Socioeconomic differentials in childhood immunization in India, 1992–2006
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Transcript of Socio-economic differentials in childhood immunization in India, 1992–2006
1 23
Journal of Population Research ISSN 1443-2447 J Pop ResearchDOI 10.1007/s12546-011-9069-y
Socio-economic differentials in childhoodimmunization in India, 1992–2006
Abhishek Kumar & Sanjay K. Mohanty
1 23
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Socio-economic differentials in childhood immunizationin India, 1992–2006
Abhishek Kumar • Sanjay K. Mohanty
� Springer Science & Business Media B.V. 2011
Abstract This paper examines the socio-economic differentials in coverage of
basic childhood immunization in India and the states of Bihar and Gujarat using
three rounds of National Family Health Survey data. States are selected on the basis
of changes in full immunization coverage during 1992–2006. Bivariate, multivari-
ate, and progression rate is used to understand the differentials and changes in
immunization coverage. Results indicate that there has been a substantial increase in
partial immunization in most of the states, but the increase in full immunization
coverage is relatively slow in many of the states. Along with mother’s education,
standard of living, mass media exposure, and availability of health card is a sig-
nificant predictor in explaining the full immunization coverage irrespective of time.
Keywords Immunization � Progression rate � DPT3 � Measles � India
Introduction
In the last three decades, substantial resources of national government and
international donors have been invested to increase the immunization coverage in
developing countries. As a result, the basic childhood vaccinations have been
integrated in the public health programs of most of the developing countries and
helped to improve child survival (Hardon and Blume 2005; Jolly 2004; Stephen
A. Kumar (&)
International Institute for Population Sciences, Govandi Station Road, Deonar,
Mumbai 400088, India
e-mail: [email protected]
S. K. Mohanty
Department of Fertility Studies, International Institute for Population Sciences,
Govandi Station Road, Deonar, Mumbai 400088, India
e-mail: [email protected]
123
J Pop Research
DOI 10.1007/s12546-011-9069-y
Author's personal copy
et al. 2008). The first global initiative to increase childhood immunization was
the Expanded Program on Immunization (EPI) by WHO in 1974. Following this,
the global goal for universal child immunization against the six basic infections
(measles, poliomyelitis, diphtheria, pertussis, tetanus, and tuberculosis) was articu-
lated at the World Health Assembly in 1977. In 1984, UNICEF in partnership with
other stake-holders launched Universal Childhood Immunization (UCI) with the
target of 80% coverage in childhood immunization by 1990 (Keja et al. 1988). The
Global Alliance on Vaccines and Immunizations (GAVI) was launched in 1999 with
aims to accelerate the coverage of basic vaccines and to introduce the new vaccines in
low-income and middle-income countries. In addition, priority was also given to
childhood immunization in the Millennium Development declaration so as to improve
child health (United Nations 2005).
Immunization coverage has been accorded high priority on international and
national agendas as the vaccine-preventable diseases have been a major cause of
child mortality and morbidity (Anand and Barnighausen 2007; Lopez et al. 2006;
United Nations 2005). In the late twentieth century, about 9 million children
throughout the world died each year before reaching their fifth birthday (UNICEF
2007); of these deaths 4% were due to measles and 7% to tetanus (WHO 2002).
Despite the longstanding global, national, and local efforts, improvement in
immunization coverage is stagnating across and within the countries (Brugha et al.
2002; Hardon and Blume 2005; Starling et al. 2002; Westly 2003) with greater
socio-economic divides (Anwar et al. 2004; Carr 2004; Collin et al. 2007; Gwatkin
2000; Gwatkin et al. 2000; Kakwani et al. 1997). Several factors such as household
structure (Bronte-Tinkew and Dejong 2005; Gage et al. 1997), household economic
resources (Bronte-Tinkew and Dejong 2005; Pande and Yazbeck 2003), parental
education (Desai and Alva 1998; Streatfield et al. 1990), socio-cultural context
(Pebley et al. 1996), and accessibility of health services (Gauri and Khaleghian
2002; Gore et al. 1999) were identified as significant determinants of the extent of
childhood vaccinations.
In India, the basic childhood immunization service has been part of essential
health services and accorded top priority in its health delivery system. Following
the Alma Ata Declaration in 1978, the country had adopted the Expanded Program
on Immunization (EPI) and introduced six childhood vaccines—Bacillus Calmette-
Guerin (BCG), DPT, Polio, typhoid, and measles (Basu 1985; Kanitkar 1979).
These services were delivered at all public health centres and sub-centres free of
cost. To further accelerate the implementation of the immunization program, the
Government of India launched the Universal Immunization Program (UIP) in
1985–1986 with the target of universal immunization of all children and pregnant
women by the 1990s against the six vaccine-preventable diseases. All states of the
country were reportedly served by UIP (Sokhey et al. 1993). The UIP became a part
of the Child Survival and Safe Motherhood Program in 1992 and Reproductive and
Child Health (RCH) Program in 1997 (MOHFW 2003). The targets of universal
immunization were revised in the subsequent National Population Policy and the
National Rural Health Mission (MOHFW 2000, 2005).
The coverage of basic childhood immunization in India had never reached the
majority of children. For instance among children of age 12–23 months, 43% had
A. Kumar, S. K. Mohanty
123
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received all recommended doses of vaccines and 5% were not immunized at all
(IIPS and Macro International 2007). Immunization coverage varies largely across
the states: 23% in Uttar Pradesh compared to 81% in Tamil Nadu. Also, the
differentials in immunization coverage continued to be large by economic and
social status of the household: in 2005–2006, the full immunization of children aged
12–23 months belonging to the lowest wealth quintile was 24.4% compared to
71.0% among the richest quintile (IIPS and Macro International 2007). Studies
indicate that wealth and regional inequalities in India are correlated with the overall
level of immunization in a non-linear fashion (Pande and Yazbeck 2003). Realizing
the need, the National Population Policy and the National Rural Health Mission
reiterated the need to achieve universal immunization by 2012 (MOHFW 2000,
2005).
