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Vaccination Practices And
Factors Influencing Expanded Programme Of Immunization
In The Rural And Urban Set Up Of Peshawar.
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Hamzullah
Khan (1),
Nadeem Jan (2),
Abdul Hameed (3)
Principal
author and address for correspondence:
MR HAMZULLAH KHAN
Final year MBBS, Khyber Medical College,Peshawar,
Pakistan.
Mobile: 0092-345-9283415, Email: hamza_kmc@yahoo.com,
Alternative emai: hamzakmc@gmail.com
Co-authors:
- DR NADEEM JAN,
MBBS, MPH
Country representative, Save the children, Nairobi,
Kenya.
- PROFESSOR DR ABDUL
HAMEED
Professor and head department of child health,
Khyber Medical College, Peshawar, Pakistan.
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ABSTRACT
Objectives:
to appreciate the vaccination practices
and factors influencing expanded program
of immunization in the rural and urban set
up of Peshawar.
Methods:
A cross sectional observational survey
was conducted from December 2005 to September
2006. Khyber teaching hospital was assigned
as urban setup where only respondents belonging
to the city area were selected and interviewed.
Women from Palusi village (rural area) were
included as rural sampling in the present
study. Relevant information was recorded
from the respondents with the help of a
pre-designed proforma.
Results:
A total of 440 respondents including
280(63.63%) from urban and 160(36.37%) from
rural areas were selected. Of the total
sampling, 98.57% of the urban and 86.37%
of the rural women had started vaccination
of their infants. Of the urban sampling
67.14% and rural sampling 48.12% had fully
immunized their children for polio, hepatitis
B, diphtheria, pertussis, tuberculosis,
measles and tetanus vaccination. Mother
education level in urban and rural areas
varies significantly and this has an impact
on the EPI services. Maternal education
levels were: illiterate (urban 54.64%, rural
78.75%), primary (25%, 11.87%), matriculate
(11.78%, 6.25%) while only 1(0.71%) of urban
and none in rural women had postgraduate
qualifications. Father education was: illiterate
(urban 21.78%, rural 39.37%), primary (32.85%,
24.37%), matriculate (16.85%, 16.25%), while
postgraduate qualification (7.14%, 1.25%)
recorded. Maternal occupation also influences
the EPI program in both set ups. Maternal
profession recorded was: house wife (urban
55.71%, rural 70.62%), skilled woman (25.71%,
13.75%), student (11.78%, 10%) and government
servant (6.78%, 1.8%).
Conclusion:
Starting immunization of infants in
urban and rural areas is satisfactory but
full immunization of infants is not as satisfactory
especially in the rural setup and they are
often missed in the repeated doses of vaccination.
Maternal education and occupation are the
main factors that strongly affect the immunization
of children and EPI program goals.
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Key
words: Expanded program of immunization, vaccination
of infants, urban and rural area, Peshawar
...........................................................................................................................
In Pakistan by year 2003, 82%
of one-year-old children were immunized for tuberculosis,
67% for DPT3 (Diphtheria, tetanus and pneumonia),
69% for polio, and 61% for measles. Data for children
immunized for hepatitis B vaccine is not available.1
To improve awareness and knowledge of mothers
regarding vaccine preventable diseases and the
immunization status of children under five through
health education messages, the Aga Khan University
conducted a survey that concluded that the health
education messages significantly increased the
vaccination status of children under 5 in the
intervention area.2 A total of 5486 cases of poliomyelitis
were reported in Pakistan between 1988 and 1993.
In 1994, the country joined the international
polio eradication program and has since conducted
eight national polio campaigns during which oral
polio vaccine was given to children at special
community centers throughout Pakistan under the
auspices of the Expanded Program on Immunization
3. BCG vaccination has been routinely offered
to infant Asian children since 1965. Routine BCG
vaccination in infant Asians confers useful protection
against the development of tuberculosis in childhood
4. A study on the consequences of low coverage
levels of a single dose of measles vaccine concluded
that there is a dire need to increase the immunization
coverage to reduce the rate of vaccine failure
and achieve effective control of measles 5. Another
study shows Protein-energy malnutrition remains
an important underlying cause of death among preschool
children in Pakistan. Female illiteracy, poor
household income and overcrowding and little attention
towards immunizing their children are important
risk factors for stunting. There is a prevalent
belief that in rural Pakistan, parents pay attention
to feeding male children at the cost of female
children 6. the present study was conducted to
appreciate the vaccination practices and factors
influencing an expanded program of immunization
in the rural and urban set up of Peshawar.
A cross sectional observational
survey was conducted from December 2005 to September
2006. Khyber teaching hospital was assigned as
an urban setup where only respondents belonging
to the city area were selected and interviewed.
