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Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh
p e d i a t r i c i n f e c t i o u s d i s e a s e x x x ( 2 0 1 4 ) 1 e6
Available online at www.sciencedirect.com
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Original Article
Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh Satish C. Agrawal a,*, Anita Kumari b a b
Department of Pediatrics, Muzaffarnagar Medical College, Muzaffarnagar, Uttar Pradesh 251001, India Department of Pediatrics, SRMS Institute of Medical, Sciences, Bareilly, Uttar Pradesh 243202, India
article info
abstract
Article history:
Background: Despite the ongoing National Immunization Program, the immunization
Received 13 October 2013
coverage is still not satisfactory, particularly in U.P. Moreover, there is a wide disparity in
Accepted 24 December 2013
coverage, indicating the influence of various social, economic and cultural factors.
Available online xxx
Aims: The present study was conducted to know the immunization status of children, 12 e23 months of age, in the Rohilkhand region of U.P. and to assess the effects of various
Keywords:
factors influencing it.
Children
Settings and design: The present study was carried out as a cross sectional study, between
Immunization
September 2012 and February 2013 at the pediatric OPD of SRMS Institute of Medical Sci-
Social factors
ences, Bareilly. Methods: The subjects of the study were OPD children. A total of 450 children, aged 12e23 months were included. Immunization status, with regard to the doses of BCG, OPV, DPT and measles vaccine given in the 1st year was assessed by interviewing parents and checking immunization cards. Information about various social factors was also taken. Percentages and Chi square test were used for analyzing data. Results: Overall, 40.66% children were found completely immunized, 45.11% were partially immunized, while 14.22% had received no immunization. The factors, which had a significant impact on immunization status were gender of the child, family’s income and parental education. Birth order, religion and habitation were not found to have significant impact on the immunization status of children. Conclusions: There is need for improving economic and educational status of families for reducing the burden of vaccine preventable diseases. Copyright ª 2014, Indian Academy of Pediatrics, Infectious Disease Chapter. All rights reserved.
* Corresponding author. Tel.: þ91 9639883730 (mobile). E-mail addresses: [email protected], [email protected] (S.C. Agrawal). 2212-8328/$ e see front matter Copyright ª 2014, Indian Academy of Pediatrics, Infectious Disease Chapter. All rights reserved. http://dx.doi.org/10.1016/j.pid.2013.12.004
Please cite this article in press as: Agrawal SC, Kumari A, Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2013.12.004
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1.
p e d i a t r i c i n f e c t i o u s d i s e a s e x x x ( 2 0 1 4 ) 1 e6
Introduction
The world in general and the developing world in particular, besets with the problem of infectious diseases, which take a heavy toll of life, especially of under five children.1 Immunization is one of the most effective known interventions to reduce this morbidity and mortality and its cost-effectiveness and benefits, particularly to developing countries are beyond doubt.2,3 In India the overall immunization coverage, as seen by successive National Family Health Surveys is far from satisfactory in most of the places.4e6 Moreover, there is wide disparity with regard to the coverage, among different populations, indicating the influence of various social, economic and cultural factors.7 Though a number of studies are available, conducted at the national and state levels and also in different small regions of the country, there has been a paucity of work in this part of the country, the Rohilkhand region, a cultural unit with its epicenter at Bareilly, situated in western Uttar Pradesh (U.P.). The present study was carried out to have an idea about the immunization status of children, 12e23 months of age, in this region (in and around Bareilly) and to assess the effects of various factors influencing the immunization.
2.
Subjects and methods
The present study was carried out between September 2012 and February 2013 at the pediatric outpatients department (OPD) of Shri Ram Murti Smarak (SRMS) Institute of Medical Sciences, Bareilly, which is situated on the northern outskirts of the city and attracts patients mainly from the adjoining rural and semi-urban areas. The subjects of the study were children being brought to the hospital OPD as patients. Children aged 1 year and above, but under 2 years (up to 23 months), were included in the study. While assessing the immunization status, only the vaccines used in the national immunization program (NIP) were taken into account, viz., the bacillus Calmette Gurein (BCG) vaccine, the oral polio vaccine (OPV), the diphtheria-pertussis-tetanus (DPT) vaccine and the measles vaccine. The hepatitis B vaccine was not included in the study as this vaccine was included by the U.P. government as a part of routine immunization only in late 2011 and is still not being given everywhere, especially at the peripheral health facilities.8 Similarly, the recent Catch up Measles Vaccine Campaign, being a recent development, was also not taken into account. Special care was taken to see that the doses of OPV administered during the Pulse Polio Program are not taken into account, as quite often, parents falsely feel contended as having their children adequately immunized against polio just by giving these OPV doses. The status was determined, wherever possible, by the immunization card or by history obtained from parents. Complete immunization was defined as receipt of one dose of BCG vaccine soon after birth, three subsequent doses of DPT and OPV, and one dose of measles vaccine. ‘No immunization’ was defined as failure to receive any vaccine listed above. All children who fell between complete and no immunization were taken as partially immunized. Although, scientifically speaking, immunization
and vaccination are not synonymous words, for the purpose of simplicity both the terms have been used interchangeably. The total number of children was 450, taken randomly, except for excluding critically ill patients. A proforma had been prepared to record the details, which were obtained from the mother (preferably) or the father and this included, besides the general information and the age, the social factors taken for the study, viz. the gender, the birth order, the religion, the type of habitation or locality, the family income, and the educational status of the father and also of the mother separately.
2.1.
