Maternal determinants of immunization status of children aged 12–23 months in urban slums of Varanasi, India

Impact of maternal depression and anxiety on immunization status of children: a prospective cohort study

BACKGROUND

Maternal depression and anxiety can have a detrimental impact on birth outcomes and healthy child development; there is limited knowledge on its influence on immunization schedule adherence. Therefore, the objectives of this study were to determine the impact of maternal depression and anxiety in the perinatal period on prolonged vaccine delay of childhood vaccines.

METHODS

In this prospective cohort study, we analyzed linked survey and administrative data of 2,762 pregnant women in Calgary, Alberta, Canada. Data were collected at two time-points: prenatal (< 25 weeks of gestation) and postpartum (4 months postpartum). We used multivariable logistic regression to examine the association between depression and anxiety with prolonged immunization delay, adjusting for covariates.

RESULTS

In multivariable analysis, maternal depression at either time point was not associated with prolonged delay for DTaP-IPV-Hib (OR 1.16, 95% CI 0.74-1.82), MMR/MMRV (OR 1.03, 95% CI 0.72-1.48), or all routine childhood vaccines combined (OR 1.32, 95% CI 0.86-2.04). Maternal anxiety at either time point was also not associated with prolonged delayed for DTaP-IPV-Hib (OR 1.08, 95% CI 0.77-1.53), MMR/MMRV (OR 1.07, 95% CI 0.82-1.40), or all vaccines combined (OR 1.00, 95% CI 0.80-1.26). In both the depression and anxiety models, children of Canadian-born mothers had higher odds of prolonged delay, as did those with low-income mothers.

CONCLUSION

Health care providers can be reassured that maternal depression and anxiety do not appear to influence maternal commitment to routine immunization. Findings suggested that low income and household moves may influence adherence to vaccine schedules and health care providers may want to provide anticipatory guidance to these families.

Trends in childhood immunisation amongst Muslim children of Punjab (India): An empirical study

India's immunisation programme is one of the largest in the world and achieved great success over the years, however, some significant gaps are still observable in terms of achieving universal immunisation of children. Religion has emerged as a strong correlate for immunisation rates at national, state and global level. It has been observed that the rate of immunisation among children from Muslim families is comparatively less at global as well as at national level. Therefore, the paper attempts to understand immunisation trends among Muslims children from the north-western Indian state of Punjab. Based on the cross-sectional study of 400 households from district Sangrur of Punjab, results of the study show that rate of full immunisation among children from Muslim families was 88 per cent and none of the children were non-immunised. Reasons stated for partial immunisation of children included distrust of the government and belief that it would cause infertility amongst children. The present study reveals that religion per se does not appear to be influence rates of full immunisation. Geographical location, embeddedness of the community in the larger political and social milieu of their area, reach and acceptance of health workers at grassroots level emerge as strong factors contributing to higher rates of immunisation amongst Muslim children of Malerkotla.

Exploring the Pattern of Immunization Dropout among Children in India: A District-Level Comparative Analysis

The dropout rate is one of the determinants of immunization coverage and program performance, program continuity, and follow-up. The dropout rate refers to the proportion of vaccine recipients who did not finish their vaccination schedules, and it is determined by comparing the number of infants who started the schedule to the number who completed it. It is the rate difference between the first and final dosage or the rate difference between the first vaccination and the last vaccine dropout; thus, it denotes that the first recommended dose of vaccine was received, but that the subsequently recommended dose was missed. In India, immunization coverage has shown significant improvements over the last two decades, but full immunization coverage has remained stagnant at 76.5%, of which 19.9% are partially immunized, and 3.6% are children who have been left out. In India, the Universal Immunization Programme (UIP) is challenged with cases related to dropout in immunization. Although immunization coverage in India is improving, the program is challenged by vaccination dropouts. This study provides an analysis of the determinants of vaccination dropout in India using data from two rounds of the National Family Health Survey. The finding shows that the mother's age, education, family wealth, antenatal care visit, and place of delivery were some of the variables that significantly contributed to reducing the dropout rate of immunization among children. The findings of this paper show that the dropout rate has reduced over a certain period of time. The overall improvement in the rates of dropout and increase in full immunization coverage could be attributed to various policy measures taken in the last decade in India, which brought structural changes with a positive impact on full immunization coverage and its components.

