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 Table of Contents  
Year : 2019  |  Volume : 63  |  Issue : 4  |  Page : 334-340  

Immunization coverage among under-five children living along a school student through child-to-child and child-to-parent information, education and communication strategy

Professor and Principal, Pravara Institute of Medical Sciences (DU), CON, Ahmednagar, Maharashtra, India

Date of Web Publication18-Dec-2019

Correspondence Address:
Dr. Radha Vaidyanathan
Pravara Institute of Medical Sciences (DU) CON, Loni (Bk), Ahmednagar - 413 736, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_424_18

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Background: In spite of being a principal producer and exporter of vaccines and billions spent over decades, India is home to one-third of the world's under-five children (U5C) with no immunization. Objectives: The objective of this study was to find the outcome of child-to-child and child-to-parent Information, Education and Communication (IEC) strategy on the current percentage of immunization coverage (IC). Methods: A mixed design research with multilevel concurrent sampling was conducted in Pune. Based on school students' households, 44 clusters having U5C were divided randomly into 11 experimental/control groups each. IEC strategy to students was independent variable and IC among U5C was dependent variable. Data were collected from 1092 students and 2352 U5C parents over 6 years. Vaccination card and Bacillus Calmette–Guérin mark were considered as evidence to conclude on full, partial and no IC. Change in knowledge quotient (KQ) among students/parents and U5C IC before and after IEC strategy assessed. Results: Rural/urban age-appropriate full IC of U5C was 51% and 67% before and 88% and 85% in post-IEC, respectively. The mean KQ change score of 8–12/20 in students is likely to increase full IC by 37% and 18%, decrease partial coverage at 14% and 12%, and improve none coverage at 23% and 16%, from its existing level positively in experimental groups. Numerous factors discouraged parents to pursue their U5C immunization. Conclusions: Advocacy through school students can be an economically viable alternative marketing strategy for inadequate U5C IC than billions spent on treating vaccine-preventable diseases and impractical options.

Keywords: Child to child and parent, immunization coverage, information-education and communication strategy, knowledge quotient, school students, under-five children

How to cite this article:
Vaidyanathan R. Immunization coverage among under-five children living along a school student through child-to-child and child-to-parent information, education and communication strategy. Indian J Public Health 2019;63:334-40

How to cite this URL:
Vaidyanathan R. Immunization coverage among under-five children living along a school student through child-to-child and child-to-parent information, education and communication strategy. Indian J Public Health [serial online] 2019 [cited 2023 Mar 20];63:334-40. Available from:

   Introduction Top

Among the 27 million children born each year in India, 44% only receive a full schedule of vaccines.[1],[2] It is paradoxical that in spite of India being a principal producer and exporter of vaccines, it is home to one-third of the world's under-five children (U5C) with no immunization.[3] Multipronged efforts on advertisements and awareness programs have attained a saturation point in creating an impact with masses on immunization messages. Alternative strategies [4],[5],[6],[7] may have to be accelerated in order to improve current immunization coverage (IC) rate.

No regulations, laws, or fines exist in India to prevent parents who increase their nonimmunized children's vulnerability to preventable infectious diseases in a country where vaccine-preventable diseases (VPDs) are accountable for more than 5 lakh deaths annually still.[8] Who will sway the decisions of such vaccine-hesitant parents? A tangent focus is hence imminent to approach the problem. School students constitute 16%–20% of India's population and are also its future citizens. As adolescents, they impact parents and peers considerably and can link up neighbors too. As peer group influence is at a high, it can be an intelligent administrative whack that health information endowed with few students can reach others easily and effectively on a mass level. There are limited researches on its impact with evidence. This study aimed to assess the existing IC rate among U5C living along a school student with documentary/physical check evidence and evaluate outcome of IEC strategy on immunization to school students upon current IC percentage.

