Research Article

A Community-Based Study of Coverage and

Determinants of Immunization in Children
Aged 1 to 3 Years in a Rural Population
of Muzaffarnagar
Pradeep Kumar Choudharuy1, Nirankar Singh2, Sanjeev Davey3, Santosh Kumar Raghav4

Abstract
Background: The year 2012-13 was declared as ‘Year of intensification of Routine Immunization (IRI)
in India’. As per CES, DLHS and AHS, full immunization for the children of age group of 12–23 months
of Uttar Pradesh is 30.2 (DLHS 2007), 40.9 (CES 2009) and 45.3 (AHS 2010-11). Studies have been
done to assess the primary immunization status, i.e., BCG, OPV3, DTP3 and measles. Data on the
booster doses and additional vaccine is insufficient.

Objectives: To assess the status of full Immunization, complete immunization and the status of
immunization with regard to different vaccine and reasons for partial and no immunization.

Design and Methodology: A community-based cross-sectional study was done (1stApril 2015 to 31st
march 2016) in the field practice area of rural health and training center (RHTC) of Muzaffarnagar
Medical College, Muzaffarnagar. 50% of the villages, i.e., 2 villages (Bilaspur, Shernagar) were
selected by simple random sampling technique and the age group selected was one to three years of
age. The data was analyzed using MS Excel sheet and the software used was software Epi-info
version 7.1.3.

Results and Conclusion: Full immunization in the age group of children between 12 and 23 months
was 66% with antigen coverage maximum for BCG (93%) and lowest for measles (68%). Reason for
partial and unimmunized children was majorly due to non-availability of vaccine at the center
followed by fear of AEFI. Complete immunization in the age group between 24 and 36 months was
46% with MCV 2 coverage being the lowest (33%). Full immunization in the age group of 24–36
months is significantly more than 12–23 months age group. Tendency is to have less and less
immunization as the age of the child grows (P<0.05).

Keywords: Immunization, Rural area, Children

1
PG Student, 2Professor, 3Ast. Professor, 4Satiastician cum Lecturer, Department of Community Medicine, Muzaffarnagar Medical
College, Muzaffarnagar, UP.

Correspondence: Dr. Pradeep Kumar Choudharuy, Muzaffarnagar Medical College, Muzaffarnagar, UP.

E-mail Id: docprdp@yahoo.com

Orcid Id: http://orcid.org/0000-0002-4530-1558

How to cite this article: Choudharuy PK, Singh N, Davey S et al. A Community-Based Study of Coverage and Determinants of
Immunization in Children Aged 1 to 3 Years in a Rural Population of Muzaffarnagar. Epidem. Int. 2017; 2(1): 3-9.

ISSN: 2455-7048

© ADR Journals 2017. All Rights Reserved.