Vaccination Status and Its Determinants Among Children Aged 12 to 23 Months in Mettu and Sinana Districts, Oromia Region, Ethiopia: A Comparative Cross Sectional Study

Background

Globally, more than 19 million children have not received all of their vaccination benefits, resulting in an estimated one million deaths worldwide each year. Vaccine-preventable diseases are becoming more common in Ethiopia, despite the fact that official vaccination coverage is sufficient to develop herd immunity locally for some diseases such as measles. This mistrust of the official report prompted us to conduct a community survey and compare it to other areas where there have been no reports of vaccine-preventable disease.

Methods

A community-based comparative cross-sectional study was conducted from 20/01–20/02/2021 in Sinana and Mettu districts. Probability proportional to estimate size was used to select 23 clusters. We recruited 228 from Mettu and 436 from Sinana by systematic random sampling. We used a structured questionnaire to collected data from mother–child pair using card and history. We conducted independent t-tests to test coverage differences between districts. We identified determinants of full vaccination status by multivariate logistic regression analysis after bivariate candidate selection.

Results

Fully vaccinated children accounted for 62.7% in Sinana and 91.6% in Mettu, demonstrating a significant coverage difference (p<0.001). Being a resident of Mettu (AOR: 3.5, 95% CI [1.5, 6.9]), intended pregnancy (AOR 5.9, 95% CI [2.4, 11.3]), 4 or more antenatal care visits (AOR: 2.09, 95% CI [1.4, 3]), having postnatal care (AOR: 3.5, 95% CI [1.6, 7.9]), younger child age (AOR: 0.87, 95% CI [0.8, 0.9]), having up to three children (AOR 3, 95% CI [1.13, 8]) and good knowledge of vaccine schedule (AOR: 2.4, 95% CI [1.4, 4]) were associated positively with full vaccination status.

Conclusion

Full vaccination status was 91.6% in Mettu and 62.7% in Sinana district. Place of residence, ANC, PNC, pregnancy intention, child number, age of child and knowledge of vaccination schedule were significantly associated with vaccination status of the children.

Mother’s Media Use and Children’s Vaccination Status in Indonesia: A Community-Based Cross-Sectional Study

Exposing appropriate information to mothers is a key factor for children’s immunization status. This study aims to assess the influence of mothers’ media use on their children’s vaccination status in Indonesia, using the 2017 Indonesia Demographic Health Survey data. A multilevel multinomial logistic regression model was employed. Mothers who used media irregularly and regularly had higher odds of having partially vaccinated children (vs unvaccinated) than mothers who never used media with adjusted odds ratio (aOR): 1.74; 95% Confidence interval (95% CI): 1.06-2.85 and aOR: 1.48; 95% CI: 1.02-2.16, respectively. Furthermore, they had higher odds of having a fully vaccinated child (vs unvaccinated) (aOR: 1.86; 95% CI: 1.12-3.08 for irregular media use and aOR: 2.41; 95% CI: 1.64-3.53 for regular media use vs. no media use). Our findings suggest that mothers’ media use could positively affect their children’s vaccination status by increasing mothers’ knowledge about children’s vaccination.

Public health facility quality and child immunization outcomes in rural India: A decomposition analysis

