Spatial access inequities and childhood immunisation uptake in Kenya.

BACKGROUND: Poor access to immunisation services remains a major barrier to achieving equity and expanding vaccination coverage in many sub-Saharan African countries. In Kenya, the extent to which spatial access affects immunisation coverage is not well understood. The aim of this study was to quantify spatial accessibility to immunising health facilities and determine its influence on immunisation uptake in Kenya while controlling for potential confounders. METHODS: Spatial databases of immunising facilities, road network, land use and elevation were used within a cost friction algorithim to estimate the travel time to immunising health facilities. Two travel scenarios were evaluated; (1) Walking only and (2) Optimistic scenario combining walking and motorized transport. Mean travel time to health facilities and proportions of the total population living within 1-h to the nearest immunising health facility were computed. Data from a nationally representative cross-sectional survey (KDHS 2014), was used to estimate the effect of mean travel time at survey cluster units for both fully immunised status and third dose of diphtheria-tetanus-pertussis (DPT3) vaccine using multi-level logistic regression models. RESULTS: Nationally, the mean travel time to immunising health facilities was 63 and 40 min using the walking and the optimistic travel scenarios respectively. Seventy five percent of the total population were within one-hour of walking to an immunising health facility while 93% were within one-hour considering the optimistic scenario. There were substantial variations across the country with 62%(29/47) and 34%(16/47) of the counties with < 90% of the population within one-hour from an immunising health facility using scenarios 1 and 2 respectively. Travel times > 1-h were significantly associated with low immunisation coverage in the univariate analysis for both fully immunised status and DPT3 vaccine. Children living more than 2-h were significantly less likely to be fully immunised [AOR:0.56(0.33-0.94) and receive DPT3 [AOR:0.51(0.21-0.92) after controlling for household wealth, mother's highest education level, parity and urban/rural residence. CONCLUSION: Travel time to immunising health facilities is a barrier to uptake of childhood vaccines in regions with suboptimal accessibility (> 2-h). Strategies that address access barriers in the hardest to reach communities are needed to enhance equitable access to immunisation services in Kenya.

Assessment of missed opportunities for vaccination in Kenyan health facilities, 2016.

BACKGROUND: In November 2016, the Kenya National Vaccines and Immunization Programme conducted an assessment of missed opportunities for vaccination (MOV) using the World Health Organization (WHO) MOV methodology. A MOV includes any contact with health services during which an eligible individual does not receive all the vaccine doses for which he or she is eligible. METHODS: The MOV assessment in Kenya was conducted in 10 geographically diverse counties, comprising exit interviews with caregivers and knowledge, attitudes, and practices (KAP) surveys with health workers. On the survey dates, which covered a 4-day period in November 2016, all health workers and caregivers visiting the selected health facilities with children <24 months of age were eligible to participate. Health facilities (n = 4 per county) were purposively selected by size, location, ownership, and performance. We calculated the proportion of MOV among children eligible for vaccination and with documented vaccination histories (i.e., from a home-based record or health facility register), and stratified MOV by age and reason for visit. Timeliness of vaccine doses was also calculated. RESULTS: We conducted 677 age-eligible children exit interviews and 376 health worker KAP surveys. Of the 558 children with documented vaccination histories, 33% were visiting the health facility for a vaccination visit and 67% were for other reasons. A MOV was seen in 75% (244/324) of children eligible for vaccination with documented vaccination histories, with 57% (186/324) receiving no vaccinations. This included 55% of children visiting for a vaccination visit and 93% visiting for non-vaccination visits. Timeliness for multi-dose vaccine series doses decreased with subsequent doses. Among health workers, 25% (74/291) were unable to correctly identify the national vaccination schedule for vaccines administered during the first year of life. Among health workers who reported administering vaccines as part of their daily work, 39% (55/142) reported that they did not always have the materials they needed for patients seeking immunization services, such as vaccines, syringes, and vaccination recording documents. CONCLUSIONS: The MOV assessment in Kenya highlighted areas of improvement that could reduce MOV. The results suggest several interventions including standardizing health worker practices, implementing an orientation package for all health workers, and developing a stock management module to reduce stock-outs of vaccines and vaccination-related supplies. To improve vaccination coverage and equity in all counties in Kenya, interventions to reduce MOV should be considered as part of an overall immunization service improvement plan.

