Hrev_master [page 62] [Healthcare in Low-resource Settings 2013; 1:e18] Factors affecting immunization coverage in urban slums of Odisha, India: implications on urban health policy Santosh K. Prusty,1 Bhuputra Panda,2 Abhimanyu S. Chauhan,2 Jayanta K. Das3 1Department of Health and Family Welfare, Government of Odisha, Bhubaneswar; 2Indian Institute of Public Health, Public Health Foundation of India, Bhubaneswar; 3National Institute of Health and Family Welfare, New Delhi, India Abstract Infectious diseases are major causes of mor- bidity and mortality among children. One of the most cost-effective interventions for improved child survival is immunization, which has significant urban-rural divides. Slum dwellers constitute about one-third of Indian population, and most children still remain incompletely immunized. The main purpose of this study was to understand the factors behind partial or non-immunization of children aged 12-23 months in slum areas of Cuttack district, India. Session-based audit and a population-based survey were conducted in the urban slums of Cuttack city, April-June 2012. Total 79 children were assessed and their mothers were interviewed about the nature and quality of immunization services provided. Children fully immunized were 64.6%. Antigen-wise immunization coverage was highest for Bacillus Calmette-Guérin (BCG) (96.2%) and lowest for Measles (65.8%), which indicates high instances of late drop-out. Frequent illnesses of the child, lack of informa- tion about the scheduled date of immuniza- tion, frequent displacement of the family and lack of knowledge regarding the benefits of immunization were cited as the main factors behind coverage of immunization services. The study showed that there is an urgent need to revise the immunization strategy, especially for urban slums. District and sub-district offi- cials should reduce instances of early and late dropouts and, in turn, improve complete immunization coverage. Community participa- tion, inter-sectoral co-ordination and local decision making along with supportive super- vision could be critical in addressing issues of drop-outs, supply logistics and community mobilization. Introduction Infectious diseases are major causes of mor- bidity and mortality among children. One of the most cost effective and easy methods for child survival is immunization. Childhood immunization is a proven strategy for preven- tion of many infectious diseases.1 Worldwide, about 2.5 million deaths of under-5 children are averted annually by immunization against diphtheria, tetanus, pertussis, and measles.2 In India, vaccine preventable diseases (VPDs) are still responsible for over 0.5 million deaths annually. In May 1974 the World Health Organization (WHO) officially launched a global immunization programme known as Extended Programme of Immunization (EPI) to protect all children against six VPDs by 2000. The EPI was launched in India in January 1978 and subsequently in 1985 was renamed as Universal Immunization Programme (UIP). It covered nine VPDs, namely tuberculosis, diphtheria, whooping cough (pertusis), tetanus, polio, measles, mumps, rubella and hepatitis-B. The National Population Policy (NPP) (2000) highlighted the need for immunizing all children against six common childhood diseases (tuberculosis, tetanus, pertussis, diphtheria, measles and polio). There are wide coverage disparities between the rich and the poor and between urban and rural children.3 There is wide inter- district, intra-district, urban-rural and rich- poor difference with respect to immunization coverage. For instance, as compared to the rest of India, the coverage is poor in empowered action group (EAG) states which constitutes more than 40% of the total population.4 Complete immunization coverage in urban areas of Odisha was 49% as compared to 84 and 73% in Tamil Nadu and Kerala, respective- ly.5 One of the recent studies indicate that about 60% children in aged 12-23 months are fully immunized in Odisha, the same for poor children is a dismal 43%.6 This variation indi- cates a service coverage gap and reinforces the fact that those who need these services the most are the ones who are also neglected the most. Despite a steady rise in overall immu- nization coverage, children living in large numbers of slum dwellers remain incomplete- ly immunized.7 Government of Odisha defines a slum as a compact settlement of at least 20 households with a collection of poorly built ten- ements, mostly of temporary nature, crowded together usually with inadequate sanitary and drinking water facilities in unhygienic condi- tions.8 Emerging evidences indicate immu- nization coverage has been steadily increasing but the average level remains far less than desired. Only 44% of infants in