganda Research Ethical Committee; PPS: Probability Proportional to Size; SDG: Sustainable Development Goal; UNCST: Uganda National Council for Science & Technology; VA: Vitamin A; VAD: Vitamin A Deficiency; VANK: Vitamin A-related Nutrition Knowledge; VAS: Vitamin A Supplementation.

Ethics approval and consent to participate

This study was approved by Mildmay Uganda Research Ethical Committee (MUREC). All respondents provided informed consent and, confidentiality and anonymity were observed. All relevant ethical guidelines were followed.

Data Availability

The data used for this manuscript are obtainable upon reasonable request.

Consent for publication

Not applicable.

Funding

Kyambogo University provided partial funding for the study.

Authors’ contributions

GM conceived the study, conducted the field data collection and analysis and prepared the manuscript. EN, DMDK reviewed the tools, contributed to the data analysis and writing of the manuscript. RKB contributed to the data analysis and writing of the manuscript. The final draft was read and approved by all the authors.

Acknowledgments

The authors acknowledge the following: caregivers, for providing the data for this study; Bukwo District local administration and Local Council (LC) leaders, for allowing the study and providing moral support; Kyambogo University, Kampala (Uganda), for financial and moral support.

Competing interests

The authors declare no conflicts of interest.

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No competing interests reported.

Vitamin A-related Nutrition Knowledge Gaps and Predictors among Caregivers of Preschool Children in Eastern Uganda: A cross-sectional study

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