Social factors
Determining the sex (gender) and the birth order of the child is self explanatory; only 2 groups were formed on the basis of birth order, viz. those who were the 1st or 2nd in birth order, and those higher than 2nd in birth order. For the purpose of this study, only 2 religious groups were assigned, viz. Hindus (which included other groups like Sikhs, Jains, Buddhists etc as their number was negligible) and Muslims. The type of habitation was determined by the size of the government’s administrative unit e those with gram sabha and nagar panchayat were considered rural and semi-urban respectively and those above this level e municipal board or corporation, as urban. To assess the family income, all families were divided into 3 groups, viz., the low-income group, the middleincome group and the high-income group. In view of the fact that there exists a variation in the family size and the family income at different periods, that most of the persons are not able to tell their exact income and particularly, the controversy attached to who should be called poor, any classification can at best be an approximate one. For the low-income group, we used the existing criteria as spelled out by the Planning Commission for defining below poverty line (BPL); however, for the purpose of simplicity, the figures were rounded off and the same figures were used for rural/semi-urban/urban families, though slightly different figures were given by the Planning Commission, as per capita income per day for rural and urban families respectively.9 For the present study, a family (of 5 members on an average) with a monthly income up to Rs 4000 was considered as belonging to the low-income group, a family income of 40,000 (10 times of that in the low-income group) or above was considered as high income and those falling in between as the middle-income group. For the purpose of the parents’ educational status, mothers and fathers were divided into 3 groups, viz. those with education under
Fig. 1 e Immunization status of the studied children.
Please cite this article in press as: Agrawal SC, Kumari A, Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2013.12.004
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Table 1 e Results at a glance: Social factors and their effects. Variable
Total number of children (n ¼ 450)
Completely immunized children (n ¼ 183)
Partially immunized children (n ¼ 203)
Children with no immunization (n ¼ 64)
p value
132 (45.51%) 51 (31.87%)
120 (41.37%) 83 (51.87%)
38 (13.10%) 26 (16.25%)
0.019
90 (44.55%) 93 (37.5%)
82 (40.59%) 121 (48.79%)
30 (14.85%) 34 (13.70%)
0.210
100 (43.10%) 83 (38.07%)
104 (44.82%) 95 (43.57%)
28 (12.06%) 40 (18.34%)
0.159
79 (37.26%) 63 (40.64%) 41 (49.39%)
98 (46.22%) 69 (44.51%) 36 (43.37%)
35 (16.50%) 23 (14.83%) 6 (7.22%)
0.202
87 (35.35%) 71 (43.29%) 25 (62.50%)
119 (48.37%) 69 (42.07%) 15 (37.50%)
40 (16.26%) 24 (14.63%) 0 (0%)
0.006
101 (35.68%) 40 (35.71%) 42 (76.36%)
136 (48.05%) 54 (48.21%) 13 (23.63%)
46 (16.25%) 18 (16.07%) 0 (0%)
0.000
129 (35.53%) 35 (53.84%) 19 (86.36%)
171 (47.10%) 29 (44.61%) 3 (13.63%)
63 (17.35%) 1 (1.53%) 0 (0%)
0.000
Sex Male 290 Female 160 Birth order 2 or less 202 >2 248 Religion Hindu 232 Muslim 218 Habitation Rural 212 Semi-urban 155 Urban 83 Income group Low 246 Middle 164 High 40 Father’s educational status Uneducated 283 Matriculate 112 Graduate 55 Mother’s educational status Uneducated 363 Matriculate 65 Graduate 22
matriculation, those having been educated up to matriculation level or above, but not yet graduates, and those who were graduates or above. For statistical evaluation, Chi-square test was done and a p value of <0.05 was considered significant.
3.
Results
Results are summarized in Fig. 1 and Tables 1 and 2. Regarding the overall immunization status, as can be seen in Fig. 1 (and also in Table 1), 183 children (40.66%) were found completely immunized, 203 children (45.11%) were partially immunized
Table 2 e Reasons of defaulting for immunization (partial/no immunization e n [ 450). S.n. 1. 2. 3. 4.
5.
6. 7. 8.
9.
Reasons
Number
Percentage
Lack of knowledge Forgetfulness Illness of the child Family problems (illness of other family member(s), death in the family, marriage etc.) Lack of initiative (non-visit of health worker, health facility situated far away from home) Fear of adverse effect of vaccine Did not get time (busy in work) Bad experience following vaccination (death, illness in family, neighborhood) Others (migration etc)
170 152 115 98
37.7 33.7 25.5 21.7
and the remaining 64 children (14.22%) had received no immunization. Table 1 shows the complete demographic profile with various social factors and their effect on the immunization status of children in the studied sample. It can be clearly appreciated by comparing the number of completely immunized, partially immunized and non-immunized children with different groups based on a specific factor that all the studied social factors have an appreciable impact with some having a significant statistical correlation (p value <0.05); this correlation is highly significant with some factors, viz. the family income and particularly, the educational status of parents. In cases of children with partial or no immunization, the reasons for not getting their children vaccinated or not completing vaccination based on the parents’ answers are listed in Table 2. As in some cases more than 1 reason was cited, there is considerable overlapping and the total sum is more than the total number of cases (or >100 in the case of percentage).
