REASONS FOR INCOMPLETE VACCINATION IN CHILDREN OF RAWALPINDI AND ISLAMABAD

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1 ORIGINAL ARTICLE REASONS FOR INCOMPLETE VACCINATION IN CHILDREN OF RAWALPINDI AND ISLAMABAD HASSAN BIN USMAN SHAH1, SHAHID PERVAIZ1, HASEEB TAUSEEF2, MUHAMMAD IBRAHIM2, OSAMA TARIQ2, TABISH NISAR2, KIRAN TAUSEEF3, HUMAIRA ZAFAR4 ABSTRACT OBJECTIVES: To identify the reasons for incomplete vaccination in children of Rawalpindi and Islamabad. STUDY DESIGN: A Cross sectional study PLACE & DURATION: Yusra Medical and Dental College, Islamabad conducted from 1st March 2015 to 30th August METHODOLOGY: A survey was conducted by a group of undergraduate medical students by randomly selected public places in various urban areas of Rawalpindi and Islamabad to find out various reasons for incomplete vaccination in children. All the documentations were dealt according to questionnaire addressing the apprehensions, fears and administrative issues pertaining to health providers. RESULTS: A total children sampled were 803, out of which 70.6%were completely vaccinated, 4.1% had ongoing vaccination status, 4.4% were partially vaccinated, and 20.7% were never vaccinated. Most of the parents 63%who never vaccinated their children were either uneducated or had only primary education. 61.1% of parents lived in slums and their children were never vaccinated. 15.4% of parents had no knowledge about vaccination/epi. 84.3% of the parents had no idea about their area vaccinators. Long waiting (>04-05 hours) time at the health facility was seen in 64.7% interviewed parents. 55.3% parents had apprehension for long distance to the health facility.40.0%, think vaccines cause diseases and had side effects. In 38% area vaccinator never came. While 34% had mistrust on health staff. CONCLUSION: Long waiting time at vaccination centers, fear of reuse of syringes, long distances to the health care facilities, lack of awareness about beneficial and harmful effects of vaccines, and mistrust on the health staffs are the important reasons for incomplete vaccination in children of Rawalpindi and Islamabad. KEY WORDS: Incomplete Vaccination, Children, Vaccination Centers, Vaccines, Awareness. INTRODUCTION developing countries, not with standing all efforts, fail to reach adequate vaccination coverage. 5-7 Even though immunization coverage in South Asia has risen to 50% from 5% in the 1970s, it is an unsettling fact that half the children remain unvaccinated. Only 54% of the children in Pakistan receive vaccination, with the EPI coverage rates in KPK (including FATA) (38%) and Baluchistan (16%) being the lowest. 8 As an example, polio, a vaccine preventable disease, has been eradicated the world over except Pakistan and two other countries. 9,10 Local issues and national policies determine the ground reality of vaccination campaigns in any country, although global endorsement of immunization policies is carried out by international agencies such as WHO and UNICEF.11,12 EPI (Expanded Program on Immunization), a project of WHO, aims to immunize all the children of the world against vaccine preventable diseases.13,14 An understanding of the underpinnings of various factors that influence vaccination coverage is necessary for improvements to take a proper direction. Such factors would comprise of parental beliefs about vaccines, including their awareness of vaccine preventable diseases, information and views about the vaccines themselves. Other aspects to be taken into account are the health infrastructure and practices of health professionals, major facets themselves, which are in turn affected by the attitude and motivation of vaccinators, availability of vaccines, absence of vaccinators, quality and safety of vaccines, and maintenance of cold chain. 15Bridging these major issues is the complex relationship between vaccinators and the general public. 16,17 Therefore in view of high prevalence of EPI recommended As per WHO guidelines for the year 2012, the National Expanded Program on Immunization (EPI), aims to fight against eight vaccine preventable diseases. These include tuberculosis, poliomyelitis, diphtheria, pertussis, neonatal tetanus, hepatitis B, Haemophilus influenza type b (Hib), and measles. 1Thus, vaccination is considered one of the most important revolutionary public health advances of the 20th century.2 Improvement in vaccine accessibility as well as the health infrastructure and public awareness over the past two to three decades has resulted in a marked decrease of vaccine preventable diseases. 3,4Almost two million children die globally per annum due to vaccine preventable diseases, despite the accessibility of low cost vaccines5. Including Pakistan, many 1.A ssistant Professor Community Medicine, 2.5 th Yr Medical Student Yusra Medical & Dental College Islamabad. 3.A ssistant Professor of Haematology 4.A ssistant Prof. of Microbiology Al-Nafees Medical College & Hospital, Isra University Islamabad Campus Pakistan Corresponding to: Hassan Bin Usman Shah Assistant Professor Community Medicine, Yusra Medical & Dental College, Islamabad hassanbinusman@hotmail.com Received for Publication: Accepted for Publication:

2 diseases, the current study was planned to shed light on the reasons for incomplete vaccination in children of Rawalpindi/Islamabad. Thus, theses preventable diseases can be prevented by creating awareness regarding the preventive / vaccinating strategies. METHODOLOGY This cross sectional study was conducted in various Urban areas of Rawalpindi (Commercial market, Westridge, Saddar, Saidpur road, Lalazar, Lalkurti and slums) and Islamabad (Sectors F, G, H, st th I), from 1 March 2015 to 30 August The sample size was 350 (information of 803 children). The sampling technique was non probability convenience sampling. The families residing in the specific study area were Included. While the parents who were unwilling to answer, couples without children were excluded from the study. The information was obtained through direct interview after taking informed consent from the parents and standardized close ended questionnaires were filled. The questionnaire used for study proceedings was designed after a thorough study of literature review. The details regarding the importance/ knowledge of vaccinations, their beneficial and side effects were asked in depth, by all the team members involved in this survey. The data analysis was done using SPSS version 22, chi square test was applied and p value of less than 0.05 was considered significant. RESULTS Figure - 1 shows that 350 families were included in the study which had a total of 803 children, out of which 567 (70.6%) children were completely vaccinated, 33 (4.1%) were ongoing through vaccination, 36 (4.4%) were partially vaccinated, and 167 (20.7%) children were not at all vaccinated. A majority of the parents with incompletely vaccinated children belonged to low income households, (p value = 0.000). A total of 61.1% of parents who never vaccinated their children live in slums, while 29.8% of parents who never vaccinated their children reside in urban areas and 8.9% of parents who never vaccinated their children live in rural areas, (p value = 0.000). Table I, shows the knowledge of parents about EPI vaccination. Majority of the parents (62%) got their children vaccinated from a government health facility, followed by private health facility (18%) and home vaccination (10%). Out of those who never got their children vaccinated 65.6% of parents were either uneducated or had only primary education. A majority of the parents who had their children vaccinated were educated beyond secondary level, p value is statistically significant (0.000). Table II (A) shows that upon comparison for reasons regarding partially vaccinated with non vaccinated children, a significant p-value (<0.05) was seen for the parental sickness on the vaccination day (p-value 0.01), followed by the fear of using dirt & reused syringes (p-value 0.007), long distance for vaccination center (p-value 0.008), lack of trust on vaccination staff (p-value 0.00), parental social commitments (p-value 0.021), fear of using expired vaccines (p-value 0.014), previous unpleasant experience due to side effects (p-value 0.000) and non availability of vaccines at health care centers (p-value 0.008). Table - II (B) also highlighted that upon comparison of reasons for partially vaccinated with non vaccinated children, significant p-values were seen for the parents having pressure by the family/friends (p-value 0.000), non availability of health staff at vaccination center (p-value 0.000), sickness of child on vaccination day (p-value 0.001), complications of previous vaccination (p-value 0.003) and migration/ shifting in last 06 months (p-value 0.008). FIGURE-1: VACCINATION STATUS OF ENROLLED CHILDREN (n=803) TABLE - I: PARENTS KNOWLEDGE ABOUT EPI VACCINATION (n=803) 173

