Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada.
Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
JAMA Netw Open. 2018 Dec 7;1(8):e185152. doi: 10.1001/jamanetworkopen.2018.5152.
Previous work has underscored subnational inequalities that could impede additional health gains in Kenya.
To provide a comprehensive assessment of the burden, distribution, and change in inequalities in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions in Kenya from 2003 to 2014.
DESIGN, SETTING, AND PARTICIPANTS: This population-based cross-sectional study used data from the 2003, 2008, and 2014 Kenya Demographic and Health Surveys. The study included women of reproductive age (ages 15-49 years) and children younger than years, with national, regional, county, and subcounty level representation. Data analysis was conducted from April 2018 to November 2018.
Socioeconomic position that was derived from asset indices and presented as wealth quintiles. Urban and rural residence and regions of Kenya were also considered.
Absolute and relative measures of inequality in coverage of RMNCAH interventions.
For this analysis, representative samples of 31 380 women of reproductive age and 29 743 children younger than 5 years from across Kenya were included. The RMNCAH interventions examined demonstrated pro-rich and bottom inequality patterns. The most inequitable interventions were skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits, whereby the absolute difference in coverage between the wealthiest (quintile 5) and poorest quintiles (quintile 1) was 61.6% (95% CI, 60.1%-63.1%), 33.4% (95% CI, 31.9%-34.9%), and 31.0% (95% CI, 30.5%-31.6%), respectively. The most equitable intervention was early initiation of breastfeeding, with an absolute difference (quintile 5 minus quintile 1) of -7.9% (95% CI, -11.1% to -4.8%), although antenatal care (1 visit) and diphtheria-tetanus-pertussis immunization (3 doses) demonstrated the best combination of high coverage and low inequalities. Our geospatial analysis revealed significant socioeconomic disparities in the northern and eastern regions of Kenya that have translated to suboptimal intervention coverage. A significant gap remains for rural, disadvantaged populations.
Coverage of RMNCAH interventions has improved over time, but wealth and geospatial inequalities in Kenya are persistent. Policy and programming efforts should place more emphasis on improving the accessibility of health facility-based interventions, which generally demonstrate poor coverage and high inequalities, and focus on integrated approaches to maternal health service delivery at the community level when access is poor. Scaling up of health services for the urban and, in particular, rural poor areas and those residing in Kenya's former north eastern province will contribute toward achievement of universal health coverage.
先前的工作强调了国家以下层面的不平等，这可能会阻碍肯尼亚在健康方面取得更多进展。
提供肯尼亚生殖、孕产妇、新生儿、儿童和青少年健康（RMNCAH）干预措施的负担、分布和不平等变化的综合评估，这些干预措施的评估时间跨度为 2003 年至 2014 年。
设计、地点和参与者：这是一项基于人群的横断面研究，使用了 2003 年、2008 年和 2014 年肯尼亚人口与健康调查的数据。研究对象包括育龄妇女（15-49 岁）和 5 岁以下儿童，在全国、地区、县和分区层面都有代表性。数据分析于 2018 年 4 月至 11 月进行。
社会经济地位，通过资产指数得出，并表示为财富五分位数。还考虑了城市和农村居住以及肯尼亚的地区。
RMNCAH 干预措施的覆盖范围的绝对和相对不平等衡量标准。
在这项分析中，纳入了来自肯尼亚各地的 31380 名育龄妇女和 29743 名 5 岁以下儿童的代表性样本。研究中检查的 RMNCAH 干预措施表现出了有利于富人且不利于穷人的不平等模式。最不平等的干预措施是熟练的接生、计划生育需求得到满足以及接受 4 次或更多次产前护理，其中最富裕（五分位数 5）和最贫穷五分位数（五分位数 1）之间的覆盖率绝对差异分别为 61.6%（95%CI，60.1%-63.1%）、33.4%（95%CI，31.9%-34.9%）和 31.0%（95%CI，30.5%-31.6%）。最公平的干预措施是早期开始母乳喂养，绝对差异（五分位数 5 减去五分位数 1）为-7.9%（95%CI，-11.1%至-4.8%），尽管产前护理（1 次）和白喉-破伤风-百日咳免疫接种（3 剂）显示出高覆盖率和低不平等的最佳组合。我们的地理空间分析显示，肯尼亚北部和东部地区存在显著的社会经济差异，这导致干预措施的覆盖率不理想。农村和弱势群体的差距仍然很大。
RMNCAH 干预措施的覆盖率随着时间的推移有所提高，但肯尼亚的财富和地理空间不平等仍然存在。政策和规划工作应更加重视改善基于卫生机构的干预措施的可及性，这些干预措施通常覆盖范围较差且不平等程度较高，同时应关注在获得服务较差的社区层面提供综合的孕产妇保健服务提供方法。扩大城市，特别是肯尼亚前东北部省份的城市和农村贫困人口的卫生服务将有助于实现全民健康覆盖。
