ABSTRACT
Since the launch of Expanded Program on Immunization in India in 1985, the country has made a tremendous progress in terms of coverage and so has the national capital, New Delhi. The present study assesses the immunization coverage, determinants, knowledge, attitude and practices (KAP) of respondents and proportion of Fully Vaccinated For Age (FVFA) children (i.e. those receiving timely immunization (within one month of due date)) and determinants of the same. A universal sample consisting of all children between 1 and 3 years was taken and information regarding status and KAP of respondents was obtained by house to house survey.
Out of the 235 children that were included in the study, 86.6% males and 77.9% females were fully immunized. The immunization coverage of the various vaccines was 97% for BCG, 93.3%
for OPV-1, DPT-1, OPV-2 & DPT-2, 89.6% for OPV-3 & DPT-3 and 86.7% for measles. The knowledge about vaccines was rather poor and only 50% of the respondents knew about Polio vaccine. The determinants of immunization status were availability of immunization card, tetanus immunization of mother, place of immunization, religion, parentÊs education, birth order and type of family. Out of the 196 fully immunized children, 104 (53.1%) were FVFA. The determinants of FVFA status were institutional delivery, working mother, awareness of immunization schedule, motherÊs education & fatherÊs occupation. The study shed light on the coverage and various determinants of immunization. Also, it is a unique study that has taken up the issue of timely immunization and no other study has been conducted in the country on this issue. Immunization coverage of a rural population was found to be better than the rest of Delhi as stated by survey NFHS-3 (National Family Health Survey). It has also brought out the success that the hard working staff of the local health centre have achieved in maintaining a high immunization coverage.
Keywords: Coverage, Determinants, FVFA, Immunization, KAP.
Study of Coverage and Determinants of
Immunization in Children Aged 1 to 3 Years in a Rural Population of Delhi
A Rathi1, GS Meena1
1Department of community medicine, Maulana Azad Medical College, New Delhi
Corresponding author: Akanksha Rathi, Department of community medicine, Maulana Azad Medical College, New Delhi E-mail: [email protected]
INTRODUCTION
The government of India launched Expanded Program on Immunization with the objective of reducing the mortality and morbidity resulting from vaccine preventable diseases of childhood and to achieve self-sufficiency in the production of vaccines. Universal Immunization Program was launched in 1985. It has 2 vital components: immunization of pregnant women against tetanus and immunization of children in their first year of life against the 6 vaccine preventable diseases. Significant achievements have been made under this program. In 1985, vaccine coverage ranged between 29% for BCG and 41% for DPT. By the end of 2008, coverage levels have gone up significantly 87% for BCG, 66% for 3 doses of DPT, 70% measles and 67% for 3 doses of OPV1.
The vaccination coverage is a slightly better in the national capital, Delhi. According to the DHLS-3 survey, the fully immunized children is 67%; BCG coverage is 92%; OPV 3 & DPT 3 coverage is 76.7%; and Measles coverage is 83%2.
Apart from the vaccines in National Immunization Schedule, the extra vaccines in the immunization schedule of Delhi are Hep-B vaccine given at birth and 6, 10 & 14 weeks old, MMR vaccine given at 15 months and Typhoid vaccine between 2-5 years of age. However, due to erratic supply, their coverage is low4.
Only one study by Chhabra P. et al is available that is throwing light on the immunization in urbanized villages of Delhi4. There are no studies on the timeliness of immunization and factors affecting immunization of Fully Vaccinated For Age children (FVFA) (i.e. those children who have received vaccines within one month of due date).
The present study assesses immunization coverage among children of a rural area of Delhi. In addition to immunization coverage, knowledge, attitude and practices of respondents, determinants of full immunization and proportion of FVFA are also examined in the study.
OBJECTIVES
1. To find out the immunization coverage amongst children aged 1 to 3 years in the study area.
2. To study the Knowledge, Attitude and Practice of the mothers/respondents with regard to immunization.
3. To find out the proportion and determinants of fully immunized, partially immunized, unimmunized and Fully Vaccinated for Age children.