   Materials and Methods Top

Study design and participants

The study adopted a mixed design of experimental (randomized parallel block design for recruiting homogeneous group with less variability), evaluation, and action research. The CONSORT research protocol as per [Figure 1] was established at the commencement of the study and diligently followed.
Figure 1: CONSORT research protocol.

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School students having U5C in their own household or immediate neighborhood with parents were eligible to participate in the study and enrolled. Those students who were willing to give IEC to parents/neighbors as well attended all 6-day sessions of IEC strategy were randomly selected through multilevel concurrent sampling. This study had two questionnaires as tools – Tool I (structured) for school students and Tool II (part tool of the Coverage Evaluation Survey (CES) 2009 vetted by the UNICEF and Technical Advisory Committee to Govt of India) to parents of U5C for data collection. Tools were found to be strongly valid and reliable.


The setting was in rural and urban areas of Pune (Maharashtra, India) on the basis of geographical contiguity with household location of school students. A random number table was prepared till occurrence of the highest number both for rural and urban; then, through public lottery pick method, two schools were selected for each for selecting primary samples called as primary sampling units (PSUs), i.e., school students. By arbitrary allocation, number was given to each household location of PSUs, and this formed a “cluster” (called as “wasti” locally). In each cluster, a list of all U5C around a PSU was generated and called as secondary sampling units (SSUs). Then, by random selection, a total of 44 clusters were picked by public lottery and equally allocated to experimental and control groups. Both participant samples and interviewing auxiliary nurse midwives (ANMs) (outcome assessors) were blinded on intervention allocation arms.

Data collection process and sample size

A pilot study of 3 months followed by data collection was done in four phases as per the set algorithm in research protocol from February 2012 to July 2018. Tool I was used for PSUs to assess their awareness on immunization (pretest and posttest with 0–20 marks), and Tool II was used to interview parents for assessing IC of SSUs. All National Family Health Survey-3,[9] District Level Household and Facility Survey-3,[10] and CES 2009[11] coverage percentages were taken as reference values (with 10% for attrition) for estimation of sample size for SSUs. It was calculated with the formula:

n = D* z 21-ά/2 × P × (1-P)/d 2 where

  • n = Required sample size
  • Z1-ά/2 = Z-score corresponding to “ά” level of confidence, i.e., ±1.96
  • d = Permissible margin of error in the estimate (5%)
  • P = Assumed value of the indicator (50%)
  • D = Design effect (1.5)

Researcher visited each household before and after intervention as per research protocol. Eight ANMs working in SVP Cantonment Hospital Pune and 10 ANMs of Loni Kalbhor Primary Health Center (PHC) interviewed parents on subsequent days in rotation. All were familiar with local dialect and proficient in English/Marathi/Hindi. Research in each cluster was carried out in teams. Each team had two ANMs in rotation with researcher. Assignment of PSUs to teams and various logistical decisions was made by a researcher. Each team was to make a minimum of three callbacks, if no informant was available in a household for interview at the time of visit. Each data was examined for completeness and all clarifications if any were made promptly by spot checks. If discrepancy was observed, then interviewers were required to revisit respondent again to rectify. Field data were entered directly from precoded completed questionnaires into computers simultaneously using a Computer aided parent interview and data entry (CAPIDE) method by a researcher, with the help of handheld laptop.

Training of ANMs on interview protocol was conducted by a researcher (UGC recognized professors of 31 years' experience in teaching health team members at different levels) with regard to the method of data collection in their respective location. The team was trained on obtaining information from mothers' memory recall, appropriate filling of pro forma, inspection of scar mark of Bacillus Calmette–Guérin (BCG) at left upper deltoid region, checking immunization card, making tally of households, etc. Apart from that, field exercise was given to each ANM to fill Tool II. Training and selection of interviewers involved classroom teaching, practice sessions, and simulation sessions at PHCs and in community. The purpose of these sessions was to ensure uniformity in data collection procedures. Those ANMs who were able to achieve the satisfactory level of performance only were included, intensely monitored in a participatory manner by an investigator in field.

