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Indian Journal of Community Medicine

Primary Immunization Status of Children in Slum Areas of South Delhi - The Challange of Reaching the Urban Poor

Author(s): Malini Kar, V.P. Reddaiah*, Shashi Kant*

Vol. 26, No. 3 (2001-07 - 2001-09)

Abstract:

Research question: What is the immunization status of children in slum areas and what are the reasons of partial and non-immunization?

Objectives: 1. To evaluate immunization status of children aged 12 to 23 months and to find out reasons for non-immunization and partial immunization, if any, in slum areas. 2. To find out the coverage of Vitamin A and pediatric IFA tablets in the above children.

Design: Cross-sectional study.

Setting: Two slum areas of South Delhi namely Ambedkar Camp and Rajiv Gandhi Camp.

Participants: Children aged 12 to 23 months, mothers of principal caretakers.

Statistical analysis: Percentages, Chi square test.

Results: The study found that 69.3% of the children were fully immunized with BCG, DPT3, OPV3 and measles; 15.7% were partially immunized and 15.1% were non-immunized. The major cause of incomplete immunization was postponement of immunization due to the illness of the child whereas mother's lack of information about place, schedule and eligible age of immunization constituted the main reasons for non-immunization. The coverage of oral Vitamin A concentrate (at least one dose) was 75.9%, whereas, 97% did not get any pediatric folifer tablets.

Conclusion: It was concluded that lack of appropriate information is still the main hurdle for success of primary immunization in slum areas.

Keywords: Immunization coverage, Children, Urban slums

Introduction:

Universal Immunization Programme aims at completing the primary immunization (BCG, DPT3, OPV3, and Measles) for all the children in the country by the time children become one year old1. Despite all the efforts put by governmental as well as non-governmental institutes for 100% immunization coverage, there are still pockets of low coverage areas. Urban slums constitute one of the high-risk areas for the vaccine preventable diseases2,3. The present study was carried out to find out utilization of preventive child health services in the form of coverage of immunization, oral Vitamin A and pediatric folifer tablets.

Material and Methods:

Using the national average of 80% as immunization coverage and allowing an error of 10%, sample size was calculated to be 100 children of 12 to 23 months of age. Again assuming national average birth rate as 30 per 1000 population and average household size as 5 and IMR as 80 per 1000 live births, it was calculated that 600 households need to be covered to get the required number of study subjects. The study was conducted in slums of Rajiv Gandhi camp and Ambedkar camp in New Delhi. These two slums were selected because the Centre for Community Medicine provides health services in these areas.

The first household was selected at random. Then using systematic random sampling every 10th household was identified for the study. If the selected house was locked or vacant, then the next house in serial (i.e. 11th) was included. If that one was also found to be locked or vacant, then the previous (i.e. 9th) household was selected. All the children of the household in the age group of 12 to 23 months were included. The mothers were interviewed by the investigator personally (first author) using a pretested semi-structured schedule. The interview schedule included questions about household identification data, educational status and occupation of both the parents, income of the family, utilization of child health services and reasons for non-utilization if any. Kuppuswamy scale was used for assessing the socio-economic status of the family.

During interview the mother was asked if she had the immunization card for the child. If a card was available, then it was easy to know the exact immunization status of the child. In case card was not available, the immunization status was ascertained by asking the mother and inspection for the BCG scar.

Results and Discussion:

Table I: Distribution of immunization coverage for individual vaccines.

Coverage DPT No. (%) OPV No. (%) BCG No. (%) Measles No. (%)
Three doses 123 (74.1) 125 (75.3) -   -  
Two doses 10 (6.0) 10 (6.0) -   -  
One dose 4 (2.4) 4 (2.4) 129 (77.7) 121 (72.9)
Nil 29   27 (16.3) 37 (22.3) 45 (27.1)
Total 166 166 166 166

 

There were 166 children aged between 12 to 23 months. It was found that 115(69.3%) children were fully immunized against all the six vaccine preventable diseases. The coverage level for individual vaccine is shown in Table I. Twenty six children (15.7%) were partially immunized and 25(15.1%) were non-immunized.

Table II: Association of different factors with the immunization status of the child.

Variables Complete immunization Partial/non-immunization Total
Sex of baby
Male 65 (70.7) 27 (29.3) 92
Female 50 (67.6) 24 (32.4) 74
Type of Family
Nuclear 106 (70.2) 45 (29.8) 151
Joint 9 (60.0) 6 (40.0) 15
Mother's literacy status
Illiterate 97 (71.3) 39 (28.7) 136
Literate 18 (60.0) 12 (40.0) 30
Father's literacy status
Illiterate 31 (67.4) 15 (32.6) 46
Upto middle 57 (73.1) 21 (26.9) 78
High school & above 27 (64.3) 15 (35.7) 42
Religion
Hindu 93 (69.9) 40 (30.1) 133
Non-Hindu 22 (66.7) 11 (33.3) 33
Mother's occupation
Housewife 91 (69.5) 40 (30.5) 131
Working 24 (68.6) 11 (31.4) 35
Father's occupation
Labourer 47 (64.4) 26 (35.6) 73
Bussiness/service 68 (73.1) 25 (26.9) 93
Socio-economic status
Lower 86 (73.5) 31 (26.5) 117
Middle 29 (59.2) 20 (40.8) 49

Figures in parentheses denote percentages. In all the above cases p>0.1.