Universal coverage of routine childhood vaccines remains a challenge in many low- and middle-income countries (LMICs). In India, vaccination campaigns have increased full immunization coverage among 12–23 month old children from an estimated 62% in 2015–2016 to 76% in 2019–2020. Long-term improvements in coverage will likely require systemic changes to both the supply and demand sides of immunization programs. However, the effect of health system inputs on child vaccination outcomes remains poorly quantified in India. We examined the association between the quality of public health facilities and child vaccination outcomes in rural India using data from the nationally representative Integrated Child Health and Immunization Survey (2015–2016) which covered 1,346 public primary health sub-centers and 44,571 households. We constructed two indices of sub-center quality using multiple correspondence analysis: one related to the general health infrastructure quality and the other measuring vaccine service delivery. Using probit regression, we analyzed the relationship between vaccination outcomes in children under 2 years of age and sub-center quality, controlling for household socioeconomic characteristics. Additionally, we conducted Fairlie decomposition analysis by wealth group — bottom wealth quintile relative to the top four wealth quintiles— to examine factors contributing to gaps in immunization between rich and poor households. Infrastructure quality index was positively associated with completion of seven vaccination outcomes: full immunization, DPT-1 (first dose of diphtheria, pertussis, and tetanus), DPT-2, DPT-3, Bacillus Calmette–Guérin (BCG), hepatitis B (birth dose), and on-time vaccination (OTV). Vaccine service delivery index was positively associated with completion of measles vaccination. The distribution of infrastructure quality contributed to increased gaps in full immunization and OTV between rich and poor households, while greater proximity to vaccination site for poorer households reduced these gaps. Improved quality of health facilities, particularly facilities used by low-income households, may improve vaccination outcomes.

Vaccination coverage and the factors influencing routine childhood vaccination uptake among communities experiencing disadvantage in Vellore, southern India: a mixed-methods study

BACKGROUND

In 2015, the Vellore district in southern India was selected for intensified routine immunization, targeting children from communities experiencing disadvantage such as migrant, tribal, and other hard-to-reach groups. This mixed-methods study was conducted to assess routine immunization coverage and the factors influencing childhood vaccination uptake among these communities in Vellore.

METHODS

We conducted a cross-sectional household survey (n = 100) and six focus group discussions (n = 43) among parents of children aged 12-23 months from the known communities experiencing disadvantage in Vellore during 2017 and 2018. Multivariate logistic regression was conducted to examine associations between the parental characteristics and children's vaccination status in the household survey data; the qualitative discussions were analyzed by using the (previously published) "5As" taxonomy for the determinants of vaccine uptake.

RESULTS

In the household survey, the proportions of fully vaccinated children were 65% (95% CI: 53-76%) and 77% (95% CI: 58-88%) based on information from vaccination cards or parental recall and vaccination cards alone, respectively. Children whose mothers were wage earners [Adjusted prevalence odds ratio (aPOR): 0.21, 95% CI = 0.07-0.64], or salaried/small business owners [aPOR: 0.18, 95% CI = 0.04-0.73] were less likely to be fully vaccinated than children who had homemakers mothers. In the focus group discussions, parents identified difficulties in accessing routine immunization when travelling for work and showed knowledge gaps regarding the benefits and risks of vaccination, and fears surrounding certain vaccines due to negative news reports and common side-effects following childhood vaccination.

CONCLUSIONS

Vaccination coverage among children from the surveyed communities in Vellore was suboptimal. Our findings suggest the need to target children from Narikuravar families and conduct periodic community-based health education campaigns to improve parental awareness about and trust in childhood vaccines among the communities experiencing disadvantage in Vellore.

Investigating Factors Associated with Immunization Incompletion of Children Under Five in Ebonyi State, Southeast Nigeria: Implication for Policy Dialogue

Purpose. To investigate factors associated with immunization incompletion of children under 5 years in Ebonyi state, Southeastern part of Nigeria. Method. A cross-sectional and a cluster sampling design were implemented; 400 women of childbearing age in families with children between 0 to 59 months of age were interviewed in Ebonyi state. Demographic characteristics of the child and mother, the child’s immunization history, and reasons for partial immunization were obtained with the use of a self-administered questionnaire. Data were analyzed using descriptive statistics of mean, standard deviation, t-test and ANOVA with SPSS version 23 and hypothesis tested at P < .05. Results. Findings revealed that 180 (48.1%) females, and 194 (51.9%) males’ children were immunized; Less than half 155 (41.9%) of the children had 1 missed dose, considered as partial immunization cases indicating low coverage. Of the reasons given for incomplete immunization mothers, mothers agreed that immunization centers are far from home (x̄ = 2.55 ± 0.92). This reason significantly affects mothers who were young (≤20 years) (x = 2.86 ± 0.94; P = .018), single (x = 2.84 ± 1.05; 0.037), had secondary education (x = 2.65 ± 1.08;0.000), students (2.89 ± 1.08; P = .000), poor (x = 2.63 ± 1.05; P = .009), and primiparous (x = 2.50 ± 1.08; P = .036) are more affected and they agreed (grand mean >2.50). Conclusion. Immunization coverage was low, and far location from health facility was indicted thus policy implementers should locate health facilities close to homes. also health education on the importance of immunization should be given to mothers especially those who are young and has low socio-economic status.

