Dr. V. M. Sarode
Reader in Statistics, Mulund College of Commerce,
Mulund (West), Mumbai - 400 080.

Email: vijaymsarode@yahoo.com

Infectious diseases are a major cause of morbidity and mortality in children. One of the most cost effective and easy methods for child survival is immunization. In May 1974, the World Health Organization (WHO) officially launched a global immunization programme known as Expanded Programme of Immunization (EPI) to protect all the children of the world against six vaccine preventable diseases by the year 2000 (Yadav et al., 2006).

The vaccination of children against six serious but preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles) has been a cornerstone of the child health care system in India. As part of the National Health Policy, the National Immunization Programme is being implemented on a priority basis. The Expanded Programme on Immunization (EPI) was initiated by the Government of India in 1978 with the objective of reducing morbidity, mortality, and disabilities from these six diseases by making free vaccination services easily available to all eligible children. Immunization against poliomyelitis was introduced in 1979-80, and tetanus toxoid for school children was added in 1980-81. Immunization against tuberculosis (BCG) was brought under the EPI in 1981-82. In 1985-86, immunization against measles was added to the programme (Ministry of Health and Family Welfare, 1991).

The Universal Immunization Programme (UIP) was introduced in 1985-86 with the following objectives: to cover at least 85 percent of all infants against the six vaccine preventable diseases by 1990 and to achieve self-sufficiency in vaccine production and the manufacture of cold-chain equipment (Ministry of Health and Family Welfare, 1991). This scheme has been introduced in every district of the country, and the target now is to achieve 100 percent immunization coverage. Pulse Polio Immunization Campaigns began in December, 1995, as part of a major national effort to eliminate polio. The standard immunization schedule developed for the child immunization programme specifies the age at which each vaccine is to be administered, the number of doses to be given, and the route of vaccination (intramuscular, oral, or subcutaneous). Routine vaccinations received by infants and children are usually recorded on a vaccination card that is issued for the child.

The National Population Policy (2000) aims at complete protection of all children against vaccine preventable diseases by 2010. Urban poor, many residing in slums, comprise about one-fourth of India's 285 million urban population. 60% of the children aged 12-23 months in urban India are fully immunized; coverage among urban poor children is a dismal 43%. The inter-state variations of immunization coverage in urban areas, reveals a service coverage gap which calls for a rethink on resource allocation and strengthening processes to improve immunization coverage amongst urban poor. Debilitating environmental conditions and high population density in slums expedite disease transmission. Comparisons of urban-rural disease incidence indicate a particular urban risk for vaccine preventable diseases.

An attempt (Agarwal et al., 2005) was made to understand the current scenario and challenges in improving immunization coverage in urban slums; immunization being one of the most successful public health interventions of the past century. It also discusses possible mechanisms for effectively reaching the often left-out urban poor. Coordinated activities by the multitude of providers, accurate information based outreach, effective monitoring and community enablement to demand quality services are critical for improving utilization of immunization services by a heterogeneous urban poor population.

Another study (Nath, 2007) was aimed at determining the coverage and to identify the various factors of primary immunization in urban slums of Lucknow district. Mother, father or relative of a total of 510 children with 17 children per cluster were interviewed in the study. About 44% of the children studied were found to be fully immunized. Multinomial logistic regression analysis revealed that an illiterate mother (OR=4.0), Muslim religion (OR=2.5), scheduled caste or tribes (OR=2.3) and higher birth order (OR?2) were significant independent predictors of the partial immunized status of the child; while those associated with the unimmunized status of the child were low socioeconomic status (OR=10.8), Muslim religion (OR=4.3), higher birth order (OR=4.3), home delivery (OR=3.6) and belonging to a joint family (OR=2.1) and the study was concluded with the status of complete immunization was about half of what was proposed to be achieved under the Universal Immunization Program which emphasizes the imperative need for urgent intervention to address the issues of both dropout and lack of access, which were mainly responsible for partial immunization and non-immunization respectively.