Choudharuy PK et al.
Introduction
The Greek word “immune” means “to be protected”.
The process of introduction of various antigens or ready-
made antibodies is known as “immunization”.1 The first
successful vaccine in modern era was developed by
Edward Jenner in 1796 when he used cowpox
inoculation to protect against smallpox. Experience with
smallpox eradication program convinced the health
policy makers that immunization is the most powerful
and cost-effective measure for control preventable
diseases.1
Since the Millennium Summit in 2000, immunization has
moved center stage as one of the driving forces behind
efforts to meet the Millennium Development Goals
(MDGs) in particular, the goal to reduce deaths among
children under five years old (MDG 4). In developing
countries, more vaccines are available and more lives
are being saved. For the first time in documented
history, the number of children dying every year has
fallen below 1 million which can be attributed to
improved access to clean water and sanitation,
increased immunization coverage, and the integrated
delivery of essential health interventions. Despite
extraordinary progress in immunizing more children
over the past decade, in 2007, 24 million children
(almost 20% of the children born each year) did not
complete routine immunization scheduled for their first
year of life. WHO has estimated that if all the vaccines
now available against childhood diseases were widely
adopted, and if countries could raise vaccine coverage
to a global average of 90% by 2015, an additional two
million deaths a year could be prevented among
children under five years of age.
The Government of India launched Expanded Program
on Immunization in 1978, with the objective of reducing
mortality and morbidity resulting from vaccine-
preventable diseases of childhood and to achieve self-
sufficiency in the production of vaccines. Universal
Immunization Program was launched in 1985.
It has two vital components: immunization of pregnant
women against tetanus and immunization of children in
their first year of life against the six vaccine-preventable
diseases. Significant achievements have been made
under this program. In 1985, vaccine coverage ranged
between 29% for BCG and 41% for DPT. By the end of
2008, coverage levels have gone up significantly (87%
for BCG, 66% for DPT 3 doses, 70% for measles and 67%
for OPV 3 doses). The vaccination coverage is better in
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Epidem. Int. 2017; 2(1)
Muzaffarnagar. According to the DLHS-3 survey, fully
immunized children are 29.3%, BCG coverage is 73%,
OPV3 39.3% and DPT 3 coverage is 37.8% and measles
coverage is 45.7%.2 However, the NFHS-3 report reveals
that the coverage of fully immunized children has
increased instead of decline over the few years.
Apart from the vaccines in National Immunization
Schedule, the extra vaccines in the immunization
schedule of Muzaffarnagar are Hep-B vaccine given at
birth and 6, 10 and 14 weeks, MMR vaccine given at 15
months and Typhoid vaccine between 2 and 5 years of
age.2 Very few studies show the reasons behind the
decline of immunization coverage in Muzaffarnagar as
brought out byNFHS-3 report. There is a paucity of
studies showing the coverage of DPT booster, OPV
booster, MMR booster and other newer vaccines which
are not included in the National Immunization Schedule.
Very few studies have been conducted to find out the
proportion of children not fully vaccinated for age
(FVFA) and causes for the same.
Therefore, the current study was conducted with the
objective of assessing the immunization coverage of a
rural population of Muzaffarnagar, the determinants
affecting it, knowledge, attitude and practices of
respondents and the status of timely immunization.
Materials and Methods
The study area was rural population of Muzaffarnagar. It
was a rural field practice area of Department of
Community Medicine, Muzaffarnagar Medical College,
Muzaffarnagar. The villages had 1730 families,
registered at Rural Health Training Center (RHTC). The
total population of villages was 10,365. A community-
based cross-sectional study was carried out from April
2015 to March 2016. Two villages were included for the
present study in the field practice area of RHTC. Total
number of registered families residing in these two
villages was 1730, with a population of 10,365 (Bilaspur-
8142 and Shernagar-2223). A total of 617 children
between 1 and 3 years of age were taken for the study
by house to house survey.
As per Coverage Evaluation Survey-2009 (CES-2009), the
coverage of 40.5% was considered for calculation of
sample size for the study. Permissible error of 10% of
the prevalence rate was taken which gave a sample of
588 using formula 4PQ/L.2 Taking 5% of the non-
response rate, a total of 617 children were included in
the study.
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Epidem. Int. 2017; 2(1) Choudharuy PK et al.

Results was not present then father was interviewed and this
revealed following sociodemographic data. As shown in
Sociodemographic Profile of the Study Population Table 1, majority of the children were in the age group
12–23 months (58.8%); rest were 24–36 months of age
Every effort was made to interview the mother as she is 263 (42.0%).
the primary caregiver to the child but in case the mother
Table 1.Sociodemographic Profile of the Study Population
S. No. Characteristics No. %
1. Age of children (Months) 12–23 354 58.0
24–36 263 42.0
Total 617 100.0
2. Sex Male 321 52.0
Female 296 48.0
Total 617 100.0
3. Religion Hindu 259 42.0
Muslim 358 58.0
Total 617 100.0
4. Mother’s education Illiterate 108 17.5
Primary 60 9.7
Middle 157 25.4
High school 145 23.6
Intermediate 10 1.6
Graduate & above 137 22.2
Total 617 100.0
5 Mother’s working status Housewife 578 93.7
Working 39 6.3
Total 617 100.0
6 Father’s education Illiterate 71 11.5
Primary 29 4.7
Middle 112 18.2
High school 284 46.0
Intermediate 6 1.0
Graduate & above 115 18.6
Total 617 100.0
7 Father’s occupation Unemployed 29 4.7
Unskilled worker 216 35.0
Skilled worker 72 11.7
Self employed 154 25.0
Service 146 23.6
Total 617 100.0
8 Type of family Nuclear 275 44.6
Joint 342 55.4
Total 617 100.0
9 Socio economic status* Upper-I 3 0.5
Upper middle-II 42 6.8
Middle-III 236 38.2
Lower middle-IV 281 45.6
Lower-V 55 8.9
Total 617 100.0
*Modified B.G. Prasad classification

