title: Factors Affecting Access to Healthcare: An Observational Study of Children under 5 Years of Age Presenting to a Rural Gambian Primary Healthcare Centre.
abstract: OBJECTIVE
  Prompt access to primary healthcare before onset of severe illness is vital to improve morbidity and mortality rates. The Gambia has high rates of child mortality and research is needed to investigate contributing factors further. This study aimed to identify factors affecting access to primary healthcare for children <5 years (y) in rural Gambia focusing on delayed presentation and severe illness at presentation as indicators in a setting where primary healthcare is delivered free of charge.
  
  
  METHODS
  Data were extracted from an electronic medical records system at a rural primary healthcare clinic in The Gambia for children (0-5y) between 2009 and 2012. First clinic attendances with malaria, lower respiratory tract infections (LRTI) and diarrhoeal disease, the main contributors to mortality in this setting, were identified and categorized as delayed/non-delayed and severe/non-severe representing our two main outcome measures. Potential explanatory variables, identified through a comprehensive literature review were obtained from an ongoing demographic surveillance system for this population. Variables associated with either delayed/non-delayed and/or with severe/non-severe presentations identified by univariate analysis (p<0.1) were assessed in multivariate models using logistic regression (p<0.05).
  
  
  RESULTS
  Out of 6554 clinic attendances, 571 relevant attendances were identified. Delayed presentation was common (45% of all presentations) and there was a significantly reduced risk associated with being from villages with free regular access to transport (OR 0.502, 95%CI[0.310, 0.814], p = 0.005). Children from villages with free regular transport were also less likely to present with severe illness (OR 0.557, 95%CI[0.325, 0.954], p = 0.033).
  
  
  CONCLUSIONS
  Transport availability rather than distance to health clinic is an important barrier to accessing healthcare for children in The Gambia, and public health interventions should aim to reduce this barrier.
authors.affiliation: Centre for Primary Care & Public Health, Barts & The London School of Medicine & Dentistry, London, United Kingdom.
authors.forename: Claire P
authors.identifier: http://orcid.org/0000-0001-5649-7835
authors.initials: CP
authors.lastname: Rees
authors.affiliation: MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom.|MRC International Nutrition Group, at MRC Keneba, MRC Unit The Gambia, Banjul, The Gambia.
authors.forename: Sophie
authors.initials: S
authors.lastname: Hawkesworth
authors.affiliation: MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom.|MRC International Nutrition Group, at MRC Keneba, MRC Unit The Gambia, Banjul, The Gambia.|MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, United Kingdom.
authors.forename: Sophie E
authors.initials: SE
authors.lastname: Moore
authors.affiliation: MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom.|MRC International Nutrition Group, at MRC Keneba, MRC Unit The Gambia, Banjul, The Gambia.
authors.forename: Bai L
authors.initials: BL
authors.lastname: Dondeh
authors.affiliation: MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom.|MRC International Nutrition Group, at MRC Keneba, MRC Unit The Gambia, Banjul, The Gambia.|University of Edinburgh, Department of Child Life and Health, Edinburgh, United Kingdom.
authors.forename: Stefan A
authors.initials: SA
authors.lastname: Unger
mesh_terms: D002675:Child, Preschool; D003967:Diarrhea / Q000453:epidemiology; D005163:Factor Analysis, Statistical; D005260:Female; D005714:Gambia / Q000453:epidemiology; D005843:Geography; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008288:Malaria / Q000453:epidemiology; D008297:Male; D011320:Primary Health Care / Q000706:statistics & numerical data*; D062486:Public Health Surveillance; D012141:Respiratory Tract Infections / Q000453:epidemiology; D019035:Rural Health Services / Q000706:statistics & numerical data*