The study of an assessment of the service-delivery system in a maternal child health (MCH) clinic in Dhaka city revealed that the rate of missed opportunities for providing immunizations were 44% among children coming to the MCH clinics and one in 10 children aged less than 5 years visited the clinics, with the problem of acute respiratory infection.

Although immunization coverage has increased substantially in recent years, large numbers of slum dwelling children remain incompletely immunized (WHO, 2003). The urban poor, many residing in slums, comprise about one-fourth of India's 285 million urban population (Banthia, 2001). Immunization services do not reach over one third of urban poor children; as only 43% are fully immunized (EHP-USAID, 2003). Hence it was felt necessary to impart knowledge about the status of the immunization among the children in the urban slums where even the mother remains unaware of the existing health facilities available in the area.

Keeping in view the above research work an attempt is made to evolve a suitable strategy for knowing the immunization status of the child in the study area and utilization of child care services and the health facilities available to the children of these mothers in slum in the area of Greater Mumbai, this study has been initiated.

Background of the study area
The city of Mumbai is originally a cluster of seven islands having an area of 603 sq. km. It has grown at a tremendous pace over the years. Between 1941 and 1961 the population grew 2.5 times and between 1961 and 1981 was of two times. Between 1981 and 2001 the population increased from 82 lacs to 120 lacs. Thus the overall population density of Greater Mumbai works out to be 19,000 persons per sq. km. where Maharashtra's is only 314. This high density of population coupled with dearth of housing has lead to the development of degrading slums.

According to Census of India 2001, about 49 percent of the population of Mumbai lives in slums. About 28 percent and 21 percent of total population is male and female respectively who live in slums.

The present study is an attempt to know:

i) the immunization practice among the study women towards their child,
ii) the health facilities available to these children in the study area and
iii) the utilization of child care services in the study area.

Measuring household standard of living
In the absence of data on income and consumption measures, household standard of living indices are often constructed using three sets of information, namely source of drinking water, toilet facility, type of house and ownership of selected consumer durables (Montgomery et al., 2000). Index scores for the present study ranges from 1-6 for a low SLI to 7-9 for a medium SLI and >=10 for a high SLI (Appendix).

Data
For the present investigation, two stage sampling procedure has been adopted. In the first stage, the slums in Greater Mumbai according to their population size, were listed using the "Directory of Slums" published by office of the additional collector (ENC), Mumbai & Mumbai Sub. Dist. (see reference). Two lists were prepared, one for plain area slums and other for hilly area slums. From plain area slum list, one slum was selected at random. This plain area slum was Rafi Nagar slum located at Deonar, Mumbai which comes under M/E-ward of Brihan Mumbai Municipal Corporation. The populations of this slum (study area) were 5500 respectively.

In the second stage of sampling, from this selected slum area, using cluster sampling, two clusters were selected at random. From these two clusters of Rafi Nagar slum area 433 households were selected, thus it represents the slum population in Greater Mumbai. The survey was conducted by the trained graduate/undergraduate girls who normally work with the supervision of doctors/ANMs for the pulse-polio programme. This survey was conducted from June to August, 2005.

In order to know immunization status, health facilities available in the study area and their utilization, the children born to mothers during the last three years prior to survey were considered.

Method of analysis
Logistic regression analysis was used to assess the effect of socio-economic determinant variables on child care practice controlling for other variables included in the model. For the logistic regression analysis purpose, the births born to mothers in the last three years prior to survey were considered.

Child Care
Infant breastfeeding practices have significant effects on both mothers and children. Mothers are affected through the influence of breastfeeding on the period of postpartum infertility, and hence on fertility levels and the length of birth intervals. These effects vary by both the duration and intensity of breastfeeding. Proper infant feeding, starting from the time of birth, is important for the physical and mental development of the child. Breastfeeding improves the nutritional status of young children and reduces morbidity and mortality. Breast milk not only provides important nutrients but also protects the child against infection.

