|Year : 2015 | Volume
| Issue : 2 | Page : 169-174
Gender equality in primary immunisation
Deepak S Khismatrao, Smita S Valekar, Samir A Singru
Department of Community Medicine, Smt. Kashibai Navale Medical College and General Hospital, Narhe, Pune, Maharashtra, India
|Date of Web Publication||13-Mar-2015|
Deepak S Khismatrao
6/6, Anand Nagar Park, Paud Road, Kothrud, Pune - 411 038, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Immunization, a well-known and effective method of preventing childhood illnesses is basic service under primary health care. Most surveys in India measure primary immunization coverage and quality, but no "Gender Equality." Aims: Assess "Gender Equality" in primary immunization with reference to coverage, quality, and place of immunization. Settings and Design: Cross-sectional survey in a primary health center, Pune, Maharashtra using World Health Organization 30-cluster sampling method with 14 beneficiaries (7 girls and 7 boys) to be selected from each cluster. Instead of 420 children, data collected for 345 children, as requisite numbers of children were not available in low population villages and also children whose mothers were not present during survey were excluded. Materials and Methods: Vaccination data collected from either records and/or history by mother. Children born on or between 13-09-2009 and 13-09-2010, were included. Statistical Analysis Used: SPSS 14.01 version with Chi-square as test of significance. Results: Of the study population, 171 (49.6%) were females and 174 (50.4%) males. A total of 64.1% children had immunization records with female proportion 69.0% and males 59.2%. Primary immunization coverage was 80.0%, with female proportion 82.5% and males 77.6%. One male child was completely unimmunized and remaining partially immunized, with unaware of schedule and illness of child being major reasons for partial immunization. There was no gender wise statistically significant difference observed in Primary Immunization with reference to coverage, quality, and place of immunization. Conclusions: Immunization coverage is nearing 85% benchmark with major contribution from Universal Immunization Program. Gender Equality observed in primary immunization. Preservation of immunization records by community and timely vaccinations are areas for improvement.
Keywords: 30-cluster sampling, gender equality, immunization coverage, quality of immunization, World Health Organization methodology
|How to cite this article:|
Khismatrao DS, Valekar SS, Singru SA. Gender equality in primary immunisation. Med J DY Patil Univ 2015;8:169-74
| Introduction|| |
Immunization is one of the most well-known and effective methods of preventing childhood illnesses.  Every year, 10.6 million children die before the age of 5 years; 1.4 million of these are due to diseases that could have been prevented by vaccines. Taking into account both children and adults, vaccine-preventable diseases kill 3 million people around the world every year.  Hence, Global Alliance for Vaccine Initiative (GAVI) was started, which is a private public global health partnership committed to saving children lives by increasing access to immunization with a vision "GAVI must reach every child everywhere. " The millennium development goals also stress on reducing under-5 mortality by increasing coverage of immunization as one of the strategy.  Routine immunization, is a basic service under primary health care, which constitutes primary immunization, and encompasses provision of Bacillus Calmette-Guerin (BCG) and zero oral polio vaccine (OPV) at birth, three doses of OPV/diphtheria, pertusis & tetanus (DPT)/hepatitis B virus (HBV) and measles vaccine before the first birthday and this gives every child best chance for healthy life.  Released by World Health Organization (WHO), in November 2010, the review confirms that there are no significant differences in immunization rates between boys and girls. However, we must continue to monitor equity and redress any underlying discriminations that continue to exist.  Most surveys in India measure primary immunization coverage and quality, but no "Gender Equality" in it. This study was conducted, therefore, to unearth "Gender Equality" in primary immunization with reference to coverage, quality, and place of immunization, if any.
| Materials and Methods|| |
A cross-sectional study was conducted in a primary health center (PHC), District Pune, State Maharashtra under rural field practice area of medical college using a WHO 30-cluster sampling technique.  The total population of PHC is 37,860 with 36 villages in the area. The detailed calculations and selection of 30-clusters and number of beneficiaries selected in each cluster in the study area is demonstrated in [Table 1]. One village which got selected as cluster had a population of 148, and hence another village was selected randomly from amongst villages not already selected as cluster to complete the survey. It is a limitation of the cluster sampling survey that the probability of selection of village with higher population as a cluster is higher than that of a village with low population.
As per cluster sampling survey technique, seven beneficiaries in the age group of 1-2 years are selected in each cluster, but to assess gender equality, it was decided to select total 14 beneficiaries (7 girls and 7 boys) from each cluster. A child born on or between 13-9-2009 and 13-9-2010 was included in the sample. Children whose mothers were not available during survey were excluded from the sample. In certain villages, which were selected as clusters no requisite number of children (7 girls and 7 boys) was available due to low population. Therefore, data could be collected for 345 beneficiaries, instead of 420 children. Data collection were done using predevised and pretested performa [Table 1].
