Original Article National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 20-26

Assessment of Immunization coverage and its

Determinants in urban slums of Raipur city, Chhattisgarh

Manuscript Reference
Number: Njmdr_232_14

Surendra Kumar PainkraA, Nirmal VermaB, Dhiraj BhawnaniC, G.P. SoniD

APost Graduate Student, Department of Community Medicine, Pt. J.N.M. Medical
College, Raipur (C.G.), India
BAssociate Professor, Department of Community Medicine, Pt. J.N.M. Medical
College, Raipur (C.G.), India
CAssistant Professor, Department of Community Medicine, CM Medical College,
Durg (C.G.), India
DProfessor, Department of Community Medicine, Pt. J.N.M. Medical College, Raipur (C.G.), India
Abstract:
Introduction: Children of today are citizens of tomorrow, which is why it is extremely
important to ensure proper health care of the children. There has been more attention
paid to improve immunization coverage especially in developing countries like India.
Despite all the efforts put by governmental as well as non-governmental institutes
for 100% immunization coverage, there are still pockets of low coverage areas. Urban
slums constitute one of the high-risk areas for the vaccine preventable diseases. The
current study seeks to describe immunization coverage and its determinants in slums
of Raipur city.
Methodology: A community based, cross-sectional study was conducted in 30
selected clusters (urban slums) of Raipur city during July 2012 to June 2013. The
sample size was 210. House to house visit was made to collect data by using
predesigned pretested proforma through interview technique. The immunization
status of children was assessed with the help of immunization cards, examination of
child and interview of mothers/caretakers.
Result: Regarding individual vaccine coverage in children, the coverage was highest
for BCG (96.67%) and lowest for OPV-3 (82.86%). For DPT-3 & measles it was
83.33% & 84.29% respectively. Majority (75.24%) of children were fully immunized.
Immunization status of childrens was significantly associated with place of deliveries,
birth order, family size, literacy of mothers, working status of mothers and ANC visit
by mother.

Date of submission: 16 March 2014

Date of Editorial approval: 21 March 2014
Date of Peer review approval: 21 July 2014
Date of Publication: 30 September 2014
Conflict of Interest: Nil; Source of support: Nil
Name and addresses of corresponding author:
Dr. Dhiraj Bhawnani,
c/o Prof. Bhawnani,

Conclusion: Overall coverage of immunization services among children aged 12-23

months were higher than National & state data. Measure should be taken to motivate
and counsel the mothers/caretakers for possession of immunization card. Scheme to
increase institutional delivery like JSY (Janani Suraksha Yojna) should be promoted.
Special campaign should be organized for working mothers at their respective
working places to improve immunization coverage.
Key words: Immunization coverage, slum, Raipur, Chhattisgarh.

Aamdi Mandir ward,

Near Digamber Jain Mandir,
Deepak Nagar, Durg (C.G.), India
E-mail: dhiraj.bhawnani@gmail.com
Mobile- +91-7869448124 & +91-9827401757
Source of Support: Nil
Conflict of Interest: None declared.

Introduction:
Children of today are citizens of
tomorrow, which is why it is extremely

20

important to ensure proper health care of

the children. The young child under 3 years
is most vulnerable to disease/ infection and
resultant disability all of which influence

National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 20-26

the present condition of a child at micro level and the future

human resource development of the nation at the macro
level [1]. Thus immunization practices should be promoted
to prevent children from various vaccine preventable
diseases.
Immunization has been one of the most significant, costeffective and stimulatory public health interventions. India,
along with the whole world, stands committed to the welfare
of children, as reflected in the theme of World Health Day,
2005, viz., Make every mother and child count [2].
The disease burden due to vaccine preventable diseases in
India was very high in 1974-79, i.e. before the start of EPI
in 1978. Nearly 6 lakh cases were reported due to vaccine
preventable diseases and this has declined 1 lakh cases of
all VPD in the year 2001. Infant mortality rate has been
declined from 104 in 1984 to 53 in the year 2008. Thus
over the last 20 years there has been decline in reported
number of cases of VPD [3].
In India 43.5% of children between 12-23 months were
fully immunized (BCG 78.%, three dose of polio 78.2%,
three dose of DPT 55.3% and 58.8% of children received
measles vaccine) (DLHS3 [4] and NFHS3 [5] 2006).
UNICEF Survey of 2009 indicated 61% of children fully
immunized, coverage for BCG 86.9%, DPT 3rd dose 71.5%,
OPV 3rd dose 70.4% and measles 74.1%.Thus the coverage
levels of primary immunization need to be improved
through well planned strategy [3].
The World Health Organization (WHO) launched the
Expanded Program on Immunization (EPI) in 1974 globally
with focus on prevention of the six childhood vaccinepreventable diseases by the year 2000. This was launched
in India January 1978 [6]. Later, on November 19, 1985,
the Universal Immunization Program (UIP) was introduced
in India with the objective to cover at least 85% of all
infants by 1990 [7]. Further, a national socio-demographic
goal was set up in National Population Policy (NPP) 2000
- to achieve universal immunization of children against all
vaccine-preventable diseases by 2010 [7].
In the last 50 years, Indias population grew two and onehalf times, but urban India grew nearly five times [8]. Most
of this growth is due to migration, leading to mushrooming
of slums. With the rapid growth of big cities, an impending
threat of outbreak of vaccine-preventable diseases always
exists due to the high population density, continuous influx

