Why infants miss vaccination during routine immunization sessions? Study in a rural area of Anand district, Gujarat
Tushar A Patel1, Niraj B Pandit2
1 Assistant Professor, Department of Community Medicine, Pramukh Swami Medical College, Karamsad, Guajrat, India
2 SBKS Medical Institute and Research Centre, Pipariya, Gujarat, India
Tushar A Patel1, Niraj B Pandit2
1 Assistant Professor, Department of Community Medicine, Pramukh Swami Medical College, Karamsad, Guajrat, India
2 SBKS Medical Institute and Research Centre, Pipariya, Gujarat, India
| Date of Web Publication | 30-Jan-2012 |
Correspondence Address:
Tushar A Patel
402, Radhasharnam Apartment, Near Bhaikaka Statue, Vallabh Vidyanagar, Dist - Anand, Gujarat
India
Tushar A Patel
402, Radhasharnam Apartment, Near Bhaikaka Statue, Vallabh Vidyanagar, Dist - Anand, Gujarat
India
 Abstract |
A cross-sectional study was conducted in a rural area of Anand District, Gujarat to measure the efficiency of immunization sessions and to identify the reasons for missing a vaccine in a session. Caregivers of infants aged less than one year and in need of any vaccine as per routine immunization schedule were interviewed by a house-to-house survey after immunization session was completed. Efficiency of immunization session was 66.7%. Reasons for 'missed' vaccination were prior reminder not given (32.9%, P<0.01); mother's forgetfulness (26.6%); unavailability of vaccine (15%). Higher birth order (OR=2.86; 3.16-2.56), mother's current residence at father's home (OR=3.17; 3.53-2.81) were associated with 'missed' vaccination. There are barriers in health care system such as lack of prior reminder and unavailability of vaccines which should be assessed and eliminated.
Keywords: Missed vaccine, Routine immunization, Mother′s forgetfulness, Reminder regarding vaccination
Only 45.2% of children in the age group of 12-23 months are 'fully immunized' in Gujarat. [1] Studies have been conducted to identify the reasons for non-immunization, but most of them are part of coverage evaluation surveys in which subjects are in the age group of 12 to 23 months, so there is a chance of recall bias. These studies have not considered the factors related to health service delivery. The present study is conducted with the objective of measuring the efficiency of immunization sessions and identifying the barriers in provision and utilization of routine immunization service.
A cross-sectional study using survey method was carried out in the rural areas of Anand district, Gujarat in the period of October 2008 to November 2009. Children aged less than one year and in need of any vaccine as per routine immunization schedule were included in the study.
According to District Level Health Survey-III, 26.8% of children in Anand district were not 'fully' immunized and missed at least one vaccine. [2]Sample size was determined with the formula n=4pq/L 2 (P = 26.8% and allowable error L=10%). Sample size required was 1093 infants. In each session, it was estimated that at least 10 infants will be vaccinated. Subjects were selected with multi-stage sampling. It was decided to include all 44 PHCs of the district. In each PHC, three sub-centers were selected by lottery method. Sub-centers organize immunization sessions in rotation as per Anganwadi area which usually caters 1000 population. In each sub-center, one session was studied, accounting to 132 sessions in total. From 132 sessions, a total of 1296 infants were studied.
Andersen's behavioural model [3] of Health Services Utilization was used as a conceptual framework. It considers two aspects for studying vaccination use and its determinants.
1. Infant and family characteristics which include infant's gender, birth order, mother's current residence, knowledge about schedule, ritual belief etc. 2. Health Care System which includes availability of vaccine, distance from session site, reminder given by health staff etc. Efficiency of immunization session was defined as percentage of eligible infants who received their required vaccine.
The dependent variable was defined as the child who either had or had not received all required vaccine. Vaccines and schedule recommended by National Immunization Programme was followed to consider infant due for vaccination. The independent variables were the population and health care system characteristics.
Children aged less than one year and in need of any vaccine as per routine immunization schedule were included as study subjects. It was decided to interview all infants due for vaccination during that session. Study subjects were identified by a house-to-house survey. If there was no exact information on previous date of vaccination and thus inability to decide whether infant is due for vaccination, subjects were excluded.