Structural equation modeling to detect correlates of childhood vaccination: A moderated mediation analysis

Objectives

This study used a health belief theory derived framework and structural equation model to examine moderators, mediators, and direct and indirect predictors of childhood vaccination.

Methods

A secondary analysis was conducted using data collected from a cross-sectional survey of a random sample of 1599 parents living in urban and rural areas of Mysore district, India. Applying two-stage probability proportionate-to-size sampling, adolescent girls attending 7^th through 10^th grades in 23 schools were selected to take home a questionnaire to be answered by their parents to primarily assess HPV vaccine intentions. Parents were also asked whether their children had received one dose of Bacillus Calmette–Guérin; three doses of Diphtheria, Pertussis, Tetanus; three doses of oral Polio vaccine; and one dose of Measles vaccine. In addition, parents were asked about their attitudes towards childhood vaccination.

Results

Out of the 1599 parents, 52.2% reported that their children had received all the routine vaccines (fully vaccinated); 42.7% reported their children had missed at least one routine vaccine, and 5.2% reported that their children had missed all routine vaccinations. Perceptions about the benefits/facilitators to childhood vaccination significantly predicted the full vaccination rate (standardized regression coefficient (β) = 0.29) directly and mediated the effect of parental education (β = 0.11) and employment (β = -0.06) on the rate of full vaccination. Parental education was significantly associated indirectly with higher rates of full vaccination (β = 0.11). Parental employment was significantly associated indirectly with decreasing rates of full vaccination (β = -0.05). Area of residence moderated the role of religion (β = 0.24) and the ‘number of children’ in a family (β = 0.33) on parental perceptions about barriers to childhood vaccination. The model to data fit was acceptable (Root Mean Square Error of Approximation = 0.02, 95% CI 0.018 to 0.023; Comparative Fit Index = 0.92; Tucker–Lewis Index = 0.91).

Conclusions

Full vaccination rate was relatively low among children in Mysore, especially among parents who were unsure about the benefits of routine vaccination and those with low educational levels. Interventions increasing awareness of the benefits of childhood vaccination that target rural parents with lower levels of education may help increase the rate of full childhood vaccination in India.

Complete vaccination service utilization inequalities among children aged 12-23 months in Ethiopia: a multivariate decomposition analyses

BACKGROUND

Although World Health Organization works to make vaccination service available to everyone everywhere by 2030, majority of the world's children have been unvaccinated and unprotected from vaccine-preventable diseases. In fact, evidences on factors contributing to changes in vaccination coverage across residential areas, wealth categories and over time have not been adequate. Therefore, this study aimed at investigating inequalities in vaccination status of children aged 12-23 months owing to variations in wealth status, residential areas and over time.

METHODS

Maternal and child health service data were extracted from the 2011 and 2016 Ethiopian Demographic and Health Survey datasets. Then, multivariate decomposition analysis was done to identify the major factors contributing to differences in the rate of vaccination utilization across residences and time variations. Similarly, a concentration index and curve were also done to identify the concentration of child vaccination status across wealth categories.