MATERIALS AND METHODS
The present study is a community based, cross sectional study done in a rural area, Barwala that lies in the north-west district of Delhi and has a population of 6500 out of whom 90% are Hindus, 7% are Muslims, 2% are Sikhs and 1% are Christians. Number of families residing in the area are 642, out of which 60% are joint families and the rest are nuclear families. There are 120
infants in the area and 260 children between 1 and 3 years of age. A guardian’s family members including, mother, father, grandmother, other family members, and his/her children aged 1 to 3 years were included in the study. The area has a government run health centre that provides weekly immunization. Apart from that there are various private practitioners and nursing homes in the vicinity that provide immunization services.
Operational Definitions That Were Used
- Fully immunized:A child 12-23 months old who received one dose of BCG, 3 doses of DPT and OPV each and one dose of Measles within the first 12 months of his/her life. The child must have attained the said age on/before 1st May 2011 as that is the date of starting the data collection.
- Partially immunized: If a child has received one or more dose of vaccine less than those mentioned above.
- Unimmunized: If a child has not received even one dose of any vaccine in the first year of life.
- Fully vaccinated for age (FVFA): A child more than 1 year of age who has received all primary vaccinations (BCG, 3 OPV, 3 DPT and Measles) within one month of due date.
- Timely immunization: Immunization within one month of due date.
A quick survey was done by health worker staff (Public Health Nurse and Sanitary Inspector) of the health centre to determine whether the households had children of the desired age. It was done over a period of one week before the start of data collection by the author and they collected information like number of families and those having children. No other information was collected in that survey. Then, an exhaustive house to house survey was carried out by the author between 1st May 2011 to 31st July 2011 and all the houses in the area were visited at least once during that period to ensure that no child was left during the quick survey. About 260 children were found to be eligible (i.e they were between the age of 12-23 months on/before 1stMay 2011).
An informed consent was taken and the aim of the study was explained to the families in the language that they understood. They were also assured that the authors would take full initiative to get immunization or treatment for their children even if they choose not to participate in the study. Every effort was made to include the mother of the child in the study but in case she was not available, the preference was given to father, grandmother or any other family members in the mentioned order. The houses that were found to be locked were visited two times more to get the response. There were 15 houses that were marked locked after the third visit and no more visits were made to them. Around, 25 families refused to participate in the study on grounds like non-availability of time, non-availability of the guardian of the child and non-interest. Thus, the total number of children included in the study was 235. A pre-coded, pre-tested semi-structured questionnaire was used to collect the data. The questionnaire had 3 parts. One part had questions about the identification data (details about the education of parents, occupation of parents, age of parents, religion, socio economic status of the family, total family members and total number
of children, address), second part enquired about knowledge, attitude and practices of the respondent (ANC check ups of the mother, place of delivery of the child, faith in immunization, knowledge about schedule of immunization, knowledge about the place of immunization etc.) and third about the immunization status of the child (immunized or not and timely immunized or not). The immunization data was collected with the help of the immunization card or other health records. This was considered to be the most valid information, but if no card was available then the respondents were enquired about the vaccines received. To validate immunization histories taken by recall method, informants were asked about the time, source and number of vaccination, the health care provider and the health care facility. In most of the cases this information was sufficient to validate the history, but in case the respondent was not sure or ambiguity was sensed then the presence of BCG scar was also noted. In case of ambiguity, the child was considered partially immunized whether he/she had the BCG scar or not. Data about immunization was recorded including BCG, DPT, OPV, Measles, DPT-B, OPV-B, Hepatitis-B, MMR, Typhoid and other newer vaccines that are not included in the Delhi Immunization Schedule. The time of immunization was noted and the reasons for delayed, partial or no immunization were asked. Children were categorized as fully immunized, partially immunized or unimmunized. Children who were fully immunized were further divided between FVFA or not FVFA. Then the knowledge, attitude and practice of the mothers/respondents were assessed.