Child Vaccination
In the study area the vaccination programme is implemented by taking Pulse Polio camps. The community volunteers visit the house of the eligible child's mother and bring them to the camp with the eligible child. The immunization begins by asking the question whether mother has an immunization card for the youngest child. The questionnaire also had the same question and investigators questioned study mothers in both the slum areas about the status of the vaccination of the eligible child. If a card was available, the interviewer was required to copy carefully the dates when the child received vaccinations against each disease. For vaccinations not recorded on the card, the mother's report that the vaccination was or was not given was accepted. If the mother could not show a vaccination card, she was asked whether the child had received any vaccinations. If any vaccination had been received, the mother was asked whether the child had received a vaccination against tuberculosis (BCG); diphtheria, whooping cough (pertussis), and tetanus (DPT); poliomyelitis (polio); and measles. For DPT and polio, information was obtained on the number of doses of the vaccine given to the child. Mothers were not asked the dates of vaccinations. To distinguish Polio 0 (polio vaccine given at the time of birth) from Polio 1 (polio vaccine given about six weeks after birth), mothers were also asked whether the first polio vaccine was given just after birth or later.

Table 1 gives the percentages of Rafi Nagar slum children age 12-23 months who received vaccinations at any time before the interview according to whether a vaccination card was shown to the interviewer or the mother was the source of all vaccination information. The 12-23 month age group was chosen for analysis because both international and Government of India guidelines specify that children should be fully immunized by the time they complete their first year of life. Because the date of vaccination was not asked of the mother if she could not show a vaccination card, the proportion of vaccinations given during the first year of life to children whose information is based on the mother's report is assumed to be the same as the proportion of vaccinations given during the first year of life to children with an exact date of vaccination on the card.

Table 1: Percentage of Children age 12-23 months who received specific vaccinations by Selected background Characteristics in Rafi Nagar Slum, Deonar, Mumbai.

In this survey, children who have received BCG, measles, and three doses each of DPT and polio (excluding Polio 0) are considered to be fully vaccinated and are also standard measure. Based on information obtained from a card or reported by the mother ('either source'), 71 percent of children age 12-23 months are fully vaccinated in Rafi nagar Slum; only 6 percent have not received any vaccinations at all in Rafi nagar Slum area. Coverage for each vaccination except Polio and Measles is much higher than the percentage fully vaccinated in areas. There has been substantial improvement in full vaccination coverage in Maharashtra since the time of NFHS-1 when the proportion of children fully vaccinated was 64 percent. Many more children were brought into the programme in the six years between the surveys. The proportion of children who did not receive any vaccinations declined substantially, from 8 percent in NFHS-1 to 2 percent in NFHS-2. The coverage of all vaccinations, especially vaccination against measles, has improved considerably since NFHS-1. For Maharashtra to attain the goal of full immunization coverage in the near future it has to improve the coverage of the measles vaccination and address the dropout problem for DPT and polio vaccinations.

Government statistics suggest a somewhat higher level of vaccination coverage than NFHS-2 estimates for most vaccinations, although the two sets of estimates are fairly close in the case of BCG and measles. According to government statistics for Maharashtra for 1997-98, 83 percent of children age 12-23 months are fully vaccinated and coverage is 95 percent for BCG, 95 percent for the third dose of DPT vaccine, 96 percent for the third dose of polio vaccine, and 85 percent for measles vaccine (Ministry of Health and Family Welfare, 1999b).

According to the immunization schedule, all primary vaccinations, including measles, should be completed by the time a child is 12 months old. For measles vaccination, however, which is supposed to be given when the child is nine months old, only 48 percent of children in Rafi nagar area who were vaccinated against measles received the vaccination after their first birthday is too low compared with BCG and DPT. These data indicate that the programme has to stress not only on the coverage but also on the timing of measles vaccination.

In the study area, vaccination coverage was higher for girls than for boys. The relationship between vaccination coverage and birth order varies in the study area. In Rafinagar Slum area, as birth order increases vaccination coverage for BCG also increases and for Polio, there is fixed pattern and for the rest i.e. DPT and Measles, there is no fixed pattern.

