Association between childhood immunisation coverage and proximity to health facilities in rural settings: a cross-sectional analysis of Service Provision Assessment 2013–2014 facility data and Demographic and Health Survey 2015–2016 individual data in Malawi

Abstract

ObjectivesDespite significant progress in childhood vaccination coverage globally, substantial inequality remains. Remote rural populations are recognised as a priority group for immunisation service equity. We aimed to link facility and individual data to examine the relationship between distance to services and immunisation coverage empirically, specifically using a rural population.Design and settingRetrospective cross-sectional analysis of facility data from the 2013–2014 Malawi Service Provision Assessment and individual data from the 2015–2016 Malawi Demographic and Health Survey, linking children to facilities within a 5 km radius. We examined associations between proximity to health facilities and vaccination receipt via bivariate comparisons and logistic regression models.Participants2740 children aged 12–23 months living in rural areas.Outcome measuresImmunisation coverage for the six vaccines included in the Malawi Expanded Programme on Immunization schedule for children under 1 year at time of study, as well as two composite vaccination indicators (receipt of basic vaccines and receipt of all recommended vaccines), zero-dose pentavalent coverage, and pentavalent dropout.Findings72% (706/977) of facilities offered childhood vaccination services. Among children in rural areas, 61% were proximal to (within 5 km of) a vaccine-providing facility. Proximity to a vaccine-providing health facility was associated with increased likelihood of having received the rotavirus vaccine (93% vs 88%, p=0.004) and measles vaccine (93% vs 89%, p=0.01) in bivariate tests. In adjusted comparisons, how close a child was to a health facility remained meaningfully associated with how likely they were to have received rotavirus vaccine (adjusted OR (AOR) 1.63, 95% CI 1.13 to 2.33) and measles vaccine (AOR 1.62, 95% CI 1.11 to 2.37).ConclusionProximity to health facilities was significantly associated with likelihood of receipt for some, but not all, vaccines. Our findings reiterate the vulnerability of children residing far from static vaccination services; efforts that specifically target remote rural populations living far from health facilities are warranted to ensure equitable vaccination coverage.

Assessing Vaccination Delivery Strategies for Zero-Dose and Under-Immunized Children in the Fragile Context of Somalia

“…Strong evidence exists that individual, community and health system level factors such as wealth, maternal education, proximity to health facilities, availability of services and vaccination governance have close associations with immunization coverage in resource-constrained settings [ 39 , 41 , 42 , 43 , 44 ]. Governance is particularly important as one of the main health systems’ building blocks.…”

Disparities in Vaccination Coverage and Timeliness among Children Aged 12 to 23 Months within Calabar South, Cross River State, Nigeria

“…The research adopted a community-based cross-sectional descriptive design among children aged 12 to 23 months while information about them were obtained through interviews with proxy caregivers. Assessment of vaccination coverage and related characteristics among children in this age group controls for recall bias [21]. The restriction to this age group is also to ensure that recommendations from the EPI which could change over time, as new vaccines are introduced were the same for all these children [22].…”

Using community-based, participatory qualitative research to identify determinants of routine vaccination drop-out for children under 2 in Lilongwe and Mzimba North Districts, Malawi

“…10 Contrary to similar settings in sub-Saharan Africa, Malawi's coverage rates are higher in rural areas than in urban areas, at 77% and 70% full vaccination coverage, respectively, in 2015-2016. 11 Reviews of reporting forms and anecdotal evidence from the facilities involved in this study indicate that vaccination record-keeping tools and processes also differ between urban and rural facilities; in rural regions such as Mzimba North, facilities track individual children's records in paper-based vaccination registers, while in urban settings such as Lilongwe, facilities keep daily, paper-based tallies of antigens delivered, but do not keep records for individual children due to the much higher patient numbers as well as the likelihood of caregivers visiting multiple different facilities for vaccination services.…”