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

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 <24 months. A HBR was in hand and reviewed for three-quarters of the children. Nearly one-third (n = 41) of those without a HBR in hand at the visit noted that they did not know the importance of bringing the document with them. Roughly two-thirds (n = 443) of caregivers noted they were asked by clinic staff to see the HBR during the clinic visit. Across the 516 reviewed HBRs, recording areas were most commonly identified for the child’s demographic information (80% of HBRs) and vaccination history (82%) with information marked in >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.