The data was analyzed with the help of SPSS 16. Percentages and frequencies were used to describe the data.
Chi square test/Fishers’ Exact test was used to observe the differences between proportions. Two- way tables were utilized to assess the relationship between the dependent and the independent variables.
P<0.05 was considered significant. Odd’s ratio was calculated to find out the magnitude of determinants. To determine which factors were most strongly associated, Binary logistic regression was applied to determinants having a p-Value of less than 0.2. For the logistic regression analysis, all variables were entered in one step and removed from the model according to the tolerance statistic fitting the model using the backward Likelihood Ratio. Binary logistic regression is a method of doing multivariate analysis. It is done to exclude confounders and their effects on the independent determinants. In univariate analysis, many factors become significant because of the effect of confounders. Thus, multivariate analysis is needed to exclude them.
Ethical Clearance
Facilities for immunization were provided to all the children at the centre or in the field whether or not they participate in the study. The study was approved by Ethical committee of Maulana Azad Medical College.
RESULTS
Out of 235 respondents, 205 (87.2%) were mothers 8 (3.4%) were fathers, 17 (7.2%) were grandmothers and 5 (2.1%) were others like aunts and uncles. Maximum respondents (57%) were
in the age group 25-35, 77 (32.8%) were less than 25 years of age, 7 (3%) were between 35-45 years and 17 (7.2%) were more than 45 years of age. The mean age of respondents was 28.16 years (8.31 SD).
The respondents (i.e., both mothers and fathers) were asked about educational level and occupation. Mothers of 41 (17.4%) children were illiterate, 87 (37%) had education of middle school and below, 55 (23.4%) were high school pass and 52 (22.1%) were graduate and above.
On the other hand, amongst the fathers, fathers of 27 (11.5%) children were illiterate, 108 (46%) were high school pass, 44 (18.7%) were graduate and above and the rest had education of middle school and below.
Socio-economic status scale (rural) by Udai Pareek and G. Trivdedi (1964) attempts to examine the socio-economic status for the rural or mixed population only. This scale consists of 9 factors which includes caste, occupation, education, social participation, land, house, farm power, material possession and types of family. It classifies families into 5 categories of socio economic status: upper, upper middle, middle, lower middle and lower. Even though, it does not take the economic aspect into consideration, socio economic status still is a reliable tool for evaluation in the rural setting. According to Udai Pareek and G. Trivedi classification for rural areas, 1 (0.4%) family was in upper class, 16 (6.8%) in upper middle and 90 (38.3%) in middle. The highest percentage of families (45.5%) belonged to lower middle class and 21 (8.9%) belonged to lower class.
Maximum number of families had 2 children (i.e. 97 (41.3%)), 76 (32.3%) had only one child, 46 (19.6%) had 3 and only 16 (6.8%) families had more than 3 children. Thus, almost three-fourth of the families had 2 or less than two children.
Amongst the study children, the number of males (63.4%) was almost twice as much as the number of females (36.6%).
Out of 149 males, 129 (86.6%) were fully immunized and the rest were partially immunized. Out of the 86 girls, 67 (77.9%) were fully immunized, 17 (19.7) were partially immunized and 2 (2.3%) were unimmunized. Since the proportion of unimmunized children is too small for analysis, the number of partial and unimmunized children has been clubbed together.
Out of the 196 fully immunized children, 104 (53.1%) were Fully Vaccinated for Age (i.e. they had received all the primary immunizations within one month of due date).