The aim of this paper is to identify the changes and the underlying factors
associated with childhood immunization in India. The differentials in immunization
coverage have also been examined across selected socio-economic contexts in
the country. The paper has been conceptualized with the following rationale.
First, evidence from large-scale population-based surveys revealed that there is a
large gap between target and achievement of childhood immunization. Second, the
trends in immunization services seem to have stagnated in recent years compared to
other reproductive and child health services: for example, the coverage of full
immunization had increased by 4% points during 1992–1998 and 5% points during
1998–2005. Third, the spatial pattern in immunization coverage is quite puzzling. A
number of states (8 out of 29) had shown a decline in full immunization during
1998–2005. While the demographically backward states such as Bihar, Uttar
Pradesh, and Orissa had shown an increase in coverage of child immunization, it
had declined in the economically progressive states of Gujarat and Maharashtra.
Though the coverage of immunization varies largely across the states of India, little
is known on the trends, pattern, and the cause of such changes.
Data and methods
Data
Data for the study is taken from three successive rounds of the National Family
Health Survey (NFHS) conducted during 1992–2006. The first round of NFHS was
conducted in 1992–1993, the second round in 1998–1999 and the third in
2005–2006. For convenience, we refer to the periods between 1992–1993 and
1998–1999 as 1992–1998, between 1998–1999 and 2005–2006 as 1998–2005 and
between 1992–1993 and 2005–2006 as 1992–2005. The NFHS is similar to other
Demographic and Health Surveys (DHS) and covers a wide range of topics such as
fertility, mortality, family planning, immunization of children and nutritional status
of children. All three rounds of NFHSs are nationally representative and covered
more than 99% of India’s population. The NFHS-1 covered a sample of 89,777
ever-married women aged 13–49, NFHS-2 covered 90,303 ever-married women
Socio-economic differentials in childhood immunization in India, 1992–2006
123
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aged 15–49 and NFHS-3 covered 124,385 women (unmarried and married) aged
15–49. Along with other states, the NFHS-3 sample covered three newly created
states, Jharkhand, Uttaranchal, and Chhattisgarh, that were created from the
erstwhile states of Bihar, Uttar Pradesh, and Madhya Pradesh respectively. To make
the state-specific estimate comparable we have estimated immunization coverage
separately for Bihar, Uttar Pradesh and Madhya Pradesh for all three periods.
In all DHS surveys, detailed information on vaccination was collected for the live
births to mothers in a reference period. In NFHS-1, information on vaccination was
collected for the last three births in the 4 years preceding the survey; in NFHS-2, it
was the last two births in the 3 years preceding the survey. In NFHS-3, information
was collected for the last five births in the 5 years preceding the survey. To make
the estimate comparable, we have used immunization coverage of children
12–23 months for the last two births (as it is common in all three rounds of the
survey). This cutoff point also reflects the immunization coverage in recent years.
However, we acknowledge that a significant minority of immunized children were
vaccinated between the ages 23 and 48 months.
Immunization status is measured using the information based on health card or
based on mother’s reporting. This is the standard practice for measuring
immunization status using the large-scale population-based survey (Boerma and
Bicego 1994; Langsten and Hill 1998). The immunization coverage is analysed as
‘full immunization’—surviving children who have received one dose of BCG, three
doses of DPT vaccine, three doses of polio vaccine, and one dose of measles
vaccine; ‘partial/any immunization’—surviving children who have received at least
one vaccine; and ‘no immunization’—surviving children who did not receive any
vaccines. We have considered children of age 12–23 months only, according to the
WHO schedule of immunizations.
The study used pertinent socio-economic and demographic variables to explain
the differentials and determinants of immunization coverage. The socio-economic
variables considered in the study are mother’s education, place of residence, religion
of household, caste of household, standard of living index, working status, and
exposure to mass media of mother. The demographic variables are sex of the child,
parity, age of mother. Others variables are antenatal care (ANC) visits and the
availability of health cards.
After defining the dependent variables we have analysed trends and change in
childhood immunization coverage for India and its states during the last 14 years.
Afterwards, we have restricted our analysis to India and states of Bihar and Gujarat
only (the selection criteria of states is briefly described in the results section), in
order to understand the differentials and determinants of immunization coverage.
Methods
Descriptive analysis is used to understand the differentials and changes in
immunization coverage across socio-economic context. The chi-square test is used
to understand the significant association of immunization coverage across selected
socio-economic variables. The progression rate of each vaccine is used to
A. Kumar, S. K. Mohanty
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understand the sequential progression from one vaccine to another. Multivariate
analysis is used to understand the significant determinants of immunization
coverage. As our dependent variable is nominal and consists of three outcomes, no
immunization, partial immunization, and full immunization, we have used the
multinomial logit model. The logit model allows the effects of the independent
variables to differ for each outcome, and handles the non-independence of the
categories of the dependent variable by simultaneous estimation of the models for
all outcomes. Analysis is carried out using Stata 8.0 and maps are prepared using
ArcGis software.
Results
Trends in immunization coverage in India
Figure 1 presents the trends in childhood immunization in India over last 14 years.
While full immunization increased from 35% in 1992–1993 to 44% in 2005–2006,
partial immunization increased from 35 to 51% during the same period. On the other
hand the country has experienced a sharp decline in no immunization from 30% in
1992–1993 to 14% in 1998–1999 and 5% in 2005–2006.
The spatial pattern of immunization coverage in the last 14 years is presented in
Figs. 2, 3, and 4. Full immunization varies across the states over time (Fig. 2).