4. 95
21.1
65 45 35
14.4 10.0 7.7
43
9.5
Discussion
The complete immunization coverage in our study is found to be 40.66%. The overall immunization coverage in India, despite showing improvement remains far from satisfactory. As per the NFHS-3 data (2005e06), a slight improvement, from 42% to 43.5%, was noted since NFHS-2 (1998e99).5,6 However, the figures from U.P. remained abysmally low; improving from 20% to 23% only, the full immunization coverage being lowest in India except Nagaland.6 Other studies carried out in
Please cite this article in press as: Agrawal SC, Kumari A, Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2013.12.004
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different parts of U.P. and adjoining states of North India observed complete immunization rates of 30%, 44%, and 33.3% respectively.10e12 Interestingly, the studies made in and around Delhi show higher rates, varying from 69% to over 71%, though one study showed a percentage as low as 25%.13e15 The rates for partial immunization and no immunization in all these studies varied between 15% and 48%, and between 8.5 and 34%, while the comparable rates in our study are 45.11% and 14.22% respectively.10e15 The vast difference between these coverage rates can be explained by differences in setting and of course the facilities available in different parts of North India, Delhi, in most studies, evidently showing much better results, better even than pan-India coverage. One large study, consisting of about 19,000 children, carried out in 90 districts, scattered in different parts of India is worth mention, which gave rates of complete immunization in the districts lying in U.P. as 51% and with other BIMARU states (Bihar, Madhya Pradesh, Rajasthan and U.P.) had much poorer performance than the national average.16 Another survey, found complete immunization in 48% children from four BIMARU states against the national average of 63%, these 4 states constituting 70% of the country’s unvaccinated children.17
4.1.
Influence of social factors
4.1.1.
Sex (gender)
While studying the effects of social factors on the immunization status (Table 1), we found significantly higher vaccine coverage among boys. The rates of complete immunization showed 45.10% in males against a figure of 31.87% in females, while the male to female coverage was just reversed for partially immunized (41.37e51.87%) and non-immunized children (13.10e16.25%). This difference was found statistically significant. Almost in all other studies, this difference was reported including the NFHS-3 data which reported a gender gap of 5% for most of the vaccines, the gap being higher in the so called more developed states.3,10,12e14,18 Gender gap was noted in several other studies including the UNICEF survey e 2009e10 and the Ministry of Health and Family Welfare coverage evaluation survey e 2001e02.19,20
4.1.2.
Birth order
Birth order also came out to be an important factor to influence the vaccination coverage in our study, children in the lower birth order showing a better coverage but this difference was not found statistically significant (Table 1). The NFHS-3 data also showed a declining vaccination trend with increasing birth order.6 Several other studies also show the effect of birth order on immunization coverage, including a Goa study.10e13,21
4.1.3.
Religion
Influence of religion is known to be widespread, on several aspects of life as it is related with culture, customs and lifestyle. In the present study, while 43.10% Hindu children were found to be fully immunized, the corresponding rate in Muslim children was 38.07% only; the rates were reversed in case of non-immunized children (Table 1). This apparently big difference though, was not found statistically significant. A Hindu-Muslim gap with regard to immunization coverage was also observed by Nath et al and Masand et al11,12 NFHS-3
survey reported that Muslim households had lower complete vaccination and higher non-vaccination than Hindu families.6 UNICEF coverage evaluation survey - 2010 also showed higher vaccination rate in Hindu infants (61.2%) as compared to Muslim infants, as did the Department of Family Welfare Survey.19,20
4.1.4.
Habitation (rural, semi-urban and urban areas)
A higher percentage of urban children (49.39%) was found to be fully immunized than those living in semi-urban (40.64%) or rural areas (37.26%). The trend was opposite in case of nonimmunized children. This difference in our study, however, was not found to be statistically significant (Table 1). The NFHS-3 survey had also found 57.6% of urban children fully vaccinated against a much lower percentage of 38 in case of rural children.6 A similar urban-rural gap was reported in the ICMR 1999 survey, the UNICEF 2009e10 survey and the Department of Family Welfare survey done in 2002, all of which reported an urban-rural gap ranging from 9% to 24% for fully immunized children.16,19,20
4.1.5.
Economic status
There was a significant difference between the immunization rates in children from families from different income groups. While 35.35% children from low income families showed complete immunization, percentage of such children was a whooping 62.50% from the high-income group, the rate being 43.29% in the middle-income group children. On the contrary, there was not a single non-immunized child from the high-income group against 16.26% such children from low income families. A clear difference can be seen in case of partially immunized children also (Table 1). This result shows a significant statistical correlation between the family income and immunization coverage. Various studies have used different criteria to assess economic/socioeconomic status of families. NFHS-3 survey applied a classification using wealth index a composite score comprising living standard based on domestic assets.6 Most other studies have used Kuppuswamy’s scale, which takes into account besides economic condition, several social criteria.12e14 We, however, have used pure economic criterion to study its impact, as other social factors are being studied independently. The NFHS-3 survey reported 40% urban poor children fully vaccinated against over 65% non-poor children, showing a statistically significant difference.6 Similarly, the UNICEF 2009-10 survey also reported a direct correlation between the economic status of families and vaccination coverage.19 The earlier UNICEF survey of 2005 had shown that families living in kachcha houses had only 40% of their children fully immunized against much higher figures of 57% and 65% among the children living in semi-pucca and pucca houses respectively.22 Masand et al from Rajasthan reported that 47% children belonging to Kuppuswamy’s upper class I and II were completely immunized as compared to 23% children of class III, IV and V.12
4.1.6.
Parents’ educational status
We also tried to assess the influence of parental educational level on the immunization coverage of their children. This was assessed for both the parents (fathers and mothers) separately.