The primary immunization coverage amongst children 12-23 months of age was found out to be 84.4%. The coverage for BCG was 97.0%, OPV & DPT 1stand 2nddose was 93.3%, OPV-3 &
DPT-3 was 89.6% and Measles was 86.7%. The dropout rate between BCG and measles was 10.3% and between DPT-1 and DPT-3 was 3.7%. The coverage of OPV-0 dose was 80.0% and that of Hep-B-0 dose was 74.0%. The coverage of Hep-B 1st, 2ndand 3rddose was 91.1%, 91.1%
and 87.4%
Amongst all the 235 children, 204 (86.8%) have received vitamin A-1stdose; 106 (45.1%) have received vitamin-A 2nd dose; 161(68.5%) have received MMR; 11(4.7%) have received
Hemophilus Influenza vaccine; 2 (0.8%) have received chicken pox vaccine; and 1(0.4%) has received influenza and Hepatitis-A vaccine each. Amongst the 150 children between 18-36 months of age (age eligible for boosters), 111 (74.0%) children have received DPT and OPV boosters. Out of 100 children between 24-36 months of age, 37 (37.0%) have received Typhoid vaccination.
Even though all 235 respondents had heard about immunization, only 77.9% knew why children were immunized out of which, 60.4% said that immunization was done to save the child from certain diseases and 17.5% said it was for general well being of a child. The most common source of information included being a health worker (58.3%), followed by other places like hospital (15.0%), family and friends (11.1%), electronic media (10.2%), print media (2.0%) and some said they just know about it (3.0%).
A large proportion (81.7%) did not know about the immunization schedule, only 18.3% said they knew it and among 18.3% only 8.5% knew it correctly.
Almost all the respondents said they had faith in immunization, but most of them had this perception that child cannot be immunized against fever and diarrhea.
The significant determinants of full immunization using univariate analysis have been depicted in Table 1. Availability of the immunization card was the most significant determinant of full immunization (OR=36.3). Out of the 235 respondents, 24 could not present the immunization card. The main reason was to misplace the card in the wrong house or mistakenly leave the card in native place. Out of those 24 respondents, 5 could correctly tell the months during which various primary immunizations were given and the number of injections or oral vaccine that was given each time. Thus, the children of these 5 respondents were put in the category of fully immunized and that of other respondents were put in the category of partially immunized.
Children whose mothers were immunized against tetanus during antenatal period were 25.03 times more likely to be fully immunized. Place of immunization was also a significant factor as the children who were immunized at the government run health centre were 24.11 times more likely to be fully immunized. Hindu children were more likely to be fully immunized than Muslim children (OR=11.46). Father’s and mother’s educational level (e.g., more than middle school) was positively associated with full immunization status of the child (OR=4.27 & 3.24 respectively). Children with birth order 1 and 2 were 3.45 times more likely to be fully immunized than the children having a higher birth order. Type of family was a significant factor as children belonging to a joint family were more likely to be fully immunized than children belonging to a nuclear family (OR=2.96). The number of fully immunized children increased as the Socio Economic Status (SES) improved. Children belonging to upper and upper middle SES were 94.1% fully immunized, while those belonging to middle, lower middle and lower SES were 85.6%, 85.0% and 57.1% fully immunized respectively. Statistical analysis showed that a significant difference in immunization status is present in children belonging to families with lower SES as compared to families with other SES. Thus, for ease of interpretation of data, families have been divided as per two categories of SES (upper + upper middle + middle + lower
middle = Upper* SES & lower=Lower* SES). As can be seen in Table 1, the difference between immunization status of children belonging to lower* SES and higher* SES (lower middle SES and above) is highly significant. The children belonging to lower* SES are 4.60 times more likely to be partial/ unimmunized.
One of the major determinants of immunization status is the sex of the child. The proportion of males who are fully immunized (86.6%) is more than that of females (77.9%). However, the difference is not statistically significant as p-Value is more than 0.05. The females are 1.82 times more likely to be partial/ unimmunized.
As mentioned in the methodology, binary logistic regression was used to do multivariate analysis.
As seen in table 2, 5 factors were found to be most significant. Tetanus immunization of a mother
Table 1. Factors associated with full immunization status
is the most significant factor (OR=44.52). Children having the immunization card were 30.42 times more likely to be fully immunized. Children who were immunized at the health centre were 22.74 times more likely to be fully immunized. When number of family members were more than 5 then the child was 4.98 times more likely to be fully immunized. Number of children was also a significant factor in determining whether a child got immunized. When the number of children was 1 or 2, a child is more likely to be fully immunized (OR=4.02).