of a new pool of infective agents with the immigrating

population and poor coverage of primary immunization
in the urban slums [9,10]. In view of this, it is necessary
to understand the dynamics of utilization of immunization
services by the community. Hence the present study was
undertaken to find out the various reasons responsible for
the suboptimal coverage of immunization in the urban
slums of Raipur city. Raipur is the capital of Chhattisgarh
its 5.10 lakh population residing in the slums. A recent
annual health survey indicated that 74.1% of children aged
12-23 months were fully immunized in Chhattisgarh.
Even though fully immunization coverage is still below the
target average percentage of 85% in India, there has been
more attention paid to improve immunization coverage
especially in developing countries like India. Despite all the
efforts put by governmental as well as non-governmental
institutes for 100% immunization coverage, there are still
pockets of low coverage areas. Urban slums constitute one
of the high-risk areas for the vaccine preventable diseases
[11].
The current study seeks to describe immunization coverage
and its determinants in slums of Raipur city.

Methodology:
Study design: Cross- sectional community based study.
Study duration: July 2012 to June 2013.
Study Area: Selected slums of Raipur city.
Study population: Children of age group 12 months to 23
months residing in slums of Raipur.

Inclusion criteria:
1. Children of age 12 to 23 months residing in selected
clusters for more than 6 months.

Exclusion criteria:
1. Children of age 12 to 23 months residing in selected
clusters for less than 6 months.
2. Those are not willing to participate in the study
Sample size: 210 children.
Sampling method: 30 Cluster sampling method.

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 20-26

Study tools: Predesigned, Pretested Proforma.

Study technique: Interview technique and examination of
child
Ethical consideration: Ethical approval for study was
obtained from the institutions ethical committee. Verbal
informed consent was obtained from all participants before
examination.

50.48% respectively. Only 58.10% of mothers were found

to possess immunization card. Majority of mothers 83.33%
were of age group 20-30. Nearly 73.81% of mothers were
literates, while rest was Illiterates. Non-working mothers
were 84.29%. Most of mothers (96.1%) attended ANC
visits. The present study revealed that a majority of women
(90%) did not avail or access post natal checkup after
pregnancy (Table-1).
Table 1Background characteristics of study subjects

The study was conducted in the urban slums of Raipur City

(C.G.), India. To identify the cluster, 30 cluster sampling
were followed. 30 clusters (slums) were identified for
data collection. The sample size was as per standard
of coverage evaluation that is 210. House to house visit
was made to collect data through interview technique
after inform consent. Subsequent houses were visited till
at least 7 children aged 12-23 months were identified in
each cluster and their immunization status was recorded.
The date of birth of child was determined by immunization
card, examination of child, birth certificate or verbally by
interviewing mothers/caretakers .If mothers/caretakers
failed to tell the exact date and month of English Calendar,
then they were asked to tell exact day and date of Hindi
month or dates in relation to local festival /event and thus,
the exact date of birth was calculated for all identified
children. The immunization status of children was assessed
with the help of immunization cards, interview of mothers/
caretakers. Data from 30 clusters was collected in same
manner.

