Background Access to quality essential healthcare services and vaccines for all is key to achieving universal health coverage. Inequities driven by differences in place of residence and socio-economic status persist among different communities hindering the achievement of sustained performance on immunization indicators. Innovative community-based Reach Every Child (REC) interventions at the sub-county and county level can reduce these local inequities. This study determines the effect of an enhanced door-to-door immunization strategy on improving immunization coverage in hard-to-reach areas of Migori. Methods This was a cross-sectional review of District Health Information System 2 immunization data for July and August 2018 for Migori County. During the presidential immunization rapid results initiative (RRI) in July 2018, poorly performing wards/facilities were mapped using the Quantum Geographic Information Systems methodology, and unreached rural-urban populations identified. Through review of facility level Kenya Expanded Programme on Immunization data, 64 health facilities with over 100 unimmunized children each between January 2017 and June 2018 in all sub-counties were prioritized. In August 2018, intensified fixed-point immunization services were offered within the prioritized facilities. Further, a 3-day door-to-door defaulter tracing by community health volunteers and household level immunization by nurses was conducted. Immunization coverage performance for access and utilization for the two periods were compared using z-tests/t-tests. Results Cumulatively, a total of 10,744 and 14,809 children were reached with immunization in July and August respectively for the 64 facilities. There were significant increases in the immunization coverage for BCG (74.4% vs 89.9%, P = 0.0001), Penta 1(96.2% vs 102%, P = 0.0649), Penta 3 (92.3% vs 112.1%, P = 0.0001), MR1 (81.7% vs 111.5%, P < 0.0001) and the fully immunized children at 1 year (78.6% vs 103.9%, P < 0.0001). Penta 3 and MR1 drop-out rates (3.99% vs − 9.86%, P = 0.0007; 15.06% vs − 9.27%, P = 0.0001 respectively) decreased significantly. Similar significant effects were observed at the subcounty levels ( P < 0.05). Conclusion Hard-to-reach populations require multiple REC strategies to reach every child with immunization. Health facilities should actively analyze and use routine immunization data and invest in community health strengthening systems to identify hard-to-reach areas to be targeted with outreaches to improve immunization coverage.
Background More women are accessing modern contraceptive use in Kenya, however, contraceptive discontinuation has stagnated over the decades. Any further increase in contraceptive use will most likely be from past users, hence understanding the dynamics of discontinuation while addressing quality of family planning services offered at health facilities and communities is critical for increasing the contraceptive prevalence rate and reducing the unmet need of family planning. The paper presents a study protocol that intends to evaluate the dynamics of contraceptive use, discontinuation, and switching among women of reproductive age initiating use of a contraceptive method. Methods This longitudinal mixed-methods study is being conducted in Migori and Kitui counties, Kenya. A formative assessment using Interviews with adolescents, older women, heterosexual couples, health care workers, and community health volunteers explored barriers to contraceptive continuation and perspectives on discontinuation utilizing a qualitative cross sectional study design. Following the formative assessment, a client-centered intervention focusing on improving quality of family planning services, including counseling, will be implemented in 10 health facilities. A 24-month prospective cohort study among women of reproductive age initiating contraception with follow-up at 3, 6, 12, and 24 months will then be undertaken to assess the discontinuation rates, examine the dynamics of contraceptive use, discontinuation and switching, and further explore barriers and enablers for contraceptive continuation and switching among the study population. Discussion In sub-Saharan Africa, contraceptive discontinuation studies have mainly been based on survey data that is collected retrospectively. By implementing a longitudinal mixed-methods study, we gain deeper insights into the contraceptive dynamics influencing the decision to continue, discontinue, and even switch following implementation of a client-centered intervention that enhances quality of care. Additionally, the study will shed more light on the profile of women discontinuing contractive use and further explore individual and couple-level dynamics influencing decision-making on continuation and discontinuation. The findings of this study will provide information that can be used to develop and implement human-centered interventions that focus on improving quality of family planning services and consequently improved continuation rates and overall satisfaction with method. Trial registration The study is registered with the Clinical Trials Registry, NCT03973593 .
Background Integrated community case management (iCCM) improves access to management of leading causes of under 5 (U5) mortality. Evidence of iCCM on maternal and newborn health and immunization services is scanty. The objective of this study was to determine the additional effect of iCCM on antenatal, skilled birth attendance (SBA) and immunization coverage in hard-to-reach communities.Methods A quasi-experimental (nonequivalent control group pretest – posttest) design for iCCM in Migori county. The intervention was iCCM training, mentorship/coaching and supportive supervision of 20 community health volunteers (CHVs). Twelve months pre-post intervention Kenya Health Information System (KHIS) data between July 2017-Sept 2019 reviewed. Differences in proportions for MNCH indicators pre – post-training were tested through test of proportions and considered statistically significant at P≤0.05 values.ResultsPost-training, average monthly community cases identification increased from 1.3-5, 0-1.5, 8.9-11.8 for suspected pneumonia, malnutrition and malaria positive cases treated in the intervention sites respectively. Intervention communities reported significant increases in proportions of malaria positive cases treated (32.0% vs 47.8%), pregnant women referred for ANC (25.4% vs 45.8%), defaulters referred for ANC (9.8% vs 14.9%), newborns with danger signs referred (1.4% vs 7.3%), U5s referred for immunization (4% vs 7.5%) and defaulters referred for immunization (2.2% vs 3%) (P≤0.05). Control communities reported significant reductions in proportion of malaria positive cases treated (57.6% vs 41.6%) and U5s referred for immunization (10% vs 5%) (P<0.0001) with no changes in MNH indicators (P≥0.05). Intervention facilities reported significant increases in 4th ANC coverage (39.4% vs 79.3%), SBA (24.5% vs 43%) and immunization coverage for U5s in all key expanded program on immunization antigens (P≤0.05) with no change in the control facilities.Conclusion iCCM improved access and utilization of ANC, SBA and immunization coverage in the hard-to-reach communities. Community level management of childhood illnesses using simple algorithms by CHVs as well as identification and referral of antenatal mothers for ANC, immunization defaulters, and newborns with danger signs for hospital management improved. Governments should strengthen community health systems so that CHVs are motivated and retained to carry out demand creation for maternal, newborn and child health and immunization services in hard-to-reach communities.
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