To study the Knowledge regarding immunization schedule among parents and the source of information regarding vaccination

Background: Immunization, the most cost-effective public health intervention, continues to be under-used. It is profoundly tragic that almost two million children still die each year from disease for which vaccines are available at low cost. The aim of study is to correlate parents knowledge practices and children immunization completeness. Material & Methods: A one year prospective cross-sectional study was carried out on children admitted in Pediatric ward of Kamla Nehru hospital, Gandhi Medical College, Bhopal. Total 240 cases as any of the six VPDS were studied according to a pre-designed proforma. Knowledge about vaccination, age, place and person were collected among parents and recorded along with the reason for non-vaccination. A comparison with trend five years back in the same hospital was done. Result: In present study the highest incidence was of TB 47.92% followed by tetanus, measles, diphtheria & neotetanus. Highest mortality is of tetanus neonatorum followed by tetanus, Diphtheria, Measles & tuberculosis in descending order, among 240 admitted patients. The incidence of VPDS was higher among unvaccinated child as compared to vaccinated child except tuberculosis where vaccination rate was higher (52.17%) and all VPDS were much common in illiterate fathers and mothers. Conclusion: There is a need to increase awareness and knowledge about the benefits and importance of vaccination, as well as the harmful consequences of non-complete immunization. A planned educational programme is needed; the educational level of the parents needs to be taken into consideration when the programme is planned, especially as regards those with a lower educational level.


Introduction
The six vaccine preventable diseases kill, blind, cripple and cause mental damage to about ten million children worldwide each year, Immunization of children against serious communicable diseases is the most cost effective strategy to decrease overall morbidity and mortality among children [1]. In order to accomplish this strategy, high coverage of vaccination is essential to be maintained [2]. Immunization is one of the cost effective interventions to prevent a series of major illness. It prevents 2 million deaths per year worldwide and is widely considered to be" overwhelmingly good" by the scientific community. Vaccination coverage has now reached a plateau in many developing countries and even where good coverage has been achieved; reaching the children who were yet to be vaccinated has  [3]. Factors such as knowledge, attitude and practices of parents contribute to contribute to success or failure of immunizations program. Information about knowledge, attitude and practices about immunization is lacking in developing countries [4].
VPDs contribute significantly to Under five mortality. In India Under five mortality is 68.8/ 1000 [5]. Routine immunization is one of the most cost effective public health interventions & was 1st introduced in India in 1978. Yet despite the concrete efforts of government & other health agencies, a large proportion of vulnerable infants & children in India remain unimmunized. India has the highest no. (approx. 10 million) of such children in the world [6]. National Family Health Survey (2005)(2006) reports that only 43.5% of children in India received all of their primary vaccines by 12 months of age1. Main reasons identified for poor coverage includes inadequacy of community participation in Routine Immunization & IEC activities [7]. Therefore the study was carried out to assess the level of knowledge and attitude of mothers of Under Five children regarding VPDs & routine immunization & at the same time mothers can be motivated by updating their level of knowledge regarding the importance of immunization, as the mothers of Under Five children are very receptive to advice given by doctors & paramedical staff regarding the health of the child [7,8].

Material and Methods
Total 240 cases as any of the six VPDS were studied according to a pre-designed proforma. Knowledge about vaccination, age, place and person was collected among parents and recorded along with the reason for non-vaccination. A comparison with trend five years back in the same hospital was done.
Study design-A prospective cohort observational study.
Exclusion criteria-Age more than 6years, outside admission, other vaccine preventable diseases.
Technique: The relevant information were collected from parents of the children by questionnaire method on a predesigned proforma.
Data collection: Detailed information regarding age, sex, religion, locality, month of admission, immunization status of the patient, source of vaccination, history of contact with tuberculosis and measles, clinical presentation and knowledge and practices of parents regarding immunization were recorded. Finally, the result that whether the patient was relieved or absconded or left against medical advice (LAMA) or expired was recorded. Regarding Tetanus neonatorum, the information about the immunization of mother with two doses of tetanus toxoid, place of delivery, cord care practices, clinical presentations, etc. were recorded. These data were finally depicted in the tabular form observation section.
Statistical Analysis-odds ratio and log odd ratio with chisquare test of significance were used for statistical analysis of data. Statistical test of significance was defined as p<0.05.

Results
Total 240 cases as any of the six VPDS were studied according to a pre-designed proforma. Knowledge about vaccination, age, place and person were collected among parents and recorded along with the reason for non-vaccination. A comparison with trend five years back in the same hospital was done.   Above mentioned table shows that the incidence of VPDS was higher among unvaccinated child as compared to vaccinated child except tuberculosis where vaccination rate was higher (52.17%) The above table shows that all VPDS were much more common in illiterate mothers. The above table shows that all VPDS were much common in illiterate fathers. Above table shows that highest source of information regarding vaccination are health workers followed by medical practitioners, neighbours, media then self and relatives.

Reason for non-vaccination Percentage
Lack of knowledge about vaccination, time and place of vaccination 92% Wrong idea when to vaccinate the child 36%

No faith in vaccination 21%
Time not available 18%

Child illness 26%
No male member to take for vaccination 38% Apathy 42% Above table shows that highest reason for non vaccination is Lack of knowledge about vaccination, time and place of vaccination, followed by wrong idea, no faith in vaccination and availability of time.

Discussion
It is widely accepted that childhood immunization programs have played a great part in the prevention of many diseases; hence, vaccination coverage is an indirect way to assess child health care from the point of view of public health [9]. Eighty percent of the parents were unaware that not all the vaccines are administered under the national program and there are few vaccines which are in the recommended immunization schedule and need to be taken in addition to the routine vaccines. Similar results were seen by Inamder et al in Madhya Pradesh and Angelillo et al in Italy [10,11].
Among those who have heard about the vaccine, more than half were not aware of the diseases against which the vaccine confers protection. There were many misconceptions regarding vaccine efficacy and duration of protection. Respondents were noted to be not well aware of the possible side effects of vaccines, with the exception of fever (46%), redness (22%) and pain (23%). Seizures though uncommon is an important side effect which only a meagre percent of the parents (1%) are aware of. Similar results were obtained by the EKOS research associates, Inamder et al and Tang CW et al [14,15].
92% of our patients have Lack of knowledge about vaccination, . In the study by EKOS research associates, most parents are confident in the safety of childhood vaccines, with 65% of parents rating them as highly safe, 30% rating them as moderately safe and very few saying that they are unsafe [16].
In the present study health workers are common source of information followed by medical practitioners, and neighbours. In contrast physicians are a main source of information regarding immunization accounting to 55%. Internet (14%), pamphlets at hospital (11%) and friends (13%) were the next main source of information in a study [15]. Ekos research associate showed that parents rely mostly on Internet (63%) and physicians (54%

Conclusion
The present study highlighted the knowledge of mothers on immunization. A better understanding of health issues associated with the immunization constituted a challenge for clinician and researchers. So there is a great lot scope for exploring this area.
Research should be conducted to identify the attitude and practice of mothers on immunization. Low literacy level of mothers is a matter of worry. Some of them don't know about the diseases for which their child is being immunized, So there is a dire need to arrange for health education program sessions for mothers of Under five children with main emphasis on importance of vaccination & Vaccine Preventable Diseases (VPDs).

Funding: Nil, Conflict of interest: Nil Permission from IRB: Yes
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