OJHAS Vol. 10, Issue 4:
|Exploring the Causes of Low Immunization Status in School Going Children
Madhuri Inamdar, Assistant Professor, Department of Community Medicine,
Saurabh Piparsania, Senior Resident, Department of Pediatrics,
Savita Inamdar, Professor Emeritus, Department of Pediatrics,
Kuldeep Singh, Professor and Head, Department of Pediatrics,
Sri Aurobindo Institute of Medical Sciences, Indore-452003, Madhya Pradesh, India.
Dr. Madhuri Inamdar,
Address for Correspondence
22/10,Yeshwant Niwas Road,
Indore - 452003,
Madhya Pradesh, India.
Inamdar M, Piparsania S, Inamdar S, Singh K. Exploring the Causes of Low Immunization Status in School Going Children. Online J Health Allied Scs.
Submitted: Sep 27,
2011; Accepted: Jan 4, 2012; Published: Jan 15, 2012
Although a definitive immunization program has been advocated for children
in our country, the immunization coverage is far from satisfactory.
There is paucity of survey studies related to immunization pattern. Objective:
This study has been undertaken to explore the social and attitudinal
factors with parents resulting into adverse immunization. Material and
Methods: The study was school based cross-sectional study conducted
in 50 schools of Indore district selected by random sampling from three
groups. Information was collected from parents by providing pre-tested
Association of parent’s literacy and socioeconomic status with successful
immunization could be established. Overall coverage rate with vaccines
was poor in school going girls as compared to the boys; proving thereby
that gender discrimination exists putting girls in disadvantageous position. Conclusion:
It can be expected that the immunization status of school children will
improve if identified risk factors such as parental education, socioeconomic
status, awareness status are improved and attitudinal gender discrimination
status; Gender discrimination; Parental education; Adolescent immunization
through immunization against vaccine preventable diseases, disabilities
and death is the birth right of every child. Vaccines remain one of
the most cost-effective public health initiatives.1
A lot of progress has been made globally as far as protection against
six vaccine preventable diseases is concerned; yet the coverage against
VPDs remains far from complete. Recent estimates suggest that approximately
34 million children are not completely immunized with almost 98 per
cent of them residing in developing countries.2
Vaccination coverage in India is also far from complete despite a longstanding
commitment to universal coverage. A recent evaluation of VPD coverage
in India found that 18 million children did not receive any coverage
is one of the best indicators to evaluate the available health services.
It is also one of the most cost-effective interventions to prevent a
series of major illnesses, particularly in environments where children
are undernourished and die from vaccine preventable diseases. Given
the extensive social benefits of immunization, any inequities in the
knowledge, attitude and practices that leave out large sections of the
most deprived populations are a cause for serious policy concern. There
is evidence of inequalities in immunization in India, despite the fact
that childhood immunization has been an important part of maternal and
child health services since the 1940s.4
increased accessibility of healthcare services in both urban and rural
areas, an increase was expected in the utilization of the services;
however, studies reveal low utilization of healthcare services including
MCH service by different segments of the society.5 The current scenario depicts that only 44% of infants in
India are fully immunized (NFHS III),6 which is much less than the desired goal of achieving
85% coverage. Globally about 20% of children remain unimmunized. The
unimmunized may be difficult to reach or may belong to groups who traditionally
do not use healthcare services. These groups are frequently low in literacy
skills, so may not respond well to conventional methods of communication
and health education, and may live in severely underprivileged conditions
in remote areas or urban slums.
It has been
found that a child with high birth order, belonging to an orthodox family,
those residing in rural areas, children with illiterate parents and
coming from low socioeconomic status and those from high household size
had significantly low immunization coverage as compared to children
from opposite groups. A number of studies have drawn attention to the
problem of discrimination against the female child and few studies have
shown that immunization coverage of female children is far lower than
that of male.
In spite of
enthusiastic universal immunization program, we know that the number
of beneficiaries during school age is not up to the mark, as the school
age is still a neglected area.
as to why immunization is not up to the mark need to be found. The possibilities
need to be discussed:
- Is there lack of
awareness among parents regarding immunization? Can parental educational
status be responsible for low immunization status?