The vaccination status was assessed by immunization records and/or history given by mother. Actual vaccination dates were noted if records were available and if not, specific questions were asked in local language to the mother of the child to assess vaccination history. The data were collected in 3 days starting from 13-9-2011, with help of 10 teams (20 students of medical, nursing and physiotherapy branches). All the teams underwent a training of 1 full day on data collection. Furthermore, data collected were validated by crosschecking data randomly for 6 children in each cluster. Missing data were collected immediately within next 2 days and entire survey was completed in 5 days.
Data were computerized, cleaned, coded, recoded and then analyzed using SPSS 14.01 version, SPSS Inc. Indicators for coverage, quality and place of immunization are computed and gender-wise comparison has been done using Chi-square test as test of significance.
Operational definitions of indicators
Completely/not completely immunized children
- Children completely immunized for primary immunization - it is defined as children who have received BCG, zero dose of OPV, all three doses of OPV/DPT/hepatitis B and measles vaccines.
- Children not completely immunized for primary immunization - It is defined as children who have not received either BCG, zero dose of OPV, any of the three doses of OPV/DPT/hepatitis B or measles vaccine.
Missed doses of vaccines
a. Proportion of children missed BCG vaccineProportion of children missed all three DPT vaccine
b. Proportion of children missed all three hepatitis B vaccineProportion of children missed measles vaccine.
Quality of vaccination
- Proportion of children having immunization records
- Proportion of children given timely vaccination - it has been calculated for only those children whose immunization records were available and correct dates mentioned on the immunization records.
- BCG given within 48 h of birth
- Third dose of OPV/DPT given within 6 months of birth
- Measles given within 9-12 months of birth
Hepatitis B vaccine is not included under timely vaccination, as it has comparatively a lesser public health impact on childhood morbidity and mortality than other vaccines and it still can be given in later stage of life.
c. Proportion of children reporting adverse events following immunization (AEFI) like abscess, fever, induration, convulsions or any other event reported by mother following immunization
d. Proportion of children with visible BCG scar on the left upper arm in deltoid region out of the total children given BCG vaccine
Place of vaccination
The place of vaccination is as informed by the mother and is recorded as public if given at any government hospital, Anganwadi or by PHC staff; and as private if given in any private doctors clinic; and mix if few vaccines given in public and few in private.
| Results|| |
Out of the 345 children surveyed, 171 (49.6%) were females and 174 (50.4%) males. A total of 276 (80.0%) children were completely immunized and the remaining was partially immunized including one male child completely unimmunized for primary immunization.
The above Graph 1 [Additional file 1] shows that there is no statistically significant difference in coverage for primary immunization between male and female children.
Graph 2 [Additional file 2] shows indicators under quality of immunization services. It is observed that only 51.9% of children have immunization records available with them. The proportion of children with timely vaccination is about 62% for DPT/OPV and measles and 39.7% for BCG. The presence of BCG scar, a marker for quality of immunization, was seen in 80.6% of the children.
[Table 2] shows that proportion of completely immunized female children is higher (82.5%) as compared to males (77.6%), but this difference is not statistically significant. There are 14.5% of children who have missed all three doses of hepatitis B vaccine followed by 7.8% of children missing measles vaccine. It is very comforting to see that 99.1% of children have received BCG vaccine with 80.6% out of them having BCG scar present on their left upper arm in deltoid region. Immunization records were available with only 51.9% of the children which seems to be an opportunity for strengthening in the program.
The BCG dates were available for 191 children from the immunization records out of which 37.2% received BCG within 48 h. The reason for the low percentage is probably because of the fact that there are home deliveries in rural areas, and for such children the BCG vaccine is given at 6 weeks along with DPT 1 , OPV 1 , HBV 1 . The DPT dates were available for only 167 children out of which 67.1% of children received all three doses of DPT within 6 months of age. The measles vaccination dates were available for 158 children out of whom 70.3% received timely vaccination between 9 and 12 months and 14.6% of children received measles vaccine before the completion of 9 months of age and about 15.2% received measles vaccine after 12 months of age. The above mentioned figures are comparable with other states of India as seen from the Annual Health Survey 2011. 
|Table 2: Gender wise comparison of primary immunization coverage; proportion of children with missed vaccine doses; quality of immunization; and place of immunization|
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There are only 15.1% of children who have been vaccinated purely from private sector and an additional 11.1% of children have received few vaccines in private, but majority (73.8%) have received vaccine in public sector, which is the strength of the Universal Immunization Program (UIP).