Children aged more than 15 months were eligible for booster dose of DPT/OPV. It was found that 44.9% of the children between the age of 15-17 and 49.4% of the children of 18-23 months had received booster dose for DPT and OPV. Similar results were reported by a study done in resettlement and JJ colonies of Delhi in 19904. According to National Family Health Survey, 58% of children aged 12 to 23 months were fully immunized at the time of interview5. Guyer et al reported that many infants of inner city of Baltimore were under-immunized despite having age-appropriate preventive visits, health insurance coverage through Medicaid and free availability of vaccines from public agencies6.

Sex of the child, parents' literacy status, occupational status of the parents or socio-economic status of the family did not significantly affect the immunization status of the child. Association of different factors with immunization status is shown in Table II.

Table III: Reasons for partial immunization of the child.

Reason Children No. (%)
Child unwell, immunization postponed 8 (30.8)
Lack of knowledge of immunization schedule 6 (23.1)
Migration to native village 6 (23.1)
Negative attitude 2 (7.7)
Due for 2nd/3rd dose, started late 2 (7.7)
Lack of time 2 (7.7)
Total 26 (100.0)

It was observed that 26 out of the 166(15.7%) children had received partial immunization. The reasons for incomplete immunization were asked from the mothers, which are listed in Table III. Freeman reported that provision of information to mothers regarding when to start the immunization and how often the child should be immunized were the key factors in determining immunization status. Maternal education was found to be positively associated with the knowledge about immunization, but was not significantly associated with actual immunization practice7.

The major cause for incomplete immunization was postponement of vaccination due to illness of the child (30.8%), lack of knowledge of immunization schedule (23.1%) and migration to native village (23.1%).

Table IV: Reasons for non-immunization.

Reason Children No. (%)
Lack of information 16 (64.0)
Obstacle 5 (20.0)
Lack of motivation 4 (16.0)
Total 25 (100.0)

Twenty five children were non-immunized. The reported reasons for non-immunization were multiple. So, they were grouped into 3 main categories, which are shown in Table IV. Mother's lack of information (64%) constituted the major cause for non-immunization. This category included lack of knowledge about place, schedule and eligible age of immunization. Obstacles (20%) were timing of immunization clashed with busy hour of household work, illness of child, opposition by in-laws etc. Lack of motivation (16%) was mainly due to uncertainty regarding the benefits of immunization.

Studies done in West Bengal and Delhi indicate that incorrect information regarding immunization of child during illness leads to non/partial immunization8,9.

Vitamin A coverage with atleast one dose was 75.9% (25.9% had received two and 6% received three doses). Mother's literacy status was found to have significantly affected the coverage (*2=8, df=2, p<0.05).

The coverage of pediatric folifer was found to be very low. Most of the mothers (97%) stated that their children (12 to 23 months) did not receive any IFA tablets.

Conclusions:

It is evident from the study that lack of appropriate information is still the main hurdle for success of primary immunization in slum areas. Special health education camps and community mobilization may help in identifying and referring the children for vaccination. Every opportunity should be used to vaccinate eligible children in these areas if we want to achieve the goal of 100% immunization coverage.

References:

  1. Govt. of India. National Child Survival and Safe Motherhood Programme. New Delhi: Ministry of Health and Family Welfare; 1994.
  2. UNICEF. The Invisible Child: A look at the Urban Child in Delhi. New Delhi: UNICEF; 1990.
  3. Lodha R, Dash NR, Kapil A, Kabra SK. Diphtheria in urban slums in north India. Lancet 2000; 355(9199): 204.
  4. Chawla SC, Bachani D, Bansal RD. Vaccination coverage of infants and mothers, prevalence of poliomyelitis and incidence of neonatal tetanus in the resettlement and JJ colonies of Delhi. Project report. Centre for monitoring and evaluation of immunization programme and surveillance of vaccine preventable diseases in Delhi. Ministry of H&FW, G.O.I. and I.C.M.R. Nov. 1990.
  5. International Institute for Population Sciences, Bombay. Population Research Centre, Institute of Economic Growth, Delhi, National Family Health Survey (Delhi), 1993. Delhi 1995.
  6. Guyer B, Hughart N, Holt E et al. Immunization coverage and its relationship to preventive health care visits among inner-city children in Baltimore. Pediatrics 1994; 94(1): 53-8.
  7. Freeman PA, Thomason JA, Bukenya GB. Factors affecting the use of immunization among urban settlement dwellers in Papua New Guinea. PNG Med J 1992; 35(3): 179-85.
  8. Mukherjee B, Ray SK, Kar M et al. Coverage evaluation surveys amongst children in some blocks of West Bengal. Ind J Pub Health. 1990; 34(4): 209-14.
  9. Bhattacharjee J, Singh J, Sharma RS. Reasons for immunization failure in infants of North India. Ind J Comm Med 1993; 18(4): 160-3.

Malini Kar, V.P. Reddaiah*, Shashi Kant*
Deptt. of Community Medicine,
PGIMER, Chandigarh.
*AIIMS, New Delhi

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