Please cite this article in press as: Agrawal SC, Kumari A, Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2013.12.004
p e d i a t r i c i n f e c t i o u s d i s e a s e x x x ( 2 0 1 4 ) 1 e6
While evaluating the effect of the father’s educational status, a big difference was seen between the children of uneducated fathers and those of educated ones. While only 35.68% children of uneducated fathers showed complete immunization, this rate became more than double e 76.36% in the children of graduate fathers. An interesting finding was that there was no case of non-immunized child in the group of graduate fathers (Table 1). This difference was found statistically significant. Most studies on immunization have focused on the mother’s education; fewer have ventured to study the father’s, many of them studying a composite parental education level. There was found a direct correlation between parental education and vaccination status in the UNICEF survey e 2005.22 The ICMR survey (1999) found a direct relationship with paternal literacy, showing a difference of about 14% between groups with fathers of different educational levels.16 A cross-sectional study of children in two villages of Delhi also showed an impact of the father’s education on the immunization.23 The influence of the maternal education has been studied more extensively. In the present study, a highly significant correlation was noticed between maternal education and the immunization status of children (Table 1). The rate of complete immunization was 35.53% in the group of uneducated mothers, while the same was 53.84% in matriculate mothers and an impressive 86.36% in the group of graduate mothers. Even more noticeable difference was seen in cases of partial and no immunization. Only one child (1.53%) from the matriculate mothers’ group was found non-immunized and the number was zero in the graduate mothers. The UNICEF 2009 and the ICMR 1999 survey had shown a similar correlation.19,16 In a study conducted in two urbanized villages in Delhi and a study from West Bengal also showed better vaccination rates in children of more educated mothers.23,24 Masand et al found father’s education having a minimal impact on the immunization status of their children, as compared to education status of the mother.12 Similarly, in a study of 1e7 year old children, the parental literacy had a beneficial effect, such that up to 20% more children were immunized.25 In a study from the US, authors found ‘children of more educated mothers significantly less likely to be underimmunized at all ages’.26 Surprisingly, however, in a Lucknow study, mother’s literacy status was not found to significantly affect the immunized status of the child in the absence of confounding factors.11
4.2.
Reasons for partial/no immunization
While doing the present study, an attempt was also made to find, through interviewing parents, the reasons for not getting their children immunized (either when scheduled or not at all). The reasons are listed in Table 2. The most commonly observed reason for partial or no immunization was lack of proper knowledge about the time of the next dose or the correct schedule. Other noteworthy reasons were forgetfulness, illness of some other person in the family, some domestic problem, or simply lack of initiative or concern. Apprehension of adverse effect was also cited as a reason by an appreciable number of parents. Most other workers also have mentioned almost similar reasons.10e14
4.3.
5
Strengths and limitations of the study
The present study had a reasonably large sample, larger than most studies carried out in other small regions of the country. Therefore, the results carry a good credibility. However, being a hospital-based study, this cannot be taken as truly reflective of the community. An ideal set-up is a randomized field study, which could better represent a community.
Conflicts of interest All authors have none to declare.
references
1. Anonymous. Maternal, Newborn, Child and Adolescent Health: Child Health Epidemiology. WHO; 2013. Available from: www. who.int/maternal_child_adolescent/epidemiolgy/child/en. Accessed 21.06.13. 2. Walker DG, Hutubessy R, Beutels P. WHO guide for standardization of economic evaluation of immunization programmes. Vaccine. 2010 Mar 8;28(11):2356e2359. Epub 2009 Jun 28. 3. Ozawa S, Mirelman A, Stack ML, Walker DG, Levine OS. Costeffectiveness and economic benefits of vaccines in low-andmiddle income countries: a systematic review. Vaccine. 2012 Dec 17;31(1):96e108. http://dx.doi.org/10.1016/ j.vaccine.2012.10.103. Epub 2012 Nov 8. 4. International Institute for Population Sciences (IIPS). National Family Health Survey (MCH and Family Planning), 1992e93. India. Mumbai: IIPS; 1995. 5. International Institute for Population Sciences (IIPS) and ORC Macro. National Family Health Survey (NFHS-2), 1998e99. India. Mumbai: IIPS; 2000. 6. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005e06. India. Mumbai: IIPS; 2008. 7. Mathew JL. Inequity in childhood immunization in India: a systemic review. Indian Pediatr. 2012;49:203e223. 8. Khyati S. U.P. Government Includes Hepatitis B Vaccination in Routine Immunization Plan. Lucknow: The Indian Express; Oct 4, 2011. 9. Anonymous. Poverty Definition Issues Resolved: Montek, Ramesh. New Delhi: Press Trust of India; Oct3, 2011. Available from: www.buisness-standard/article/economy-policy. Accessed 21.06.13. 10. Saxena P, Prakesh D, Saxena V, Kansal S. Assessment of routine immunization in urban slums of Agra district. Indian J Prev Soc Med. 2008;39(1):60e62. 11. Nath B, Singh JV, Awasthi S, Bhushan V, Kumar V, Singh SK. A study on determinants of immunization coverage among 12e23 months old children in urban slums of Lucknow district, India. Indian J Med Sci. 2007;61:598e606. 12. Masand R, Dixit AM, Gupta RK. Study of immunization status of rural children (12e23 months age) of district Jaipur, Rajasthan and factors influencing it: a hospital based study. J Indian Med Assoc. 2012;110:795e799. 13. Kar M, Reddaiah VP, Kant S. Primary immunization status of children in slums areas of South Delhi: the challenge of reaching urban poor. Indian J Commun Med. 2001;26:151e154. 14. Khokar A, chitkara A, Talwar R, Sachdev TR, Rasania SK. A study of reasons for partial immunization and nonimmunization among children aged 12e23 months from an