Timely immunization is defined as immunization within one month of due date. Those children who received all the primary immunizations timely were FVFA children and others were not FVFA. Factors affecting their immunization were illustrated in Table 3. Table 3 shows the various factors affecting timely immunization. When a child had an institutional delivery the likelihood of timely immunization increased (OR=4.61). Children of working mother were 3.5 times more likely to be FVFA. Children whose caretakers were aware of the immunization schedule were more likely to be FVFA (OR=3.32). A mother with middle school education or more was positively associated with the FVFA status of the child (OR=2.60). When a father’s occupation was in the category of business such as self-employed or service, the child was 2.16 times more likely to be timely immunized. On multivariate analysis, 3 factors were found to be significant.
Children who had institutional delivery were 4.40 times more likely to be FVFA. Knowledge of immunization schedule was also a significant factor determining timely immunization (OR=2.68). Children whose mothers were educated up to middle school or higher were 2.43 times more likely to be FVFA.
Table 2 Binary Logistic Regression Analysis of Factors Associated with Partial/ Non Immunization of Children.
* Variables that were adjusted were mother’s education, father’s education, religion, total members, type of family, socio-economic status, no. of children, place of delivery, place of immunization, person immunizing, care given during immunization (next due date told, informed about adverse reactions and PCM provided after DPT injection) sex of child, birth order, presence of immunization card, tetanus received by mother in ante-natal period.
N: 235
Goodness of fit R2=0.824
DISCUSSION
The present study was carried out to assess the immunization coverage of a rural area of Delhi, to know about the KAP of the respondents and to study the factors affecting partial/non or untimely immunization. Studies to determine the immunization coverage usually adopt the standard WHO 30-cluster sampling method. In the present study, universal coverage was done as the population of the village is small and it was feasible to enumerate all eligible children.
The most common respondent was a mother as she is the primary care giver of a child. Out of the total children, 82.6% had literate mothers and 88.5% had literate fathers. The results are consistent with those of census 20113 for the North-West district of Delhi (89.74% and 78.76%
are male and female literacy rates respectively). Almost three-fourth of the families had one or two children; however, the people are opting for fewer children and contraceptive methods are readily available and easily accessible. More than half of the families are Joint families as such families are still prevalent in rural parts of our country.
The earlier studies done on immunization coverage have mainly included children between 12- 23 months, but in the present study, children aged 12-36 months are included so that coverage of other antigens (MMR, booster doses of DPT and OPV, Typhoid, others vaccines) can also be assessed.
The immunization coverage as was found out by the present study was 97% for BCG, 93.6% for OPV/DPT-1, 93.2% for OPV/DPT-2, 89.8% for OPV/DPT-3 and 85.5% for Measles. The proportion of fully immunized children is 84.4%. This is much higher than the immunization coverage of two urbanized villages of Delhi as per Chabra P. et al4 (2007) who stated that Table 3. Factors affecting timely immunization
coverage for BCG was 82.7%, 81.5% for DPT/OPV-1, 76.8 for DPT/OPV-2, 70.7% for DPT/OPV-3 and 68.3% for Measles. The reason of this low coverage is that these villages of east Delhi have a large population of migrants and thus have a lower coverage. A study done by Kar M. et al in 2009 on slum areas of south Delhi revealed a much lower coverage. According to the authors, 69.3% of the children were fully immunized with BCG, DPT3, OPV3 and measles;
15.7% were partially immunized and 15.1% were non-immunized5. Another study done by Imteyaz A. Et al in 2008 on slum children of Delhi revealed a much lower coverage with only 50.4% fully immunized, 41.9% partially immunized and 7.6% were not immunized6. These two studies were done on slum children in slum areas, where generally a low immunization coverage is seen because of ignorance on the part of respondents and neglect on the part of service providers. DLHS-3 done in 2007-2008 reflected lower primary immunization coverage of about 67.6% and coverage for different antigens was also less than the present study. The coverage was 91.9% for BCG, 76.7% for OPV-3 & DPT-3 and 83.1% for Measles2. NFHS-3 done in 2005-2006 stated an even lower percentage of fully immunized children in Delhi. According to this survey, only 63% children between 12-23 months of age are fully immunized. The coverage for BCG is 87%, for DPT-3 is 72%, for OPV-3 is 79% and for Measles is 78%7. The reason for lower coverage in surveys is the difference in survey methods. However, in 2006 an immunization coverage evaluation survey was done by UNICEF reflects similar results compared to the current study. The coverage by different antigens came out to be 96.3% for BCG, 90.7% for OPV-0, 92.8% for OPV-1, 95.1% for DPT-1, 90.8% for OPV-2, 91.3% for DPT-2, 87.3% for OPV-3, 88.3% for DPT-3 and 89.2% for Measles. The proportion of fully immunized children came out to be 84.6% that is similar to the results reported in the current study (83.4%)8.