Qualitative insights into reasons for missed opportunities for vaccination in Kenyan health facilities.

BACKGROUND: In 2016, Kenya conducted a study of missed opportunities for vaccination (MOV)-when eligible children have contact with the health system but are not fully vaccinated-to explore some of the reasons for persistent low vaccination coverage. This paper details the qualitative findings from that assessment. METHODS: Using the World Health Organization MOV methodology, teams conducted focus group discussions among caregivers and health workers and in-depth interviews of key informants in 10 counties in Kenya. Caregivers of children <24 months of age visiting the selected health facilities on the day of the assessment were requested to participate in focus group discussions. Health workers were purposively sampled to capture a broad range of perspectives. Key informants were selected based on their perceived insight on immunization services at the county, sub-county, or health facility level. RESULTS: Six focus group discussions with caregivers, eight focus group discussions with health workers, and 35 in-depth interviews with key informants were completed. In general, caregivers had positive attitudes toward healthcare and vaccination services, but expressed a desire for increased education surrounding vaccination. In order to standardize vaccination checks at all health facility visits, health workers and key informants emphasized the need for additional trainings for all staff members on immunization. Health workers and key informants also highlighted the negative impact of significant understaffing in health facilities, and the persistent challenge of stock-outs of vaccines and vaccination-related supplies. CONCLUSIONS: Identified factors that could contribute to MOV include a lack of knowledge surrounding vaccination among caregivers and health workers, inadequate number of health workers, and stock-outs of vaccines or vaccination-related materials. In addition, vaccination checks outside of vaccination visits lacked consistency, leading to MOV in non-vaccinating departments. Qualitative assessments could provide a starting point for understanding and developing interventions to address MOV in other countries.

Acceptability, adherence, and clinical outcomes, of amoxicillin dispersible tablets versus oral suspension in treatment of children aged 2-59 Months with pneumonia, Kenya: A cluster randomized controlled trial.

Amoxicillin dispersible tablet (DT) is now recommended by the WHO as a first-line drug for the treatment of pneumonia in children below 5 years. The study aim was to compare acceptability, adherence and clinical outcome of amoxicillin DT and amoxicillin oral suspension (OS) in the treatment of children aged 2-59 months with pneumonia in Kenya. We conducted a two-arm cluster randomized controlled trial and utilized quantitative methods. The community unit was the unit of randomization. Children aged 2-59 months with pneumonia were enrolled and treated with either amoxicillin DT or OS. Acceptability was defined as the perception of taste of medication as the same or better compared to other medicines and expression of willingness of caregivers to use DT/OS in future, adherence was measured based on the dose, frequency, and duration of treatment, and clinical outcome as complete resolution of symptoms without change of antibiotic treatment. Equivalence was defined as a difference of ≤8% between study arms. We found high levels of acceptability among both DT (93.9%) and OS (96.1%) arms (difference 2.3%, 90% CI -2.6-7.3). The objective measure of adherence on day four and the overall objective measure were significantly higher among children on DT compared to children on OS (88.7% vs. 41.5% (difference 47.2%, 90% CI 31.0-63.3) & 83.5% vs. 39% (difference 44.5%, 90% CI 27.9-60.9), respectively). Cure rates were high in both arms (DT (99.5%), OS (98.1%), difference 1.4%, 90% CI -0.2-3.2). There is reported better adherence to Amoxicillin DT compared to OS and equivalence in acceptability and clinical outcomes.

Integrated and simplified approaches to community management of acute malnutrition in rural Kenya: a cluster randomized trial protocol.