Vaccination card and BCG scar mark were considered as evidence to conclude on immunization status (dependent variable) into full, partial, or none coverage appropriate to age. Standardized structured IEC strategy on immunization (independent variable) was the additional intervention given only to experimental group PSUs as per standard algorithm established, whereas ongoing routine propaganda by GOI, media, etc., was common to control group PSUs as well. IEC strategy included structured training sessions on meaning of immunization, VPDs with pictorial posters, story reading of “Meena comic cartoon of UNICEF - ” by a PSU, listing venue for vaccination, discussion on age-specific vaccines using placards and take home leaflet on immunization schedule [Figure 2]. Data were collected from 1092 PSUs and 2352 SSUs' parents (at least 2 years for each SSU, from the time of entry into the study by when they were expected to receive primary and booster doses of mandatory vaccines till 5 years of age). Change in knowledge acquired from IEC strategy which is called as knowledge quotient (KQ) scores of PSUs, parents, IC status of SSUs, factors contributing were assessed.
Figure 2: Information, Education and Communication Strategy protocol.

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Ethical clearance was obtained from the institutional ethics committee. Permission was obtained from Chief Executive Officer (CEO) Camp, PHC, District Education Officer (DEO), District Health Officer (DHO), Zilla Parishad of Pune, principals of schools, and Village Panchayat of Loni to carry out the study. Written consent from mothers of students, U5C, and assent from school students was included in study. Even as no drugs or invasive procedures were involved, the study was registered following the WHO guidelines for randomized trials in PIMS University registry (PMT/PIMS/RC/5/2012/144) which is the institutional monitoring agency.

Statistical analysis

The power of study at 0.9 and CI of 95% was selected as a target level. Content (qualitative) data analysis was done for categorization of verbal data responses. Software used for analysis was Bio Medical Data Processing package (Ku Leuven, 2016, Nederlands) and InStat 3 version (Graphpad software, 2018 Free Trial, CA). For comparing ratio variables, normality test (KS) was applied. If data passed test for both the groups, “t” test was applied for testing significance of difference. Otherwise, appropriate nonparametric tests were applied. Effectiveness of IEC strategy were analyzed using mean, standard deviation, Chi-square, degrees of freedom, “Z” test and RIDIT analysis. Hypothesis testing was obtained using Chi-square statistics, Pearson's correlation coefficient (linear), and Spearman's rho (monotonic), and statement level of significance (P < 0.05) was maintained.


IEC strategy on immunization provided to PSUs is expected to demonstrate direct and indirect impact in IC through transfer of message provided by a researcher to school students being transmitted to his/her peers and parents living in his/her household and immediate neighborhood having U5C. Based on authentic recording in immunization card issued by a medical facility, a child was categorized as full, partial, or not immunized.

   Results Top

One thousand and ninety-two school students as PSU samples and 2352 U5C as SSU samples with mothers participated in the study. Among PSUs, 37% were male and 63% were female, and the ratio of PSU: SSU was 1:2.2 in majority of the clusters. By IEC strategy, the statistical probability of having a higher KQ gained by experimental group PSUs was 90.2% (mean RIDIT value of 0.902) for rural and 81.2% (mean RIDIT value of 0.812) for urban at P = 0.001. However, difference between experimental and control groups on VPDs was significant with two-tailed P = 0.0004 and t = 17.121 with 3 df and on primary vaccines P = 0.0007 with 3 df. KQ score grading showed no gender variation and it uniformly had effect on parents irrespective of their demographic factors.