The immunization coverage of Hepatitis-B is quite high as it has been included in the state immunization schedule in 2001 and since then the coverage has been increasing. In the current study, the coverage of Hep-B-0, 1st, 2ndand 3rddose was found out to be 74%, 91.1%, 91.1% and 87.4% respectively. The coverage is much higher than that found in a study authored by Yadlapalli S. K. et al9in 2010 (80%, 76% and 70% of Hep-B 1st, 2ndand 3rddose) and Puri S. et al10(44.7%).
The booster coverage (DPT & OPV) in the current study was 74% which is a little higher than coverage of DPT booster (68.3%) and of OPV booster (65.3%) seen in the UNICEF study8 and it was much higher than findings of Chabra P. et al4(41.4%) and Kar M. et al5(44.9% and 49.4%
of DPT and OPV boosters respectively).
The coverage of MMR in the present study was 68.5% compared to 41.6% coverage of another study (Chabra P. et al4). However, it was lower than a study done in Chandigarh on newer vaccines by Puri S. et al10(79%). The coverage of Typhoid vaccine in the current study was 37%
as compared to 6% coverage of another study (Puri S. et al10).
The coverage of vitamin-A first dose as per the current study is 86.8% which is much higher than the results of UNICEF survey8(30%). However, other studies like the ones done by Yadlapalli S.K. et al9 (72-76%) and Kar M. et al5(75%) stated a much better vitamin-A coverage.
In the current study, though more than half knew that immunization is done to save the children from some diseases; however, the knowledge about the various Vaccine Preventable Diseases was rather limited. Only 50.2% could name Polio; 39.6% could name Measles; 12.8% knew about Typhoid; 11% knew about Pertussis; 10.2% about Tetanus; and 21% could name other diseases like hepatitis, chicken pox, diarrhoea etc. When compared to UNICEF survey it was found that the proportion of people knowing about VPDs was much lower: only 24.7% could name Polio’ 18.4% could name Measles; 21.4% knew about DPT and 29.9% about BCG8. When enquired about the immunization schedule, only 18.3% said they knew about the schedule, out of which only 8.5% (20 out of 235) knew it correctly. This reflects the very poor knowledge about immunization schedule. Thus the percentage of respondents correctly knowing about the immunization schedule is about half of that stated by the UNICEF survey (15.8%)8. Grey literature on epidemiology of unimmunized child stated that the knowledge that parents have is often low but does not affect the behavior much11.
Delivery at home was significantly associated with immunization status. Out of those delivered at home, 30.2% were partial and unimmunized as compared to 13.5% of those who delivered in institutions. These findings are consistent with other studies4, 12, 13, 14, 15
. The reason is that in case of institutional deliveries, vaccination is started at birth and parents are informed about the subsequent immunizations.
In the current study it was observed that a child having a birth order of more than 2 is 3.45 times more likely to be partial/ unimmunized. The findings are consistent with studies done in Nigeria12 and Malawi16as both studies stated that as the birth order increases, the likelihood of complete immunization decreases16. Studies done using NFHS data have also concluded that birth order has an inverse relationship with immunization17, 13, 18, 19. There are two countervailing effects of increasing birth-order on likelihood of vaccination. The positive one is learning effect about immunization which almost does not vary with higher birth-order. The negative one is negligence effect to the higher order births and this effect perhaps highly increases with higher birth-order.