Adverse events following immunization has been reported by only 28.4% of children and majority have responded fever as AEFI, which actually may not be considered as AEFI. There have been only 15 children who reported pain and induration at the site of injection. There was one child reported of an abscess and one child of unconsciousness post vaccination.
Overarching to all the above findings, it is clearly seen that there is gender equality in all aspects of immunization services - coverage of primary immunization; doses of vaccines missed; quality of immunization with reference to availability of records, timely vaccination, reporting of AEFI and presence of BCG scar; and place of immunization.
[Table 3] shows gender-wise comparison of reasons quoted for partial or no immunization and it is observed that the statistical significance is due to protection of higher proportion of girls during illness from vaccination.
|Table 3: Gender-wise comparison of reasons for partial or no immunization|
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| Discussion|| |
The current study shows that overall proportion of completely immunized children is 80.0% and in female children is higher (82.5%) when compared to males (77.6%), but this difference is not statistically significant these findings of the study show a higher coverage than that for whole Maharashtra based on District Level Household Survey-3 survey conducted in 2007-2008,  wherein the overall primary immunization coverage in rural area was 71.2% with coverage of BCG vaccine being 96.1%. There is a considerable improvement in coverage as compared to findings of National Family Health Survey (NFHS) - 3 Maharashtra conducted in 2005-2006,  wherein the overall primary immunization coverage in rural areas was only 49.8%. Both these national surveys did not have the component of assessing the quality and gender equality in primary immunization services. The coverage evaluation survey conducted in 2009  by UNICEF and Ministry of Health and Family Welfare showed overall 79% coverage in Maharashtra, with no urban-rural bifurcation in the report. However, the report shows that overall in India, 48.9% of children had immunization records with them which is similar to current study wherein 51.9% of children were found to have immunization records. The report is again in congruence with current study findings that "not aware about vaccines" is the major reason for partial immunization. Even this report does not have gender equality indicator.
A study conducted by International Institute of Population sciences  for trend analysis of three rounds of NFHS, compared gender inequities. The study concluded that despite a decline in urban-rural and gender differences over time, children residing in rural areas and girls were disadvantaged. The study has no specific reference of gender comparison in rural Maharashtra.
A similar study was conducted by a team from various institutes across the globe which again compared the trends of three rounds NFHS surveys conducted in India.  This study pointed that girls were found to have significantly lower immunization coverage (P < 0.001) than boys for BCG, DPT, and measles across all three surveys. The findings of current study contradicts the findings of the both these studies, wherein the immunization coverage is higher in girls than boys, although not statistically significant.
A similar study conducted by Gupta et al.  in another area of rural Maharashtra found an overall coverage of 86.7% and a marginally higher proportion in males (87.6%) when compared to females (85.6%).
Although the current study cannot be generalized, it is triumphant that in a specific geographical area, the coverage is nearing the benchmark of 85% and there is no gender inequality at least in primary immunization service.
Therefore, it can be concluded that the primary immunization coverage in rural areas is nearing, but has not reached the desired level of 85% benchmark. The major contribution of this coverage is due to the UIP. The preservation of immunization records by the community is low and there is scope for improvement in timely vaccinations for BCG, DPT/hepatitis B and measles vaccines. The gender equality is maintained in coverage, quality and place of immunization, denoting that there is no neglect of girl child in primary immunization services.
All partially and unimmunized children were counseled and with the assistance of Anganwadi worker and PHC staff were immunized as per schedule. It is recommended that staff should focus on timely vaccination, which means three doses of DPT/hepatitis B to be completed before 6 months and measles vaccine to be given immediately on completion of 9 months. They should strive toward improved maintenance of immunization records by the community.
| Acknowledgement|| |
This work has been carried out with kind permission and support from the staff of Primary health centre, without which the study would not have been conducted smoothly. A special thank you to the staff nurses of PHC, who accompanied the data collection teams. We are indebted to the medical, nursing and physiotherapy students of our institutes, who sincerely participated in the data collection during the survey and we acknowledge the support and guidance provided by the heads of these medical, nursing and physiotherapy institutes who promptly gave permission to their students to participate in this survey. We are also grateful to our team of social workers who supervised the data collection teams during the survey and actively participated in the entire process of data collection, validation and computerisation. The support and motivation from the dean of our own institute to carry out the study was available throughout the study period.
| References|| |
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[Table 1], [Table 2], [Table 3]