On comparison of KQ change scores between pre- and posttests, it was 12 and 8 for rural and urban experimental groups, whereas it was 3 and 4 for rural and urban control groups, respectively, out of 20 [Table 1]. It is evident that IEC on immunization given to PSUs in experimental groups affected considerably than control groups' knowledge. Further female PSUs scored (10.60 ± 4.42) better than males (8.79 ± 5.73) in rural with statistically significance (P = 0.001).
Table 1: Comparison of knowledge quotient change score among primary sampling units between urban and rural

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Both experimental (rural, urban) and control (rural, urban) group mothers had similar (45%, 46%, and 44%, 33%, respectively) awareness on U5C vaccines during pre-IEC that is slightly lower with national surveys at 58% (CES 2009). All groups acquired substantial awareness during post-IEC assessment, which was 93%, 94% and 68%, 47%, respectively. Reporting on vaccines spontaneously like measles, hepatitis B, Vitamin A and booster doses were low in all groups during pre-IEC assessment compared to other vaccines. Reporting on optional vaccine was equally low at 7% in both groups in rural initially that was 19% and 13% in experimental and control groups, respectively, in urban. After IEC too, optional vaccine voluntary recall memory was at 41% and 44% in rural and urban experimental groups, respectively, and 23% in both control groups. It could be as a result of frequent changes in vaccines, scheduled for immunization of U5C by government programs.

Age-appropriate full IC rate from birth to 5 years was 51% in rural and 67% in urban experimental groups before IEC, and it was 88% and 85% post-IEC in rural and in urban, respectively, which are comparable with coverage reports of national surveys and studies. Partial IC rate was at 25% and 14% during pre-IEC that was 11% and 10% during post-IEC for rural and urban experimental groups, respectively. None IC rate was at 24% and 19% in pre-IEC which was at 1% in post-IEC for both rural and urban experimental groups, respectively [Figure 3].
Figure 3: Distribution percentage of immunization coverage of under-five children who received specific vaccination by Routine immunization and optional vaccines according to vaccination card in rural and urban experimental groups (n = 1176).

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On further analysis of individual IC, 78% of experimental groups and 79% of control groups had received BCG during pre-IEC assessment that was found to be 96% and 91%, respectively, at post-IEC assessment. Reasons for lower rate could be attributed to the practice of not obtaining/recording a vaccination card promptly subsequent to giving vaccines and faulty administration of BCG vaccines that do not leave a distinct mark on the left upper deltoid site of a child. On individual assessment of booster doses of OPV, DPT and measles, respectively, they were at 75%, 66% and 58% during pre-IEC that was found at 99%, 93%, and 90% post-IEC in experimental group. BCG–measles dropout rate was initially 22% in experimental and 17% in control groups that were found to be 11% and 17%, respectively, after IEC.

Experimental group results [Table 2] were found to have considerable statistical significance (P = 0.0037) implying an association between KQ scores and IC rates. Control group results too showed differences in rates but were not statistically significant (P = 0.0667). It affirms that on having improved KQ scores on immunization among PSUs, there was an increase in IC percentage of SSUs in each cluster by transfer of knowledge to their mothers which motivated them to vaccinate their U5C, thereby increasing the existing coverage rates. Results were found to have considerable statistical significance in both rural and urban experimental groups with high positive correlation values (r) of 0.7854 and 0.8611, respectively, with extremely significant P < 0.0001.
Table 2: Comparison of pre- and posttest knowledge quotient scores of primary sampling units with immunization coverage percentage in rural and urban experimental groups before and after Information, Education and Communication strategy according to vaccination card

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It concluded that a mean change in KQ score of 8–12 upon 20 is likely to increase full IC rate by 37% and 18%, decrease partial coverage at 14% and 12%, and further improve none coverage at 23% and 16% from its existing level (Pearson's correlation coefficient r = 0.9183 and Spearman's rho of 0.82857) positively in rural and urban experimental groups, respectively (confidence interval = 0.04156).

