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

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Study Justification:
– The study aimed to assess the ownership and utilization of Home-based Records (HBRs) in selected Kenyan communities.
– HBRs are important tools for frontline health workers to make informed decisions about immunization services.
– There are concerns about incomplete or outdated recording areas in HBRs, which may affect the quality of care.
Study Highlights:
– A total of 677 children were included in the study, with three-quarters having a HBR.
– One-third of caregivers without a HBR did not know the importance of bringing it.
– Two-thirds of caregivers were asked by clinic staff to see the HBR during the visit.
– Most commonly recorded areas in HBRs were demographic information and vaccination history.
– Less frequently recorded areas included eye/vision problems, growth monitoring, and vitamin A.
Recommendations for Lay Reader:
– Emphasize the importance of HBRs and ensure health workers request them at every health encounter.
– Ensure all children receive a HBR and counsel caregivers on its importance.
– Ensure all sections of the HBR are legibly completed for continuity of care.
– Periodically review and assess the design and content of HBRs to meet user needs.
Recommendations for Policy Maker:
– Strengthen the importance of HBRs in reducing missed opportunities for vaccination.
– Develop strategies to ensure all children receive a HBR and caregivers are educated on its importance.
– Provide training and support to health workers to ensure complete and legible recording in HBRs.
– Allocate resources for periodic review and assessment of HBR design and content.
Key Role Players:
– Government programme officials
– Immunization partners
– Health workers
– Caregivers
– Ministry of Health staff
– WHO/Kenya
– WHO Regional Intercountry Support Team for East and Southern Africa
– UNICEF/Kenya
– Clinton Health Access Initiative
– WHO Headquarters
– United States Centers for Disease Control and Prevention
– United States Agency for International Development sponsored Maternal and Child Survival Program
Cost Items for Planning Recommendations:
– Training for health workers and interviewers
– Tablets or electronic devices for data collection
– Supervisors and drivers for field teams
– Review and assessment of HBR design and content
– Educational materials for caregivers
– Resources for HBR distribution to all children

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a mixed-methods approach and provides descriptive statistics. The study utilized a convenience sample and focused on selected study communities in Kenya. To improve the strength of the evidence, the study could have used a more representative sample and included a larger number of health facilities. Additionally, conducting a comparative analysis between different communities or regions would have provided more robust findings.

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 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.

This study is a secondary analysis of data collected as part of a WHO-led initiative, conducted in collaboration with government programme officials and immunization partners in Kenya, to characterize MOV among children aged less than two years. The MOV assessment is designed to be completed in less than 10 days inclusive of training, data collection and preliminary data analysis. It is a mixed-methods approach that consists of exit interviews with caregivers attending a health facility, knowledge-attitudes-practices surveys of health workers, in-depth interviews of health administrators and semi-structured, qualitative interviews with health workers and caregivers. The assessment which provided the data for this secondary analysis was conducted during November 2016 using revised methods [12] based on assessments conducted in 1988 [13] and 2013. The Kenya MOV assessment team selected 40 health facilities across 10 counties (4 health facilities per county). Counties were selected purposively to represent a range of geographic areas and immunization performance levels, which were based on administrative vaccination coverage for the third dose of diphtheria-tetanus toxoid-pertussis-hepatitis B-Haemophilus influenzae type b (or pentavalent) vaccine. The sampling of health facilities was guided by a WHO recommendation to assess at least 30 health facilities, when possible, with a minimum of 20 health facilities to be visited. Health facilities were selected to reflect a range of sizes (i.e., Kenya Essential Health Package levels 2–5), types (Ministry of Health, nongovernmental organization, religious, private), and locations (urban and rural). Because of restrictions on the number of days available for data collection, logistical access of selected areas was also considered. Prior to going to the field, the study team reviewed and customized a generic questionnaire [14] to align with the specific vaccination schedule and terminology used in Kenya. Interviewers and supervisors were drawn from Kenya Ministry of Health staff, WHO/Kenya, WHO Regional Intercountry Support Team for East and Southern Africa, UNICEF/Kenya, Clinton Health Access Initiative, WHO Headquarters, United States Centers for Disease Control and Prevention and the United States Agency for International Development sponsored Maternal and Child Survival Program. All interviewers were centrally trained between 31 October and 2 November 2016 in Nairobi. A pilot test of the questionnaire was carried out during a half-day field exercise included in the training, during which interviewers went to five different health facilities in Nairobi to practice conducting interviews. Ten field teams were formed (one team per county) to conduct a minimum of 600 exit interviews with caregivers during a three- to five-day period. Each team was expected to complete at least 20 sequential exit interviews with caregivers per day. Field teams were comprised of two to three interviewers (25 interviewers total) and overseen by a supervisor (three supervisors in total, each responsible for three or four teams). Each team and each supervisor was supported by a driver (13 drivers total). A target sample of 300 health workers (10 health worker interviews per health facility) was also interviewed to gather information about reasons for MOV; however, these are not the focus of this manuscript. All interviews in the Kenya MOV assessment were conducted during 3–8 November 2016. Interviewers were instructed to position themselves at the exit or other strategic location of selected health facilities. All caregivers of children age 0–23 months exiting selected health facilities were eligible to be interviewed regardless of the reason for visiting the health facility, their place of residence or relationship to the child. For this study, the caregiver was defined as the person accompanying the child at the time of the interview and may have been the person who gave birth to or adopted the child or was otherwise taking care of the child, such as an aunt, grandmother, or father. All persons exiting the health facility with a child were sequentially approached and asked to participate in the study. Each potential participant was pre-screened on age of accompanying child only. Per protocol, exit interviews were conducted with adult caregivers (≥15 years of age) accompanying children between the ages of 0–23 months visiting one of the study selected health facilities on the day of the assessment. Prior to each interview, the selected individual was made aware that their participation was voluntary and they were asked to provide verbal consent. Caregiver exit interviews were conducted by trained interviewers in the appropriate local language. If a consenting adult caregiver was accompanied by more than one child, the interviewer was instructed to focus the exit interview on the youngest child. All consenting adults were interviewed irrespective of the availability of a HBR at the time of the interview. For children without a HBR, teams abstracted dates of vaccination from health facility registers after completing caregiver interviews. Field interview teams were instructed to make an effort to identify a mix of caregivers with infants (aged 0–11 months) and one-year old (12–23 months) children, and if possible, to conduct 10 interviews with caregivers of children in each age group at each selected facility. Field teams were also asked to conduct interviews at health facilities on days and during hours (usually morning hours) when immunization services were occurring, and to interview the caregivers after they had received service at the facility. Field teams were also instructed to interview consecutive eligible caregivers at the exit of the health facility, so as to achieve a mix of caregivers attending the facility for a variety of purposes (i.e. immunization as well as other services). All data was collected electronically using tablets programmed with the standardized exit interview questionnaire. As part of each exit interview, caregivers were asked several questions related to how they obtained and used their child’s HBR (see S1 Appendix). Additionally, among caregivers with a HBR in hand, the field team reviewed the recording areas that appeared on the HBR. Specifically, the teams identified whether the following sections existed on the child’s HBR: background demographic information, vaccination history, receipt of vitamin A, growth monitoring, early eye or vision screening and newborn delivery information. If a recording field existed, the team also noted if an effort had been made to record information in the section. A recording field was deemed filled or marked if ANY deliberate entry was observed in the recording area. The aim of the WHO MOV assessments is to provide a national immunization programmes with a rapid, snapshot characterization of missed opportunities in selected areas. The pooled data obtained from the purposive sampling of health facilities and non-random, sequential convenience sample of caregivers (and their children) were analysed using simple descriptive summary statistics. All analyses were conducted using Stata v14 (Stata Corporation, College Station, Texas). The Missed Opportunities for Vaccination protocol was submitted to the Kenyan Ministry of Health for ethical review and was deemed a Government of Kenya led programme assessment, and was therefore exempt from further review.