3 TABLE - II (A) : REASONS OF INCOMPLETE VACCINATION (N=803) 174

4 TABLE - II (B) : REASONS OF INCOMPLETE VACCINATION DISCUSSION Lack of vaccination in Pakistan does not have a clearly defined chain of cause and effect. It is a complex effect of many different 18 causes. The current study reveals that 84.3% of parents do not know their area vaccinators, despite 61.2% implying that they have received house calls by them (38.8% of the parents stated that they missed vaccinations because their area vaccinator never came to their house to vaccinate their children). This finding is different from the study reports showing that government of Pakistan appoints vaccinators to areas whose duties include safe provision of pentavalent as well as other vaccines. They also provide health education to parents, including information about all possible side effects. Other concerns related to health staff include mistrust in 34.1% cases, while 24.7% had given a history of previous unpleasant experience at health facility. This finding of current study is in favour of a report by Luman etal, showing around 14.1% health staff members were usually absent from their duties in 22 underdeveloped country. Parents reporting a fear of vaccinators using dirty syringes include 55.3%. This is in favout of study results carried by Angelillo et al. He also narrated the same factor imparting a significant reason for incomplete 22,23 vaccination. Parents report a long wait at health facilities (64.7%). This is against the findings of a study by Angelillo et al, who described that in 15.2% cases, duties of vaccinators are not 23 being carried out in the ideal manner. Approximately 20.3% of parents stated that they were not told by a doctor or any other health educator to vaccinate their children. Although this is a higher number than a study conducted in rural Nigeria (79%), this is a disturbing number. 22 The data further highlights a need to raise public awareness. Our study shows that parental concern about vaccine safety is a major barrier to complete immunization. Around 40% of those parents who have not immunized their children believe that vaccines cause diseases and/or side effects. Studies done in 22,23 Nigeria and India, other underdeveloped countries, reports a close 38.8% for the same variable, while one in America, and Italy, developed countries, reports a markedly low 9.6% and % respectively. A majority of parents in this study who have completed their children's vaccinations fall in the middle and high income group, while those who fail to have their children vaccinated fall on the low end of the socioeconomic spectrum. Other similar studies have also demonstrated that low household income can be 25 associated with low immunization, one cause being lack of transportation (31.8%) to vaccination sites. Where money is an issue, immediate needs take precedence over something that might happen in the future. Around 33.1% of the parents say they did not know that vaccines were available free of charge. This implies a false belief that money is required for 26 vaccinations. Previous studiesreveal that educational status has a high association with high vaccination uptake. This study supports the same assertion. Out of total unvaccinated, 65.6% of parents who never vaccinated their children were either uneducated or 175

5 Hassan Bin Usman Shah et al. Contribution of authors: Hassan Bin Usman: Introduction writing Shahid Pervaiz: Supervising the entire research form concept provision uptil finalization Haseeb Tauseef: Questionnaire designing, data collection, Data entry, writing the methodology, Results compilation Muhammad Ibrahim: Data entry on SPSS and discussion writing Osama Tariq: Data collection Tabish Nisar: Data collection Kiran Tauseef Bukhari: Corresponding Author, Questionnaire filling and writing the methodology, Publication proceeding. Humaira Zafar: Finalizing the entire manuscript and sequencing and citation of references as per Vancouver style had only primary education, while a majority of the parents who had their children vaccinated were educated beyond secondary level. Vaccination education was also found to be lacking. 25,26 CONCLUSION Our study concluded that long waiting time at vaccination centers, fear of reuse of syringes, long distances to the health care facilities, lack of awareness about beneficial and harmful effects of vaccines, and mistrust on the health staffs are the important reasons for incomplete vaccination in children of Rawalpindi and Islamabad. LIMITATIONS OF STUDY REFERENCES We gathered data from different locations in Islamabad and Rawalpindi, albeit using a convenience sampling technique. We undertook to minimize sampling bias by including a number of locations and a variety of parents from different social strata. Another concern that might affect the results would be the honesty of those we interviewed. Parents might have given us false information. Logically they would tend to state that their children have been vaccinated even if they had not been, given that the researcher appeared to be a member of health sciences. We tried to minimize this by having our researchers appear informal to diminish the outsider effect. 1. Masud T, Navaratne KV. Expanded program of immunization in Pakistan. Website:[ worldbank.org/healthnutritionandpopulation/ Resources/ /EPIinPakistan.pdf] 2. Daniel AS, Jason WS, Stephen T. Public Health and the Politics of School Immunization Requirements in USA. Immunol 2002;40 (3): Centre for Disease Control and Prevention (CDC). Immunization information system progress: United States, MMWR Morb Mortal Wkly Rep. 2005;54 (1): Michel Z, Jos V, Debra K, Bjorn M, Prashant Y, AntwiA, et al. The imperative for stronger vaccine supply and logistics systems. Vaccine. 2013: 73(2): Nawab KM, Mazhar A, Babar TS. Is Expanded Program on Immunization doing enough? Viewpoint of Health workers and Managers in Sindh, Pakistan. J Pak Med Asso. 2008; 58(1): Aiken KD, Clark SJ, "Reasons hospitals give for not offering hepatitis B vaccine to low-risk newborns." Clin Pediatr. 2002; 41(9): Immunization in Pakistan. PILDAT, Website: [ ninpakistan.pdf-] 8. Nazish S, Altaf K, Nighat N, Azfar AS. Assessment of EPI (Expanded program of immunization) vaccine coverage in a peri-urban area. J Pak Med Asso. 2007;57(8): Masud, T, Navaratne KV. The Expanded Program on Immunization in Pakistan: Recommendations for improving performance. HNP Discussion Paper, World Bank Website: [worldbank.org/.../resources/ /EPIinPakistan.pdf] 10. Federal Bureau of Statistics [Pakistan], Pakistan Demographic and Health Survey, Islamabad: National Institute of Population Studies (NIPS) Website: [ 11. Naeem M, Adil M, Abbas SH, Khan MZ, Naz SM, Khan A. Coverage and causes of missed oral polio vaccine in urban and rural areas of Peshawar. J Ayub Med Coll Abot. 2011; RECOMMENDATIONS 1. Considering that more than 50% of those who remain unvaccinated touch upon the practices of health workers being a deterrent to vaccination, this study suggests that further light needs to be shed on the matter. 2. Vaccinators are the main line of propagation of vaccines, as well as education of parents on vaccines. Public opinion varies significantly due to the actions of these individuals. So, vaccinators should be properly educated about their duties and the need to further educate parents. GAVI guidelines should be taught and followed. 3. Public perception, as in many similar studies, comprises of numerous misconceptions about vaccines that may, in some cases, have a basis in fact. The public health infrastructure needs to be updated and competently run. 4. The requirement of awareness campaigns, especially in low socioeconomic areas, is apparent. The best tool for the job would be to utilise existing media platforms (TV, newspapers, radios) which locals prefer to spread awareness. 5. Regional leaders and men of influence, including political leaders as well as religious leaders can be taken onboard to give extra weight to the vaccination mission. An additional measure that could be implemented is that patients could be educated from gynaecology and paediatric wards about the importance of vaccinations. Similarly, the village dais could be brought on the team to spread awareness. 176

