Association between childhood immunisation coverage and proximity to health facilities in rural settings: a cross-sectional analysis of Service Provision Assessment 2013–2014 facility data and Demographic and Health Survey 2015–2016 individual data in Malawi

OBJECTIVES: Despite significant progress in childhood vaccination coverage globally, substantial inequality remains. Remote rural populations are recognised as a priority group for immunisation service equity. We aimed to link facility and individual data to examine the relationship between distance to services and immunisation coverage empirically, specifically using a rural population. DESIGN AND SETTING: Retrospective cross-sectional analysis of facility data from the 2013–2014 Malawi Service Provision Assessment and individual data from the 2015–2016 Malawi Demographic and Health Survey, linking children to facilities within a 5 km radius. We examined associations between proximity to health facilities and vaccination receipt via bivariate comparisons and logistic regression models. PARTICIPANTS: 2740 children aged 12–23 months living in rural areas. OUTCOME MEASURES: Immunisation coverage for the six vaccines included in the Malawi Expanded Programme on Immunization schedule for children under 1 year at time of study, as well as two composite vaccination indicators (receipt of basic vaccines and receipt of all recommended vaccines), zero-dose pentavalent coverage, and pentavalent dropout. FINDINGS: 72% (706/977) of facilities offered childhood vaccination services. Among children in rural areas, 61% were proximal to (within 5 km of) a vaccine-providing facility. Proximity to a vaccine-providing health facility was associated with increased likelihood of having received the rotavirus vaccine (93% vs 88%, p=0.004) and measles vaccine (93% vs 89%, p=0.01) in bivariate tests. In adjusted comparisons, how close a child was to a health facility remained meaningfully associated with how likely they were to have received rotavirus vaccine (adjusted OR (AOR) 1.63, 95% CI 1.13 to 2.33) and measles vaccine (AOR 1.62, 95% CI 1.11 to 2.37). CONCLUSION: Proximity to health facilities was significantly associated with likelihood of receipt for some, but not all, vaccines. Our findings reiterate the vulnerability of children residing far from static vaccination services; efforts that specifically target remote rural populations living far from health facilities are warranted to ensure equitable vaccination coverage.