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Choudharuy PK et al. Epidem. Int. 2017; 2(1)

Regarding gender of the child, most children were male as compared to nuclear families 275 (44.6%). According
321 (52.0%); rest were female 296 (48.0%) majority to modified B.G. Prasad classification for rural areas, 3
were Muslim 358 (58%) and rest were Hindu 259 (42%). (0.5%) families were in upper socioeconomic class, 42
Mothers of children 108 (17.5%) were illiterate, 509 (6.8%) in upper-middle and 236 (38.2%) belonged to
(82.5%) were literate. On the other hand, amongst the middle class.
fathers 71 (11.5%) were illiterate, 141 (22.9%) had
education up to middle school, 284 (46%) were high Characteristics of the Study Children
school pass, 115 (18.6%) were graduate and above.
Amongst father’s occupation, unemployed were 29 Immunization Status of study children
(4.7%), unskilled workers were 216 (35.0%), skilled
The full immunization coverage was found to be 66%,
workers were 72 (11.7%), self-employed were 154
partial immunization coverage was 32.1% and
(25.0%) and service were 146 (23.6%). Amongst the
unimmunized were 1.9% and fully vaccinated for age
families, more than half were joint families 342 (55.4%)
were 44.9%.
Table 2.Immunization Status of Study Children
S. No. Immunization Status No. %
1 Unimmunized 12 1.9
2 Partially immunized 198 32.1
3 Fully immunized 407 66.0
Total 617 100.0
4 Fully vaccinated for age(FVFA) Yes 277 44.9
No 340 55.1
Total 617 100.0

Immunization Status in Different Age and appreciated from this table, full Immunization in the age
Gender group of 24–36 months is more (72.6%) than 12–23
months age group (61%). So there was less and less
Table 3(a) shows the immunization status of children immunization as the age of the child increased.
belonging to different age groups. As can be easily
Table 3(a).Immunization Status of Children in Different Age Groups
Age Group Full Immunization Partial Immunization No immunization Total
No % No % No % No %
12–23 months 216 61.0 131 37.0 7 2.0 354 57.4
24–36 months 191 72.6 67 25.5 5 1.9 263 42.6
Total 407 66.0 198 32.1 12 1.9 617 100
(% calculated in row-wise)

As depicted in Table 3(a), greater number of children
were present in the age group 12–23 months (57.4%)
than 24–36 months (42.6%).
Out of 321 males, 221 (68.8%) were fully immunized and
rest 100 (31.2%) were partially immunized. Out of the
296 females, 186 (62.8%) were fully immunized, 98
(33.1%) were partially immunized and 12 (4.1%) were
unimmunized as shown in Fig. 1.
Since the proportion of unimmunized children is too
small, so for further analysis the number of partial and
unimmunized children has been clubbed together. The
full immunization of children were 407, partially
immunized were 198 and unimmunized were 12, fully
vaccinated for age were 277 and not FVFA were 340
(Table 4).

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Epidem. Int. 2017; 2(1) Choudharuy PK et al.