- Are vaccines not
affordable by the parents, particularly newer vaccines and optional
- The fact that vaccination
is not part of school health program. Should it be made part of school
- Are we interested
in vaccination beyond infancy?
- Is immunization
coverage better in male children as compared to female of the same age
In order to
get answers to the above questions, it is important to know the exact
status of immunization beyond infancy i.e. in the school age and during
Indore is the
largest city and commercial capital of the Indian state of Madhya Pradesh,7 covering an area of 3,398 Km 2. The total population
in 2001 was reported to be 2,465,827.8 Males constitute
1,289,352 of the population and females 1,176,475. As per 2001 census,
the city of Indore has an average literacy rate of 75.15%, higher than
the national average of 59.5%.
As Indore is
a modern city of Madhya Pradesh with diverse social characteristics,
this survey was conducted in the school going children attending government,
private and public schools to determine the immunization status and
also to identify the social and attitudinal causes (such as socioeconomic
status, educational status of parents and gender discriminative attitude
of the family) resulting in lower immunization rates. The study was
carried out in the MR-10, Vijay Nagar and Palasia area (an urbanized
locality) of the Indore district. There were about 90 government schools,
30 private and 18 public schools in the area. The schools are categorized
School: The term “government school” refers to government-funded
schools that are run by the government but does not include the
government-aided schools that are privately managed.
Government-aided schools that are privately managed.
The “public schools” referred to in the rest of this study include
recognized schools that charge fees and do not receive any financial
support from the government and are managed privately.
and Sampling Technique:
was a school based cross-sectional study conducted in 50 schools, which
were selected randomly from 3 groups.
Inclusion criteria: All the children
going to school, falling between 5-16 years of age were included in
Exclusion criteria: All the children
not coming within the age range were excluded from the study.
- Government schools
- Private Schools
- Public schools
A total of
5010 children in the age group of 5-16 years (2024 children from government,
1541 children from private and 1445 children from public schools) were
included in the study.
Collection Technique and Tools:
was carried out from November 2008 - August 2009.
was collected by providing pre-tested proforma and questionnaire to
the students of each selected school.
the questions related to the preliminary information about the child
viz. name, age, sex, religion and class. Proforma also included parents
name, their educational status, occupation, annual income, total family
members, and information regarding the immunization status of these
children (vaccines covered under UIP, EPI and IAP).
proforma were collected and analyzed. Incomplete or partially filled
proforma were excluded from analysis.
As the study
was school based including children in the age group of 5-16 years, parental
recall and their response to the immunization status of children in
the proforma was relied upon. Some schools,
in particular, public and private schools and some parents who had immunization
cards available with them were relied upon.
full, partial and no immunization:
A child was considered fully immunized if vaccinated against BCG, 3
doses of OPV and DPT and 1 dose of measles during infancy and first
boosters of OPV and DPT as recommended in UIP.
A child was labeled as partially immunized if he/she had missed any
one of the vaccines recommended in UIP.
A child was labeled as unimmunized if he/she had not taken any of the
status of the parents was determined using modified Kuppuswamy’s scale. The influence
of parental education and socioeconomic status on immunization status
of school children (male and female) was determined. After data
collection data was analyzed using SPSS 17 Software Package and Windows Excel Sheet.
P value was generated, and a P value of < 0.05 was taken as significant
and P value
> 0.05 was taken as non-significant.
1 is depicting the association of literacy status of fathers of
studied subjects with immunization status of boys and girls belonging
to different categories of schools. It can be observed from Table 1 that
immunization coverage was higher in males as compared to females in each
group, suggesting existence of gender discrimination. A highly significant
association is noticed between father’s literacy and immunization status of
their children (p-Value <0.0001). In general, the immunization status was
proportionately better in children whose fathers were educated.
Table 1: Association
of father’s education with immunization
Male (n and %)
Female (n and %)
Total (n and %)|
As in Table 2, a highly significant association between mother’s literacy and
immunization status of their children is observed (p-Value <0.0001),
suggesting maternal literacy has appreciable effect on nullifying gender
bias. Only 24.46% of female children were fully immunized as compared
to 75.54% of male children when mothers were illiterate. The immunization
of female children increased as the education of mother increased. None
of the postgraduate mother had unimmunized child, girl or a boy.