Variable
Age group of child (in month)
12-15
16-19
20-23
Sex of Child
Male
Female
Place of delivery
Home
Govt. Hospital
Private Hospital
Birth Order
1
2
3
>3
Socio Economic Status of family
Upper middle
Middle / lower middle
Lower / upper lower
Lower
Family Size
<4
>5
Immunization Card availability
Yes
No
Age group of mother (in Years)
< 20
21-25
26-30
31-35
36-40
Literacy of mother
Illiterate
Literate
Working Status of mother
Working
Non working
ANC Visit
Yes
No
PNC Visit
Yes
No

Data was compiled in MS Excel and checked for its

completeness and correctness. Then it was analyzed with
the help of epi info software and appropriate test were
applied for the statistical significant. P value of < 0.05 was
considered statistically significant for interpretation of
finding.

Results:
A total of 1308 families were visited in the present study
to cover 210 childrens. Maximum number of children
belonged to age group 16-19 months (54.76%). Majority
98.1% were females. In the present study 49.52% child
were delivered in institutional. In the birth order of child, 2
were 74.29% and >3 were 25.71%. The families belonging
to Lower/Upper lower class were found 85.24%. Family
size having family members 4 and > 5 were 49.52% and

No. (%)
51 (24.29%)
115 (54.76%)
44 (20.95%)
122 (58.1%)
88 (41.9%)
106 (50.48%)
61 (29.05%)
43 (20.48%)
83 (39.52%)
73 (34.76%)
34 (16.19%)
20 (9.52%)
4 (1.9%)
27 (12.86%)
178 (84.76%)
1 (0.49%)
104 (49.52%)
106 (50.48%)
122 (158.1%)
88 (41.9%)
23 (10-95%)
118 (56.19%)
57 (27.14%)
5 (2.38%)
7 (3.33%)
55 (26.19%)
155 (73.81%)
33 (15.71%)
177 (84.29%)
202 (96.1%)
8 (3.9%)
21(10%)
189 (90%)

Regarding individual vaccine coverage in children, the

coverage was highest for BCG (96.67%) and lowest for
OPV-3 (82.86%) for DPT3 & measles it was 83.33% &
84.29% respectively. Looking at the immunization status
of children it was found that majority (75.24%) of children
were fully immunized, 22.38% were partially immunized,
while the corresponding figure for the non immunized child
was 2.38%.(Table-2)

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 20-26

Table 2 Vaccination coverage and Immunization status among

study subjects
Variable
Vaccine coverage
BCG
DPT-1
OPV 1
DPT 2
OPV 2
DPT 3
OPV 3
Measles
Immunization status
Fully immunized
Partially immunized
Not Immunized

Table 3 Association of Immunization status of childrens with

background characteristics

No. (%)
Fully Immunized
Child No. (%)
Age group of child (in month)
12-15
37 (72.55%)
16-19
86 (74.78%)
20-23
35 (79.55%)
Sex of Child
Male
97 (79.51%)
Female
61 (69.32%)
Place of delivery
Home
72 (67.92%)
Institution
86 (82.69%)
Birth Order
1
71 (85.54%)
2
57 (78.08%)
3
19 (55.88%)
>3
11 (55%)
Socio Economic Status
Upper
4 (100%)
Middle
24 (88.89%)
Lower
130 (73.03%)
Lower
0 (0%)
Family Size
<4
89 (85.58%)
>5
69 (65.09%)
Immunization Card availability
Yes
100 (89.97%)
No
58 (65.91%)
Age group of mother in Years
Variable

203 (96.67%)
201 (95.71%)
200 (95.23%)
192 (91.43%)
191 (90.95%)
174 (82.86%)
174 (82.86%)
177 (84.29%)
158 (75.24%)
47 (22.38%)
5 (2.38%)

Fully immunized male (79.51%) were more than

female (69.32%). But there was no correlation found
between age and sex of children on immunization status.
Immunization status of children was significantly higher
amongst institutional deliveries (82.69%) compared to
that of (67.92%) home deliveries (p<0.001). Immunization
coverage was significantly better among birth order
2 as compare to birth order 3. (p<0.001) There was
no correlation found between socioeconomic status on
immunization status. Immunization status decreases
significantly with increasing of family size. (p< 0.001).
Coverage was better in case of children who had their
immunization card available (p <0.05).
Children of mothers aged 21-30 years old had the highest
vaccination coverage as compare to other age groups. 80%
of the children of literate mothers were fully immunized
which was significantly higher than that of illiterate
(61.82%) mothers (p<0.01). Greater proportion of children
of non-working mothers (80.23%) were fully immunized
than that of working(48.48%) mothers.(p< 0.001) Only
15.71% of mothers were working and the immunization
status suffered decline with working mothers. Association
between the immunization status of children and ANC
visited by mother is found to be highly significant.
(p<0.001) There was no correlation between PNC Visits of
mother on immunization status (Table-3).