6 23(4): Steven M, Neil A, Noor MA, Khalid O, José Legorreta S. Anne Cockcroft, Equity and vaccine uptake: a cross-sectional study of measles vaccination in Lasbela District, Pakistan. BMC Int Health &Human Rights. 2009; 9(1): Tayyab M, Kumari VN. The Expanded Program on Immunization in Pakistan Recommendations for improving performance, Health, Nutrition and Population (HNP) Discussion Paper, World Bank, Islamabad, Pakistan, W e b s i t e : [ s i t e r e s o u r c e s. w o r l d b a n k. o r g / healthnutritionandpopulation/.../epiinpakistan.pdf] 14. An Assessment of Vaccine Supply Chain and Logistics Systems in Thailand, September 2011, PATH, World Health Organization, Health Systems Research Institute, and Mahidol University. Website:[ / publications/files/ TS_opt_vac_sup_thai.pdf-], 15. Asfandyar S, Bushra I, Anabia E, Maria R, Hiba AS, Hina AU, etal. Reasons for non-vaccination in pediatric patients visiting tertiary care centers in a polio-prone Country. Arch Pub Health. 2013; 71 (4): Sanderson C, Masud T, Galayda V. Pakistan New Vaccines Decision-Making Exercise, 2010; 4(2): WHO EMRO expanded program of immunization. Website: [ /expanded-programme-on-immunization.html]. 18. Health department, Punjab government. Website: [ 19. Pakistan vaccinator's salaries. Website: [ org /Library/News/Statements/2015/ Pakistanvaccinators--salaries/] 20. Abdulraheem IS, Onajole AT, Jimoh AA, Oladipo AR. Reasons for incomplete vaccination and factors for missed opportunities among rural Nigerian children. J Pub Health & Epidemiol. 2011; 3(4): Ingale A, Dixit JV, Deshpande D. Reasons behind incomplete Immunization: A cross sectional study at Urban Health Centre of Government Medical College, Aurangabad. Natl J Community Med 2013; 4(2): Luman ET, Barker LE, Shaw KM, McCauley MM, Buehler JW. Timeliness of childhood vaccinations in the United States. J Ame Med Asso. 2005; 293(1): Angelillo IF, Ricciardi G, Rossi P, Pantisano P, Langiano E, Pavia M. Mothers and vaccination: knowledge, attitudes, and behaviour in Italy. Website: [ /bulletin/archives/77(3)224.pdf?ua=1] 24. Klevens RM, Luman ET. US children living in and near poverty: risk of vaccine-preventable diseases. Am J Prev Med. 2001; 20 (4): Carr J, Martin M, Clements C, Ritchie P. Behavioural Factors in Immunization. In Behavioural Science Learning Modules. World Health Organization Geneva. 2000;1(2): Glauber JH. The immunization delivery effectiveness assessment score: a better immunization measure? Pediatrics. 2003; 112(4):

THE IMPACT OF PARENTAL EDUCATION AND SOCIOECONOMIC STATUS ON ROUTINE CHILDHOOD VACCINATION: AN OBSEVATIONAL STUDY

ORIGINAL ARTICLE THE IMPACT OF PARENTAL EDUCATION AND SOCIOECONOMIC STATUS ON ROUTINE CHILDHOOD VACCINATION: AN OBSEVATIONAL STUDY Samreen Ahmad 1, Shahzada Bakhtyar Zahid 2, Anwar Zeb Jan 3 ABSTRACT Objective: