Factors Associated with Routine Childhood Vaccine Uptake and Reasons for Non-Vaccination in India: 1998-2008

"...efforts to increase uptake should address parental fears related to vaccination to improve trust in government health services as part of ongoing social mobilization and communication strategies."

The Government of India launched the Universal Immunization Program (UIP) in India back in 1985, but, today, the proportion of children aged 12-23 months receiving the full schedule of vaccinations in India is only around 61%. In particular, demand-side factors associated with routine vaccination uptake are complex and often multi-faceted. In light of the Indian Government's aim to boost full immunisation coverage of UIP vaccines to 90% through the Mission Indradhanush initiative by 2020, this study examined socio-demographic factors associated with partial-vaccination and non-vaccination and the reasons for non-vaccination among Indian children during 1998 and 2008.

The pooled dataset (pre-existing, nationally representative datasets from 3 rounds (1998-99, 2002-04, and 2007-08) of India's District Level Household and facility Survey, or DLHS) contained information on 178,473 children 12-23 months of age; 53%, 32%, and 15% were fully vaccinated, partially vaccinated, and unvaccinated respectively. Compared with the 1998-99 survey, children in the 2007-08 survey were less likely to be unvaccinated (adjusted prevalence odds ratio (aPOR): 0.92, 95% confidence interval (CI) = 0.86-0.98) but more likely to be partially vaccinated (aPOR: 1.58, 95%CI = 1.52-1.65). Vaccination status was inversely associated with female gender, Muslim religion, lower caste, urban residence, and maternal characteristics such as lower educational attainment, non-institutional delivery, fewer antenatal care (ANC) visits, non-receipt of maternal tetanus vaccination, and non-retention of children's vaccination cards.

Across the 3 surveys, the most frequently occurring reason for non-vaccination was that mothers were "unaware of the need for immunization". Other noteworthy reasons were not knowing the place for and timing of vaccinations, fear of side effects, access to immunisation facilities ("place of immunization too far"), and the absence of health workers ("ANM [Auxiliary Nurse Midwife] absent"). Over the 10 years spanning the surveys, issues of poor parental awareness (regarding the need for and place and timing of immunisations), acceptance of vaccines (including fear of side effects, lack of trust, and false contraindications), and affordability (financial and non-financial costs) were the most important underlying reasons for non-vaccination. These findings suggest that communication strategies to increase immunisation coverage focusing on improving parental knowledge alone may not be sufficient to change vaccination behaviour.

Reflecting on the findings, the researchers observe that the pathways through which maternal characteristics may influence immunisation decisions for children are complex. For example, previous research from India highlights the role of health knowledge and the ability to communicate in mediating the effect of maternal education on childhood immunisation decisions. It is unclear if the associations between religion and caste with children's vaccination status represent differential access to routine immunisation services or perceived barriers, health beliefs, and lack of awareness regarding vaccinations in general. Thus, they call for further research disentangling the role of supply-side and demand-side barriers to immunisation and investigating the causal pathways through which important maternal and social characteristics influence decision-making for childhood vaccinations in order to inform governmental interventions to improve uptake of routine vaccination in India.

The researchers suggest that past and recent reports of vaccine refusal related to the oral polio vaccine (OPV) and diphtheria-pertussis-tetanus (DPT) vaccines from different parts of the country and clustering of vaccine-refusing households can provide some insights on other dynamics affecting vaccine decisions. Expanding and leveraging the successful Social Mobilization Network (SMNet) approach used in the National Polio Eradication Programme, incorporating the use of local religious leaders and community influencers, may improve trust between parents and health providers. The Indian UIP may also consider parental time constraints through the organisation of regular catch-up sessions for missed vaccinations and the wider use of mobile immunisation reminder services such as the "vRemind" and "IAP-ImmunizeIndia" to help reduce India's immunisation gap.

In conclusion: "Efforts to increase vaccine uptake should address parental fears related to vaccination to improve trust in government health services as part of ongoing social mobilization and programmatic communication strategies."