Women from Palusi village (rural area) were included
as a rural sampling in the present study.
Inclusion criteria were all women who had at least
one child less than two years of age. Exclusion
criteria were all females with no children, unmarried
women, freshly married, and infertile women.
Relevant information was collected
with the help of a pre-designed questionnaire,
prepared in accordance with the objectives of
the study. A total of 440 respondents including
280(63.63%) from urban and 160(36.37%) from rural
area were selected. In hospital only those ladies
were selected who belong to the main city area
of Peshawar, but just to obtain the information
on our door step, our hospital was labeled as
an urban area for collecting information on immunization
practices. From the rural setup information was
collected by female medical students. Informed
consent was taken from every women and she was
assured that the information would not be disclosed.
We faced problems in getting the relevant information
from rural women because of Pushtoon culture and
taboos that specially influence our society.
The questionnaire contained
preliminary information regarding age, address
and education of the respondents. It also contained
information about the manner of immunization initiation,
history of full immunization for polio, hepatitis
B, diphtheria, pertussis, tuberculosis, measles
and tetanus vaccination in infants of urban and
rural women of Peshawar.
Finally statistical analysis
of the data was performed and association of risk
factors with breast-feeding was studied.
1. History of vaccination:
Of the total sampling 98.57% of the urban and
86.37% of the rural women had started vaccination
of their infants. Of the urban sampling 67.14%
and rural sampling 48.12% had fully immunized
their children for polio, hepatitis B, diphtheria,
pertussis, tuberculosis, measles and tetanus vaccination.
Table No I.
2. Education of the
parents and its impact on immunization of children.
Mother education level in urban and rural areas
varies significantly and this has its impact on
the EPI services. Maternal education levels were:
illiterate (urban 54.64%, rural 78.75%), primary
(25%, 11.87%), matriculate (11.78%, 6.25%) while
only 1(0.71%) of urban and none in rural women
had postgraduate qualifications. Father education
was: illiterate (urban 21.78%, rural 39.37%),
primary (32.85%, 24.37%), matriculate (16.85%,
16.25%), while postgraduate qualification (7.14%,
1.25%) recorded. Table No II.
3. Occupation of mother
and its impact of EPI program: Maternal occupation
also influenced the EPI program in both set ups.
Maternal profession recorded was: house wife (urban
55.71%, rural 70.62%), skilled woman (25.71%,
13.75%), student (11.78%, 10%) and government
servant (6.78%, 1.8%). Table No III.
Table 1. Vaccination history (N=440)
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Vaccination Started
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Number of the urban subgroup (n=280)
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Number of the rural
subgroup (n=160)
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YES
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276 (98.57%)
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139 (86.87%)
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NO
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4 (1.42%)
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21 (13.12%)
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Table 2. History
of fully immunization for polio, hepatitis
B, diphtheria, pertussis, tuberculosis,
measles and tetanus vaccination. (n=440).
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History of fully immunization for polio,
hepatitis B, diphtheria, pertussis, tuberculosis,
measles and tetanus vaccination.
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Number of the urban subgroup (n=280)
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Number of the urban subgroup (n=160)
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Infants fully immunized for polio, hepatitis
B, diphtheria, pertussis, tuberculosis,
measles and tetanus vaccination.
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188 (67.14%)
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77 (48.12%)
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Infants not yet fully immunized for
polio, hepatitis B, diphtheria, pertussis,
tuberculosis, measles and tetanus vaccination.
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92 (32.85%)
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83 (51.87%)
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Table 3. Education of the parents
(n=440).
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Education levels
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Number of the urban subgroup (n=280)
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Number of the rural subgroup (n=160)
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Mother education (n=280)
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Father education (n=280)
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Mother education (n=160)
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Father education (n=160)
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Illiterate
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153 (54.64%)
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61 (21.78%)
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126 (78.75%)
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73 (39.37%)
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Primary education
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70 (25%)
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92 (32.85%)
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19 (11.87%)
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39 (24.37%)
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Matriculate (SSc)
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33 (11.78%)
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47 (16.85%)
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10 (6.25%)
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26 (16.25%)
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Secondary Intermediate education
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16 (5.71%)
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27 (9.64%)
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4 (2.5%)
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8 (11.25%)
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Graduate
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6 (2.14%)
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33 (11.78%)
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1 (0.62%)
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12 (7.5%)
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Postgraduate qualification
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2 (0.71%)
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20 (7.14%)
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-----
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2 (1.25%)
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Table 4. Occupation of mother
and its impact of EPI program (n=440).