RESULTS

Among children aged 12-23 months, the prevalence of complete childhood vaccination status increased from 20.7% in rural to 49.2% in urban in 2011 and from 31.7% in rural to 66.8% in urban residences in 2016. The decomposition analyses indicated that 72% in 2011 and 70.5% in 2016 of the overall difference in vaccination status was due to differences in respondent characteristics. Of the changes due to the composition of respondent characteristics, such as antenatal care and place of delivery were the major contributors to the increase in complete childhood vaccination in 2011, while respondent characteristics such as wealth index, place of delivery and media exposure were the major contributors to the increase in 2016. Of the changes due to differences in coefficients, those of low wealth status in 2016 across residences significantly contributed to the differences in complete childhood vaccination. On top of that, from 2011 to 2016, there was a significant increment in complete childhood vaccination status and a 59.8% of the overall increment between the surveys was explained by the difference in composition of respondents. With regard to the change in composition, the differences in composition of ANC visit, wealth status, place of delivery, residence, maternal education and media exposure across the surveys were significant predictors for the increase in complete child vaccination over time. On the other hand, the wealth-related inequalities in the utilization of childhood vaccination status were the pro-rich distribution of health services with a concentration index of CI = 0.2479 (P-value < 0.0001) in 2011 and [CI = 0.1987; P-value < 0.0001] in 2016.

CONCLUSION

A significant rural-urban differentials was observed in the probability of a child receiving the required childhood vaccines. Children in urban households were specifically more likely to have completed the required number of vaccines compared to the rural areas in both surveys. The effect of household wealth status on the probability of a child receiving the required number of vaccines are similar in the 2011 and 2016 surveys, and the vaccination status was high in households with high wealth status. The health policies aimed at reducing wealth related inequalities in childhood vaccination in Ethiopia need to adjust focus and increasingly target vulnerable children in rural areas. It is of great value to policy-makers to understand and design a compensation mechanism for the costs incurred by poor households. Special attention should also be given to rural communities through improving their access to the media. The findings highlight the importance of women empowerment, for example, through education to enhance childhood vaccination services in Ethiopia.

Coverage, quality, and correlates of childhood immunization in slums under national immunization program of India: A cross-sectional study

Adequate and quality immunization coverage plays a key role in controlling the outbreaks of vaccine preventable diseases. Places where immunization coverage is low, vaccine preventable diseases contribute to worse health outcomes. This is especially true in Indian slum dwellings where 33.0% of the urban population live. The aim of the study was to explore the coverage, quality, and correlates of primary immunization under national immunization program among children aged 12–23 months, living in slums of Mumbai. A community based cross-sectional survey was conducted. Parents or caretakers of 550 eligible children aged 12–23 months were interviewed using a structured interview schedule. Regression analysis was used to detect correlates of full immunization coverage (children who received one dose each of BCG, measles, and three doses each of DPT, OPV, and HBV by his/her first birthday) and of quality immunization coverage (children who received primary vaccines at appropriate age and intervals as mentioned above and had filled immunization card). Out of total 550 children, 402 (73.1%), 131 (23.8%), and 17 (3.1%) were fully, partially, and unimmunized, respectively. Almost 86.0% children received quality immunization coverage. In the regression analysis, reminder for immunization services was found to be the single most significant correlate of full and quality immunization coverage.

In this study, full immunization coverage was found to be below the expected level. This study also revealed that the awareness regarding the importance of adequate immunization was still lacking in the slum population. Emphasizing on reminders for immunization services, encouraging institutional deliveries, and scaling up use of postnatal care services may act as keys to improving the immunization coverage in Indian slums.

Demand-side determinants of timely vaccination of oral polio vaccine in social mobilization network areas of CORE Group polio project in Uttar Pradesh, India

Background

Children who receive all doses of scheduled vaccines reduce their susceptibility to vaccine-preventable diseases. In India, full immunization coverage has increased significantly. However, only a small proportion of children are immunized on time. Globally, studies on factors affecting coverage of childhood immunization have found a significant impact by demand and supply-side determinants. This paper explores the demand-side determinants of timely immunization of the third dose of oral polio vaccine (OPV3) among children aged 6–11 months in the catchment areas of CORE Group Polio Project India.

Methods

We analyzed secondary de-identified data from a household level ‘Doers and Non-doers survey’ conducted in 2015. Determinants of timely OPV3 immunization were identified by modeling the characteristics of index children and survey respondents, surveyed households, respondents’ media habits, their exposure to immunization services and perceptions towards child immunization, through a multinomial regression analysis.

