Access to health care and mortality of children under 5 years of age in the Gambia: a case-control study.
OBJECTIVE
To assess whether traditional measures of access to health care (distance and travel time to a facility) and non-traditional measures (social and financial support indicators) are associated with mortality among children under 5 years of age in the Gambia.


METHODS
We conducted a case-control study in a population under demographic surveillance. Cases (n = 140) were children under 5 years of age who died between 31 December 2003 and 30 April 2006. Each case was matched in age and sex to five controls (n = 700). Information was gathered by interviewing primary caregivers. The data were analysed using conditional logistic regression.


RESULTS
Of traditional measures of access, only rural versus urban/periurban residence was important: children from rural areas were more likely to die (OR: 4.9; 95% confidence interval, CI: 1.2-20.2). For non-traditional measures, children were more likely to die if their primary caregivers lacked help with meal preparation (OR: 2.3; 95% CI: 1.2-4.1), had no one to relax with (OR: 1.8; 95% CI: 1.1-2.9), had no one who could offer good advice (OR: 23.1; 95% CI: 4.3-123.4), had little say over how earned money was spent (OR: 12.7; 95% CI: 1.3-127.6), were unable to cut spending for health care (OR: 2.5; 95% CI: 1.5-4.2) or had to carry out odd jobs to pay for the care (OR: 3.4; 95% CI: 2.1-5.5). A protective effect was observed when the caregiver had other children to care for (OR: 0.2; 95% CI: 0.1-0.5).


CONCLUSIONS
Improving access to health-care for children in the Gambia and similar settings is not simply a matter of reducing travel time and distance to a health facility, but requires improvements in caregivers' support networks and their access to the financial resources they need.
Centre for International Health, University of Otago, Dunedin, New Zealand.
Merrin E
ME
Rutherford
John D
JD
Dockerty
Momodou
M
Jasseh
Stephen R C
SR
Howie
Peter
P
Herbison
David J
DJ
Jeffries
Melissa
M
Leach
Warren
W
Stevens
Kim
K
Mulholland
Richard A
RA
Adegbola
Philip C
PC
Hill
D016022:Case-Control Studies; D046688:Child Mortality / Q000639:trends*; D002675:Child, Preschool; D005260:Female; D005714:Gambia / Q000453:epidemiology; D006297:Health Services Accessibility; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D011795:Surveys and Questionnaires