Among the major states, the coverage of full immunization in 2005–2006 was
highest in Tamil Nadu (81%) followed by Kerala (75%), Himachal Pradesh (74%),
Jammu & Kashmir (67%), Haryana (65%), and West Bengal (64%). It was lowest in
the state of Uttar Pradesh (23%) followed by Rajasthan (27%), Assam (31%), and
Bihar (33%). Among the smaller states, the coverage of full immunization during
2005–2006 was highest in Goa (82%), Sikkim (75%), New Delhi (63%), and
Uttaranchal (60%), while it was lowest in Nagaland (20%), Arunachal Pradesh
(25%), and Meghalaya (32%). Figure 3 presents the coverage in partial immuni-
zation among the states for last 14 years. The coverage of partial immunization
during 2005–2006 was highest in Uttar Pradesh (73%) followed by Rajasthan
Fig. 1 Percentage of children who received full immunization, partial immunization and noimmunization in India, 1992–2005
Socio-economic differentials in childhood immunization in India, 1992–2006
123
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(67%), Bihar (60%), and Assam (53%). Among the smaller states it was higher
in Jharkhand (61%), Nagaland (60%), Arunachal Pradesh, and Meghalaya (50%
for each). The proportion of children not immunized against any infections
in 2005–2006 (Fig. 4) was highest in Assam (15%) followed by Orissa (12%),
Fig. 2 Percentage of children who received all recommended childhood vaccinations in India,1992–2005
A. Kumar, S. K. Mohanty
123
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Haryana (8%), and Bihar (7%). In the smaller states it was higher in Arunachal
Pradesh (25%), Nagaland (20%), Meghalaya (18%), Mizoram (11%), and New
Delhi (10%). The spatial patterns in immunization coverage remained similar over
the period.
Fig. 3 Percentage of children who received at least one but not all childhood vaccinations in India,1992–2005
Socio-economic differentials in childhood immunization in India, 1992–2006
123
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Changes in immunization coverage in India and states
Table 1 presents the percentage changes in full immunization, partial immunization,
and no immunization in India during 1992–1998, 1998–2005, and 1992–2005. It
is observed that progress in full immunization has stagnated in the country: 11%
Fig. 4 Percentage of children who received no childhood vaccination in India, 1992–2005
A. Kumar, S. K. Mohanty
123
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increase each during 1992–1998 and 1998–2005; while partial immunization
increased 33% during 1992–1998 and 10% during 1998–2005. On the other hand no
immunization coverage is in consistent decline: 52% decline during 1992–1998 and
63% decline during 1998–2005. Among the major states of India, the percentage of
children without any single vaccination was observed in all the states: more among
the economically and demographically backward states of Jharkhand (93%),
Chhattisgarh (92%), Uttar Pradesh (92%), Rajasthan and Bihar (87% in each), and
Madhya Pradesh (86%). Regional patterns in partial immunization are mixed over
the years. It substantially increased in Rajasthan (121%), Uttar Pradesh (98%),
Bihar (64%), Punjab (62%), and Gujarat (60%), and declined in Kerala (33%), West
Bengal (31%), Himachal Pradesh (19%), and Haryana (8%). Among the smaller
states it increased in Nagaland (185%), Jharkhand (102%), and Arunachal Pradesh
(70%), and declined in New Delhi (25%), Tripura (10%), and Uttaranchal (7%).
Full immunization coverage has increased in most of the states during the last
14 years. Among the major states, Bihar had the maximum increase (204%)
followed by West Bengal (88%), Assam (62%), and Orissa (44%). On the other
hand, the full immunization coverage has declined in the economically progressive
states of Gujarat (9%), Maharashtra (8%), and Punjab (3%) during the same period.
Among the smaller states, full immunization coverage has increased for all states
except Mizoram. Based on changes in full immunization coverage among the major
states we have selected Bihar and Gujarat for further analysis as these two states
present extreme situations: Bihar showed maximum and constant increase in full
immunization over the period while Gujarat showed maximum as well as constant
decline in full immunization coverage. We have focused only on the major states in
order to have a sufficient sample size.
Socio-economic & demographic differentials in full immunization
in India and states
The differentials in full immunization coverage across selected socio-economic and
demographic characteristics are shown in Table 2. In India, full immunization
coverage varied largely with parity, age of mother, place of residence, mother’s
schooling, standard of living, caste, exposure to mass media, antenatal care of
mother, and availability of health card. In 2005–2006 the coverage of full
immunization was higher among lower-parity (55%) than higher-parity women
(31%), younger mothers (44%) than older mothers (29%), urban areas (58%) than
rural areas (39%), higher-educated mother (74%) than less-educated mother (30%)
and children with a high standard of living (62%) than low standard of living (28%).
Similarly, full immunization coverage is higher among children of other castes
(54%) than children belonging to Scheduled Castes/Scheduled Tribes (SC/ST)
(37%). In addition, full immunization coverage is higher among those children
whose mother received 3 or more antenatal checkups than among those whose
mother received less than three: 59% vs. 26%. Immunization coverage is higher
among children with a health card than among those without a health card (76% vs.
