|BRIEF RESEARCH ARTICLE
|Year : 2014 | Volume
| Issue : 2 | Page : 116-120
Does seasonal migration for sugarcane harvesting influence routine immunization coverage? A cross-sectional study from rural Maharashtra
Abhijit P Pakhare1, Radhakishan Pawar2, Ganesh S Lokhande3, Shib Shekhar Datta4
1 Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh, India
2 District RCH Officer, Beed, Maharashtra, India
3 Taluka Health Officer, Patoda, Dist. Beed, Maharashtra, India
4 Assistant Professor, Department of Community Medicine, Mahatma Gandhi Medical College and Research Institute, Pudducherry, Tamil Nadu, India
|Date of Web Publication||12-May-2014|
Dr. Abhijit P Pakhare
Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Saket Nagar, Bhopal - 462 024, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A cross-sectional study was conducted to estimate and to compare immunization coverage and to understand reasons of partial/non-immunization among children of seasonal migrant sugarcane harvesting laborers and nonmigrating children. Caretakers of a total of 420 children between 12 and 23 months age were interviewed in 30 clusters consisting 14 children from each cluster (seven from each group) by expanded program on immunization cluster survey method. Statistical analysis was performed with proportions, their 95% confidence intervals (CI), Chi-square test, and binary logistic regression. Full immunization coverage rate was 89.5% (95% CI: 86.5-92.5) for children in nonmigrating group and 70.5% (95% CI: 66.0-74.9) for migrant group. Reasons cited for unimmunized/partially immunized were, place or time of vaccination not known, unavailability of immunization services at site, inconvenient time of sessions, unaware of need for vaccination etc. Thus full immunization coverage rate was significantly lower among children of seasonal migrant sugarcane harvesting laborers.
Keywords: Cluster sampling, Full immunization, Immunization status, Migrant laborers, Seasonal migration, Social networks, Sugarcane harvesters
|How to cite this article:|
Pakhare AP, Pawar R, Lokhande GS, Datta SS. Does seasonal migration for sugarcane harvesting influence routine immunization coverage? A cross-sectional study from rural Maharashtra. Indian J Public Health 2014;58:116-20
|How to cite this URL:|
Pakhare AP, Pawar R, Lokhande GS, Datta SS. Does seasonal migration for sugarcane harvesting influence routine immunization coverage? A cross-sectional study from rural Maharashtra. Indian J Public Health [serial online] 2014 [cited 2019 Sep 20];58:116-20. Available from: http://www.ijph.in/text.asp?2014/58/2/116/132288
Global Immunization Vision and Strategy sets a goal of protecting more people against more diseases by expanding the reach of immunization to every eligible person. Identifying and reaching the unreached people in every district is one of the key strategies to achieve this goal.  Beed district, located in Marathwada region of Maharashtra is known for large scale seasonal out-migration of laborers for sugarcane cutting (harvesting). Every year laborers migrate in October/November and return to their homes in April/May. One couple, i.e., husband and wife is considered as a working unit for sugarcane harvesting. Therefore, whole family, i.e., husband and wife, even if she is pregnant migrates along with their younger children. Their hectic lifestyle at a sugar factory site and relatively unknown area affects healthcare seeking behavior and access. Pregnant women and children below 5 year are most vulnerable groups affected and are deprived from preventive and promotive health services like antenatal care (ANC), institutional delivery, immunization sessions etc. In 2006 and 2010, wild polio virus cases were identified in Beed district.  Parents of both of these cases were migrant laborers for sugarcane cutting therefore they didn't have timely routine immunization. It has been reported that most of the RCH indicators including full immunization coverage rate are influenced by migration. ,
As per District Level Household and Facility Survey (DLHS-3), more than two-third (69%) of children aged 12-23 months received full immunization, 1% of children could not receive any vaccine. In Beed district full immunization rate was 75.7%.  Currently available coverage rates were for the whole district. However, seasonal out-migration for sugarcane harvesting is a district specific problem. Therefore, it was decided to conduct a study to estimate and compare full immunization coverage rate and to understand reasons and determinants for non/partial-immunization among children of 12-23 months of age among nonmigrants and migrants.
Cross-sectional study was carried out in Beed district of rural Maharashtra in July-2011. Study groups were migrant and nonmigrant groups comprising children of 12-23 month's age at the time of survey, who migrated along with their parents and who didn't migrate. Sample size required per group for cluster survey to test the difference in immunization coverage at 5% level of significance, 80% power (1-sided test, design effect of 2) with anticipated coverage of 85% for nonmigrants and 70% for migrants was 189. To achieve this sample size WHO-expanded program on immunization cluster sampling technique was used wherein caretakers of seven children from each group in every cluster were interviewed from 30 clusters. Seasonal out-migration for sugarcane harvesting is a phenomenon in certain villages in Beed district, wherein almost entire village migrates, therefore we have defined health sub-center as a cluster which comprises on an average four to five villages, 30 health sub-centers out of 280 were selected by population proportionate to size method. Within a cluster first village was randomly selected and first household was also randomly selected by using information of below 2 year children from R-16 register of concerned ANM. If the selected first household was not available for assessment, the interviewers proceeded to the nearest household. Then details of the study were explained to caretaker of an eligible child and informed consent was obtained before interviewing. Basic socio-demographic details, migration history, mother's use of antenatal services, delivery, the child's gender, and date of birth/age were recorded. In case date of birth was not known approximate age was estimated by probing and telescoping with major festivals or events. Immunization history was recorded from immunization card, in case the card was not available or record seemed incomplete, interviewer probed the respondent for child's immunization history. The survey team then proceeded to next nearest household seeking an eligible child. If all eligible children of that village were covered and sample size of each group was not achieved then team moved to the next village in random sequence of concerned sub-center. This process continued until desired sample size of that cluster is achieved, thus in almost every cluster two or more villages were needed to be surveyed.