Sixty-seven percent of first order births in Rafi nagar Slum area are fully vaccinated, compared with 67 percent of fourth or higher order births which are same as the first order in Rafi nagar area. Sixty-eight percent of children of illiterate mothers in Rafi nagar Slum are fully vaccinated, compared with 75 percent of children whose mothers have at least completed middle school and above.

In Rafi nagar area, not only Hindu and other children are more likely than Muslims children to have received each specific vaccination except measles. Even Hindu children are more likely than Muslim children to be fully vaccinated (74 and 71 percent, respectively). SC, ST children are much less likely than other children to receive each specific vaccination except DPT in Rafi Nagar slum.

The standard of living of the household has a strong positive relationship with vaccination coverage. SLI categories, low, Medium and high category shows consistent increase in receiving each specific vaccination in Rafi nagar slum area except DPT and Measles, in fact it shows negative relationship.

Thus it is concluded that the children of Rafi Nagar slum have not gone for vaccination more in percentage.

Vitamin A Supplementation
Vitamin A deficiency is one of the most common nutritional deficiency disorders in the world, affecting more than 250 million children worldwide (Bloem et al., 1997). The National Programme on Prevention of Blindness targets children under age five years and administers oral doses of vitamin A every six months starting at age nine months. In the survey the investigators asked mothers of children born during the three years before the survey whether their children ever received a dose of vitamin A. Those who said that their child had received at least one dose of vitamin A were asked how long ago the last dose of vitamin A was given. Table 1 shows the percentage of children age 12-35 months who received at least one dose of vitamin A and who received a dose of vitamin A within the past six months by selected background characteristics. In the slums as a whole, 34 percent of children age 12-35 months received at least one dose of vitamin A in Rafi nagar slum area. This indicates that a very nominal number i.e. just one-third of children in the study area have received vitamin A supplementation. Children from groups that are less likely to have received at least one dose of vitamin A supplementation are also less likely to have received a dose in the past six months. Poorer performance in study areas indicates that the vitamin A supplementation programme is weak in slums of Mumbai.

Table 1 b gives the percent distribution of children under age three years who have received any vaccinations by the source of most of the vaccinations, according to selected background characteristics. The public sector is the primary provider of childhood vaccinations in the study area. In Rafi nagar slum area, seventy percent of all children who have received vaccinations received most of them from a public sector source and only 3 percent received them from a private sector medical source (the corresponding percentages for India as a whole are 82 percent from the public sector and 13 percent from the private medical sector). Thus it can be concluded that the children from Rafi nagar slum area where the majority of Muslims reside, have gone less in percentage for vaccination from public sector i.e. Govt./municipal hosp, Govt dispensary or UHC/UHP/UFWC. But these children have gone for vaccination more in percent from Pulse Polio Center (27 percent) and private sector (3 percent) than Hindu children i.e. just 3 percent and 0.6 percent.

In Mumbai, a much larger proportion of children from non-slum areas received their vaccinations from the private medical sector (44 percent) than children from slum areas (20 percent) (NFHS-2).

Children of more educated mothers and those belonging to households with a high standard of living are much more likely than other children to receive vaccinations from the private medical sector. Muslim children are more likely than Hindu children to receive vaccinations from the private medical sector, perhaps because Muslims are disproportionately concentrated in urban areas. Children from scheduled tribes and other backward classes are less likely than other children to receive vaccinations from the private medical sector.

Table No. 1b Sources of childhood vaccination

Child Morbidity and treatment
This section discusses the prevalence and treatment of acute respiratory infection (ARI), fever, and diarrhoea. Mothers of children less than three years old were asked if their children suffered from fever, cough, diarrhoea or diarrhoea with blood when child was of four-weeks old, and if so, the type of treatment given. Accuracy of all these measures is affected by the reliability of the mother's recall of when the disease episode occurred. Table 2 shows the percentage of children with fever, cough, cough accompanied by fast breathing (symptoms of acute respiratory infection), diarrhoea and diarrhoea with blood when child was of four-weeks old and the percentage with acute respiratory infection who were taken to a health facility or provider, by selected background characteristics.

