Vitamin A is an essential micronutrient required for normal vision, reproduction, healthy immune function, growth, and development (1, 2). However, inadequate intake of vitamin A increases the risk of mortality, and visual impairment, and weakens the body’s ability to fight off infection, notably in children (3). On the other hand, vitamin A supplementation (VAS) reduces all causes of mortality by 25% (4, 5), diarrhea-related mortality by 30%% (5), and measles and other respiratory infections (6).

In low and middle-income countries (LMIC), VAS coverage is below 70% (7), and vitamin A deficiency affects one-third of children, particularly in Sub-Saharan Africa (SSA) (8). The most severe outcomes of vitamin A deficiency such as corneal xerophthalmia, severe illness, and death are primarily found in children aged 6–59 months, making this population an urgent priority for vitamin A supplementation (VAS) (9). In areas where vitamin A deficiency is a significant public health concern, to reduce morbidity and mortality associated with vitamin A deficiency, the World Health Organization (WHO) recommends VAS for all children aged 6–59 months (10, 11). In such regions, an 80% coverage rate is recommended (9), because VAS is a cheap, safe, and cost-effective way to eliminate this nutritional deficiency and improve child survival (11).

However, VAS coverage remains below the recommended level, with notable geographical disparities. For instance, coverage rates in South Asia are 62%, in West and Central Africa 71%, in East and South Africa 57%, and in the East Asia and Pacific region 20% (12). In Sub-Saharan Africa, only 56.3% of children were received VAS (13). Coverage also varies widely across low and middle-income countries (LMIC), with countries like Mozambique 42.8%, Senegal 46.1%, Sierra Leone 86.9% (14), Guinea 68% (15), Mali 80% (16), Nigeria 43% (17). Tanzania 53.18% (18), Cambodia 42.8% (19), India 60.5% (20), and Brazil 41.5% (21). This indicates that the coverage is below the optimal level in many regions (22). These studies revealed that child age (6–12 months and 35–59 months) (23, 24), exposure to mass media (16, 18, 22, 25, 26), fathers educational status (16, 25, 27), mothers employment status (17, 18), antenatal care (17, 18), delivery in a health facility (17, 18), mothers secondary educational level (17, 19, 21, 25), receiving information from health care workers and peers (28), household wealth (17), place of residence (29), mothers with education secondary school are factors that affect vitamin A supplementation (23, 28, 29).

VAS has been a global health strategy, often integrated with routine immunization and campaigns to reduce the burden of vitamin A deficiency and its severe consequences (9). Various efforts have been implemented to enhance the coverage of vitamin A and mitigate the effect of vitamin A deficiency. For example, WHO recommends supplementation for every child every 4–6 months, and in SSA, door-to-door distribution has been used successfully to achieve high VAS coverage (30). In Ethiopia, the national nutritional program has promoted supplementation, and over the past two decades, the Ministry of Health has introduced different strategies to enhance VAS through health extension programs and other campaign-based approaches such as enhanced outreach strategy, community health days, and periodic supplementation (31, 32). The VAS program has now been integrated into the routine immunization program (32). Additionally, Ethiopia’s first and second transformation Plans aimed to increase VAS coverage in children to 95% by the end of 2020 (33, 34).

Despite these efforts, VAS coverage and vitamin A deficiency remain a significant public health challenge in Ethiopia (35, 36). In Ethiopia, several studies investigated VAS coverage and contributing factors at the district level and through national surveys. However, the findings on VAS coverage and the contributing factors are fragmented and inconsistent, ranging from 36.2% (37) to 83.1% (38). These figures do not provide comprehensive and robust conclusions for stakeholders. Therefore, the present meta-analysis assesses the vitamin A supplementation coverage and associated factors among children 6–59 months of age in Ethiopia. The findings of this study will help to prevent vitamin A deficiency and its related consequences by identifying factors that affect VAS and by providing evidence-based information to policymakers and program implementers. Furthermore, it will serve as a baseline data for future researchers.