Outcome measure was the proportion of children who received full immunization against six vaccine preventable diseases (VPDs) i.e., Bacillus Calmette-Guérin (BCG); three doses each of the diphtheria-pertussis-tetanus (DPT) and oral polio vaccine (OPV) at 6, 10 and 14 weeks of age; measles vaccine between 9 and 12 months of age. Hepatitis B vaccine (HBV) was introduced in routine immunization schedule in 2008 and hence we have also calculated an indicator of full immunization against seven VPDs. Immunization status was considered partial when child had missed any one dose and unimmunized when no vaccine was administered. Gender, birth order of the child; mother's age, education, occupational, history of ANC, place of delivery of the index child; father's education, occupational and family size were considered as independent variables. Statistical analysis was done by calculating coverage in proportion, their 95% confidence intervals (CIs), Chi-square and Z-test for the difference between two proportions. Binary logistic regression analysis was done separately for each group to identify determinants of partial immunization. Initially, each independent variable was regressed against dependent variable, i.e., immunization status. Those variables with a minimum P = 0.25 were considered for binary logistic regression analyses using forward step-wise method. All analyses were carried out using SPSS 17.0 (SPSS Inc., Chicago).
Ethics Committee of SRTR Medical College, Ambajogai approved the study protocol. Parents of partially/un-immunized children were advised about appropriate immunization and date of next immunization session in their village.
Migrants had distinct and statistically significant differences in socio-demographic characteristics than nonmigrants. Migrants had a higher proportion illiteracy, unskilled laborer in parents, backward class (SC-ST-OBC combined 112 [53.3%]). Full immunization coverage rate against seven VPDs for nonmigrants was 89.5% (95% CI: 86.5-92.5) and for migrants it was lesser 70.5% (95% CI: 66.0-74.9) (P < 0.001). Drop-out rates were higher in migrants, 25% for BCG to measles dose, and 12% for DPT1 to DPT3 dose (P < 0.001; Z-test) [Table 1].
|Table 1: Distribution of socio-demographic variables, immunization coverage, and drop-out rate among study groups|
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Results of binary logistic regression are shown in [Table 2]. For both groups Omnibus test for model coefficients was statistically significant (P < 0.001), while Hosmer-Lemeshow goodness of fit test was nonsignificant indicating fit of the model. Among migrant group father's education and place of delivery were identified as independent determinants, odds of being partially immunized were higher for illiterate fathers (odds ratio [OR] = 2.5, 95% CI: 1.1-5.5) and for home delivered children (OR = 3.0, 95% CI: 1.1-7.9). For nonmigrant group also father's education was identified as independent determinant in addition to mother's occupation.
|Table 2: Binary logistic regression estimates of partial immunization among migrant and nonmigrant group|
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Migrants cited multiple reasons for partial immunization which includes, place and/or time of immunization was not known to parents (36/66 [58.1%]), unavailability of immunization services at the factory site (20/66 [32.3%]), inconvenient timing of immunization session (22/66 [35.5%]) and unaware about the need for immunization (13/66 [21.0%]). Common reasons among nonmigrants were busy mother (10/22), unavailability of vaccine (8/22) etc.
Our study shows that, the immunization uptake among children of seasonal migrant laborers is significantly lower than that of nonmigrants. Full immunization coverage rate against six VPDs was 92.4% (95% CI: 89.8-95.0) among nonmigrants and 72.4% (95% CI: 68.0-76.7), (P < 0.001) among migrants. As per DLHS-3 (2007-2008) full immunization coverage rate (against six VPDs) for Beed district was 75.7%, thus this study reports higher coverage rate in nonmigrants while coverage was lower in migrants.  Time interval between DLHS-3 (2007) and this study might be the reason for higher coverage among nonmigrants in our study. Immunization coverage declined over scheduled period in both groups. Antigen-wise coverage for BCG, DPT1/OPV1/HBV1 and DPT2/OPV2/HBV2 was comparable within both groups but it was significantly lower for DPT3/OPV3/HBV3 and measles among migrant group.
Immunization coverage did not differ by gender of the child which was similar to other studies on migrants. ,, We found father's education an independent determinant in both groups. Educated males have better social networks and therefore after migration likelihood of immunization increases if the father is educated. Likelihood of partial immunization was found to be more in home delivered children, similar findings were reported by other workers. ,,,,
Lack of information about place/time of immunization sessions, inconvenient timing and unavailability of services at the site were common reason for partial immunization among migrants. In routine immunization program outreach sessions are held in villages with the help of support group involving Anganwadi Worker and Accredited Social Health Activist. However, these migrants usually live in the vicinity of sugar factories which are usually located outside the village or town also their work schedule starts from 4 am to 4 pm which makes access to outreach session of that particular village inconvenient in place and time.
As reported by Kusuma et al., low uptake of immunization can be attributed to migrants' vulnerability, marginalization and alienation in the new socio-cultural environment.  Antai has reported that the likelihood of full immunization for children of migrants is associated with the disruption caused by migration itself.  Migrants everywhere share the vulnerability resulting from limited social networks, alienation and livelihood insecurity, ,, therefore findings of this study are important and can be generalized for geographical areas from where there is a large scale out-migration for seasonal work. Thus, this study shows that seasonal migration significantly reduces full immunization coverage rate and highlights necessity of health services package specifically for migrant laborers at a convenient site and timings.
| Acknowledgment|| |
We are thankful to District Health Administration for granting permission to conduct a study. We are also thankful to staff of concerned primary health centers, sub-centers and participants of the study.
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[Table 1], [Table 2]