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urban community of Delhi. Indian J Prev Soc Med. 2005;36:836e839. Mathew JL, Babber H, Yadav S. Reasons for non immunization of children in an urban, low income group in North India. Trop Doct. 2002;32:135e138. Singh P, Yadav RJ. Immunization status of children of India. Indian Pediatr. 2000;37:1194e1199. Singh P, Yadav RJ. Immunisation status of children in BIMARU states. Indian J Pediatr. 2001;68:495e500. Srivastava SP, Nayak NP. The disadvantaged girl child in Bihar: study of health care practices and selected nutritional indices. Indian Pediatr. 1995;32:911e913. UNICEF. 2009 Coverage Evaluation Survey. Government of India, Ministry of Health & Family Welfare and UNICEF. Available from: www.unicef.org/india/health_ 5578.htm and www. unicef.org/india/National_Fact_ Sheet_CES_2009.pdf. Accessed 21.06.13. Department of Family Welfare, Ministry of Health and Family Welfare, Government of India. Coverage Evaluation Survey e 2002. IPPI, Routine Immunization and Maternal Care. National Report. Available from: http://202.71.128.172/nihfw/ nchrc/sites/default/files/Coverage%20Evaluation%20Survey%
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20-%202002%20-20IPPI,%20Routine%20Immunization%20and %20Maternal%20Care%20-%20National%20Report_0_0.pdf. Accessed 21.06.13. Dalal A, Silveira MP. Imunization status of children in Goa. Indian Pediatr. 2005;42:401e402. Anon. Coverage Evaluation Survey. All India Report 2005. Available from: http://202.71.128.172/nihfw/nchrc/sites/ default/files/All%20India%20Report%202005%20Coverage% 20Evaluation%20Survey-1044_2.pdf. Accessed on 21.06.13. Chhabra P, Nair P, Gupta A, Sandhir M, Kannan AT. Immunization in urbanized villages of Delhi. Indian J Pediatr. 2007;74:131e134. Som S, Pal M, Chakrabarty S, Bharati P. Socioeconomic impact on child immunisation in the districts of West Bengal, India. Singap Med J. 2010;51:406e412. Elliott C, Farmer K. Immunization status of children under 7 years in the Vikas Nagar area, North India. Child Care Health Dev. 2006;32:415e421. Bobo JK, Gale JL, Thapa PB, Wassilak SGF. Risk factors for delayed immunization in randomized samples of 1163 children from Oregon and Washington. Pediatrics. 1993;91:308e314.
Please cite this article in press as: Agrawal SC, Kumari A, Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2013.12.004
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Original Article
Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh Satish C. Agrawal a,*, Anita Kumari b a b
Department of Pediatrics, Muzaffarnagar Medical College, Muzaffarnagar, Uttar Pradesh 251001, India Department of Pediatrics, SRMS Institute of Medical, Sciences, Bareilly, Uttar Pradesh 243202, India
article info
abstract
Article history:
Background: Despite the ongoing National Immunization Program, the immunization
Received 13 October 2013
coverage is still not satisfactory, particularly in U.P. Moreover, there is a wide disparity in
Accepted 24 December 2013
coverage, indicating the influence of various social, economic and cultural factors.
Available online xxx
Aims: The present study was conducted to know the immunization status of children, 12 e23 months of age, in the Rohilkhand region of U.P. and to assess the effects of various
Keywords:
factors influencing it.
Children
Settings and design: The present study was carried out as a cross sectional study, between
Immunization
September 2012 and February 2013 at the pediatric OPD of SRMS Institute of Medical Sci-
Social factors
ences, Bareilly. Methods: The subjects of the study were OPD children. A total of 450 children, aged 12e23 months were included. Immunization status, with regard to the doses of BCG, OPV, DPT and measles vaccine given in the 1st year was assessed by interviewing parents and checking immunization cards. Information about various social factors was also taken. Percentages and Chi square test were used for analyzing data. Results: Overall, 40.66% children were found completely immunized, 45.11% were partially immunized, while 14.22% had received no immunization. The factors, which had a significant impact on immunization status were gender of the child, family’s income and parental education. Birth order, religion and habitation were not found to have significant impact on the immunization status of children. Conclusions: There is need for improving economic and educational status of families for reducing the burden of vaccine preventable diseases. Copyright ª 2014, Indian Academy of Pediatrics, Infectious Disease Chapter. All rights reserved.
* Corresponding author. Tel.: þ91 9639883730 (mobile). E-mail addresses: [email protected], [email protected] (S.C. Agrawal). 2212-8328/$ e see front matter Copyright ª 2014, Indian Academy of Pediatrics, Infectious Disease Chapter. All rights reserved. http://dx.doi.org/10.1016/j.pid.2013.12.004
Please cite this article in press as: Agrawal SC, Kumari A, Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2013.12.004
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Introduction
The world in general and the developing world in particular, besets with the problem of infectious diseases, which take a heavy toll of life, especially of under five children.1 Immunization is one of the most effective known interventions to reduce this morbidity and mortality and its cost-effectiveness and benefits, particularly to developing countries are beyond doubt.2,3 In India the overall immunization coverage, as seen by successive National Family Health Surveys is far from satisfactory in most of the places.4e6 Moreover, there is wide disparity with regard to the coverage, among different populations, indicating the influence of various social, economic and cultural factors.7 Though a number of studies are available, conducted at the national and state levels and also in different small regions of the country, there has been a paucity of work in this part of the country, the Rohilkhand region, a cultural unit with its epicenter at Bareilly, situated in western Uttar Pradesh (U.P.). The present study was carried out to have an idea about the immunization status of children, 12e23 months of age, in this region (in and around Bareilly) and to assess the effects of various factors influencing the immunization.
