Effect of sociodemographic factors on age-appropriate immunization of children in slums of Lucknow, capital of Uttar Pradesh.
Immunization is the process of artificially inducing immunity for protection from diseases. This may be done either by stimulating the body's immune system with a vaccine or toxoid to produce antibodies or through the use of an externally produced antibody. The WHO launched the Expanded Programme on Immunization in 1974 with focus on prevention of the six vaccine-preventable diseases by universal immunization.  This was endorsed by the Government of India in 1978 with the objective of reducing morbidity, mortality, and disabilities occurring due to these diseases by providing free immunization services to all eligible children. Further, a national sociodemographic goal was set up in National Population Policy (NPP) 2000 to achieve universal immunization of children against all vaccine-preventable diseases by 2010.  Urban population in India has increased with a growth rate of 31.8% in the last decade in comparison to 12.3% in rural areas. According to the Census 2011, 65.4 million people are living in slums in India, whereas the figure was 45 million during 2001 census.  The most cost-effective and easy method for the child survival by preventing infectious diseases is immunization.  National Family Health Survey (NFHS) III has shown that only 40% children are completely immunized in slums leaving others vulnerable to various diseases. 
Therefore, it is necessary to understand the pattern of utilization of immunization services by the community especially with respect to immunization services. Thus, the present cross-sectional study was undertaken to assess the immunization coverage, and to find out the various reasons responsible for the suboptimal coverage of immunization in the urban slums of Lucknow.
Material and Methods
The study was conducted in slums of Lucknow, capital of Uttar Pradesh.
Community-based cross-sectional study.
The present study was conducted among children of age group 9 months-2 years, residing in urban slums of Lucknow city.
Children in age group 9 months-2 years.
Duration of Study
The study was completed during the period from August 2014 to July 2015.
A total 327 children in the age group of 9 months-2 years were enrolled in the study via multistage sampling. Urban area of Lucknow has six municipal corporation zones. Out of these six zones, four zones were selected by random sampling method. From each selected zones, two wards were selected by simple random sampling method. Thus, total 8 wards were selected. From each selected ward, two slums were selected by simple random sampling method. Thus, a total 16 slums were selected from urban area. Equal number of children in the age group of 9 months-2 years was selected from these slums.
Data Collection Methods
A pretested structured questionnaire was used to collect the information from the study participants. Information was collected on the various sociodemographic factors, about the immunization status, and reasons for partial immunization and nonimmunization of the children. The vaccination card and the recall method were used for the determination of the vaccination status. Mother of the child was the primary respondent; and in their absence, the child's father was interviewed as the next respondent. When both of them were absent, most adult person in the household was interviewed.
An infant who has received all vaccinations recommended under National Immunization Schedule appropriate to his/her age. 
An infant who has received at least one or more of vaccinations recommended under National Immunization Schedule appropriate to his/her age. 
An infant who has not received any vaccination recommended under National Immunization Schedule appropriate to his/her age. 
The information collected on the study schedule was transferred on the pre designed classified tables and analyzed according to the aims and objectives.
One-fourth (24.1%) of the children studied were fully immunized while the proportions of those with partial or nonimmunization status were about 32.4% and 43.4%, respectively (Table 1).
It was found that OPV-0 and BCG had the maximum coverage of 59.6% and 58.4% followed by DPT-1(48.3%) and OPV-1(49.5%). The coverage for measles vaccine (31.8%) and vitamin A (26.9%) was lowest among all the vaccines. The dropout from OPV I to III was 25.1% followed by DPT I to III and Hep B I to III (28.4% and 26.8%, respectively). The dropout rate from Hep B III to measles was 28.2% (Table 2).
One-fourth of Hindu (26.3%) and one-fifth (20.4%) of Muslim children were immunized. The association between religion and immunization status was found to be statistically nonsignificant. About one-fifth of the children in both joint family and nuclear family were completely immunized (24.2% and 24.5%, respectively). The association between type of family and immunization status was found to be statistically insignificant. Children who belonged to middle socioeconomic status (Modified Kuppuswami Socioeconomic Scale 2014) were 30.0% immunized, while it was quite lower in lower socioeconomic group (23.3%). The association between socioeconomic status and immunization status was found to be statistically insignificant. Only 22.4% of the children who belonged to illiterate mothers were fully immunized, while 40%children of mothers who were educated up to high school level were immunized. The proportion of immunized children increased and unimmunized decreased as we moved from illiterate to those with higher education. It shows a significant association between the immunization status and mother's education. Children belonged to illiterate fathers were 19.9% immunized and 42.8% whose fathers have up to intermediate education. The proportion of immunized children increased and unimmunized children decreased as we moved from illiterate to higher education. It shows a significant association between the immunization status and father's education. Children belonged to unemployed mothers were 25.5% immunized. Significant association was found between the immunization status and mother's occupation. About 22.6% of the male children and 22.6% female children were immunized. The association between sex and immunization status was found to be statistically insignificant. Children belonged to first birth order were 26.9% immunized and 10.2% in more than third birth order. The association between birth order and immunization status was found to be statistically insignificant (Table 3).
