This cross-sectional descriptive study was performed at six MCH clinics located within Bungoma, Nandi, Trans Nzoia, and Uasin Gishu counties located in western Kenya. The clinics are located in the towns of Eldoret, Turbo, Webuye, Mosoriot, Burnt Forest, and Kitale. These Ministry of Health clinics work in close collaboration with an institutional partnership: Academic Model Providing Access to Healthcare (AMPATH). This institutional partnership isled by Moi University School of Medicine and Indiana University and aims to improve delivery of healthcare services in western Kenya (7). This existing partnership and their close collaboration with the local MCH clinics throughout the region provided the rationale for the selection of the study setting. This study was approved by the ethical committees of both Indiana University and Moi University. Moi University’s Institutional Research and Ethics Committee is registered with the U.S. Office of Human Research Protections with its own Federalwide Assurances.
From 11/7/2016 – 12/7/2016, caregivers were recruited for participation at six MCH clinic locations using convenience sampling. A research assistant attended a full pediatric clinic day and approached all caregivers meeting the following inclusion criteria: bringing a child under the age of five years to be seen and identifying their current location as their primary MCH clinic. Every present caregiver who met inclusion criteria was recruited. A total of 78 caregivers consented and agreed to participate in the study. Only one recruited caregiver declined participation. For each caregiver, the child brought to clinic was also included in the study. Only retrospective data were collected from the children’s medical record.
The Mother and Child Health Booklet was the primary data source for this study. This booklet contains the services and interventions received by the child at the MCH clinic. Kenya began using The Mother and Child Health Booklet in 2008 to link maternal and child healthcare and have one comprehensive medical record (6). The Mother and Child Health Booklet provides education on strategies to improve her and her child’s health. The book, which is the primary health record for the mother and her child, is brought to every visit with a healthcare provider. Healthcare providers record services and interventions provided at each visit in the booklet.
In Kenya, children are immunized against tuberculosis, diphtheria, whooping cough (pertussis), tetanus, polio, measles, hepatitis B, Haemophilus influenza type b (Hib), Streptococcus pneumonia, and rotavirus (5). Bacillus Calmette-Guerin (BCG) is used for immunization again tuberculosis. The pentavalent vaccine provides protection against diphtheria, pertussis, tetanus, hepatitis B, and Hib. The administration of the oral polio vaccine (OPV) immunizes again poliovirus, and measles and rotavirus each have their own vaccine. Lastly, children are vaccinated against Streptococcus pneumoniae via administration of the pneumococcal conjugate vaccine (PCV) (5). Among the six vaccines included in the routine immunization schedule in Kenya, all but one, BCG, is given in a series of multiple doses.
To prevent soil-transmitted helminth infections, which are associated with malnutrition, poor physical growth, and cognitive impairment (8, 9), the World Health Organization and Kenya’s Ministry of Health recommends children ages 12-59 months receive one dose of either albendazole or mebendazole every 6 months. Additionally, vitamin A deficiency affects nearly 30% of children in low- and middle-income countries and is linked to child mortality (10). To prevent vitamin A deficiency, high-dose vitamin A is given once every 6 months as a supplement, beginning at 6 months of age and ending at 59 months of age (5).
For data collection, brief oral interviews with caregivers and review of the Mother and Child Health Booklet were utilized. Structured oral interviews captured demographic data, such as their relationship with the child, age, and whether or not other children lived in the household. Interviews were conducted in either English or Kiswahili, whichever the participant felt most comfortable speaking. A research assistant was trained to ask questions and to categorize the responses into the pre-assigned answer choices. A free text option was available if the study team member found that available categories were not appropriate. Retrospective data collection was performed to ascertain health services related data for each child. These data were directly collected from the child’s Mother and Child Health Booklet. A research assistant reviewed the Mother and Child Health Booklets for immunizations, vitamin A supplementation, deworming, and growth monitoring. For immunizations, a research assistant also recorded the child received each dose in each vaccine series and time point or visit for vitamin A supplementation, deworming, and growth monitoring. For all health services data, eligibility for health services was verified by referencing the age of the child, presence at MCH clinic, and timing of service delivery.
Following the conclusion of data collection, health services records extracted from the Mother and Child Health Booklets and responses from the caregiver questionnaires were entered into a Microsoft Excel file. For immunizations, variables were created for each vaccine series to determine whether each child was up-to-date for each vaccine, as defined for each vaccine as the eligibility of child receiving every dose in the series based on age. For example, if a child was 12-weeks old and she received the first three doses of OPV (at birth, 6 weeks, and 10 weeks), she was determined to be up-to-date on OPV despite not receiving the last dose (given at 14-weeks). An additional variable was created to account for every vaccine and series in the immunization schedule. If a child received all vaccines and was up-to-date on all series in the immunization schedule, she was considered up-to-date on all vaccines and fully vaccinated for her age. Similar variables were created for vitamin A supplementation, deworming, and growth monitoring of weight. Height was not accounted for in the growth monitoring variable because only 30% of children had any height measurements recorded.
Statistical Analysis
Descriptive statistics were used to analyse the responses from the caregiver questionnaire and the proportion of children who received health services and those up-to-date (having received all services they were eligible for). These health services included immunizations, vitamin A supplementation, deworming, and growth monitoring. Additionally, a drop-out rate was calculated for the pentavalent vaccine, which is the proportion of children receiving the first dose in the series but not the third if eligible. Pentavalent drop-out rates are a common way to measure access to services and the capacity of health systems (i.e. MCH clinics) to provide services that require multiple visits (11). Pearson’s chi-square test was applied to determine significant differences in the proportion of males and females up-to-date on all vaccines, vitamin A supplementation, deworming, and weight measurement. Similarly, chi-square was also performed to determine differences in proportion of children fully immunized for age between households with or without other children at home, those who travelled more than 30 minutes to clinic and those who travelled less, different methods of transport, and those who reported barriers in accessing services at the clinic. All analyses were conducted using SPSS (version 24) (12).