2.
Subjects and methods
The present study was carried out between September 2012 and February 2013 at the pediatric outpatients department (OPD) of Shri Ram Murti Smarak (SRMS) Institute of Medical Sciences, Bareilly, which is situated on the northern outskirts of the city and attracts patients mainly from the adjoining rural and semi-urban areas. The subjects of the study were children being brought to the hospital OPD as patients. Children aged 1 year and above, but under 2 years (up to 23 months), were included in the study. While assessing the immunization status, only the vaccines used in the national immunization program (NIP) were taken into account, viz., the bacillus Calmette Gurein (BCG) vaccine, the oral polio vaccine (OPV), the diphtheria-pertussis-tetanus (DPT) vaccine and the measles vaccine. The hepatitis B vaccine was not included in the study as this vaccine was included by the U.P. government as a part of routine immunization only in late 2011 and is still not being given everywhere, especially at the peripheral health facilities.8 Similarly, the recent Catch up Measles Vaccine Campaign, being a recent development, was also not taken into account. Special care was taken to see that the doses of OPV administered during the Pulse Polio Program are not taken into account, as quite often, parents falsely feel contended as having their children adequately immunized against polio just by giving these OPV doses. The status was determined, wherever possible, by the immunization card or by history obtained from parents. Complete immunization was defined as receipt of one dose of BCG vaccine soon after birth, three subsequent doses of DPT and OPV, and one dose of measles vaccine. ‘No immunization’ was defined as failure to receive any vaccine listed above. All children who fell between complete and no immunization were taken as partially immunized. Although, scientifically speaking, immunization
and vaccination are not synonymous words, for the purpose of simplicity both the terms have been used interchangeably. The total number of children was 450, taken randomly, except for excluding critically ill patients. A proforma had been prepared to record the details, which were obtained from the mother (preferably) or the father and this included, besides the general information and the age, the social factors taken for the study, viz. the gender, the birth order, the religion, the type of habitation or locality, the family income, and the educational status of the father and also of the mother separately.
2.1.
Social factors
Determining the sex (gender) and the birth order of the child is self explanatory; only 2 groups were formed on the basis of birth order, viz. those who were the 1st or 2nd in birth order, and those higher than 2nd in birth order. For the purpose of this study, only 2 religious groups were assigned, viz. Hindus (which included other groups like Sikhs, Jains, Buddhists etc as their number was negligible) and Muslims. The type of habitation was determined by the size of the government’s administrative unit e those with gram sabha and nagar panchayat were considered rural and semi-urban respectively and those above this level e municipal board or corporation, as urban. To assess the family income, all families were divided into 3 groups, viz., the low-income group, the middleincome group and the high-income group. In view of the fact that there exists a variation in the family size and the family income at different periods, that most of the persons are not able to tell their exact income and particularly, the controversy attached to who should be called poor, any classification can at best be an approximate one. For the low-income group, we used the existing criteria as spelled out by the Planning Commission for defining below poverty line (BPL); however, for the purpose of simplicity, the figures were rounded off and the same figures were used for rural/semi-urban/urban families, though slightly different figures were given by the Planning Commission, as per capita income per day for rural and urban families respectively.9 For the present study, a family (of 5 members on an average) with a monthly income up to Rs 4000 was considered as belonging to the low-income group, a family income of 40,000 (10 times of that in the low-income group) or above was considered as high income and those falling in between as the middle-income group. For the purpose of the parents’ educational status, mothers and fathers were divided into 3 groups, viz. those with education under
Fig. 1 e Immunization status of the studied children.
Please cite this article in press as: Agrawal SC, Kumari A, Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2013.12.004
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Table 1 e Results at a glance: Social factors and their effects. Variable
Total number of children (n ¼ 450)
Completely immunized children (n ¼ 183)
Partially immunized children (n ¼ 203)
Children with no immunization (n ¼ 64)
p value
132 (45.51%) 51 (31.87%)
120 (41.37%) 83 (51.87%)
38 (13.10%) 26 (16.25%)
0.019
90 (44.55%) 93 (37.5%)
82 (40.59%) 121 (48.79%)
30 (14.85%) 34 (13.70%)
0.210
100 (43.10%) 83 (38.07%)
104 (44.82%) 95 (43.57%)
28 (12.06%) 40 (18.34%)
0.159
79 (37.26%) 63 (40.64%) 41 (49.39%)
98 (46.22%) 69 (44.51%) 36 (43.37%)
35 (16.50%) 23 (14.83%) 6 (7.22%)
0.202
87 (35.35%) 71 (43.29%) 25 (62.50%)
119 (48.37%) 69 (42.07%) 15 (37.50%)
40 (16.26%) 24 (14.63%) 0 (0%)
0.006
101 (35.68%) 40 (35.71%) 42 (76.36%)
136 (48.05%) 54 (48.21%) 13 (23.63%)
46 (16.25%) 18 (16.07%) 0 (0%)
0.000
129 (35.53%) 35 (53.84%) 19 (86.36%)
171 (47.10%) 29 (44.61%) 3 (13.63%)
63 (17.35%) 1 (1.53%) 0 (0%)
0.000
Sex Male 290 Female 160 Birth order 2 or less 202 >2 248 Religion Hindu 232 Muslim 218 Habitation Rural 212 Semi-urban 155 Urban 83 Income group Low 246 Middle 164 High 40 Father’s educational status Uneducated 283 Matriculate 112 Graduate 55 Mother’s educational status Uneducated 363 Matriculate 65 Graduate 22
matriculation, those having been educated up to matriculation level or above, but not yet graduates, and those who were graduates or above. For statistical evaluation, Chi-square test was done and a p value of <0.05 was considered significant.