24%). Sex and religious differences in full immunization coverage are apparent. The
Socio-economic differentials in childhood immunization in India, 1992–2006
123
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Tab
le1
Per
cen
tag
ech
ang
esin
no
,p
arti
al,
and
full
imm
un
izat
ion
cov
erag
ein
Ind
ia,
19
92–
20
05
Per
cen
tag
ech
ang
esin
imm
un
izat
ion
cov
erag
e
No
imm
un
izat
ion
Par
tial
imm
un
izat
ion
Fu
llim
mu
niz
atio
n
19
92
–1
99
81
99
8–
20
05
19
92–
20
05
19
92
–1
99
81
99
9–
20
05
19
92–
20
05
19
92
–1
99
81
99
8–
20
05
19
92
–2
00
5
Ma
jor
stat
es
Gu
jara
t-
64
.4-
32
.3-
75
.94
3.8
11
.36
0.0
-3
.5-
6.1
-9
.4
Mah
aras
htr
a-
73
.24
1.0
-6
2.2
-1
1.0
51
.93
5.1
13
.4-
19
.2-
8.4
Pu
nja
b-
52
.0-
24
.0-
63
.5-
2.5
65
.76
1.5
15
.5-
15
.7-
2.6
An
dh
raP
rad
esh
-7
3.7
-1
6.7
-7
8.1
16
.21
5.5
34
.11
4.9
-1
1.5
1.7
Jam
mu
-3
7.2
-5
8.9
-7
4.2
88
.4-
16
.75
6.7
-1
5.7
22
.02
.9
Kar
nat
aka
-4
9.9
-9
.8-
54
.91
1.5
4.6
16
.67
.3-
1.7
5.6
Him
ach
alP
rad
esh
-7
4.0
6.4
-7
2.3
-4
5.3
46
.2-
19
.33
0.0
-9
.21
8.1
Utt
arP
rad
esh
-3
0.8
-8
8.5
-9
2.0
36
.14
5.4
97
.90
.82
0.4
21
.3
Har
yan
a-
42
.4-
20
.6-
54
.32
.3-
10
.2-
8.2
12
.78
.62
2.3
Tam
ilN
adu
-8
8.5
-1
00
.0-
10
0.0
-6
3.2
63
.9-
39
.83
5.1
-8
.12
4.2
Raj
asth
an-
53
.7-
72
.6-
87
.31
01
.89
.61
21
.2-
23
.56
4.3
25
.7
Ker
ala
-8
0.3
-1
8.7
-8
4.0
-2
4.6
-1
1.6
-3
3.4
32
.54
.83
8.8
Mad
hy
aP
rad
esh
-5
6.2
-6
7.3
-8
5.7
75
.4-
15
.14
8.8
-2
8.3
99
.64
3.1
Ori
ssa
-6
6.8
24
.3-
58
.73
9.3
-2
6.9
1.7
12
.62
7.8
43
.9
Ass
am-
23
.6-
53
.3-
64
.33
6.3
4.7
42
.6-
16
.89
4.4
61
.8
Wes
tB
eng
al-
39
.1-
56
.3-
73
.4-
1.6
-3
0.3
-3
1.4
27
.64
7.3
88
.1
Bih
ar-
73
.1-
50
.1-
86
.61
04
.4-
19
.66
4.3
2.4
19
7.1
20
4.1
Sm
all
erst
ates
Miz
ora
m-
30
.01
1.1
-2
2.2
5.0
48
.15
5.5
5.0
-2
5.9
-2
2.2
Aru
nac
hal
Pra
des
h-
36
.3-
16
.7-
46
.97
0.0
0.0
70
.0-
15
.02
5.0
6.2
A. Kumar, S. K. Mohanty
123
Author's personal copy
Tab
le1
con
tin
ued
Per
cen
tag
ech
ang
esin
imm
un
izat
ion
cov
erag
e
No
imm
un
izat
ion
Par
tial
imm
un
izat
ion
Fu
llim
mu
niz
atio
n
19
92
–1
99
81
99
8–
20
05
19
92–
20
05
19
92
–1
99
81
99
9–
20
05
19
92–
20
05
19
92
–1
99
81
99
8–
20
05
19
92
–2
00
5
New
Del
hi
-2
4.7
10
6.7
55
.62
6.4
-4
0.9
-2
5.3
-1
3.6
26
.79
.5
Go
a-
10
0.0
-1
00
.0-
10
0.0
10
.0-
9.0
0.0
10
.02
.31
2.5
Utt
aran
chal
-5
6.9
-1
6.0
-6
3.8
50
.0-
38
.0-
7.0
-4
.55
2.3
45
.5
Chhat
tisg
arh
-7
7.2
-6
6.2
-9
2.3
10
0.2
-3
1.0
38
.0-
33
.81
21
.04
6.4
Man
ipu
r-
50
.0-
71
.4-
85
.71
2.5
14
.22
8.5
40
.61
4.3
60
.7
Tri
pu
ra-
47
.6-
27
.4-
62
.0-
5.9
-4
.1-
9.9
12
4.1
18
.81
66
.1
Jhar
kh
and
-5
3.9
-8
4.5
-9
2.8
11
0.1
-3
.71
02
.3-
13
.62
97
.82
43
.6
Nag
alan
d-
56
.8-
37
.1-
72
.91
59
.01
0.0
18
5.0
15
9.1
46
.72
80
.0
Meg
hal
aya
-2
2.6
-5
7.9
-6
7.4
20
.41
0.7
33
.35
4.8
15
0.7
28
8.2
Sik
kim
n.a
.-
10
0.0
n.a
.n
.a.
-3
7.5
n.a
.n
.a.
87
.5n
.a.
Ind
ia-
51
.9-
63
.1-
82
.33
3.4
10
.64
7.7
11
.11
0.6
22
.8
n.a
.In
form
atio
nn
ot
avai
lab
le
Socio-economic differentials in childhood immunization in India, 1992–2006
123
Author's personal copy
Tab
le2
Per
centa
ge
of
chil
dre
nw
ho
rece
ived
full
imm
uniz
atio
nb
yse
lect
edso
cio-e
conom
ican
ddem
ogra
phic
char
acte
rist
ics
inIn
dia
,B
ihar
and
Guja
rat,
1992
–2
00
5
Ind
iaB
ihar
Gu
jara
t
19
92
–1
99
31
99
8–
19
99
20
05–
20
06
19
92
–1
99
31
99
8–
19
99
20
05–
20
06
19
92
–1
99
31
99
8–
199
92
00
5–
20
06
Sex
of
chil
d
Mal
e3
6.7
40
.54
5.3
12
.41
2.8
38
.05
1.5
49
.64
8.5
Fem
ale
34
.13
8.2
41
.59
.18
.92
6.7
48
.34
6.9
41
.8
Bir
tho
rder
of
chil
d
14
5.5
51
.05
4.6
13
.31
3.8
44
.45
9.4
55
.45
0.0
24
1.7
45
.94
9.3
14
.61
5.2
38
.25
0.8
46
.14
8.5
3?