This meta-analysis aimed to assess the coverage of vitamin A supplementation and its associated factors among children 6–59 months of age in Ethiopia. The pooled coverage of vitamin A supplementation was found to be 54.88% (95% CI: 47.34–62.42). The current study finding was consistent with studies conducted in Tanzania (53.18%) (18), India (60.5%) (20), East and South Africa (57%) (12), and Sub-Saharan African countries (56.3%) (13). The similarity in findings may be attributed to comparable socio-demographic and economic characteristics of the study participants, study settings, and maternal and child health care services.

In contrast, the finding of this study was higher than those reported in Mozambique (42.8%), Senegal (46.1%), Cambodia (42.8%) (19), and Brazil (41.5%) (21). However, it was lower than studies conducted in West and Central Africa (71%) (12), Sierra Leone (86.9%) (14), Guinea (68%) (15), Mali (80%) (16), and South Asia (62%) (12). This disparity could be attributed to differences in the methods of vitamin A supplementation (VAS). In these counties, VAS is provided not only through routine immunization programs but also through the annual VAS campaign and national immunization day. As a result, children in these countries have better access to VAS compared to those in Ethiopia, where it is primarily distributed through the routine immunization program. Another contributing factor could be the intensive outreach efforts in those countries, which effectively target disadvantaged and older children who may fall outside the routine immunization schedule.

Additionally, these countries may have better infrastructures, such as well-developed roads and nearby health facilities, which makes VAS more accessible. In contrast, in Ethiopia, inadequate infrastructure, particularly in rural and remote areas, hinders access to vitamin A, which contributes to these disparities (56).

In this study, a sub-group analysis was conducted based on the Children’s age group to identify the possible source of heterogeneity. The lowest VAS coverage [43.71%% (95% CI: 42.71–45.14)], was found among children 6–35 months of age. This may be due to the parents’ perception that children in this age group receive enough nutrition, including vitamin A, through breast milk. Additionally, parents may be more aware of the benefit of vitamin A for older children, leading to less proactive supplementation efforts for children aged 6–35 months. To improve VAS coverage in this age group, targeted outreach supplementation, raising caregiver awareness, and integration of health services are significantly necessary and need to be prioritized (57).

This study also examined the associated factors of VAS. This study finding revealed that children whose mothers had attended four or more ANC visits were twice as likely to receive VAS. This study finding was aligned with studies conducted in Nigeria (17), and Tanzania (18). A possible explanation is that mothers who had ANC visits receive information about child vaccinations and the nutritional importance of vitamin A. As a result, they are more likely to take their children to health facilities and campaign sites for supplementation (58). This study also found that being able to reach a health facility within 30 min was an important factor associated with vitamin A supplementation in children. Similar findings have been reported in Kenya (59), and Malawi (60). One reason could be that as the distance or travel time increases, parents may be less inclined to make the journey to obtain vitamin A for their children. Another reason could be that the cost and time required for transportation place a significant burden on families, especially those living in poverty (61). Furthermore, underdeveloped and poor road infrastructures, particularly, in rural areas, affect access to health facilities and routine services (62).

The current study identified Postnatal Care (PNC), as a determinant of vitamin A supplementation in children. This finding is supported by a systematic review and meta-analysis conducted in Asia and Africa (63). One possible reason is that during postnatal visits, healthcare workers educate caregivers on the importance of vitamin A supplementation for child health, growth, and development (64). Additionally, PNC offers an opportunity for growth monitoring and assessment of children’s nutritional status (65), facilitating the early detection of vitamin A deficiency and the timely provision of high-dose vitamin A supplementation to address the deficiency.

