Missed opportunities of immunization in under-fives in adopted area of Urban Health Centre

Background: Immunization being one of the most cost effective public health interventions which is directly or indirectly responsible to prevent the bulk of mortalities in under-fives., thus vaccinating the children to the maximum is a great need of the future specially to reduce the child mortality and morbidity. Since, the programme of immunization on the whole was not found satisfactory in some of the states including Maharashtra. So the present study was conducted. Research question : What are the reasons of missed opportunities of immunization in under-fives? Objectives: To study the immunization status of under-fives in urban slums under Urban Health Centre and explore the reasons responsible for un-immunization or partial immunization. Materials and Methods : Community based Cross-sectional study conducted in Jan to April 2007. Total 420 under-fives were selected from six slums by simple random sampling method. Results: Out of 420 children, 270 (64.28%), 109 (25.95%) and 41 (9.76%) were fully immunized, partially immunized and un-immunized respectively. Immunization status of the children was significantly more in the children of educated mothers and child belonging to higher socioeconomic group. Lack of knowledge of immunization, ignorance about immunization of child and revisits for the immunization sessions were two main reasons (36.67% each) responsible for partial or un-immunization. Ignorance was most common reason (46.78%) responsible for partial immunization while lack of mother’s knowledge regarding immunization was common (46.34%) reason of unimmunization. Conclusion: Mother’s education, socioeconomic status of the family, Lack of mother’s knowledge about immunization and ignorance and fear of losing daily wages were important factors responsible for un-immunization or partial immunization.

Keywords: Education, gender, immunization, missed opportunities, socio-economic group, urban slum

Globally, each year 130 million children are born, 91 million of which are in the developing countries. However, around 10 million children under the age of five years die every year and over 27 million infants in the world do not get full routine immunization. The estimate for global child deaths under five years was 10.8 million in 2000. About 41% of these were in Sub-Saharan Africa and 34% in South Asia. ^[1] Immunization being one of the most cost effective public health interventions which is directly or indirectly responsible to prevent the bulk of mortalities in under-fives. The government of India launched its Expanded Programme of Immunization (EPI) in 1978 aiming at optimum coverage of immunization among all children below five years, later in 1985 Universal Immunization Programme was started with aim to cover the 85% of infant with three doses of DPT and OPV and 1 dose of BCG and Measles by 1990. ^[2] Despite of all efforts are being done to achieve this target but the target is still not achieved. According to National Family Health Survey -3 (2005-6) in India, only 57.5 % children of 12 to 23 months age in urban area were fully immunized. ^[3] The percentage of fully immunized children differs from state to state. The programme of immunization on the whole was not found satisfactory in some of the states including Maharashtra. Though Maharashtra stands amongst one of the good performing state for many health related indicators in India, as per National Family Health Survey-3 (2005-6) in Maharashtra, 68% children between 12-23 months residing in urban area were fully immunized while, the percentage observed in District Level Household and Facility Health Survey-3 (2007-8) was 72.7%. ^[3],[4] . Thus there are many children remained unimmunized or partially immunized. Various studies quoted the factors responsible for unimmunization or partial immunization. Among them the main factors were poor parental knowledge of immunization, parent’s neglect, domestic problems, immunization centre was far away or not at proper time hampering their routine work etc ^{[5],[6],[7],[8],[9],[10]}

So, it is important to understand the needs/problems for unimmunization or partial immunization to better manage the Universal Immunization Programme at the local level. So the present study was conducted in the adopted area of Urban Health Centre Solapur to measure the immunization status of children in the under-fives and to explore the various reasons of unimmunization or partial immunization.

Study design: Community based Cross-sectional study.

Study period: Jan 2007 to April 2007.

Study sample and method: NFHS-3 value was taken as reference value for calculation of sample size i.e. p=68%. ^[3] Calculation was done by the formula 4pq/L ^[2] with 5% allowable error. Sample estimated was 348 but in the present study 20% extra was taken and final sample size 420 was included in the study.