Possession of an immunization card among mothers stressed through PSU IEC strategy improved tremendously from 76% to 99% in rural and 81%–97% in urban experimental and 71%–82% in rural and 88%–82% in urban from control groups. 47 % of both rural and urban mothers' vaccination recall and vaccination card recording matched correctly in experimental group before IEC which was found at 84% and 83.2% afterwards respectively. Change in rural control group was found to be 48% to 58% and in urban, it was 49.6% to 55.9% between initial and second assessment. It further reiterates the need for vaccination card as evidence than relying totally on recall method. Factors such as lack of awareness, compromising logistics, unfavorable environment, fear of side effects, loss of daily wage, and confusion on changing schedule of vaccines discouraged parents to pursue their U5C immunization.

   Discussion Top

The concept of involving school students in “Educational health campaigns” making an impact on behavior of a community was originally derived and reported by UNICEF on handwashing,[12] hygiene (Dastak), and Swachh Bharat mission by the Government of India. These campaigns are held on a mass level with government support, but this study only has documented an efficacy rate, significance of which is given as a glance on research in context.

No significant difference was seen in IC of both genders in our study, a synchronized view shared by Chaudhary et al.[13] It was observed that 62% and 68% female and 56% and 61% male U5C were fully immunized before IEC in experimental and control groups, respectively. This once again reaffirms contrary to the general belief that females are neglected than male children in Indian society. As found in our study, Wadgave and Pore [14] too stated that mothers' education was related to immunization status, a fact supported by Malkar et al.[15] and Inamdar et al.[16] None of the postgraduate parents in our study had any unimmunized child in accordance with other study findings.[17],[18],[19]

Many nationwide surveys documented a similar coverage that existed during pre-IEC stage for full immunization, but they distinctly contradict no immunization rate, which is very high in our study. A possible reason could be that national surveys cover all states and union territories of India, which provide only IC rate for the age of 1–2 years only. Furthermore, this study considered vaccination card recording and physical verification of BCG mark for dependable IC than relying totally on mothers' recall. It is not the norm in majority of surveys and thus could give false-positive rate of immunized U5C population.

The coverage rate of this study on full immunization rate at postintervention was similar to other studies.[14],[15],[20],[21],[22],[23],[24],[25],[26] Lower coverage percentages reported by few other studies [19],[27] than this study could be due to regional variation and owing to the small sample size adopted by those studies than this study having a robust sample size when compared. The discrepancy found between mothers' recall, BCG scar, and vaccination card recording at 47% in rural and 50% in urban is an important concern. 21 % of rural and 6% of urban mothers do not remember any details on vaccination, calls for importance to be accorded to immunization cards as primary and reliable evidence to estimate IC which is also highlighted by Pulickal and Fernandez.[28]

Dropout rates between BCG–DPT3 and BCG booster doses were all higher in rural than urban with significant statistical levels (P = 0.0185) between pre- and post-IEC, a result also expressed by Wankhade [29] for northern Maharashtra with higher dropout of measles followed by Vidarbha and Marathwada regions and by Gupta et al.[22] for a similar rural region. The key-reported source of information on immunization in this study was health-care workers during pre-IEC period. Responses pointed out to school students as a main source of information after IEC from 34% to 72% and 43%–65% in rural and urban experimental groups, respectively, with a highly positive r = 0.9512 (P < 0.0001) compared to control groups.

   Conclusion Top

This study established the positive outcome of advocacy and documented evidence on marketing IEC strategy to benefit the health system of our country through school students on health messages for a health problem on which mammoth programs and billions of funds still evade finding an answer with convincing precision.


The author acknowledges the management of PIMS, Loni, Ahmednagar, for all administrative beginning of this study; Dr AP Kulkarni for guiding this research from the crucial phase of analysis and onward; all school students, U5C, parents of this study, ANMs of Loni Kalbhor and Pune camp; colleagues at Armed Forces Medical College, Command Hospital (SC) Pune, College of Nursing, PIMS, Loni, Dr Pratibha A Chandekar, Dr T Sivabalan, many “Friends” for supporting with logistics and resources; my family especially my mother Mrs Seethalakshmi Vaidyanathan for blessing me abundantly to do this research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]

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