India are fully immunized – much less than the desired goal of achieving a 85% coverage. Even though the coverage in urban areas is relatively better than in rural areas, studies found more than 50% of poor children are underweight and almost 60% miss total immunization before completing one year.9 We aimed to understand the current status of immunization of children aged 12-23 months and the factors affecting coverage of immunization in a slum set-up. We also stud- ied the perception of mothers about the nature and quality of immunization services provided in the public health system. Materials and Methods Study setting Cuttack city, India, has 257 identified urban slums10 with a population of about 0.6 million and a density of 4382.23/km2. Male population constitutes about 52 and female 48%. The average literacy rate of the city is 77% with a remarkable gender difference (male 86 and female 67%). Cuttack Municipal Corporation (CMC) runs health centres and provides immunization services through the fixed day outreach service delivery approach. As per 2009 slum survey, the city had 223,000 urban slums dwellers. We selected five slum settlements at random, spread across two wards (35 and 36) of the CMC. The total pop- ulation of all five urban slums together is estimated to be about 5220.11 Sampling All mothers of children aged 12-23 months residing in the above mentioned five urban Healthcare in Low-resource Settings 2013; volume 1:e18 Correspondence: Bhuputra Panda, Indian Institute of Public Health, Public Health Foundation of India, E1/1 Infocity Road, 751024 Bhubaneswar, India. Tel. +91.674.6655601 - Fax: +91.674.6655614. E-mail: bhuputra.panda@iiphb.org Key words: vaccination coverage, slum dwellers, factors of immunization, perception of quality, immunization strategy. Conflict of interests: the authors declare no potential conflict of interests. Received for publication: 17 May 2013. Revision received: 12 June 2013. Accepted for publication: 15 June 2013. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright S.K. Prusty et al., 2013 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2013; 1:e18 doi:10.4081/hls.2013.e18 No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2013; 1:e18] [page 63] slums constituted our primary respondents. All children registered in the respective Anganwadi centres (AWC) in the age group of 12 to 23 months were enlisted. Total 79 moth- ers of children aged 12-23 months were avail- able for the study against expected 105 moth- ers (calculated with crude birth rate of 20 per 1000 population). Thus, 79 children were assessed for immunization status. On further enquiry, it was found that about 26 eligible mothers had gone to their native places because of summer season and thus were excluded from the study. Data collection and analysis We used session-based audit and popula- tion-based survey as the methods for data col- lection. A semi-structured in-depth interview schedule was developed, field-tested and translated into local language. It contained ten questions in a five point Likert scale per- taining to immunization status, behavior of service providers, waiting time, satisfaction level and economic loss due to immunization, etc. It also contained questions related to studying perception of mothers on factors related to immunizing their children. Data collection was done during April-June 2012. Both quantitative and qualitative techniques were used for data collection. Quantitative analysis was done through SPSS version 16.0. Descriptive statistics was used to show the characteristics of the participants in the study and the extent of coverage against anti- gens. A bivariate analysis was undertaken for all covariates to identify the factors associat- ed with vaccination coverage. Qualitative data was used for free-listing and content analysis. Study variables We used the WHO guideline for defining full vaccination status. A child who had received one dose of Bacillus Calmette- Guérin (BCG), three doses of oral polio vac- cine (OPV) (excluding Polio 0), three injec- tions of diphtheria-pertussis-tetanus (DPT), and one dose of measles before first birthday was considered fully immunized and who had not received even a single dose was consid- ered as non-immunized. Both early and late drop-outs were calculated using Government of India definition. To cross-verify the immu- nization status, the interviewer verified the date of each received vaccination. If the mother could not show the vaccination card, she was asked if the child had received BCG, DPT, Polio and Measles. While BCG was examined in terms of the scar on the child’s arms, information about DPT and Polio was obtained on the basis of the mother’s response in terms of number of actual doses of immunization