The survey instrument was a structured questionnaire which was finalized after pre-testing and pilot study. Details regarding health system characteristics, such as availability of vaccine and staff, were collected from session site. After immunization session was closed, a house-to-house survey was conducted to identify eligible infants. Interview of adults primarily responsible for the child's care was taken after obtaining informed consent. Information on vaccination was collected from immunization card. Births of order three and above were considered as higher-order births. Measurement of distance was taken on approximate basis. Mother's forgetfulness was considered if reminder was given by health staff, but mother forgot to visit session site or gave priority to other work. Information was also collected on ritual belief, without completing rites which is usually done at one month when neonate cannot be moved outside home, to test its association with delayed initiation of vaccination. Data was collected by resident and internees after training.
Analysis was done using Epi-Info 3.4.3 software. For testing, association of multiple variables logistic regression was applied while for other variables Z test was applied.
Out of a total of 1296 infants expected to be vaccinated, 864 (66.7%) infants received their all required vaccines from routine immunization session. Efficiency of immunization session was lowest for BCG vaccine (62.9%) and was higher for DPT and OPV (68.8%) vaccine.
Reminder not given by the health staff and mother's forgetfulness were the two most common reasons for missing vaccination in 432 eligible infants. Among vaccinated infants, 63 (7.3%) mothers did not receive any reminder by health staff for vaccination. While among unvaccinated infants, 142 (32.9%) mothers didn't receive reminder. (SE=2.88, Z=8.86, P<0.01). 115 (26.6%) infants missed vaccination because of mother's forgetfulness. 65 (15%) of infants missed vaccination because required vaccine was not available at session site.
[Table 1] depicts the association of different factors with missed vaccination. Higher birth order, female sex of infant, mother's illiteracy, mother's residence at father's home and far distance were associated with 'missed' vaccination. Higher birth order [OR=2.86 (2.56-3.16) Z=6.83] and mother's stay at father's home [OR=3.17 (2.81-3.53) Z=6.48] were showing strongest association.
 | Table 1: Association of different factors with 'missed' vaccination (logistic regression) Click here to view |
Association of mothers getting reminder by health staff with various factors (like distance from session site, working mother and mother's current residence at father's home) was tested with logistic regression analysis. Association with mother's current stay at father's home [OR=1.45 (1.11-1.79) Z=2.19] was significant. If mother is at father's home, she is less likely to get reminder from health staff. Working mothers and mothers staying at far distance were not obstacles in giving reminder.
Association of mother's forgetfulness with different factors was also tested by applying logistic regression. Female child [OR=1.58 (1.26-1.9)Z=2.19], illiteracy [OR=2.58 (2.28-2.88) Z=4.31] and distance > 1 km [OR=1.95 (1.63-2.27) Z=3.13] were significantly associated with mother's negligence. Association of working mothers and higher order birth with mother's forgetfulness was not significant.
Date of first dose of vaccination was available in 1179 infants. 234 (19.8%) of infants received their first dose of vaccine after two and a half months of age. Due to ritual belief, initiation of vaccination was delayed. (Z=10.22, SE=3.49, P<0.01).
As mentioned above, reminder not given by the health staff and mother's forgetfulness were the two most common reasons for missing vaccination in the present study, followed by unavailability of vaccine. Infant's sickness was also significant for non-vaccination.
Female health workers are supposed to prepare due beneficiary list and give reminder to mothers about need of vaccination and date of immunization session. But lack of prior reminder has remained the most common cause of missing vaccination. In a study on immunization coverage in Bihar, lack of awareness has been mentioned as the main reason for non-immunization. [4] In Gujarat, mothers frequently travel between husband's home and father's home during postnatal period. The findings of the present study suggest this social behaviour as the major obstacle in giving reminder. Previous studies are not available for support of this observation. Health workers register deliveries of only daughter-in-laws of the family, not of daughters in the family, to avoid duplication of birth registration. It is likely that mothers staying at father's home will miss reminder.
Supporting the present findings, a study conducted in Rajasthan has also mentioned laziness and forgetfulness as the second most important reasons. [5] Mother's forgetfulness was associated with sex of the child, mother's illiteracy and far distance, which had corroborated with data from three consecutive rounds of the Indian National Family Health Survey that girls have significantly lower immunization coverage than boys.[6]
Unavailability of vaccine was the third reason for missing vaccination in the present study. Immunization service assessment in India done by Global Alliance for Vaccines and Immunization has found that due to irregular delivery, stocks tend to be below target amounts at state, district and PHC levels. [7] There was significant association between ritual belief and delayed initiation of vaccination.
Poor active tracking and irregular vaccine supply are the major obstacles in utilization of routine immunization service. Intervention based on health metrics strategy in which each child is tracked with computerized database for timely immunization has proven effective. [8] Regular and sufficient vaccine supply is a must for universal immunization coverage and can be achieved with appropriate logistic management.
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