Community and health worker perceptions and preferences regarding integration of other health services with routine vaccinations: four case studies.

BACKGROUND: Integration of routine vaccination and other maternal and child health services is becoming more common and the services being integrated more diverse. Yet knowledge gaps remain regarding community members and health workers acceptance, priorities, and concerns related to integration. METHODS: Qualitative health worker interviews and community focus groups were conducted in 4 African countries (Kenya, Mali, Ethiopia, and Cameroon). RESULTS: Integration was generally well accepted by both community members and health workers. Most integrated services were perceived positively by the communities, although perceptions around socially sensitive services (eg, family planning and human immunodeficiency virus) differed by country. Integration benefits reported by both community members and health workers across countries included opportunity to receive multiple services at one visit, time and transportation cost savings, increased service utilization, maximized health worker efficiency, and reduced reporting requirements. Concerns related to integration included being labor intensive, inadequate staff to implement, inadequately trained staff, in addition to a number of more broad health system issues (eg, stockouts, wait times). CONCLUSIONS: Communities generally supported integration, and integrated services may have the potential to increase service utilization and possibly even reduce the stigma of certain services. Some concerns expressed related to health system issues rather than integration, per se, and should be addressed as part of a wider approach to improve health services. Improved planning and patient flow and increasing the number and training of health staff may help to mitigate logistical challenges of integrating services.

Impact of integration of hygiene kit distribution with routine immunizations on infant vaccine coverage and water treatment and handwashing practices of Kenyan mothers.

Integration of immunizations with hygiene interventions may improve use of both interventions. We interviewed 1361 intervention and 1139 comparison caregivers about hygiene practices and vaccination history, distributed water treatment and hygiene kits to caregivers during infant vaccination sessions in intervention clinics for 12 months, and conducted a followup survey of 2361 intervention and 1033 comparison caregivers. We observed significant increases in reported household water treatment (30% vs 44%, P < .0001) and correct handwashing technique (25% vs 51%, P < .0001) in intervention households and no changes in comparison households. Immunization coverage improved in both intervention and comparison infants (57% vs 66%, P = .04; 37% vs 53%, P < .0001, respectively). Hygiene kit distribution during routine immunizations positively impacted household water treatment and hygiene without a negative impact on vaccination coverage. Further study is needed to assess hygiene incentives, implement alternative water quality indicators, and evaluate the impact of this intervention in other settings.

Integration of routine vaccination and hygiene interventions: a comparison of 2 strategies in Kenya.

BACKGROUND: Hygiene interventions reduce child mortality from diarrhea. Vaccination visits provide a platform for delivery of other health services but may overburden nurses. We compared 2 strategies to integrate hygiene interventions with vaccinations in Kenya's Homa Bay district, 1 using community workers to support nurses and 1 using nurses. METHODS: Homa Bay was divided into 2 geographical areas, each with 9 clinics. Each area was randomly assigned to either the nurse or community-assisted strategy. At infant vaccination visits hygiene kits were distributed by the nurse or community member. Surveys pre- and post-intervention, measured hygiene indicators and vaccination coverage. Interviews and focus groups assessed acceptability. RESULTS: Between April 2009 and March 2010, 39 158 hygiene kits were distributed. Both nurse and community-assisted strategies were well-accepted. Hygiene indicators improved similarly in nurse and community sites. However, residual chlorine in water changed in neither group. Vaccination coverage increased in urban areas. In rural areas coverage either remained unchanged or increased with 1 exception (13% third dose poliovirus vaccine decrease). CONCLUSIONS: Distribution of hygiene products and education during vaccination visits was found to be feasible using both delivery strategies. Additional studies should consider assessing the use of community members to support integrated service delivery.

Monitoring the marketing, distribution, and use of Sprinkles micronutrient powders in rural western Kenya.

BACKGROUND: In 2007, the US Centers for Disease Control and Prevention partnered with local Kenyan institutions to implement the Nyando Integrated Child Health and Education Project, an effectiveness study that used social marketing and a community-based distribution program to promote the sale of Sprinkles and other health products. OBJECTIVE: To describe monitoring of wholesale sales, household demand, promotional strategies, and perceived factors influencing Sprinkles sales among vendors. METHODS: Ongoing quantitative and qualitative monitoring of Sprinkles sales began in May 2007 in 30 intervention villages. Data sources included baseline and follow-up cross-sectional surveys; office records of Sprinkles sales to vendors; biweekly household monitoring of Sprinkles use; and qualitative data collection, including vendor focus groups and key informant interviews. RESULTS: A total of 550 children aged 6 to 35 months were enrolled at baseline, and 451 were available at 12-month follow-up. During this period, nearly 160,000 sachets were sold wholesale to vendors, with variability in sales influenced by the social, political, and economic context. Vendors living closer to the wholesale office purchased more Sprinkles, so a second office was opened closer to remote vendors. On average, 33% of households purchased Sprinkles during household monitoring visits. Training sessions and community launches were important for community support and raising awareness about Sprinkles. Vendor incentives motivated vendors to sell Sprinkles, and consumer incentives promoted purchases. CONCLUSIONS: Sprinkles program monitoring in Kenya was critically important for understanding sales and distribution trends and vendor perceptions. Understanding these trends led to strategic changes to the intervention over time.