the child had received. Results Results are reflected in sample characteris- tic measures, status of vaccination against antigens and bivariate analysis for factors affecting vaccination. The study found that majority of the people residing there were daily labourers, mechan- ics, rickshaw-pullers, auto drivers and small shop owners. Out of the total 79 children examined, 56% were males and 44% females. Among Hindus (n=45), 80% were schedule caste and 20% of general caste. In terms of lit- eracy level of respondents, 20% were illiter- ates, 28% had up to primary education and 42% up to secondary level education. Eighty-seven percent mothers were housewives, 9% were daily labourers and 4% were into miscella- neous profession. It was found that 65% of children were completely immunized, 33% were partially immunized and 2% were not immunized at all (Figure 1). Ninety five percent respondents considered vaccination as important for their children (Table 1). When asked about the basic reason behind the importance they attach to vaccina- tion, 81% respondents attributed this to self- belief, followed by influence of electronic media and communication of health workers (22.8%, each). With respect to immunization coverage by antigens, BCG coverage was the highest 96% whereas Measles was 65%. Dropout rate between BCG-Measles, DPT3- Measles and DPT1-DPT3 was found to be 30, 27 and 3.94%, respectively. With regard to the distance factor from the service delivery site, it was found that 63% respondents lived within a distance of one km from the nearest health centre, while 35% lived within 1-2 kms and rest 2% were living at a distance of beyond 2 kms. Eighty-five percent respondents attended Article Table 1. Importance and reasons of immunization status. Attributes Frequency n % Vaccination considered as important for child survival Yes 75 94.9 No 1 1.3 Cannot say 3 3.8 Basic reasons behind laying importance* Self-belief 64 81 Influence of neighbors 5 6.3 Health workers’ communication 18 22.8 Message aired in electronic media 18 22.8 *Multiple responses were ticked. Categories are mutually not exclusive. Figure 1. Immunization status. Table 2. Perception on key indicators of immunization services. Perception on health services Yes No Cannot say (%) (%) (%) Has it ever happened that you had come for vaccination 4 (5.1%) 74 (93.7%) 0 and found the service not available? Would you come back to same facility for vaccinating 76 (96.2%) 3 (3.8%) 0 your child again? Would you come back for vaccinating your child again 77 (97.5%) 2 (2.5%) 0 if you have option to get the same services from some other public health facility? Would you come back for vaccinating your child again 6 (7.6%) 70 (88.6%) 3 (3.8%) if you have option to get the same services from other private health facility? Do you think not getting vaccine on a prescheduled 69 (87.3%) 0 10 (12.7%) date is bad for your child’s vaccination continuity? Do you know any of your neighbors who after having 1 73 5 similar experience did not visit the health facility (1.2%) (92.4%) (6.4%) for further vaccination of his/her children? No n- co mm er cia l u se on ly [page 64] [Healthcare in Low-resource Settings 2013; 1:e18] health centres by walking and 15% travelled with their personal vehicles. 93.7% respon- dents said that services were available when they visited public health facility (Table 2). Ninety-five percent respondents preferred to take services from public health facility. However, about 7.6% respondents had also vis- ited private health facilities, and 87.3% consid- ered getting immunization at right time was important for their child. As Table 3 indicates, interestingly we found that 75% respondents’ children had adverse events following immunization (AEFI). However, when asked to enumerate the symp- toms most respondents mentioned mild fever, loose motion, crying and sleeplessness. With respect to the amount of time they had to spend to avail the services, 77% mothers wait- ed for less than an hour to immunize their children. When asked as to whether the child was taken for immunization during illness, about 60% mothers responded negatively. On the other hand, more than 60% respondents also mentioned that their children were denied immunization services by providers due to illnesses. Among illiterate mothers (n=16), seven children (43.75%) were com- pletely immunized, while amongst mothers having education level ranging from class one to graduation (n=63), 44 children (70%) were fully immunized. On a Likert’s five-point scale to rank the importance of immunization serv- ices, where 5 meant very important and 1 meant not at all important, we found that behavior of providers, AEFI, regular session, distance, health education by auxiliary nurse midwives, waiting time