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Digital Home-based Records (HBRs): Develop a digital version of HBRs that can be accessed and updated by both frontline health workers and caregivers. This would ensure that records are always up-to-date and easily accessible, even if the physical document is not present.

2. Mobile Applications: Create a mobile application that provides caregivers with reminders for immunization appointments, growth monitoring, and other important maternal health activities. This would help ensure that caregivers are aware of the importance of bringing the HBR and attending health encounters.

3. Training and Education: Implement comprehensive training programs for health workers to emphasize the importance of HBRs and ensure that all sections of the record are completed accurately and legibly. This would help improve continuity of care and reduce missed opportunities for vaccination.

4. User-centered Design: Periodically review and assess the design and content of HBRs to ensure that they meet the needs of end users. This could involve gathering feedback from caregivers and health workers to identify areas for improvement and make necessary adjustments to the HBRs.

5. Integration with Health Information Systems: Integrate HBRs with existing health information systems to facilitate data sharing and improve coordination of care. This would enable health workers to access and update HBR information electronically, reducing the risk of incomplete or outdated records.

These innovations aim to address the challenges identified in the study and improve access to maternal health by enhancing the ownership, utilization, and effectiveness of HBRs.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health is to emphasize the importance of Home-based Records (HBRs) and ensure that health workers request and review them at every health encounter. It is crucial for health workers to ensure that all children receive a HBR and counsel caregivers on its importance. Additionally, health workers should ensure that all sections of the record are completed legibly to ensure continuity of care. Periodic reviews and assessments of the HBR should be conducted to determine if the design and content areas are optimal for end user needs. This recommendation is based on the findings of the study conducted in selected Kenyan communities, which highlighted the need for improved ownership and utilization of HBRs in maternal health.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Strengthening Health Worker Training: Provide comprehensive training to health workers on the importance of home-based records (HBRs) and how to effectively use them. This includes educating health workers on the significance of recording all relevant information in the HBRs and emphasizing the importance of requesting the document from caregivers at every health encounter.

2. Promoting Caregiver Awareness: Conduct community awareness campaigns to educate caregivers about the importance of HBRs and the need to bring them to every health facility visit. This can be done through various channels such as community meetings, radio broadcasts, and posters in health facilities.

3. Improving HBR Design: Periodically review and assess the design and content areas of HBRs to ensure they meet the needs of end users. This includes optimizing the recording areas for relevant information such as demographic information, vaccination history, growth monitoring, and other important maternal health indicators.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Baseline Data Collection: Collect baseline data on the current utilization of HBRs and the level of access to maternal health services in selected communities. This can be done through surveys, interviews, and data analysis.

2. Intervention Implementation: Implement the recommended interventions in the selected communities. This may involve training health workers, conducting awareness campaigns, and improving the design of HBRs.

3. Monitoring and Evaluation: Continuously monitor the implementation of the interventions and collect data on key indicators such as HBR ownership, utilization of recording areas, and access to maternal health services. This can be done through surveys, interviews, and data analysis.

4. Comparative Analysis: Compare the data collected after the intervention implementation with the baseline data to assess the impact of the recommendations on improving access to maternal health. This can be done by analyzing the changes in key indicators and conducting statistical tests to determine the significance of the findings.

5. Reporting and Recommendations: Summarize the findings of the impact assessment and provide recommendations for further improvement. This can include identifying successful strategies, highlighting areas that need further attention, and suggesting additional interventions to enhance access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and provide evidence-based insights for future interventions.

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