The odds of being partial/ unimmunized are 11.46 (of what) for a Muslim child as compared to a Hindu child. It is consistent with findings of other studies17, 13, 19, 20, 15, 6. While a study done on NFHS study subjects in M.P. has stated otherwise18. The reason for this is the negative attitude of Muslims towards immunization. The second reason is that the village primarily belongs to Hindus; the Muslims there are migrants who have migrated in search of work. Migratory population has higher partial and unimmunized children due to the lower education status and the instability caused by migration itself. It is evident from findings of a study by Yadlapalli S.
K. et al9on migratory population of Delhi that states that the migration status is responsible for lower uptake of health care services.
In the present study, it was seen that 89.7% of the respondents had immunization card which is consistent with the findings of the UNICEF survey8 that stated that 87.6% of parents could produce the immunization card. Availability of immunization card was strongly associated with immunization status. The chance of being partial/ unimmunized is 36.3 times if the card is lost.
The findings are consistent with NFHS study subject reports17, 18, 21and other studies22, 23, 24. Out
of 235 respondents, 24 did not have the immunization card. The most common reasons of the same are misplacement of the card in the house and mistakenly leaving the card in the native place of the family. That is due to carelessness of the care-taker or lack of initiative of the health care provider to emphasize upon the importance of this document. People who lost the card did not know how important the card is to further immunizations of the child. Presence of immunization card is such an important factor because mostly parents refer to the card to know the further dates of due immunization. Also, the loss of the card depicts neglect on the part of parents that is further evident by the immunization status of their children.
An education of middle school or above was found to be positively associated with complete immunization. The child was 3.24 times more likely to be partial/unimmunized if mother’s education is less than middle school, which is consistent with the findings from other studies25,
4, 26, 27, 16, 28, 29, 30
. Studies done on NFHS survey-1 &2 stated that the most important indicator of child’s immunization status is maternal literacy31, 17, 13.
An even stronger association was seen between father’s education and immunization status.
Amongst children whose fathers had an education up to middle school and above, 87.7% were fully immunized. On the other hand, children whose fathers were either illiterate or had a lower education were only 62.5% fully immunized. Similar results are seen in another study4. The possible reason behind this finding is that even though a mother is the primary care-giver of the child but a father has more decision making power. Most of the times he accompanies both mother and child to the immunization centre. Thus, an educated father would be more aware of the need of immunization and would be keen to get his child immunized.
Although the type of family was significantly associated with immunization status, number of family members was not. The odds of being partial/ unimmunized are 2.96 if the child belongs to a nuclear family. This is different from the findings in other studies which have stated that joint family is an increased risk factor of partial immunization13, 6. Generally it is seen that in a joint family, because a mother is engaged in other work, she pays less attention to the child and thus this adversely affects the immunization status. But in our study village, the native families are usually Joint families. The Nuclear families usually belong to the migrants from other states who have come to Barwala in search of work. Migrants have a lower education status. Disruption in a child’s immunization and lower social support reflects in poor immunization status of migrant population. The finding is consistent with a study done by Yadrapalli S. K. et al on migrant population9.
It was seen that antenatal Tetanus immunization of a mother was strongly associated with the immunization status of a child. The odds of being partial/ unimmunized were 25.03 if a mother hadn’t received antenatal Tetanus immunization. This is also seen in another study25
.
Most of the other studies have found that there was a positive relationship between usage of antenatal services and full immunization of a child9, 21, 32. The reason is that mothers seeking antenatal care for themselves are more likely to seek health care and immunization for their children.Out of the total number of children, those belonging to lower SES were most partial/
unimmunized. There was not much difference in proportion of fully immunized children in the other socioeconomic classes (94.1% in upper and upper middle, 85.6% in middle and 85.0% in lower middle classes were fully immunized). The findings are consistent with that of other studies1, 13. A study done in Sudan stated that immunization depended on SES30. A study done in Kenya stated that SES affected the transportation and thus could be a hindering factor in acquiring immunization36. Grant C. from New Zealand stated that poverty lead to hindrances in transport.