and loss of wages were ranked as most important in descending order (Table 4). However, interestingly, more than 90% mothers were satisfied with the services provided at the public health facility. This could be indicative of low-level of expec- tation among slum-dwellers from public health delivery system and lower level of understanding about quality of services. Mothers during in-depth interview cited fre- quent illnesses (Figure 2) of the child, lack of information regarding the immunization schedule, frequent displacement of families for economic reasons, poor importance to the impeding diseases, insufficient family mem- bers to take the child to immunization site, service providers not attending even mild ill- nesses, poor knowledge regarding the benefit of immunization and limited but prominent AEFI as the main factors behind late drop- outs. An attempt was made to analyze at what stage the children dropped out and did not get all vaccines. The BCG to Measles dropout rate was found to be the highest (30%) in our study, followed by DPT3 to Measles (27%). Thus, in order to achieve universal immu- nization goals it is important to track all chil- Article Table 3. Perceived factors of immunization coverage. Attributes Frequency n % AEFI Yes 60 75.9 No 16 20.3 Cannot say 1 1.3 No response 2 2.5 Time taken for the child to get immunized (h) <1 61 77.2 1-2 15 19.0 No response 3 3.8 Had you ever taken your child for immunization when he/she was not well (sick)? Yes 31 39.2 No 47 59.5 No response 1 1.3 Did your child receive immunization during that illness episode* (n=31)? Yes 12 38.7 No 19 61.3 AEFI, adverse events following immunization. *Only for those respondents who had answered yes to the previous question. Table 4. Ranking of factors for quality immunization services. Attributes Scores* Mean score 5 4 3 2 1 Behavior of providers 36 40 1 0 0 4.45 Adverse effects of immunization 12 59 4 0 0 4.10 Regular outreach sessions 13 58 5 0 1 4.06 Distance of session site 2 67 4 1 1 4.04 Health education by health worker 6 66 4 0 1 3.98 Availability of vaccines all the time 9 47 21 0 0 3.88 Waiting time 5 45 7 19 0 3.47 Health education by doctor 3 14 56 1 0 3.28 Loss of daily wages 4 6 10 51 5 2.38 *5, very important; 4, important; 3, cannot say; 2, not important; 1, not at all important. Figure 2. Reasons behind partial or non-immunization (multiple responses were allowed; values are expressed as percentage). No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2013; 1:e18] [page 65] dren on regular basis. The study also revealed that about 2.5% children did not receive even a single antigen and were completely left out of the UIP. Comparable figure as reported by Coverage Evaluation Survey (CES) 2009 reported it at 5.2%. We cross-analyzed immu- nization status with level of education of mothers, and found that though there was no linear association between these two, the cov- erage of immunization varied according to the educational status of the mother. Discussion Rapid urbanization also is accompanied by proportionate growth of urban slums.12 Studies of early 20th century mainly focused on explor- ing the link between poverty and ill health.13-15 Subsequent studies found poor environmental conditions and high population density in urban areas act as precipitating factors behind frequent outbreaks of VPDs. Despite the sup- posed proximity of the urban poor to health facilities, their access to healthcare is signifi- cantly curtailed. This is on account of inade- quate public health delivery system, ineffective outreach and weak referral system. The social exclusion and lack of information and assis- tance at the secondary and tertiary hospitals makes slum dwellers unfamiliar to the modern environment of hospitals and restricts their access. On the other hand, limited purchasing power deters them from accessing private facilities. Lack of benchmark for the health delivery system, when contrasted with the rural network, makes the urban poor even more vulnerable and worse off than his rural counterpart.16-18 Demographic projections indicate by 2021 the urban population of the country will increase to 432 million and of slum population to more than 85 million.19,20 Undoubtedly, it will exert tiresome strain on the health infrastruc- ture, especially of larger towns and cities that already have serious deficiencies. Lack of preparation to foresee this will limit the options to town planners, public health depart- ments and policy makers, then. Until late 1990s the urban health centers were grossly inadequate with only one UHP per 145,854 population.21 Though the India Population Project-VIII (IPP-VIII, 1993 to 2002) created and upgraded more than one thousand facili- ties in Karnataka, Delhi, West Bengal and