26
.42
7.7
31
.18
.38
.02
5.2
41
.64
4.8
38
.3
Ag
eo
fm
oth
er
15
–2
43
7.6
40
.54
4.0
12
.31
1.6
35
.04
8.5
44
.44
4.5
25
–3
43
5.3
40
.04
5.0
10
.21
2.0
33
.75
2.2
53
.94
5.3
35
?2
0.8
25
.12
8.8
6.9
1.5
11
.94
3.5
30
.85
8.3
Pla
ceo
fre
side
nce
Urb
an5
0.8
54
.85
7.6
19
.32
2.0
45
.75
7.0
54
.15
4.7
Ru
ral
30
.93
4.9
38
.69
.61
0.3
31
.14
6.2
44
.94
0.1
Mo
ther
’ssc
ho
olin
g
Les
sth
an5
yea
rs2
6.7
29
.43
0.4
6.8
7.8
25
.43
7.5
38
.83
0.7
5–
10
yea
rs5
9.1
58
.56
0.5
27
.52
3.9
59
.57
3.3
57
.75
8.4
Mo
reth
an1
0y
ears
72
.26
8.6
74
.15
0.0
32
.08
3.3
78
.07
7.8
74
.2
Sta
nd
ard
of
livi
ng
Lo
w2
5.8
29
.02
7.7
6.0
6.4
16
.73
7.7
34
.03
1.3
Med
ium
41
.94
0.9
42
.21
7.0
15
.74
1.4
48
.24
4.9
37
.8
Hig
h6
8.7
58
.56
2.1
38
.12
4.4
62
.56
8.7
70
.15
9.1
A. Kumar, S. K. Mohanty
123
Author's personal copy
Tab
le2
con
tin
ued
Ind
iaB
ihar
Gu
jara
t
19
92
–1
99
31
99
8–
19
99
20
05–
20
06
19
92
–1
99
31
99
8–
19
99
20
05–
20
06
19
92
–1
99
31
99
8–
199
92
00
5–
20
06
Ca
ste
SC
&S
T2
5.8
33
.73
7.1
5.9
9.6
24
.54
0.4
41
.04
6.1
Oth
erB
ackw
ards
Cas
ten.a
.40.7
40.7
n.a
.10.7
35.3
n.a
.44.8
42.3
Oth
ers
38
.24
3.4
53
.91
1.7
14
.63
6.4
52
.15
7.0
48
.5
Rel
igio
n
Hin
du
36
.04
0.0
44
.41
0.3
12
.63
5.9
49
.64
7.9
46
.0
No
n-H
ind
u3
3.2
37
.14
0.6
12
.84
.41
8.5
50
.95
0.0
38
.7
Exp
osu
reto
ma
ssm
edia
No
exp
osu
re2
3.3
24
.22
6.4
7.3
9.3
22
.23
8.2
41
.73
1.4
Ex
po
sure
50
.05
2.3
51
.31
9.9
20
.94
0.5
60
.35
3.1
50
.5
Wo
rkst
atu
so
fm
oth
er
No
tw
ork
ing
36
.14
0.0
46
.31
3.5
12
.33
4.3
55
.35
1.4
50
.8
Wo
rkin
g3
3.9
38
.03
6.5
0.0
6.8
27
.14
0.8
44
.83
5.5
AN
Cch
eck
up
Les
sth
an3
vis
its
18
.52
2.2
26
.17
.39
.32
6.7
25
.42
9.8
24
.3
3an
dm
ore
vis
its
55
.55
9.5
59
.02
5.2
20
.75
7.1
62
.66
0.7
57
.1
Ava
ilab
ilit
yo
fh
ealt
hca
rd
No
hea
lth
card
24
.42
4.2
24
.06
.65
.51
8.2
41
.73
7.1
27
.0
Hea
lth
card
60
.66
9.1
76
.13
1.1
37
.46
0.6
67
.57
1.9
76
.8
n.a
.In
form
atio
nn
ot
avai
lab
le
Socio-economic differentials in childhood immunization in India, 1992–2006
123
Author's personal copy
gap in full immunization coverage across the subgroups remained similar over the
periods.
In Bihar, coverage of full immunization varied across all selected socio-
economic and demographic characteristics over the periods. Moreover the
differences across sex, parity, and maternal age have increased in the later
period. In 2005–2006, the full immunization coverage was higher among male
children (38%) than female children (27%), lower-parity women (44%) than
higher-parity women (25%), younger mothers (35%) than older mothers (12%),
and urban areas (46%) than rural areas (31%). Similarly, immunization coverage
starkly varied between uneducated mothers (25%) and educated mothers (83%),
and low standard of living (17%) and high standard (63%). Caste and religious
differences are also considerable in full immunization coverage: immunization
coverage is higher among other castes (36%) than SC/ST (25%), and Hindus
(36%) than non-Hindus (18%). The full immunization varies largely by ANC
visits of mother and health card of child: in 2005–2006, the coverage of full
immunization was 57% for mothers who have received three or more antenatal
checkups compared to 27% of those who have received less than three. Similarly,
full immunization coverage was 60% among children with health card compared
to 18% among children without health cards. Although full immunization
coverage differs across socio-economic and demographic characteristics in Bihar,
full immunization coverage has increased across all selected subgroups over the
periods.