Figure 1.Immunization Status of Study Children (N=617)

Gender-wise Distribution of Various Characteristics of Study Children (FVFA)

Table 4.Immunization Status of Study Children as per Gender of Children
S. No. Characteristics Male Female Total
No. % No. % No. %
1 Fully vaccinated for age (FVFA)* Yes 135 42.1 142 48.0 277 44.9
No 186 57.9 154 52.0 340 55.1
Total 321 100.0 296 100.0 617 100.0
2 Age 12–23(m) 187 58.3 167 56.4 354 57.4
24–36(m) 134 41.7 129 43.6 263 42.6
Total 321 100.0 296 100.0 617 100.0
3 Place of Immunization SC 270 84.1 238 80.4 508 82.3
PHC 15 4.7 27 9.1 42 6.8
CHC 32 10.0 17 5.7 49 7.9
DH 4 1.2 14 4.7 18 2.9
Total 321 100.0 296 100.0 617 100.0
(% is calculated by column-wise)

FVFA is a child more than 1 year of age who has
received all primary vaccinations (BCG, 3 OPV, 3 DPT, 3
Hep B and measles) within one month of due date.
Untimely immunization is taken as more than one
month delay in getting the child immunized. Out of the
407 fully immunized children, 277 (44.9%) were FVFA
(Table 4).
females whereas in age group 24–36 they were 263
(42.6%) out of whom 134 (41.7%) males and rest 129
(43.6%) were females, maximum number of children
immunized at SC were 508 (82.3%) whereas minimum
immunized at district hospitals were 18 (2.9%).
Status of Place of Immunization

In case of fully vaccinated for age, there were 277
(44.9%) children whereas children who were not fully
vaccinated for age were 340 (55.1%), total number of
children in age group 12–23 were 354 (57.4%), out of
whom 187 (58.3%) were males and 167 (56.4%) were
As seen from Fig. 2, majority of study children (82.3%)
got vaccinated from SC. Rest got immunized from health
center (PHC/CHC) (14.7%), and few at district hospital
(2.9%).

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Choudharuy PK et al.
Figure 2.Distribution of Study Children by Place f Immunization
Discussion
Over the past few years, the immunization coverage of
the country has improved, but the improvement has
been much slower than that seen in other countries
with similar demography. The immunization coverage in
rural areas is much lower than in urban areas. The study
was, therefore, carried out because there is a paucity of
recent studies done on immunization coverage and its
determinants in rural population of Muzaffarnagar. Also,
very few studies have been done on timeliness of
immunization.
The present study was carried out with an aim to assess
the immunization coverage of rural area of
Muzaffarnagar, to know about the knowledge, attitude,
and practices of the respondents and to study the
factors affecting partial and non or untimely
immunization. Mostly the studies to determine the
immunization coverage usually adopt the standard WHO
30-cluser sampling method. But in the present study,
universal coverage was done as the population of the
village was small and it was feasible to enumerate all
eligible children. Also, since the area was being catered
by the institution’s health center so it was easier to see
how the services were affecting the immunization
coverage and where does a rural population stand in
terms of its immunization coverage.
Conclusions
The cross-sectional study was done in two villages
Bilaspur and Shernagar that are catered by the Rural
Health Training Center (RHTC) of Muzaffarnagar Medical
College. These villages have a total population of
approximately 10,365, out of which 617 were eligible
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Epidem. Int. 2017; 2(1)
children, all were included in the study. The primary
immunization coverage of Bilaspur and Shernagar was
66%. The knowledge about various diseases, however,
was low amongst respondents and even lower was the
knowledge about the correct immunization schedule.
The factors like gender of child and occupation of
parents did not hinder immunization. The factors
associated with full immunization status were:
availability of immunization card, education of parents
above primary school, joint family, SES (above lower)
and TT immunization of the mother. The significant
determinants of partial and non-immunization status
were: family type (joint), absence of immunization card,
no tetanus immunization of the mother.
A striking difference was seen between children
immunized at SC and other places. The proportion of
children receiving timely primary immunization (FVFA)
was quite low (44.9%), the most important
determinants being the knowledge about immunization
schedule and mother’s education. The most common
reasons of partial and non-immunization, as stated by
respondents were unawareness, visit to field, loss of
card and no one to take the child. The common reasons
of untimely immunization were unawareness, no one to
take the child, visit to field, busy respondents.
Conflict of Interest: Nil
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Date of Submission: 02nd Feb. 2017
Date of Acceptance: 23rd Feb. 2017