Andhra Pradesh,22 it did not include smaller cities and towns across the country. Secondly, there is complete disproportionate staffing for areas against the growth.23 And low staff moti- vation owing to lack of supportive supervision, poor transport facilities often result in weak outreach.24 The relatively new Indian Public Health Standards has recommended minimum standards for facilities at various levels, but compliance is far from satisfactory. Various reasons may explain the lower lev- els of full immunization coverage in urban slums in India. There are several challenges that are unique to areas, such as, rapid popu- lation growth particularly in slum populations, array of types of service providers in both pri- vate and public sectors, over-crowding, poor environmental conditions and deterioration of family fabrics. These would need creative strategies to reach the marginal sub-popula- tions.25-27 Studies in Nigeria, India and Pakistan indentified factors, such as lack of confidence of health workers in administering vaccines, irregular supply of vaccines, unwill- ingness of health workers to open vaccine vials until many clients appear at the immunization site, and long interval between sessions as the main reasons for low immunization coverage in urban areas and slum areas.28-33 Some of these studies also revealed the extent of missed opportunities for vaccination in the slum settlements.31,33 The national complete immunization esti- mation is 62.5% for urban areas and 50% for rural areas. The immunization coverage in Odisha among 12-24 months aged group chil- dren is estimated at 94.2, 73.9, 78.6 and 81% for BCG, DPT3, OPV3 and Measles, respective- ly, while complete/full immunization is esti- mated at 62.3 against 54% for India District Level Household and Facility Survey-3 (DLHS- 3). There is no national level or state-specific survey data to assess the urban-rural divide or within urban areas, slum-non-slum divide. Our study found complete immunization at 64.6% in the slum area of Cuttack. Furthermore, anti- gen-wise coverage for BCG (96.2%), DPT3 (92.4%), OPV3 (92.4%) and Measles (65.8%) reflects high instances of late dropouts. Our findings on early and late drop-outs are similar to other studies conducted.27-29 The higher cov- erage of DPT3 and OPV3 could be mainly due to the recent improvement in immunization strategy during 2007-2012 which focused on micro-planning, capacity building, community mobilization and incentivized supervision. However the low coverage of measles vaccine continues to pose serious challenges to the national immunization goals which must be remedied urgently.33 Other studies have shown that maternal education, attendance for ante- natal and postnatal care, and parity are associ- ated with full vaccination among children.34 In rural areas, efficient tracking mechanisms are being followed mainly because of existence of a definite health care delivery system and availability of trained and devoted female health workers. The addition of a volunteering cadre named Accredited Social Health Activists into the health system under National Rural Health Mission has given the impetus to immunization programme for rural residents. On the contrary, for urban areas, particularly for slum dwellers, there are no link workers to track the partially immunized or unimmunized children. Co-ordination among the multitude of providers, timely and regular outreach, effective monitoring and quality services are critical for improving utilization of immuniza- tion services in urban set-ups which have the inherent characteristic of heterogeneity. The concept of urban advantage seemingly has lost its significance for the poor. The WHO puts it thus: whenever and wherever infra- structure and services are lacking, urban settle- ments are amongst the world’s most life threat- ening environments.35 Disintegration of social fabric in urban areas in general and urban slums in particular has led to erosion of confi- dence and interpersonal communication among slum dwellers.36 From demand side, it is already well established that working mothers do not get adequate family support to attend to child’s health needs, as they remain engaged in earning livelihood. From supply side, improper microplanning, underestimated indenting and consequent insufficient supply of vaccines continue to pose challenges to quality immunization for slum areas.37,38 Furthermore, the harm caused by poor injec- tion safety and waste disposal outweighs the benefits of vaccination.39,40 Some recommendations on how to bridge the gap between the community and the urban health care delivery system are here provided: i) strengthen the health system: a separate cadre of health functionaries may be created for urban areas, focusing on