In Gujarat, full immunization coverage varied by background characteristics
and declined cutting across the subgroups over time. Sex differentials in full
immunization coverage have increased in the states in the later period: 49%
among boys compared to 42% among girls in 2005–2006; it was 52% among
boys and 48% among girls in 1992–1993 and 50% among boys and 47% among
girls in 1998–1999. In 2005–2006, full immunization coverage varied largely with
parity (50% among lower-parity vs. 38% among higher-parity women), place of
residence (55% in urban areas vs. 40% in rural areas), education of mother (31%
among less than 5 years of schooling vs. 74% among more than 10 years of
schooling), and standard of living (31% among low SLI vs. 59% among high
SLI). Caste and religious differentials are comparatively lower. Full immunization
coverage substantially varied with mothers’ exposure to mass media (51% among
exposed vs. 31% among non-exposed) and work status of mother (36% working
women vs. 51% among not-working women). Full immunization coverage in
Gujarat also differs by antenatal care of mother and health card of child: it was
57% among mothers who received three or more antenatal care visits compared
to 24% among those who received less than three visits, 77% among children
with health card compared to 27% among children without health card. Though
the coverage of full immunization has declined across the socio-economic groups,
this is not so with respect to the health card. It has substantially increased among
those children who have health cards across the periods: 68% from 1992–1993 to
72% in 1998–1999, and 77% in 2005–2006.
A. Kumar, S. K. Mohanty
123
Author's personal copy
Coverage of specific childhood vaccines in India and states
Table 3 shows the trends in coverage in specific childhood vaccines in India and the
states of Bihar and Gujarat. In 2005–2006, the coverage of Polio1, Polio2 was
universal while BCG, DPT1, and Polio3 covered more than three-fourths of children
in India. Moreover the coverage of these vaccines has substantially increased over
time. For example, coverage of Polio1 increased from 70 to 93%, Polio2 increased
from 61 to 89%, BCG increased from 62 to 78%, and Polio3 increased from 54 to
79% from 1992–1993 to 2005–2006. However, the coverage for DPT3 and measles
vaccine is very slow; fewer than three-fifths of children were immunized against
these infections in 2005–2006.
In Bihar coverage of all three doses of polio vaccine was higher than that of other
vaccines in 2005–2006. More than four-fifths of children aged 12–23 months were
immunized against polio, while about two-fifths of children were immunized with
DPT3 and measles vaccines in 2005–2006. Although the coverage of each vaccine
has substantially increased over the period, the increase is comparatively high for
polio vaccines in the last 13 years: the coverage of Polio1 has increased from 46
to 90%, Polio2 from 42 to 88%, and Polio3 from 33 to 83% from 1992–1993 to
2005–2006. In Gujarat the coverage of BCG, DPT1, Polio1 and Polio2 was higher
than that of other vaccines in 2005–2006. Coverage of these vaccines was more than
four-fifths during the same period. Coverage of BCG, Polio1, Polio2, and measles
has consistently increased over the period in the states, while other vaccines have
shown fluctuating trends.
Rate of progression in successive vaccines in India and states
Table 4 shows the rate of progression of successive vaccines for India and the states
of Bihar and Gujarat for three points of time. In order to obtain the progression rate
we started with the coverage of BCG as it is the initial dose in vaccination schedule.
Subsequently we tried to ascertain how many of those children who were vaccinated
against BCG progressed to DPT1 and thus we calculated the progression rate for
DPT1. Similarly we calculated the progression rate of Polio1: out of those children
who received one dose of BCG and DPT1, how many progressed to Polio1. In that
way we calculated the progression rate for specific vaccines. This is different from
the dropout rate, which provides the difference between DPT1 and DPT3 or Polio1
and Polio3; in contrast, the progression rate applies to each vaccine.
In India the coverage of BCG remained lower than that of other vaccines over
time. Apart from this the progression rate was lowest for DPT3, followed by
measles, Polio3, and DPT1. The pattern remained similar over the time. In Bihar,
the coverage of BCG was very low for all the periods, and the progression rate in
2005–2006 was higher for Polio1, Polio2, and Polio3 followed by DPT1, DPT 2,
and DPT3. But the dropout (complement of progression rate) is highest for measles
followed by DPT3. More than half of the children, who received Polio3 had not
received measles vaccination in Bihar in 2005–2006. In Gujarat, the progression in
2005–2006 was lowest for DPT3 followed by DPT2, measles, and Polio3. Moreover
Socio-economic differentials in childhood immunization in India, 1992–2006
123
Author's personal copy
Ta
ble
3P
erce
nta
ge
of
chil
dre
nw
ho
rece
ived
spec
ific
chil
dh
oo
dim
mu
niz
atio
nin
Ind
ia,
Bih
aran
dG
uja
rat,
19
92
–2
00
5
Ind
iaB
ihar
Gu
jara
t
19
92–
19
93
19
98–
19
99
20
05
–2
00
61
99
2–
199
31
99
8–
19
99
20
05–
20
06
19
92–
19
93
19
98–
19
99
20
05
–2
00
6
BC
G6
2.2
71
.67
8.2
34
.43
6.1
64
.67
7.1
84
.78
6.4
DP
T1
66
.37
1.2
75
.94
3.7
38
.56
5.1
77
.88
3.2
81
.5
Po
lio
16
6.9
83
.29
2.9
45
.98
4.2
90
.07
7.8
89
.79
1.9
DP
T2
59
.36
5.0
66
.73
7.7
33
.05
5.6
71
.47
5.5
73
.4
Po
lio
26
1.3
77
.78
8.8
41
.87
4.6
87
.87
1.2
82
.18
3.4
DP
T3
51
.95
5.5
55
.52
9.5
25
.04
6.1
63
.86
4.1
62
.0
Po
lio
35
3.7
60
.07
8.5
32
.64
1.4
82
.86
3.1
62
.66
5.9
Mea
sles
42
.25
0.7
58
.91
4.7
16
.14
0.5
55
.96
3.6
66
.0
A. Kumar, S. K. Mohanty
123
Author's personal copy
Ta
ble
4P
rogre
ssio
nra
teof
two
succ
essi
ve
vac
cinat
ions
inIn
dia
,B
ihar
and
Guja
rat,
1992–2005
Ind
iaB
ihar
Gu
jara
t
19
92–
19
93
19
98–
19
99
20
05
–2
00
61
99
2–
199
31
99
8–
19
99
20
05–
20
06
19
92–
19
93
19
98–
19
99
20
05
–2
00
6
BC
G0
.62
0.7
20
.78
0.3
40
.36
0.6
50
.77
0.8
50
.87
DP
T1
0.9
60
.94
0.9
30
.94
0.9
20
.94
0.9
70
.95
0.9
2
Po
lio
10
.98
0.9
90
.99
0.9
80
.97
0.9
70
.98
0.9
80
.99
DP
T2
0.9
20
.94
0.9
00
.82
0.3
90
.61
0.9
10
.83
0.7
9
Po
lio
20
.99
0.9
80
.99
0.9
90
.96
1.0
00
.97
0.9
70
.97
DP
T3
0.8
90
.87
0.8
50
.71
0.3
30
.52
0.8
80
.77
0.7
3
Po
lio
30
.99
0.9
10
.93
0.9
80
.90
0.9
70
.97
0.8
90
.84
Mea
sles
0.7
60
.82
0.8
80
.41
0.3
20
.45
0.8
10
.81
0.8
2
Socio-economic differentials in childhood immunization in India, 1992–2006
123
Author's personal copy
the progression rate has decreased for DPT2 and DPT2, while it stagnated for
measles over the periods.