Proper immunization is believed to be the most costeffective way in preventing majority of morbidities and mortalities attributed to vaccine-preventable diseases. Therefore, the study was conducted to ascertain various sociodemographic factors associated with immunization. The current study revealed that despite intense immunization activities, age-appropriate immunization status of children was far from complete. Only one-fourth (24.1%) of the children were fully immunized, whereas majority were found to be partially immunized (32.4%) or unimmunized (43.4%) in the study. The findings are quite similar to the surveys conducted in slums at national level.  A study conducted by Gill et al.,  also reported similar type of findings. However, figures were much lower as compared to the studies conducted in Punjab (80%),  Karnataka (79.5%),  and Jamnagar. 
Among various sociodemographic factors on ageappropriate immunization, significant association was found between educational status of parents and immunization status. Parents of the majority of partially immunized or unimmunized children were illiterate. Similar findings were also reported by Baliga et al.,  and Gill et al., . Contradictory to the general perception, there was no significant difference in immunization status between male and female children. Similar findings were also reported in other studies. [6,11] Occupation of mother had significant effect on immunization status of the children. Mothers of the majority of unimmunized/partially immunized children were unemployed. In paradox to the studies conducted in other parts of India, this study shows significant association between occupation of the mother and immunization status of the children. [6,9,12]
Unlike various other studies conducted in different part of country, [13-15] this study does not find significant association between socioeconomic status, birth order, type of family, and religion with immunization status of children.
Consistent efforts are needed especially in slum population so that immunization coverage could be achieved to the desired level. Implementation of current strategies in a more strengthening way could optimize the immunization services in the increasing population of slums. There is a need for developing more effective strategies specially focusing on less educated parents, hence increasing their awareness regarding health-care services including immunization.
[1.] Park K. Park's Textbook of Preventive and Social Medicine, 23rd edn. Jabalpur, India: Bhanot Publishers, 2015. p. 253.
[2.] Ministry of Health and Family Welfare (MOHFW). National Population Policy, 2000. New Delhi, India: Department of Family Welfare, MOHFW, 2000.
[3.] Census of India 2011. Primary Census Data Highlights India. Executive Summary. New Delhi: Census of India; 2011. Available at: http://www.censusindia.gov.Z2011census/PCA/PCA_Highlights/ pca_highlights_file/India/4Executive_Summary pdf 2 (last accessed on November 15, 2015).
[4.] Yadav S, Mangal S, Padhiyar N, et al. Evaluation of immunization coverage in urban slums of Jamnagar city. Indian J Comm Med 2006; 31(4):300-2.
[5.] UHRC. Health of the urban poor in India. Key results from the National Family Health Survey. Urban Health Resource Centre; 2006. Available at: http:/www.uhrc.in/index.php?name=CmedsDownload&file=index&req=viewdownload&cid=1&min=10&orde rby=dateD&show=10 (last accessed on December 14, 2015).
[6.] Gill KP, Devgun P. Impact of socio-demographic factors on age appropriate immunization of infants in slums of Amritsar city (Punjab), India. Natl J Community Med 2015; 6(1):11-5.
[7.] NFHS III. Health and living conditions in eight Indian cities. Ministry of Health and Family Welfare. Govt. of India, 2006.
[8.] International Institute for Population Sciences. District Level Household and Facility Survey 2007-08, Punjab. Ministry of Health and Family Welfare, 2010.
[9.] Baliga SS, Katti SM, Mallapur MD. Immunization coverage in urban areas of Belgaum city: a cross sectional study. Int J Med Sci Public Health 2014; 3:1262-5.
[10.] Yadav S, Mangal S, Padhiyar N, Mehta JP, Yadav BS. Evaluation of immunization coverage in urban slums of Jamnagar city. Indian J Community Med 2006; 31:300-11.
[11.] Malkar VR, Khadilakar H, Lakde RN, et al. Assessment of socio-demographic factors affecting immunization status of children in age group of 12-23 months in a rural area. Indian Med Gazette 2013; 165.
[12.] Chaudhary V, Kumar R, Agarwal VK, et al. Evaluation of primary immunization coverage in an urban area of Bareilly city using cluster sampling technique. NJIRM 2014; 1(4):301-2.
[13.] Sreedhar M, Lavanya. KM, Rao N. Primary immunization status of children in 12-23 months age group: a cross sectional study in urban slums of Guntur town, Andhra Pradesh, India. Nat J Med Dent Res 2013; 1:9-13.