urban slums. The initiatives under national urban health mis- sion may be expedited to cover the high risk urban pockets on top priority. Unique tracking system can and should be developed to address the issue of frequent displacement of families. ii) Develop local ownership: renewed interest should be developed both in local health func- tionaries and beneficiaries to accelerate the optimization of immunization services. The role of local municipality may be clearly defined to address the multi-factorial causes of non-immunization or partial immunization. iii) Expand the basket of services: the basket of immunization services may be broadened, such as, family planning counselling, iron, folic acid and vitamin-A supplementation, and provision of iodized salt, to attract and retain parents’ attention during the contact period between DPT3 and measles vaccinations. It could also improve the health status of both the mother and the child under life cycle approach. iv) Revisit the urban immunization strategy: the Reproductive and Child Health (RCH) program for immunization should revise its strategy and focus on bottlenecks by reducing the late dropout and improving cover- age of measles. Improvement of interpersonal communication with the community would Article No n- co mm er cia l u se on ly [page 66] [Healthcare in Low-resource Settings 2013; 1:e18] increase awareness about sessions and ensure their involvement in service provision for its long-term sustenance. Improved vigilance at session site and supportive supervision by higher officials could improve the level of moti- vation of service providers. All missed opportu- nities must be overcome with adequate train- ing, periodic sensitization and regular review. It is high time that we create a dedicated work force for urban areas. Slum volunteering scheme (SVS) or urban social health activist (USHA) may be introduced on priority which would provide the much needed connection in the chain of events for successful immuniza- tion of all children. v) Capitalize on the oppor- tunities: municipality health department, civil society organizations, ICDS workers and panchyat raj institution (PRI) members have critical roles to play in counselling, mobilizing, monitoring and linkage establishing activities, respectively. Slum dwellers and health provider linkage must also be strengthened. A multi- stakeholder co-ordination approach may be adopted as had been done successfully in early 1990s (Universal Immunization Campaign in Kolkata).41 vi) Generate more evidence: urban slums are high risk areas leading to high rate of disease transmission.42,43 Maternal and child health indicators among slum people show that their health is two to three times worse than non-slum areas. Thus, further studies focusing on the effect of on-site corrective measures and mobilization strategies may be undertaken on time-bound manner. Conclusions Improve access to and utilization of immu- nization services is low in the urban slums owing to its unique inherent characteristics of urban slums, such as, floating population, overcrowding, poor sanitation and personal hygiene. Urban slums do have more morbidity withholding vaccinations by paramedics; there were also many instances of non-immuniza- tion of children because there was no one in the family to take the child to the health centre for vaccination. The traditional temporary migration of pregnant women for delivery, and the consequent non-availability of their records, results in missing out on services at either of the residences. This highlights the need and importance of ensuring immuniza- tion for all vulnerable poor. These findings could be helpful to the people in charge of immunization at local level. Anganwadi work- ers are responsible for identifying and tracking all eligible children for immunization along with the female health workers. Thus, co-ordi- nation between the ICDS under the Department of Women and Child Development and the Department of Health and Family Welfare at all levels will be crucial in bridging the gap between the community and the urban health care delivery system. The national UIP goals pose stiff challenges and require to address weak primary health infrastructure, hidden urban poor population, poor social access, inadequate demand for services, week monitoring and policy revision issues. Needless to say then, that there is an urgent need for formulating and implementing a comprehensive urban health policy, focusing on immunization services. If health in all poli- cies is the destination, healthy public policy could be a good beginning. References 1. Anderson RM. The concept of herd immu- nity and the design of immunity-based immunization programmes. 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