Study Setting: Study was conducted in the adopted area by Urban Health Centre of Dr. V.M. Medical College, Solapur (Western Maharashtra). There are total six slums under Urban Health Centre of population ranging from 4000-6000. It was decided to collect the sample from six slums. So from each slum area 70 under-fives were selected by simple random sampling method to fulfill the sample size. The required information was obtained from care taker i.e. mother or grandmother with pre-tested and pre-designed performa after obtaining informal consent. The accuracy and validity of the information was confirmed by immunization card and inspection for the BCG scar. Most common single reason responsible for un-immunization or partial immunization was noted.

Study Variables: sex, socioeconomic status, mother’s education. Statistical analysis was done by using SPSS software.

Test of significance used: Chi-square test.

Sample Size Formula: n = (1.96) ² pq/L ² (L = 5% allowable error)

Definition of few terminologies used:

1. Fully immunized: Child who had received all doses of vaccine for which he/she was eligible by age.
2. Partially immunized: Child had not fully immunized but received only one or two doses of vaccine for his/her age as per schedule.
3. Un-immunized: A child who had not yet received any vaccine for the age, though eligible except polio drops in the pulse polio drive.
4. Socio-economic scale used: Kuppuswamy socio-economic scale.

Among the 420 children studied, 232 (55.24%) were males and 188 (44.76%) were females. Out of 420 children, 270 (64.28%) were fully immunized, 109 (25.95%) partially immunized and 41 (9.76 %) were un-immunized. Among the male children 68.10% were fully immunized while, the percentage in female children was 59.57% (P>0.05). Mother’s education was significantly related with immunization status of the child. Only 52% of children were fully immunized of the mothers who were illiterate while, the percentage was 67.85% and 86.53% of the mothers who were educated up-to primary level and secondary and graduation respectively (P<0.01). Children of higher socioeconomic status were significantly immunized (76.19%) as compared with children of middle and lower socioeconomic status i.e. 69.57% and 60.08% respectively. (P<0.004) as shown in [Table 1].

Among the 150 children who missed the opportunity of immunization partially or completely, lack of mothers’ awareness regarding immunization (36.67%), ignorance (36.67%) and fear of losing daily wages due to inconvenience time schedule of the immunization camp (10.67%) were common reasons. Ignorance was most common reason (46.78%) responsible for partial immunization while, lack of mothers awareness regarding immunization was most common reason (46.34%) responsible for unim­munization [Table 2].

Table 2: Reasons of un-immunization or partial immunization Click here to view

The study tried to bring out the specific factors responsible for partial immunization and unimmunization as compared to similar studies. So that it will helpful to strengthen the UIP in India. In the present study the percentage of fully immunized children was 64.28% similar findings were noted by Malini Kar et al,^[11] (69.3%) and Yadhav et al,^[12] (60.8%). But Prabhakaran Nair et al,^[13] found that 77.5% children were fully immunized. While, Bhola Nath et al,^[5] Mathew et al,^[7] Kumar et al,^[8] Manjunath et al,^[10] Bhandari et al,^[14] and Nirupam et al,^[15] noted very low percentage of fully immunized children i.e. 44.1%, 25%, 17.84%, 50%, 44.65% and 34.5% respectively. The percentage of partially immunized children in present study was 25.95% similar findings were also observed by Manjunath et al,^[10] (31.3%), Malini Kar et al,^[11] (15.7%), Prabhakaran Nair et al,^[13] (18.3%), Yadhav et al^[12] (27.7%) and Nirupam et al,^[15] (32.6%). But Kumar et al,^[8] found 48% of the children assessed in tertiary care hospital of North India were partially immunized which was very high as compared to present study (25.95%). 9.76% children in the present study were un-immunized which was more in comparison with Prabhakaran Nair et al,^[13] (4.2%) in Kerala (Trivendram) but less than Bhola Nath et al,^[5] (24%), Verma et al,^[6] (13.4%), Kumar et al,^[8] (34.15%), Manjunath et al,^[10] (18.7%), Yadhav et al,^[12] (11.5%), Malini Kar et al^[11] (15.1%), and Nirupam et al,^[15] (32.9%). The difference in the findings underlines the need of effective and uniform implementation strategy of UIP to cover the every individual child. In the present study 68.1% male children were fully immunized as compared to female children i.e.59.57%. Even though the percentage of fully immunized children was more in male under-fives as compared to female but the relation was not statistically significant (P>0.05). Similar findings were also noted by Kumar et al,^[8], Tiwari et al^[9] , Malini Kar et al,^[11] , Yadhav et al,^[12] , Bhandari et al,^[14] and Nirupam et al.^[15] In present study 52% children of the illiterate mother were fully immunized. Similar findings were observed by Kumar et al,^[8] Tiwari et al,^[9] and Yadhav et al,^[12] but the findings by Malini Kar et al,^[11] (71.3%) andBhandari et al,^[14] (15.38%) were totally different from the present study. Having a significant association between immunization status and mothers’ education with more number of fully immunized children in educated mothers signifies importance of female education. Present study reveals that 76.19% children belonging to higher socio-economic group were fully immunized while the percentage in middle and lower socio-economic group was 69.5 and 60% respectively (P<0.004). Statistically significant relation was also noted by Bhola Nath et al^[5] , Tiwari et al^[9] and Bhandari et al,^[14] but Malini Kar et al,^[11] states that there is no significant relation between socio-economic group and immunization status of children where, 73.5% children of lower socioeconomic group were fully immunized as compared to middle S.E.group (59.2%).