3.
Results
Results are summarized in Fig. 1 and Tables 1 and 2. Regarding the overall immunization status, as can be seen in Fig. 1 (and also in Table 1), 183 children (40.66%) were found completely immunized, 203 children (45.11%) were partially immunized
Table 2 e Reasons of defaulting for immunization (partial/no immunization e n [ 450). S.n. 1. 2. 3. 4.
5.
6. 7. 8.
9.
Reasons
Number
Percentage
Lack of knowledge Forgetfulness Illness of the child Family problems (illness of other family member(s), death in the family, marriage etc.) Lack of initiative (non-visit of health worker, health facility situated far away from home) Fear of adverse effect of vaccine Did not get time (busy in work) Bad experience following vaccination (death, illness in family, neighborhood) Others (migration etc)
170 152 115 98
37.7 33.7 25.5 21.7
and the remaining 64 children (14.22%) had received no immunization. Table 1 shows the complete demographic profile with various social factors and their effect on the immunization status of children in the studied sample. It can be clearly appreciated by comparing the number of completely immunized, partially immunized and non-immunized children with different groups based on a specific factor that all the studied social factors have an appreciable impact with some having a significant statistical correlation (p value <0.05); this correlation is highly significant with some factors, viz. the family income and particularly, the educational status of parents. In cases of children with partial or no immunization, the reasons for not getting their children vaccinated or not completing vaccination based on the parents’ answers are listed in Table 2. As in some cases more than 1 reason was cited, there is considerable overlapping and the total sum is more than the total number of cases (or >100 in the case of percentage).
4. 95
21.1
65 45 35
14.4 10.0 7.7
43
9.5
Discussion
The complete immunization coverage in our study is found to be 40.66%. The overall immunization coverage in India, despite showing improvement remains far from satisfactory. As per the NFHS-3 data (2005e06), a slight improvement, from 42% to 43.5%, was noted since NFHS-2 (1998e99).5,6 However, the figures from U.P. remained abysmally low; improving from 20% to 23% only, the full immunization coverage being lowest in India except Nagaland.6 Other studies carried out in
Please cite this article in press as: Agrawal SC, Kumari A, Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2013.12.004
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different parts of U.P. and adjoining states of North India observed complete immunization rates of 30%, 44%, and 33.3% respectively.10e12 Interestingly, the studies made in and around Delhi show higher rates, varying from 69% to over 71%, though one study showed a percentage as low as 25%.13e15 The rates for partial immunization and no immunization in all these studies varied between 15% and 48%, and between 8.5 and 34%, while the comparable rates in our study are 45.11% and 14.22% respectively.10e15 The vast difference between these coverage rates can be explained by differences in setting and of course the facilities available in different parts of North India, Delhi, in most studies, evidently showing much better results, better even than pan-India coverage. One large study, consisting of about 19,000 children, carried out in 90 districts, scattered in different parts of India is worth mention, which gave rates of complete immunization in the districts lying in U.P. as 51% and with other BIMARU states (Bihar, Madhya Pradesh, Rajasthan and U.P.) had much poorer performance than the national average.16 Another survey, found complete immunization in 48% children from four BIMARU states against the national average of 63%, these 4 states constituting 70% of the country’s unvaccinated children.17
4.1.
Influence of social factors
4.1.1.
Sex (gender)
While studying the effects of social factors on the immunization status (Table 1), we found significantly higher vaccine coverage among boys. The rates of complete immunization showed 45.10% in males against a figure of 31.87% in females, while the male to female coverage was just reversed for partially immunized (41.37e51.87%) and non-immunized children (13.10e16.25%). This difference was found statistically significant. Almost in all other studies, this difference was reported including the NFHS-3 data which reported a gender gap of 5% for most of the vaccines, the gap being higher in the so called more developed states.3,10,12e14,18 Gender gap was noted in several other studies including the UNICEF survey e 2009e10 and the Ministry of Health and Family Welfare coverage evaluation survey e 2001e02.19,20
4.1.2.
Birth order
Birth order also came out to be an important factor to influence the vaccination coverage in our study, children in the lower birth order showing a better coverage but this difference was not found statistically significant (Table 1). The NFHS-3 data also showed a declining vaccination trend with increasing birth order.6 Several other studies also show the effect of birth order on immunization coverage, including a Goa study.10e13,21
4.1.3.
Religion
Influence of religion is known to be widespread, on several aspects of life as it is related with culture, customs and lifestyle. In the present study, while 43.10% Hindu children were found to be fully immunized, the corresponding rate in Muslim children was 38.07% only; the rates were reversed in case of non-immunized children (Table 1). This apparently big difference though, was not found statistically significant. A Hindu-Muslim gap with regard to immunization coverage was also observed by Nath et al and Masand et al11,12 NFHS-3
survey reported that Muslim households had lower complete vaccination and higher non-vaccination than Hindu families.6 UNICEF coverage evaluation survey - 2010 also showed higher vaccination rate in Hindu infants (61.2%) as compared to Muslim infants, as did the Department of Family Welfare Survey.19,20
4.1.4.