BACKGROUND: In many low income countries, the majority of acutely malnourished children are either brought to the health facility late or never at all due to reasons related to distance and associated costs. Integrated community case management (iCCM) is an integrated approach addressing disease and malnutrition through use of community health volunteers (CHVs) in children under-5 years. Evidence on the potential impact and practical experiences on integrating community-based management of acute malnutrition as part of an iCCM package is not well documented. In this study, we aim to investigate the effectiveness and cost effectiveness of integrating management of acute malnutrition into iCCM. METHODS: This is a two arm parallel groups, non-inferiority cluster randomized community trial (CRT) employing mixed methods approach (both qualitative and quantitative approaches). Baseline and end line data will be collected from eligible (malnourished) mother/caregiver-child dyads. Ten community units (CUs) with a cluster size of 24 study subjects will be randomized to either an intervention (5 CUs) and a control arm (5 CUs). CHV in the control arm, will only screening and refer MAM/SAM cases to the nearby health facility for treatment by healthcare professionals. In the intervention arm, however; CHVs will be trained both to screen/diagnose and also treat moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) without complication. A paired-matching design where each control group will be matched with intervention group with similar characteristics will be matched to ensure balance between the two groups with respect to baseline characteristics. Qualitative data will be collected using key informant and in-depth interviews (KIIs) and focused group discussions (FGDs) to capture the views and experiences of stakeholders. DISCUSSION: Our proposed intervention is based on an innovative approach of integrating and simplifying SAM and MAM management through CHWs bring the services closer to the community. The trial has received ethical approval from the Ethics Committee of AMREF Health Africa - Ethical and Scientific Review Committee (AMREF- ESRC), Nairobi, Kenya. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, and presented to local and international conferences. TRIAL REGISTRATION: PACTR201811870943127 ; Pre-results. 26 November 2018.

Using the RE-AIM framework to evaluate the implementation of integrated community case management in Kenya.

AIM: To evaluate an integrated community case management programme for sick children aged 2 to 59 months in western Kenya using the Research, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. METHODS: This was a prospective observational research project conducted between December 2013 and February 2016. Outcome variables were measured before, during and at end of implementation using a series of surveys as well as by looking at routine service statistics. RESULTS: A total of 2604 community health workers were trained in 245 community units. The average post-training knowledge level (73.5%) and retention rates (89.7) of trained community health workers was high. At the end of study, there was an increase in the proportion of children who received appropriate treatment for diarrhoea (49.2%), pneumonia (19.5%), malaria (16.4%) and vitamin A (51.5%) from baseline. Community health workers were able to assess, classify and treat sick children with a similar quality as that provided by facility-based healthcare workers (>85% concordance). CONCLUSION: Based on the RE-AIM metrics, our results demonstrate promising practical approaches and outcomes of a large-scale implementation of integrated community case management in western Kenya. The findings have important implications for future design and expansion of the programme in Kenya.

Community case management of lower chest indrawing pneumonia with oral amoxicillin in children in Kenya.

AIM: To determine the accuracy and effectiveness of community health workers (CHWs) when compared to trained nurses for management of pneumonia in Kenyan children. METHODS: In Homabay County in western Kenya, children 2-59 months of age with lower chest indrawing pneumonia were identified, classified and treated by CHWs with oral amoxicillin (90 mg/kg per day) for five days at home. Trained nurses visited the child within 24 hours to verify diagnosis; and on day 4 and 14 to assess treatment outcomes. RESULTS: CHWs identified 1906 children with lower chest indrawing pneumonia. There was an 88.7% concordance in classification and treatment for lower chest indrawing pneumonia by CHWs compared to nurses. Children with moderate malnutrition (OR 1.68; 95% CI: 1.22-2.30), comorbidities such as diarrhoea or malaria (OR 1.55; 95% CI: 1.32-1.81) or an additional day of delay in care seeking (OR 1.06; 95% CI: 1.02-1.10) were more likely to have an incorrect classification of lower chest indrawing by the CHW. Comorbidity (OR 1.66; 95% CI: 1.12-2.48) and fast breathing (OR 4.66; 95% CI: 1.26-17.27) were significantly associated with treatment failure on day 14. CONCLUSION: CHWs can correctly manage lower chest indrawing pneumonia even in high-mortality settings, such as western Kenya, in sub-Saharan Africa.

Home-based record (HBR) ownership and use of HBR recording fields in selected Kenyan communities: Results from the Kenya Missed Opportunities for Vaccination Assessment.