Acute Respiratory Infection
Acute respiratory infection, primarily pneumonia, is a major cause of illness among infants and children and the leading cause of childhood mortality throughout the world (Murray and Lopez, 1996). Early diagnosis and treatment with antibiotics can prevent a large proportion of ARI/pneumonia deaths.

In the survey, it was found that 21 percent of children under age three in Rafi nagar slum suffered from acute respiratory infection (cough accompanied by short, rapid breathing) at some time when child was of four-weeks old. Table 2 shows that ARI was somewhat more common among boys than girls and among children living in Rafi nagar slum areas. Within Mumbai, ARI was twice as prevalent in slum areas as in non-slum areas (NFHS-2). ARI was also more prevalent among children 1-11 months of age, male children, children of illiterate mothers and children from households with a low standard of living in the study area including Muslims children and 'others' caste children in Rafi nagar slum.

Fever
Fever is the most common of the three conditions examined in Table 2 with 36 percent of children suffering from fever when child was of four-weeks old. The prevalence of fever decreases with the increasing age of child in Rafi nagar slum. Fever is more prevalent among Muslim children, and 'Others caste' children in Rafi nagar slum area. The prevalence of fever is highest among children of birth order of four and more. Fever is less prevalent among children from high standard of living households, and children from households that use 'boiled water and other' for water purification in the study area. Overall, the prevalence of fever is high across all groups of children in Rafi nagar slum as seen from Table 2, indicating the widespread nature of fever affecting children irrespective of their characteristics.

Table No. 2: Percentage of Children of 4 weeks old suffering from illness with fever, cough, breath faster, diarrhoea and blood in stool by Selected background Characteristics in Rafi Nagar Slum, Deonar, Mumbai.

Diarrhoea
Diarrhoea is the second most important killer of children under age five worldwide, following acute respiratory infection. Deaths from acute diarrhoea are most often caused by dehydration due to loss of water and electrolytes. Nearly all dehydration-related deaths can be prevented by prompt administration of rehydration solutions. Because deaths from diarrhoea are a significant proportion of all child deaths, the Government of India has launched the Oral Rehydration Therapy Programme as one of its priority activities for child survival. One major goal of this programme is to increase awareness among mothers and communities about the causes and treatment of diarrhoea. Oral rehydration salt (ORS) packets are made widely available and mothers are taught how to use them. This survey asked mothers of children less than three years old a series of questions about episodes of diarrhoea suffered by their children in the two weeks before the survey, including questions on feeding practices during diarrhoea, the treatment of diarrhoea, and their knowledge and use of ORS. Table 2 shows 21 percent of children under age three suffered from diarrhoea when child was of four-weeks old.

Among children of Rafi nagar slum area, age 1-35 months, those age 24-35 months are least susceptible to diarrhoea but in the study area, age 6-11 months are most susceptible. The prevalence of diarrhoea is relatively low among children of birth order four or higher, children whose mothers completed middle school, children belonging to 'Hindu and other', children belonging to SC,ST and others, and children living in households with a high standard of living. The prevalence of diarrhoea is particularly high among Muslim children in Rafi Nagar slum. Surprisingly, the prevalence of diarrhoea is same among children living in households that use Tap-own, Tap-nearby or 'Other source' water for drinking, but as expected, it is relatively low among children living in households that purify water by alum but high among those who do not use any method for purification of water in the Rafi nagar slum area.

Six percent of all children age 1-35 months (7 percent of children who suffered from diarrhoea in the two weeks preceding the survey) had Dysentery, or a symptom of dysentery in Rafi nagar slum area. In Rafi nagar slum area, the prevalence of Dysentery falls with the level of education of the mother.
Muslim children and 'Others' caste children of Rafi nagar slum area have an elevated risk of having Dysentery.