Table 2: Association
of maternal education with immunization
Male (n and %)
Female (n and %)
Total ( n and %)|
In the present
study, full immunization coverage was highest for children belonging
to high socioeconomic class 1020 (37.49%) followed by children belonging
to lower class 971 (35.68%) and then middle class 730 (26.83%). Also
in each class immunization coverage was higher in males as compared
to females suggesting possible gender bias. The probability value of
less than 0.0001 suggests a highly significant association
between parent’s socioeconomic status and gender bias.
of Socioeconomic status of parents with immunization
Male (n and %)
Female (n and %)
Total (n and %)|
In the present
study, p value was significant (<.05) for most of the vaccines included
in national immunization schedule suggesting preference is being given
to the male child. However, p value was not significant (>.05) for
BCG and Measles vaccine. For the administration of optional (recommended)
vaccine no significant gender bias is observed (p-Value >.05) except
for varicella and pneumococcal vaccine.
Table 4: Coverage
of Individual vaccine and gender bias
# Vaccine not
computed because rubella vaccine is a constant
In the present
study, the total number of children included were 5010 of which 3025
(60.4%) were male and 1985 (39.6%) were female. Overall 28.84% (Total
1445; Male-856, Female-589) children belonged to high socio-economic
class, whereas 30.76% (Total 1541; Male-901, Female-640) and 40.4% (Total
2024; Male-1268, Female-756) children belonged to middle and low socio-economic
In the age
group of 5-16 years, 34.6% male and 19.7% female (total-54.3%) children
were fully vaccinated, while 22.8% male and 19.3% female (total-42.1%)
children were partially immunized and 3% male and .6% female (total-3.6%)
were non-immunized. Similar study was done in M.P. by Yadav RJ, Singh
P in the year 2004 showing 60.8% of children as fully immunized and
9.6% as non-immunized.9 National statistics (NFHS
III) reflects fully immunized children as 40% in Madhya
Pradesh as compared to national coverage of fully vaccinated children
In the present
study, on comparing two genders, 34.6% males were fully immunized as
against only 19.7% of females. These figures are lower than a study
done in slums of Surat.10 However gender discrimination
is obvious with preference to male school children in comparison to
of fully immunized children 27.12% (Total 738; Male-407, Female-331)
belonged to father who were graduate followed by 24.22% (Total 659;
Male-411, Female-248), 23.67% (Total 644; Male-510, Female-134) and19.03%
(Total 518; Male-296, Female-222) children belonged to fathers with
education level of high school, primary school and post graduate respectively.
Lowest number i.e. 5.95% (Total 162; Male-108, Female-54) children belonged
to fathers who were illiterate.(Table 1) A highly significant association
is noticed between father’s literacy and immunization status of their
children (p-Value <0.0001). Immunization status improved with father’s
(Total-776; Male-539, Female-237) of the fully immunized children belonged
to mothers with education up to high school, while 27.82% (Total-757;
Male-476, Female—281), 26.09% (Total-710; Male-386, Female-324) and
9.0% (Total-245; Male-155, Female-90) children belonged to mothers with
education level up to primary school, graduate and post graduate respectively.
Lowest number 8.56% (Total-233; Male-176, Female-57) of fully immunized
children belonged to mothers who were illiterate. (Table 2) Significant
discrimination against female children was noticed where mothers were
either illiterate or had education up to high school. This shows that
the literacy status of mothers as against their level of awareness is
an important factor for determining the immunization status of their
In our study
none of the graduate or post graduate mother had any unimmunized child.