Poverty hindered immunization not only because of its negative impact upon how the household functioned but also because those who were poor did not have the same access to high-quality primary care as those who are not poor48. Chance of immunization increased with the standard of living index has been stated in two studies23, 26. Review of Grey’s literature also states that SES is important factor42. In the current study, the health care is provided at the doorstep of people.
Also with free of cost and good quality, lower SES should not be a hindering factor for getting immunized. The reason for the finding is that SES acts as a proxy variable for other factors like education, awareness and utilization of health services and thus affects immunization.
In the current study, there were just 89 girls out of the total of 235 children, which is 38% of the total study children. All surveys have revealed a child-sex ratio of 850-860 in Delhi57, 58, 60. The reason of such low proportion of girls is that Barwala is a rural area and male preference is very evident amongst the people. Also, when people have two boys, they often do not opt for more children. Out of the total males, 86.6% were fully immunized and out of the number of females, 77.9% were fully immunized. Even though the coverage is higher in males, the association between gender and immunization status is not significant. The findings are consistent with that of other studies5, 7, 29. While studies done using NFHS, data suggests that gender of a child is an important indicator of immunization9, 11, 39. Other studies done all over the world have also stated that boys are more likely to be immunized than girls14, 15, 23, 43, 54
. A study by A. Singh reveals that immunization status of boys is better than the girls. The discrimination was seen both between households and within a household. Within a household, discrimination clearly suggests the reason for the same to be the gender of the child. It has also been stated that the immunization status of girls have improved only marginally between NFHS 1992-93 & NFHS 2004-0535. A systematic review by JL Mathew studied 3 nation wide data sets and revealed that gender imbalance in vaccination existed irrespective of method of determination of immunization status36. No significant gender preferences for immunization was seen in the current study as every child was considered precious, whether girl or boy. Thus, either a family did not have a girl or if they had, then she was given an equal chance for immunization.
To achieve maximal protection against VPDs, a child should receive all immunizations within recommended intervals33. Since immunization is most beneficial when received at the recommended age, age-appropriate coverage should be the benchmark for assessing immunization programme performance34.
The percentage of children who were fully vaccinated for age in the current study was 53.1%. A study done by Sadoh A. E. And Erigie C. o. in Nigeria has also reported a high percentage of children (19-65%) who delayed in receiving various vaccines33. Lack of knowledge about
importance of timeliness of immunization is the cause of a high percentage of children who do not receive timely immunization.
In the current study, the factors that were most strongly associated with untimely immunization were home being the place of delivery. For example, there is no knowledge about the immunization schedule or mother’s education is less than middle school.
Only mothers of 35.4% children having education of less than middle school were Fully Vaccinated for Age (FVFA) compared to 58.8% of those whose mothers have a higher education.
Out of the children delivered at home, 23.3% were FVFA and out of institutional deliveries, 41.6% were FVFA. Knowledge about immunization schedule also had a strong association with timely immunization. Out of 40 respondents who knew about the immunization schedule, 30 (75%) had children who were FVFA. On the other hand, out of 156 who didn’t know about the schedule, 74 (47.4%) had children who were FVFA.
Parents who know about the immunization schedule immunized their children timely. Mother’s education increases awareness and is also a proxy for institutional delivery of the child. Hence, the three factors (place of delivery, mother’s education & knowledge about immunization schedule) affect timely immunization.
ACKNOWLEDGEMENT
The author would like to extend sincere thanks to family, friends and colleagues without whom the completion of this research would not have been possible. Also, a big vote of thanks is extended to Dr. G. S. Meena for his constant inputs, support and encouragement.
CONFLICT OF INTEREST
The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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