Factors affecting coverage of immunization in India and states
To understand the significant effect of socio-economic and demographic factors on
immunization coverage, multivariate analysis is used for India and the states of
Bihar and Gujarat. We have used the multinomial logit regression considering the
nature of the dependent variable (immunization coverage), as it has more than two
categories, i.e. no immunization, partial immunization, and full immunization. The
analysis is carried out by using the pooled data from the three periods 1992–1993,
1998–1999, and 2005–2006, to attain an adequate sample size as well as to
understand the effect of time on immunization coverage. We have controlled for
significant covariates in the model such as sex of child, woman’s parity, age and
education of mother, place of residence, standard of living, caste, religion, exposure
to mass media, working status, and possession of health card. Mother’s antenatal
care visit is dropped from the multivariate analysis because of the problem of
multicollinearity. In order to avoid complexity of interpretation, the results obtained
from multinomial logit regression are presented in terms of predicted percentage
using multiple classification application (MCA). We presented results only for full
immunization (Table 5).
In India, immunization coverage significantly varied with parity of women. Full
immunization coverage was 50% among women with one child compared to 34%
among women with 3 or more children. Mother’s educational attainment and
standard of living are significant predictors of full immunization coverage: women
with 10 or more years of schooling were more likely to immunize their children
(60%) than those with less than 5 years of schooling (35%). Similarly, children with
low standard of living are less likely to be immunized (41%) than those with higher
SLI (49%). Exposure to mass media also appeared as a significant determinant of
full immunization coverage: immunization coverage is significantly higher among
those children whose mother was exposed to mass media (47%) compared to those
whose mother had no exposure (33%). Beside the socio-economic and demographic
determinants, possession of a health card appeared as a strong and significant
predictor of full immunization coverage in India: immunization coverage is 62%
among children with a health card and 44% for those without a health card. The
time effect shows a significant but very steady increase in full immunization
coverage: from 38% in 1992–1993 to 40% in 1998–1999 and 41% in 2005–2006.
Full immunization coverage significantly varies with sex of child, place of
residence, caste, religion, and work status of mother, though differences are
minimal.
In Bihar, female children were significantly less likely to be immunized than
male children (11% vs. 16%). Immunization coverage significantly differs across
mother’s educational attainment and standard of living in this state: mothers with 10
and more years of schooling were more likely to immunize their children (40%)
than those with less than 5 years of schooling (12%). Similarly, immunization
coverage is higher among children of high SLI (20%) than those of low SLI (16%).
A. Kumar, S. K. Mohanty
123
Author's personal copy
Table 5 Results of multinomial logit regression (predicted percentages): full immunization coverage in
India and selected states, 1992–2005
Explanatory variables India Bihar Gujarat
Sex of child
Male 42.8 16.1 54.0
Female 40.1*** 11.2*** 49.9
Birth order of child
1 49.7 16.7 55.8
2 45.5** 15.9 49.8
3? 34.1*** 11.7** 50.6
Age of mother
15–24 38.0 12.7 49.0
25–34 46.0*** 16.5 55.2
35? 40.0** 7.3 53.4
Place of residence
Urban 45.0 15.7 52.6
Rural 40.4*** 13.4 51.6
Mother’s schooling
Less than 5 years 35.4 11.7 42.7
5–10 years 51.3*** 22.8*** 60.6***
More than 10 years 59.9*** 39.7*** 70.6***
Standard of living
Low 40.5 15.7 47.9
Medium 34.5*** 9.0** 40.0*
High 48.8*** 20.4*** 60.7***
Caste
SC & ST 37.7 13.3 53.6
Others 42.2*** 15.3 48.4
Religion
Hindu 41.9 18.6 49.2
Non-Hindu 39.3*** 11.2* 48.7
Exposure to mass media
No exposure 33.1 14.3 49.3
Exposure 47.1*** 16.7 48.7
Work status of mother
Not working 40.2 16.1 49.5
Working 42.0*** 11.8** 48.0*
Availability of health card
No health card 43.7 13.4 46.5
Health card 62.3*** 18.9*** 49.3***
Time Dummy
1992–1993 38.4 5.8 51.9
1998–1999 39.9*** 9.2*** 50.4***
2005–2006 40.9*** 29.6*** 42.8***
* p \ 0.1; ** p \ 0.05; *** p \ 0.01
Socio-economic differentials in childhood immunization in India, 1992–2006
123
Author's personal copy
The immunization coverage differs significantly by possession of health card:
coverage was 19% among children with a health card and 13% among those without
health card. In Bihar the time effect suggests that full immunization coverage has
significantly and substantially increased over time. In Gujarat, full immunization
coverage is significantly higher among mothers with 10 or more years of schooling,
71% compared to 43% among those with less than 5 years of schooling. Similarly, it
is 61% among children belonging to households with high SLI and 48% among
children of low SLI. The full immunization coverage differs with possession of
health card: 49% among children with and 46% among children without a health
card. In Gujarat the time effect is significantly negative; suggesting that full
immunization coverage has declined over the period.