BACKGROUND: Home-based records (HBRs), which take many forms, serve as an important tool for frontline health workers by providing a standardized patient history vital to making informed decisions about the need for immunization services. There are increasing concerns around HBRs with recording areas that are functionally irrelevant because records are incomplete or not up-to-date. The aim of this report was to describe HBR ownership and report on the utilization of selected recording areas in HBRs across selected study communities in Kenya. METHODS: The Kenya Missed Opportunities for Vaccination Assessment utilized a mixed-methods approach that included exit interviews, using a standardized questionnaire, among a convenience sample of caregivers of children aged <24 months attending a health facility during November 2016 as well as interviews of health staff and facility administrators. In addition to the exit interview data, we analysed data obtained from a review of available HBRs from the children. RESULTS: A total of 677 children were identified with a valid date of birth and who were aged <24 months. A HBR was in hand and reviewed for three-quarters of the children. Nearly one-third (n = 41) of those without a HBR in hand at the visit noted that they did not know the importance of bringing the document with them. Roughly two-thirds (n = 443) of caregivers noted they were asked by clinic staff to see the HBR during the clinic visit. Across the 516 reviewed HBRs, recording areas were most commonly identified for the child's demographic information (80% of HBRs) and vaccination history (82%) with information marked in >90% of records. Recording areas were less frequently available for child early eye / vision problems (61%), growth monitoring (74%) and vitamin A (76%); with information marked in 33%, 88% and 60% of records, respectively. CONCLUSIONS: Critical to the reduction of missed opportunities for vaccination, the HBR's importance must be emphasized and the document must be requested by health workers at every health encounter. Health workers must not only ensure that all children receive a HBR and counsel caregivers of its importance, but they must also ensure that all sections of the record are legibly completed to ensure continuity of care. Programmes are encouraged to periodically review and critically assess the HBR to determine whether the document's design and content areas are optimal to end user needs.

Correction to: Seroprevalence and determinants of transfusion transmissible infections among voluntary blood donors in Homabay, Kisumu and Siaya counties in western Kenya.

Following publication of the original article [1], the authors reported that for two of the authors, Felix Humwa and Vallarie Opollo, an incorrect affiliation has been given. In this Correction the incorrect and correct affiliations are listed.

Seroprevalence and determinants of transfusion transmissible infections among voluntary blood donors in Homabay, Kisumu and Siaya counties in western Kenya.

OBJECTIVE: Since the implementation of a series of blood donation safety improvements in Kenya, information about seroprevalence and determinants of transfusion transmissible infections among voluntary blood donors especially in high HIV burden regions of Homabay, Kisumu and Siaya counties remain scanty. A cross-sectional study examining HIV, syphilis, hepatitis B and C virus sero-markers and associated determinants was conducted among voluntary blood donors. Their demographic characteristics and previous risk exposure were recorded in a pre-donation questionnaire, while blood samples collected were screened for hepatitis B, hepatitis C, human immunodeficiency viruses by ELISA and RPR (syphilis), then confirmed using CMIA. RESULTS: Overall TTIs seroprevalence was 114 (9.4%), distributed among HIV, HBV, HCV and syphilis at 14 (1.15%), 42 (3.46%), 39 (3.21%) and 19 (1.56%), respectively, with co-infections of 3 (0.25%). There were no significant differences in proportions distributions among demographic variables. However, high risk sex was significantly associated with higher odds of HBV infections [> 1 partner vs. 0-1 partner; odd ratio (OR) 2.60; 95% confidence interval (CI) 1.098-6.86; p = 0.046]. In conclusion, a substantial percentage of blood donors still harbor transfusion transmissible infections despite recent safety improvements with greater majority cases caused by HBV infections arising from previous exposure to high risk sex.

Perceived Quality of Care of Community Health Worker and Facility-Based Health Worker Management of Pneumonia in Children Under 5 Years in Western Kenya: A Cross-Sectional Multidimensional Study.

Integrated community case management (iCCM) programs that train lay community health workers (CHWs) in the diagnosis and treatment of diarrhea, malaria, and pneumonia have been increasingly adopted throughout sub-Saharan Africa to provide services in areas where accessibility to formal public sector health services is low. One important aspect of successful iCCM programs is the acceptability and utilization of services provided by CHWs. To understand community perceptions of the quality of care in an iCCM intervention in western Kenya, we used the Primary Care Assessment Survey to compare caregiver attitudes about the diagnosis and treatment of childhood pneumonia as provided by CHWs and facility-based health workers (FBHWs). Overall, caregivers rated CHWs more highly than FBHWs across a set of 10 domains that capture multiple dimensions of the care process. Caregivers perceived CHWs to provide higher quality care in terms of accessibility and patient relationship and equal quality care on clinical aspects. These results argue for the continued implementation and scale-up of iCCM programs as an acceptable intervention for increasing access to treatment of childhood pneumonia.