Results

The eight demand-side predictors based on the background characteristics and perceptions of caregivers determined timely vaccination of OPV3. The strongest predictor of timely OPV3 immunization was found to be the fathers’ educational level. Children of uneducated or lesser educated fathers had increased odds of not receiving the OPV1 vaccination, as compared to children of more educated fathers (OR > 10). Respondents who strongly perceived other (non-health) benefits of child immunization were three times more likely to timely vaccinate their children than those who do not. Furthermore, mothers who disagreed with the positive attributes of child immunization were 25 times more likely to delay or not to take their children for OPV immunization on time.

Conclusions

This study found eight essential factors that are responsible for timely OPV3. Despite limitations in data collection and analysis, immunization programs in India could use the eight identified demand-side determinants of timeliness and tailor communication strategies accordingly. We suggest that program communication efforts be directed at male community members; such messaging should address parents’ perceptions of non-health benefits and stress the positive attributes of child immunization. Further investigation would be helpful to assess the various risk factors of under-vaccination as well as vaccinators’ understating about timely immunization.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3129-2) contains supplementary material, which is available to authorized users.

Inequalities in child immunization coverage in Ghana: evidence from a decomposition analysis

Childhood vaccination has been promoted as a global intervention aimed at improving child survival and health, through the reduction of vaccine preventable deaths. However, there exist significant inequalities in achieving universal coverage of child vaccination among and within countries. In this paper, we examine rural-urban inequalities in child immunizations in Ghana. Using data from the recent two waves of the Ghana Demographic and Health Survey, we examine the probability that a child between 12 and 59 months receives the required vaccinations and proceed to decompose the sources of inequalities in the probability of full immunization between rural and urban areas. We find significant child-specific, maternal and household characteristics on a child's immunization status. The results show that children in rural areas are more likely to complete the required vaccinations. The direction and sources of inequalities in child immunizations have changed between the two survey waves. We find a pro-urban advantage in 2008 arising from differences in observed characteristics whilst a pro-rural advantage emerges in 2014 dominated by the differences in coefficients. Health system development and campaign efforts have focused on rural areas. There is a need to also specifically target vulnerable children in urban areas, to maintain focus on women empowerment and pay attention to children from high socio-economic households in less favourable economic times.

Immunization, urbanization and slums - a systematic review of factors and interventions

Background

In 2014, over half (54%) of the world’s population lived in urban areas and this proportion will increase to 66% by 2050. This urbanizing trend has been accompanied by an increasing number of people living in urban poor communities and slums. Lower immunization coverage is found in poorer urban dwellers in many contexts. This study aims to identify factors associated with immunization coverage in poor urban areas and slums, and to identify interventions to improve coverage.

Methods

We conducted a systematic review, searching Medline, Embase, Global Health, CINAHL, Web of Science and The Cochrane Database with broad search terms for studies published between 2000 and 2016.

Results

Of 4872 unique articles, 327 abstracts were screened, leading to 63 included studies: 44 considering factors and 20 evaluating interventions (one in both categories) in 16 low or middle-income countries. A wide range of socio-economic characteristics were associated with coverage in different contexts. Recent rural-urban migration had a universally negative effect. Parents commonly reported lack of awareness of immunization importance and difficulty accessing services as reasons for under-immunization of their children. Physical distance to clinics and aspects of service quality also impacted uptake. We found evidence of effectiveness for interventions involving multiple components, especially if they have been designed with community involvement. Outreach programmes were effective where physical distance was identified as a barrier. Some evidence was found for the effective use of SMS (text) messaging services, community-based education programmes and financial incentives, which warrant further evaluation. No interventions were identified that provided services to migrants from rural areas.

Conclusion

Different factors affect immunization coverage in different urban poor and slum contexts. Immunization services should be designed in collaboration with slum-dwelling communities, considering the local context. Interventions should be designed and tested to increase immunization in migrants from rural areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4473-7) contains supplementary material, which is available to authorized users.