Discussion
This study focused on trends, changes, and socio-economic differentials in
immunization coverage in India. Immunization coverage is classified into three
categories: no immunization, partial immunization, and full immunization. To
understand the trends and changes, all three categories of immunization are used,
while for differentials and determinants, full immunization coverage is used. To
understand the regional variation, the analysis was carried out for the states of Bihar
and Gujarat. The state of Bihar had recorded significant increase in immunization
and the state of Gujarat had recorded a decline in full immunization coverage over
time.
The results indicate that there is a huge gap in targets and achievements in
immunization coverage in India. Despite the longstanding government effort to
achieve the goal of universal immunization, little more than two-fifths of children
were immunized with all the recommended vaccines and the coverage of full
immunization stagnated over the period. However, partial immunization has
increased substantially. There is large regional variation in full immunization in
India and a clear north–south differential is observed (Fig. 2). The spatial pattern of
immunization remained similar over time. The economically backward states
recorded significant increases in full immunization coverage, possibly because of
starting from a low level.
The results demonstrate that the coverage of BCG, three doses of DPT, and
measles vaccine is lower than that of polio vaccine, in India and the states; moreover
there is very little improvement over time. In addition, the coverage of BCG
remained very low in India and Bihar over the periods, since BCG is a primary
vaccine, this may be a major obstacle in achieving the goal of universal
immunization. In contrast, the coverage of polio vaccines is relatively high and
even shows consistent increases over time. Results of progression rates demonstrate
that the higher dropout from DPT3 and measles may be possible reasons for slow
progress in full immunization coverage. In Bihar, the lower coverage of specific
vaccines and dropouts in DPT2, DPT3, and measles would have caused a low level
of full childhood immunization. In Gujarat, the decline in full immunization
A. Kumar, S. K. Mohanty
123
Author's personal copy
coverage may be due to the constant decline in progression rate of DPT1, DPT2,
DPT3, and Polio3 vaccines.
The findings demonstrate that full immunization coverage varied largely across
socio-economic context in India and the states over time. Discrimination against
girls appeared in coverage of full immunization, though the gap had narrowed. The
finding accords with previous studies (Hill and Upchurch 1995; Pande and Yazbeck
2003) and reflects persistent discrimination against girl children in Indian society.
Urban children had better immunization coverage than rural children, probably
because of better accessibility and the success of ‘supply side’ factor as evident
from other studies (Ibnouf et al. 2007; Pande and Yazbeck 2003). Full immunization
coverage largely varied by mother’s educational attainment and exposure to mass
media. Immunization coverage is about twice as high among mothers with more
than 10 years of schooling as among those with 5 or less years of schooling. Similar
results are observed for exposure to mass media. These findings are similar to those
of other studies documenting the link between maternal education and child health
(Desai and Alva 1998, Streatfield et al. 1990), as well as between maternal exposure
to mass media and child health (Rahman 2007). Immunization coverage varied
substantially with economic status of households. Economic disparity in immuni-
zation coverage is more pronounced in the state of Gujarat; this is consistent with
the findings of the other studies that corroborated the link between socio-economic
status and immunization coverage and other health care services across the
developing countries (Gwatkin et al. 2000; Kunst and Houweling 2001; Mohanty
and Pathak 2009; Pande and Yazbeck 2003). The lower coverage of full
immunization among children of non-Hindu (Muslim) religion is probably because
of some parents’ mistaken beliefs on the ill-effects of vaccination.
Beside the socio-economic factors, possession of a health card is strongly
associated with full immunization coverage in India and the states. In standard
practice, immunization rates from large-scale Demographic Health Surveys are
derived from the information recorded on health cards where these cards
are available (Boerma and Bicego 1994; Brown et al. 2002) and such estimates are
found to be of good quality (Langsten and Hill 1998). However, in the case of the
absence of health cards, mothers’ reports are associated with errors of overestimation,
of measles vaccine in particular (Hawe et al. 1991; McKinney et al. 1991), and
underestimation of overall immunization in general (Christopher et al. 2003;
Gareaballah and Loevinsohn 1989; Suarez et al. 1997; Valadez and Weld 1991);
our results accord with this underestimation. The coverage of full immunization based
on health cards is consistently increasing over time in India and the states, but progress
is either sluggish or stagnated among children without health cards, even in Gujarat
(see Table 2). Reporting bias may be another plausible reason for slow progress in full
immunization in India and further needs to be explored.
Conclusion
Based on the results, our study draws attentions to two points. First, special effort is
needed to accelerate the coverage of DPT and measles vaccines as coverage of these
Socio-economic differentials in childhood immunization in India, 1992–2006
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vaccines is lower than that of polio. Coverage of polio vaccine is high and a marked
increase was observed throughout India in the last 14 years as a result of
government efforts in the Massive Polio Campaign. Thus a similar approach should
be adopted for the remaining vaccines. Second, the health card should be made
compulsory for all newborn babies irrespective of home or institutional delivery to
avoid inaccuracy in reporting of immunization coverage.
Acknowledgments An earlier version of this paper was presented at the 26th IUSSP conference at
Marrakech, Morocco, 26 September–2 October, 2009. We would like to thank the chairperson Anastasia
J. Gage of Tulane University, New Orleans, for her beneficial comments and suggestions to improve the
earlier draft.
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