Table 3 shows percentage of children under age 3 who had illness (fever, cough, ARI, diarrhoea or diarrhoea with blood) when the child was of four weeks old, who was taken to a health facility or provider by selected background characteristics in Rafi nagar slum area.

Eighty-three percent of children in Rafi nagar slum area aged less than 12 months who suffered from illness were taken to the Goverment health facility for medical advice or treatment. 100 percent of children aged 24-35 months from both areas were taken to the Government facility. It indicates that mothers from Rafi nagar slum area are not that attentive towards seeking treatment for illness from a Government health facility when the child was less than 12 months old. A small percentage of mothers had taken their child to the private health facility and this percent is 10 when the child was 12-23 months old, in Rafi nagar slum.

Treatment seeking behaviour is least among illiterate mothers towards their children and is 81 percent in Rafi nagar slum area. Similarly the same percent for maximum is 88 percent in Rafi nagar slum area. This clearly states that mothers from Rafi nagar slum area are not availing themselves of Government. treatment facilities, available in the area for their children.

Eighty percent of Hindu mothers have availed themselves of a Government. health facility for their children which is the same as for the children of Muslim mothers from Rafi nagar area slum (81 percent).

Table 3 Place of treatment for different illness

Percent distribution of children under age 3 who had illness (fever, cough, ARI, diarrhoea, diarrhoea with blood) when the child was of four weeks old, by place of treatment, according to selected background characteristics, Rafi nagar slum, Deonar

'SC, ST ' caste category from the Rafi nagar slum area have utilized less Government. health facilities (78 percent). The same pattern is found in the case of standard of living index category. It seems that the mothers in Rafi nagar slum area are less aware and thus may be reluctant towards availing Government health facilities for their children during their illness, like fever, cough, ARI, diarrhoea, diarrhoea with blood.

Determinants of Utilization of child care services during illness: A Logistic Regression Analysis

Multivariate Analysis
The above discussion referring to Table 2, gives an idea of the relationship between utilization of child care services and the socio-economic predictor variables. However it does not control for the influence of other variables in the analysis and therefore is inadequate. Thus to see the effect of each of the socio-economic predictor variables independent of the other variables, the results of logistic regression are presented. Table 4 shows the odds ratios from logistic regression examining the effect of selected socio-economic variables on utilization of child care services. The odds ratio indicates the effect of each of the socio-economic factors on the utilization of child care services in the study area, controlling for other variables included in the model.

The odds ratio decreases with improvement in the position of the study women in respect of mother's education only in the case of child suffering from ARI, Diarrhoea and Dysentery. The odds ratio differed highly significantly by educational attainment when child was suffering from Diarrhoea. For example, the mothers who have completed middle school (7+) whose children are 63 percent less likely to suffer from Diarrhoea than an illiterate mother's children in Rafi nagar slum area whereas the odds ratio decreases with improvement in the position of the study women in respect of mother's education only, except those completed middle school (1-6) in the case of child suffering from illness with cough and ARI.

Odds ratios are not significant by religion and caste in the case of children suffering, from Rafi nagar slum area. Buddhist's children are less likely to suffer than Hindu i.e. 2 times and 5 times when child is suffering from Cough and Diarrhoea respectively.

The odds ratio also decreases with improvement in the position of the children of study women in respect of standard of living index number. Children from Medium SLI category from Rafi nagar slum area are 3 times more likely to suffer from illness Dysentery than children from low category SLI. This may be due to environmental unhygienic atmosphere in the slum.

High SLI category children are 40 percent and 33 percent less likely to suffer from illness ARI and Diarrhoea respectively than low category SLI children. Children from Medium SLI category from Ramabai nagar slum area are 22 percent less likely to suffer from illness with fever, 25 percent less likely to suffer from illness with cough, 25 percent less likely to suffer from illness with ARI, 26 percent less likely to suffer from illness with Diarrhoea and 5 percent less likely to suffer from illness Dysentery respectively than children from low category SLI.

Table 4: Results of Logistic Regression: Effect of Socio-economic variables on illness of child in the Rafi nagar slum area, Deonar