< 20

15 (65.22%)

21-30
135 (77.14%)
31-40
8 (66.67%)
Literacy of Mother
Illiterate
34 (61.82%)
Literate
124 (80%)
Working Status of mother
Working
16 (48.48%)
142 (80.23%)
Non working
ANC Visit
Yes
No
PNC Visit
Yes
No

Chi square test, d.f., p

value
2 = 0.6489,df = 2, p= 0.72
2 = 2.8494,df = 1, p= 0.09
2 = 15.1157,df = 1, p<0.001

2 = 16.28,df = 3, p<0.001

2 = 7.5198,df = 3, p= 0.0571

2 = 11.8214,df = 1, p< 0.001

2 =7.07%, d.f.=1, p <0.05

2=2.0537, d.f.=2, p= 0.3581

2 = 7.2032,df = 1, p<0.01

2= 15.0415, df=1, p< 0.001

157 (77.72%)
1 (12.5%)

2 = 17.5711,df = 1, p<0.001

19 (90.48%)
139 (73.54%)

2 = 2.9081,df = 1, p= 0.08

Discussion:
In present study 75.24% children were fully immunized
which was considerably higher than national (43.5%) &
state (49%) data as per NFHS III [5] and is also higher
than the DLHS III [4] projected data of national 54% and
state 59.3% .In present study partially immunized children
were 22.38% whereas children not getting even single
vaccination (not vaccinated) were 2.38% which was lower
than the state 48% (partially immunized) and with 3%
(not immunized) average as projected by NFHS III [5].
According to DLHS III [4] data, which is, national 41.5%
(partially immunized) & 4.5% (not immunized) along with
state 38.3% and 2.4% respectively. In Study by Yadav et
al [12] fully immunized were 73.3%, Partially immunized
children 23.8% and not immunized 2.8% which is nearly

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 20-26

similar to the this study.

In the present study immunization card was available with
58.10% of the mothers of children aged 12 to 23 months
which is much higher than the data 75 projected by DLHS
III [4] (36.8%). Coverage was better in case of children
who had their immunization card available. This showed
that mothers probably were well motivated and were aware
of schedule with the help of Immunization card. The study
conducted by Gupta et al [13] and Govindarajan et al [14]
in which immunization card possession was 60% and
55% respectively which is slightly more and less than the
present study.
In present study individual vaccine coverage was observed,
BCG with coverage 96.67%, Polio vaccine 82.86%, DPT
82.86% and Measles 84.29%. NFHS III [5] shows national
coverage of BCG 78.1%, 3 doses of polio vaccine 78.1%,
3 doses of DPT vaccine 55.3%, measles vaccine 58.8%
whereas Chhattisgarh state data shows nearly 85% each
for BCG, Polio vaccine and 63% for DPT and Measles
vaccine. Also according to DLHS III national coverage of
BCG was 86.7%, 3 doses of polio vaccine 66%, 3 doses of
DPT vaccine 63.5% and measles vaccine 69.5% whereas
Chhattisgarh state data shows nearly 94.8% coverage for
BCG, 69.7% for Polio vaccine 71.4% for DPT and 79.9%
coverage for Measles vaccine. In present study findings are
higher than NFHS III (5) and DLHS III (4) projected data.
Similar results were seen in study done by Gupta et al (13)
having highest coverage for BCG 98.57% then followed
by OPV 96.34%, DPT 93.01% and least for Measles with
coverage of 87.62%.
Increasing trend in the immunization status with increasing
Kuppuswamis socio-economic class has been found (fully
immunized were 0% for class V, 73.03% for class IV,
88.89% for class III and 100% for class II) in the current
study. Similar finding was seen in many other studies like
Inamdar madhuri et al [15] in Indore district in which
37.49% coverage was seen in higher class followed by
35.68% of lower class then 26.83% of middle class. Also
study done by Mahayavanshi DK et al [16] in Sunredranagar
city of Gujarat showed similar finding as Class I,II and III
had 82.93% fully immunized whereas class IV & V had
52.87% indicating much higher immunization coverage in
higher class then lower socioeconomic class.
As children with birth order 1st were having highest
coverage that is 85.54% followed by 2nd 73%, 3rd 34% and