This is in accordance to a study conducted at Goa,11
where none of the graduate mothers had an unimmunized or partially immunized
child. In MP, 80.2% of the graduate mothers had their children fully
the influence of socioeconomic status on immunization; the maximum gender
bias towards female children as compared to male children is observed
in low socioeconomic class (Female-29.25%, Male-70.75%) followed by
middle socioeconomic class and minimum in children belonging to upper
socioeconomic class (Female-42.06%; Male-57.94%).(Table 3) This may
be due to the fact that people with higher socioeconomic status are
economically well off and thus, have the resources to pay for the private
services. There is also a possibility that with the improvement in socioeconomic
and educational status, the awareness about various private facilities
increases and also the satisfaction with primary health care facilities
decreases. Most of the studies found that gender bias does exist in
favor of boys as compared to girls.
of low immunization coverage in females as compared to male is due to
the discrimination against female as also stated in a study done by
Vinit Sharma and Anuragini Sharma.12 They also stated
that the higher immunization rates in male children is because they
get more importance. The coverage rates for males were higher
than female children in Jamnagar,13 and a higher
number of females were unimmunized in Goa.11 Similar
sex bias was seen in the study done on immunization coverage in urban
area of Uttar Pradesh by Nirupam S, Chandra R, and Shrivastava VK.14
The reason for this gender bias in our study was the
thinking of most of the respondents (29.3%) that the male child will
become bread earner in the future and so needs to be protected and 22.3%
respondents felt that financial reason could be the cause for this gender
OPV, DPT and MMR were high for male children. All differences were significant
(P< 0.01). However, there was no significant difference in
the coverage of BCG and Measles (p>.05). (Table 4) This could be
attributed to the fact that most of the deliveries are institutionalized
and as BCG is the first vaccine to be administered, most of them get
their children immunized with the vaccines and if not, they at least
acquired the knowledge about it. However, beyond infancy the awareness
and the interest of the community decreases, particularly in the school
age group, depriving children from the benefits of other available vaccines.
Hence, the counseling and awareness program needs to be stressed from
Most of the
respondents were unaware of the optional vaccines, their usefulness and the time
of administration, as a result many children are exposed to some preventable
diseases. It was also observed that the mothers with a higher level of education
preferred to get their children vaccinated (routine immunization, optional
vaccines and the administration of rubella vaccine) at a secondary health care
facility or a private facility. However no significant difference was observed
for the administration of most of the optional vaccines. This could be
attributed to the fact that these vaccines are afforded only by children
belonging to high socioeconomic class where gender bias is less and
affordability as well as awareness regarding vaccination is very high.
immunization coverage has increased substantially in general in recent
years, a sizable proportion of children are not being immunized. The
study identified significant association of parental education, socioeconomic
status of the parents and gender discrimination along with unawareness
of the parents as main reasons for low immunization coverage. Gender
discrimination was responsible for further lowering of immunization
coverage in girls. It can be expected that more stress on identified
risk factors in the study will indirectly help in improving the immunization
In the last few
decades there is an advent of many new vaccines in the private Indian
market. However, most of these vaccines are at present accessible only
to those who can afford to pay for them causing social inequality among
children belonging to the underprivileged sections of the society.
Present day vaccination
programme framed by government of India emphasize six vaccine preventable
diseases during first year of life and pulse polio programme. There
is a lack of stimulus for boosters, optional vaccines and low understanding
that pulse polio is additional to the regular immunization programme.
Community need to be educated and made aware of the facts.
This study provides
us an important insight into the existing level of awareness among the
people and the areas that need attention:
Literacy and socioeconomic
status of the parents has appreciable impact on immunization.
Lack of knowledge
and interest in adolescent vaccination
are the recommendations from the present study:
remains one of the most cost-effective health interventions, more awareness
in public and more responsible attitude of healthcare system is needed.
The health education should be emphasized to enhance respondent’s
knowledge about the complete immunization program. Also gaps regarding
the knowledge about correct age of administration, dosage, type of vaccination
and difference between regular immunization and pulse polio programme
should be filled along with the improvement in the literacy status of
the mothers. This would require appropriate information dissemination,
aggressive campaigning and family involvement, which are crucial to
the success of such program.
has to be incorporated in school health programme. Further there is
a need for coverage of dropouts and a systematic inclusion of adolescent
Social science surveys
can show which subgroups of the population are not getting immunized and why. Once this is known, special activities can be planned
to immunize the missed children. Rapid assessment methods are presently
under development for this. Reaching such groups with immunization services
require innovative approaches.
Future parents need
to be educated and made aware of the preventive science including immunization.
Social awareness about gender equality needs attention. Gender discrimination
has to be curbed and status of girl child requires improvement.
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