In the present study, lack of knowledge about immunization (36.67%) and ignorance about immunization of child and revisits (36.67%) were two main reasons found responsible for partial and unimmunization of the child. Similarly, lack of knowledge about immunization was the reasons responsible for unimmunization or partial immunization noted by Bhola Nath et al,^[5] (23.8%), Kumar et al,^[8] (52.4%), Tiwari et al,^[9] (29.8%), Devivanyagan et al,^[16] (21.1%) , Punith et al,^[17] (57.5%) and Timsi et al,^[18] (51.7%) while, ignorance was the reason quoted by Bhola Nath et al,^[5] (11.7%) , Tiwari et al,^[9] (36.8%), Yadav et al,^[19] (80.36%). Thus, even after 25 years of UIP implementation, bulk of children were missed for their basic right of immunization. This underlines the intensive need to create awareness about immunization among the parents. Fear of losing daily wages due to inconvenience time schedule of the immunization camp was also one of the important factors found in 10.67% children. Similarly, Timsi et al,^[18] found 4% of the children are not brought for immunization due to inconvenience time schedule of immunization camp. 3.33% children in the present study were not immunized because immunization centre was far away. Similar reason was also noted by Mathew et al,^[7] (9.6%) and Timsi et al,^[18] (2%). Only one child in the present study was not immunized for second dose because of fear of previous reactions but this was the reason mentioned by many like , Kumar et al,^[8] (28.8%), Devivanyagan et al,^[16] (2.16%), Punith et al,^[17] (11.42%) and Timsi et al,^[18] (5.4%). In the present study, 19.5% children among the unimmunized were due to cultural and social restrictions. Similarly, cultural and social restriction or lack of faith was also mentioned by Bhola Nath et al,^[5] (16.4%), Manjunath et al,^[10] (25.2%), and Bhandari et al,^[14] (14.29%). This was the unfavorable observation that even in the era of science and technology the community is not in position to accept the basic health facilities challenging to the health system to work efficiently upto the root level.

1. Mother’s education and socioeconomic status of the family significantly influences the immunization coverage among the under-fives.
2. Lack of mother’s knowledge about immunization, ignorance, fear of losing daily wages due to inconvenience time schedule of the immunization camp and cultural and social restrictions were few important factors responsible in divulging the under-five from his/her right of immunization.

1. Intensive Information, education and communication (IEC) activity about immunization i.e. its importance and need, should be conducted focusing on individual level, family level and community level.
2. Immunization camps should be arranged by considering the work schedule of the community and the distance from the houses of beneficiaries.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.105126

[Table 1], [Table 2]