in case of more than 3 it was 20 percent (decreasing trend

with increasing birth order). NFHS-3 data [17] showed
a trend of declining vaccination with increasing birth
order. A small-scale study in Goa [18] also reported lower
proportion of fully vaccinated infants with higher birth
order; it was 86.6%, 88.8%, 69.2% and 75.0%; for birth
orders 1, 2, 3 and 4 respectively. The respective proportion
of unvaccinated infants was 1.1%, 2.0%, 7.6% and 25.0%.
The author did not report absolute numbers of children in
each group.
In present study family size of children and immunization
coverage showed significant association. Family with four
or less members had better immunization status (85.5%)
in comparison with family having five or more members
(65.09%).Similar finding was seen in a survey of Goa
[18], the immunization status was related to the size of the
household; 98.4% infants in households with less than 3
members were fully vaccinated, compared to 85.4% with
household size 3-6; and 68.0% with household size greater
than 6. From the above studies it can interpreted that as
family size increases the immunization status worsen,
it may be due to increase in financial burden leading to
cutting in health expenditure also increase in work load on
mother and family leading to children getting less attention
and care than usual .
In present study immunization status of male (79.51%)
was better than that of female (69.32%). Similar trend was
noticed in NFHS-III [17]. The UNICEF (2005) survey
across 22 states (including combined data for 7 north-east
states) reported complete vaccination among 53.9% female
infants compared to 55.1% males [19]; however no tests for
statistical significance were performed.
Proportion of fully immunized children were higher for
literate mother (80%) and father (81%) in comparison to
illiterate mother (61.82%) and father (47.06%).A survey
in West Bengal(20) reported complete vaccination among
61.2% infants with literate mothers and 37.8% with illiterate
mothers; it was 59.9% for infants of literate fathers and
37.6% with illiterate fathers. A study in Goa [18] reported
that amongst uneducated mothers, 70.8% infants were fully
vaccinated. In contrast, 91.2%, 90.7% and 100% of infants
of mothers with primary, secondary and graduate level of
education respectively had received complete vaccination.
In current study association between place of delivery
and immunization status was seen as institutional delivery

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 20-26

having higher proportion of fully immunized children

(82.69%) in comparison to home delivery which was
67.92% and this association was statistically highly
significant. Similar finding were also observed in study
done by Kulkarni and chavan [20] and Nath bhola et al
[21].

Acknowledgement:

In present study it was observed that mothers having ANC

and PNC visit had higher percentage of fully immunized
children 77.72% and 90.48% respectively compared to
12.5% and 73.54% for those who did not ANC & PNC
visits respectively, whereas not or partially immunized
among them was 22.28% and 9.52%.Similar finding was
observed in study done by Mutua K Martin et al [22] in
Nairobi, Kenya showing recipient of ANC and PNC care
were associated with full immunization of their children.

References:

We are thankful to all faculties of department of community

medicine, Pt. J.N.M. medical college, Raipur (C.G.), for
their assistance during the study.

1. Children in India 2012-a statistical appraisal, Social

Statistics Division Central Statistics Office Ministry of
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3. Sunderlal text book of community medicine 3rd edn.pg
no (533,537)

Conclusion:
Overall coverage of immunization services among children
aged 12-23 months was higher than National & state data
as per NFHS- III and DLHS III for urban slums of Raipur
city. Looking into the observations, following measures
are being suggested to enhance and sustained complete
immunization coverage1. Measure should be taken to motivate and counsel the
mothers/caretakers for possession of immunization
card.
2. Scheme to increase institutional delivery like JSY
(Janani Suraksha Yojna) should be promoted.
3. Small family norm allows increased care of children
and thus increases immunization status, thus family
planning should be made a part of immunization
coverage strategy.
4. Special campaign should be organized for working
mothers at their respective working places to improve
immunization coverage.
5. Study can be conducted on a broad scale at state and
national level in general population.

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21st ed.M/s Banarsidas Bhanot Publishers 1167, Prem
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2008.

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Survey-1044_2.pdf. Accessed on 27 December 2011.
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R Ettarh, Childhood vaccination in informal urban
settlements in Nairobi, Kenia: Who gets vaccinated?
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