[14.] Kulkarni SV, Chavan MK. A study to assess the immunization coverage in an urban slum of Mumbai by lot quality technique. Int J Med Public Health 2013; 3:21-5.
[15.] Sharma B, Mahajan H, Velhal GD. Immunization Coverage: Role of Socio-demographic Variables. Adv Prev Med 2013; 2013:5, Article ID 607935, http://dx.doi.org/10.1155/2013/607935.
Neeti Verma (1), Jai Vir Singh (1), Reema Kumari (1), Monika Agarwal (1), Abhishek Verma (2), Mukesh Shukla (3)
(1) Department of Community Medicine & Public Health, K.G. Medical University, Lucknow, Uttar Pradesh, India.
(2) Department of Surgery, K.G. Medical University, Lucknow, Uttar Pradesh, India.
(3) Department of Community Medicine & Public Health, Hind Institute Medical Sciences, Ataria, Sitapur, Uttar Pradesh, India.
Correspondence to: Neeti Verma, E-mail: [firstname.lastname@example.org
Received April 10, 2016. Accepted April 28, 2016
Table 1: Primary immunization status of children (9 months-2 years) (N = 327) Immunization status Number Percentage Fully immunized 80 24.1 Partially immunized 106 32.4 Unimmunized 143 43.4 Table 2: Coverage of individual vaccines of children (9 months-2 years) (N = 327) Vaccine Number Percentage BCG 191 58.4 OPV-0 195 59.6 DPT-1 158 48.3 OPV-1 162 49.5 Hep B-1 145 44.3 DPT-2 140 42.8 OPV-2 141 43.1 Hep B-2 132 40.3 DPT-3 113 34.5 OPV-3 114 34.8 Hep B-3 106 32.4 Measles 104 31.8 Vit A-1 88 26.9 Table 3: Association between biosocial characteristics of families and routine immunization (N = 327) Biosocial characteristics Routine immunization (children of 9 months-2 years) Total Fully Immunized (n = 80) Hindu 228 60[26.3%] Religion Muslim 98 20[20.4%] Sikh 1 0[0%] Type of family Joint 107 26[24.2%] Nuclear 220 54[24.5%] Upper middle 2 1[50%] Socioeconomic Middle 38 11[28.9%] status (#) Lower middle 148 38[25.6%] Lower 138 29[21.01] Illiterate 254 57[22.4%] Mother's Up to Primary school 66 20[30.3%] education Up to High school 5 2[40%] Intermediate & above 1 0[0%] Illiterate 216 44[19.9%] Father's Up to Primary school 43 18[41.8%] education Up to High school 61 15[24.5%] Intermediate & above 7 3[42.8%] Mother's Unemployed/Housewife 176 25[14.1%] occupation Employed 151 55[36.4%] Unemployed 3 0[0%] Father's Unskilled 220 49[22.2%] occupation Semi-skilled 91 26[28.5%] Skilled 13 5[38.4%] Gender of Male 168 44[26.2%] the child Female 159 36[22.6%] 1 89 24[26.9%] 2 109 32[29.3%] Birth order 3 80 19[23.5%] >3 49 5[10.2%] Biosocial characteristics Routine immunization (children of 9 months-2 years) Not immunized/ p value Partially immunized (n = 247) Hindu 168[73.7%] 0.476 Religion Muslim 78[79.6%] Sikh 1[100%] Type of family Joint 81[75.8%] 0.544 Nuclear 166[75.5%] Upper middle 1[50%] 0.569 Socioeconomic Middle 27[71.1%] status (#) Lower middle 110[74.4%] Lower 109[79.0%] Illiterate 197[77.6] Mother's Up to Primary school 46[69.7%] education Up to High school 3[60%] 0.013 * Intermediate & above 1[100%] Illiterate 172[80.1%] Father's Up to Primary school 25[58.2%] 0.023 * education Up to High school 46[75.5%] Intermediate & above 4[57.2%] Mother's Unemployed/Housewife 151[85.9%] 0.000 * occupation Employed 96[63.6%] Unemployed 3[100%] Father's Unskilled 171[77.8%] 0.325 occupation Semi-skilled 65[71.4%] Skilled 8[61.6%] Gender of Male 124[73.8%] the child Female 123[77.2%] 0.300 1 65[73.1%] 2 77[70.7%] 0.124 Birth order 3 61[76.3%] >3 44[89.8%] # Modified Kuppuswami Socioeconomic Scale 2014. * p < 0.05, significant.
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|Title Annotation:||Research Article|
|Author:||Verma, Neeti; Singh, Jai Vir; Kumari, Reema; Agarwal, Monika; Verma, Abhishek; Shukla, Mukesh|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Nov 1, 2016|
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