Habitation (rural, semi-urban and urban areas)
A higher percentage of urban children (49.39%) was found to be fully immunized than those living in semi-urban (40.64%) or rural areas (37.26%). The trend was opposite in case of nonimmunized children. This difference in our study, however, was not found to be statistically significant (Table 1). The NFHS-3 survey had also found 57.6% of urban children fully vaccinated against a much lower percentage of 38 in case of rural children.6 A similar urban-rural gap was reported in the ICMR 1999 survey, the UNICEF 2009e10 survey and the Department of Family Welfare survey done in 2002, all of which reported an urban-rural gap ranging from 9% to 24% for fully immunized children.16,19,20
4.1.5.
Economic status
There was a significant difference between the immunization rates in children from families from different income groups. While 35.35% children from low income families showed complete immunization, percentage of such children was a whooping 62.50% from the high-income group, the rate being 43.29% in the middle-income group children. On the contrary, there was not a single non-immunized child from the high-income group against 16.26% such children from low income families. A clear difference can be seen in case of partially immunized children also (Table 1). This result shows a significant statistical correlation between the family income and immunization coverage. Various studies have used different criteria to assess economic/socioeconomic status of families. NFHS-3 survey applied a classification using wealth index a composite score comprising living standard based on domestic assets.6 Most other studies have used Kuppuswamy’s scale, which takes into account besides economic condition, several social criteria.12e14 We, however, have used pure economic criterion to study its impact, as other social factors are being studied independently. The NFHS-3 survey reported 40% urban poor children fully vaccinated against over 65% non-poor children, showing a statistically significant difference.6 Similarly, the UNICEF 2009-10 survey also reported a direct correlation between the economic status of families and vaccination coverage.19 The earlier UNICEF survey of 2005 had shown that families living in kachcha houses had only 40% of their children fully immunized against much higher figures of 57% and 65% among the children living in semi-pucca and pucca houses respectively.22 Masand et al from Rajasthan reported that 47% children belonging to Kuppuswamy’s upper class I and II were completely immunized as compared to 23% children of class III, IV and V.12
4.1.6.
Parents’ educational status
We also tried to assess the influence of parental educational level on the immunization coverage of their children. This was assessed for both the parents (fathers and mothers) separately.
Please cite this article in press as: Agrawal SC, Kumari A, Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2013.12.004
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While evaluating the effect of the father’s educational status, a big difference was seen between the children of uneducated fathers and those of educated ones. While only 35.68% children of uneducated fathers showed complete immunization, this rate became more than double e 76.36% in the children of graduate fathers. An interesting finding was that there was no case of non-immunized child in the group of graduate fathers (Table 1). This difference was found statistically significant. Most studies on immunization have focused on the mother’s education; fewer have ventured to study the father’s, many of them studying a composite parental education level. There was found a direct correlation between parental education and vaccination status in the UNICEF survey e 2005.22 The ICMR survey (1999) found a direct relationship with paternal literacy, showing a difference of about 14% between groups with fathers of different educational levels.16 A cross-sectional study of children in two villages of Delhi also showed an impact of the father’s education on the immunization.23 The influence of the maternal education has been studied more extensively. In the present study, a highly significant correlation was noticed between maternal education and the immunization status of children (Table 1). The rate of complete immunization was 35.53% in the group of uneducated mothers, while the same was 53.84% in matriculate mothers and an impressive 86.36% in the group of graduate mothers. Even more noticeable difference was seen in cases of partial and no immunization. Only one child (1.53%) from the matriculate mothers’ group was found non-immunized and the number was zero in the graduate mothers. The UNICEF 2009 and the ICMR 1999 survey had shown a similar correlation.19,16 In a study conducted in two urbanized villages in Delhi and a study from West Bengal also showed better vaccination rates in children of more educated mothers.23,24 Masand et al found father’s education having a minimal impact on the immunization status of their children, as compared to education status of the mother.12 Similarly, in a study of 1e7 year old children, the parental literacy had a beneficial effect, such that up to 20% more children were immunized.25 In a study from the US, authors found ‘children of more educated mothers significantly less likely to be underimmunized at all ages’.26 Surprisingly, however, in a Lucknow study, mother’s literacy status was not found to significantly affect the immunized status of the child in the absence of confounding factors.11
4.2.
Reasons for partial/no immunization
While doing the present study, an attempt was also made to find, through interviewing parents, the reasons for not getting their children immunized (either when scheduled or not at all). The reasons are listed in Table 2. The most commonly observed reason for partial or no immunization was lack of proper knowledge about the time of the next dose or the correct schedule. Other noteworthy reasons were forgetfulness, illness of some other person in the family, some domestic problem, or simply lack of initiative or concern. Apprehension of adverse effect was also cited as a reason by an appreciable number of parents. Most other workers also have mentioned almost similar reasons.10e14
4.3.
5
Strengths and limitations of the study
The present study had a reasonably large sample, larger than most studies carried out in other small regions of the country. Therefore, the results carry a good credibility. However, being a hospital-based study, this cannot be taken as truly reflective of the community. An ideal set-up is a randomized field study, which could better represent a community.
Conflicts of interest All authors have none to declare.
references
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Please cite this article in press as: Agrawal SC, Kumari A, Immunization status of children and the influence of social factors: A hospital based study in western Uttar Pradesh, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2013.12.004