Delivery in a health facility was another significant factor influencing VAS for children in this study. Congruent findings were reported in Nigeria (17), and Tanzania (18). This can be attributed to the fact that newborns delivered in health facilities are linked to routine immunization and other child health services, such as growth monitoring, which helps to create a follow-up visit. Consequently, these children are more likely to receive subsequent doses of vitamin A supplements at the appropriate ages and intervals. Another possible reason is that health facilities collaborate with health extension workers to improve child immunization coverage. They organize outreach immunization campaigns, including vitamin A supplementation for children 6–59 months, which increases the likelihood of children receiving vitamin A supplementation, even if they miss a dose at the health facility (66). In agreement with studies from Sub-Saharan Africa (22), Mali (16), Tanzania (18), Bangladesh (25), and other Low and Middle-Income Countries (LIMIC) (26), this study also found that parents/caregivers media exposure was a significant factor in children vitamin A supplementation. This is because media exposure educates the parents/caregivers about the importance of immunization in protecting against communicable diseases. Another possible reason is that the media provides up-to-date information about vitamin A, its role in disease prevention, and its dietary sources, helping to raise awareness and dispel common myths and fears within the community (67). Additionally, media interviews with health professional can also provide authoritative and timely responses to the parents’ questions. Furthermore, social media platforms can highlight the risks of not vaccinating and provide evidence-based information, which encourages parents to take actions (68).

This study further showed that children whose parents had information about VAS were three times more likely to receive it. This finding aligns with studies conducted in Kenya (28), and Sub-Saharan African countries (30). A likely explanation is that parents who are informed about vitamin A’s role in preventing night blindness and overall health are more aware, and proactive in seeking vitamin A supplementation for their children. Hence this finding suggests that strengthening the VAS program through clear information and good communication can increase parents’ health-seeking behavior and improve VAS utilization (69).

Mothers’ secondary education was a significant determinant for supplementing vitamin A in Children. A consistent finding was reported from Nigeria (17, 21), Bangladesh (25), and Cambodia (19). Additionally, maternal education above secondary school is also associated with vitamin A supplementation. This is consistent with studies from Kenya (28), Sub-Saharan Africa (23), and India (29). This may be because educated mothers have a better understanding of health and nutrition including the role of vitamin A in preventing night blindness. Another reason could be that educated mothers are more proactive in seeking healthcare services and information for their children. They are more likely to take their children for regular check-ups and ensure they receive the recommended vitamin A supplements at the appropriate times (70). In addition, to the reasons, aforementioned earlier, educated mothers share information about the importance of VAS through social media and peers, participate in community-based health programs, and have a strong voice in household decisions, which creates a supportive environment for VAS (71).

This study also found that fathers’ education had a significant association with VAS in Children. This finding is consistent with similar studies conducted in Bangladesh (25, 27), and Mali (16). A possible reason could be fathers with higher educational levels are more likely to understand the value of health services like VAS and make decisions to ensure their children receive VAS (72). Another possible reason is that educated fathers tend to have better health-seeking behaviors and emphasize the importance of preventive health practices like VAS to the mother and caregiver, which creates an opportunity for their children to receive supplementation (73).

This is the first review that showed the pooled coverage of vitamin A supplementation and factors associated with it at the national level. However, all of the included studies were cross-sectional studies, by nature which may not show real temporal relationships between outcome and independent variables. Additionally, certain factors like the wealth index of the family and maternal age were not assessed, because the primary studies categorized these variables inconsistently.

In Ethiopia, the vitamin A supplementation coverage is significantly lower than both the WHO recommendation of 80% and the national target of 95%. Antenatal care, postnatal care, delivery in health facilities, Parents’ media exposure, time to reach health facilities (less than 30 min), maternal secondary educational level or above, and father’s education above secondary school were significantly associated factors that increase the likelihood of vitamin A supplementation.

Hence, the National nutritional program and expanded program of immunization stakeholders better to increase awareness of the community about VAS and other routine immunizations, particularly for parents/caregivers with low educational status, and no antenatal and postnatal care through social media and other community meetings. Additionally, like other Sub-Saharan African countries, Ethiopia’s EPI program should strengthen the outreach supplementation programs, such as door-to-door distribution to address the losses of older children and socio-economically disadvantaged populations in remote and rural areas.