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Occupation of mother
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Number of the urban subgroup (n=280)
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Number of the rural subgroup (n=160)
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House wife
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156 (55.71%)
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113 (70.62%)
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Skilled women
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72 (25.71%)
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22 (13.75%)
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Government servant
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19 (6.78%)
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3 (1.8%)
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Student
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33 (11.78%)
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16 (10%)
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In Bangladesh
the various factors affecting immunization of
children were recorded. Acceptance of DPT, measles
and BCG vaccinations were the dependent variables.
The independent variables included proximity
to health facilities, frequency of visit by
health worker, respondent's mobility, media
exposure, education, age, economic status of
household, region of residence, and gender of
child 7. Girls also have poorer access to health
services than boys: in Bombay boys have immunization
rates 16% higher than girls.3 In the present
study of urban sampling 67.14% and rural sampling
48.12% had fully immunized their children for
polio, hepatitis B, diphtheria, pertussis, tuberculosis,
measles and tetanus vaccination. In Pakistan
during 1990-1999, reported coverage estimates
of children aged 0-11 months with >3 doses
of oral poliovirus vaccine (OPV3) ranged from
57%-83% (3); however, surveys in 1998 and 1999
reported <60% coverage. In 1999, coverage
by province ranged from 27% in Balochistan to
62% in Punjab, and during January-March 2000,
surveys conducted in 20 Pakistan districts indicated
OPV3 coverage of 19%-82% (median: 43%) 9. Mother
education level in urban and rural areas varies
significantly and this has its impact on the
EPI services; maternal education levels were
illiterate (urban 54.64%, rural 78.75%). Our
findings meet those of a study from India that
shows 73% of rural women of childbearing age
are illiterate 10. Educational attainments showed
a strong association with every important variable
considered, including age at marriage, fertility
behavior, the use of and demand for family planning,
number of children desired, use of antenatal
care, delivery in a health facility, vaccination
and nutritional status of children, use of oral
dehydration solution, and infant and child mortality
11. Maternal occupation also influences the
EPI program in both set ups; maternal profession
recorded was: house wife (urban 55.71%, rural
70.62%), skilled woman (25.71%, 13.75%), student
(11.78%, 10%) and government servant (6.78%,
1.8%). Research demonstrates that low-income
women are having difficulty combining work,
breastfeeding and immunization of their infants,
which has important health implications for
their infants, and that women working in administrative
and manual occupations may face special constraints
12.
Starting immunization
of infants in urban and rural areas is satisfactory
but full immunization of infants is not as satisfactory
especially in the rural setup and they are often
missed in the repeated doses of vaccination.
Maternal education and occupation are the main
factors that strongly affect the immunization
on children and EPI program goals.
- United Nation Child
Fund (UNICEF) reports 2005. The state of
the world children. Childhood under threat.
New York, UNICEF, 2005: 104-45.
- Anjum Q, Omair A, Inam Sn, Ahmed Y, Usman
Y, Shaikh S. Improving vaccination status
of children under five through health education
J Pak Med Assoc, 2004; 54(12): 610-3.
- Carbonu DM, Hashwani S, Badruddin G,
Marshall P, Fazal S. All hands against polio.
World Health Forum, 1998;19(2):188-91.
- Packe GE, Innes JA. Protective effect
of BCG vaccination in infant Asians: a case-control
study. Arch Dis Child, 1988 Mar;63(3):277-81.
Arch Dis Child
- Tariq P. Assessment of coverage levels
of single dose measles vaccine. J Coll Physicians
Surg Pak, 2003 Sep;13(9):507-10.
- Shah SM, Selwyn BJ, Luby S, Rashida A.
Prevalence and correlates of stunting among
children in rural Pakistan. Pediatrics International,2003;
45 (1): 49-53.
- BHUIYA A, CHOWDHURY M. Factor's affecting
acceptance of immunization among children
in rural Bangladesh. Health Policy and Planning,
1995; 10(3): 304-311.
- Martineau A, White M, Bhopal R. No sex
differences in immunization rates of British
south Asian children: the effect of migration?
BMJ, 1997; 314:642.
- World Health Assembly. Global eradication
of poliomyelitis by the year 2000: resolution
of the 41st World Health Assembly. Geneva,
Switzerland: World Health Organization,
1988 (resolution WHA 41.28).
- Bansal RK. Elementary education and its
impact on health. Empowers women and improves
the health of them and their children. BMJ,
1999; 318(7177): 141.
- International Institute for Population
Studies. National family health survey 1992-93:
a summary report. Bombay: International
Institute for Population Studies; 1995.
pp. 36-39.
- Kimbro RT. On-the-job moms: work and
breastfeeding initiation and duration for
a sample of low-income women. Matern Child
Health J, 2006 Jan; 10(1):19-26.
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