Spatial access inequities and childhood immunisation uptake in Kenya

Abstract

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.

Subnational estimates of factors associated with under-five mortality in Kenya: a spatio-temporal analysis, 1993–2014

“…106 110 Healthcare utilisation rates are low due to poor infrastructure and limited geographical access, conflict and insecurity hence low immunisation rates and use of modern contraceptives. 71 73 74 101 111 However, in this region, religion and cultural beliefs might be a stronger determinant of contraception use in comparison to poverty and lack of access. [112][113][114] In view of historical and economic similarities between regions in Kenya, six economic blocs were formed.…”

“…12 68-70 Demand and supply challenges such as spatial access, health workforce, stockouts, cost of transportation and cold chain could also have hampered vaccination uptake especially in Northern Kenya where coverage was lower. [70][71][72][73][74][75] Child and maternal survival interventions such as supplements have been delivered through the Malezi Bora initiative since 2007, a health facility-based delivery system migrating away from the previous door-to-door approach to reduce implementation cost. 35 This might have also encouraged the uptake of immunisations.…”

“…74 For example, mean travel time of up to 120+ minutes was significantly associated with poor immunisation outcomes only in Northern Kenya (Isiolo and Marsabit). 71 Low breastfeeding coverage and high malnutrition levels continue to be a public health concern for Kenya with moderate gains witnessed across time. [86][87][88][89] The small improvements can partly be associated with breastfeeding initiatives (BFCI and BFHI) both at the hospital and community level, 36 food fortification, micronutrients, nutritional campaigns, school and community level initiatives (online supplemental file 1).…”

“…Spatial access to healthcare is better in most parts of these counties, hence, better healthcare utilisation rates, access to vaccinations and supplementations. 71 74 75 116 The infection prevalence of HIV and malaria have declined across much of the country but remain high in Western Kenya and parts of south-east (online supplemental file 3). This has led to targeted interventions, for example, restricting IPTp to high prevalence areas, the pilot introduction of RTSS vaccine, and focused efforts to increase coverage of ITNs, IRS larval source management 117 and increased attention to HIV preventative interventions 43 118-121 in these two regions.…”

The Socioecological Model as a Framework for Exploring Factors Influencing Childhood Immunization Uptake in Lagos State, Nigeria

“…The institutional level describes the roles that characteristics and operations of social institutions, including health facilities and their health workers, play in shaping health care decision-making (11). Studies have shown that availability and access to health care facilities signi cantly affect care-seeking behavior and utilization of health services (32)(33)(34)(35). In addition, patient-health care worker communication signi cantly impacts healthcare utilization, decision-making, acceptance of recommended health behaviors, and medical management (36)(37)(38).…”