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LETTER TO THE EDITOR
Year : 2020  |  Volume : 64  |  Issue : 3  |  Page : 311-312  

Immunization coverage among under-five children living along with a school student: A critical appraisal


1 Post-Graduate, Department of Community Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India
2 Assistant Professor, Department of Community Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India
3 Professor and Head, Department of Community Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India

Date of Submission23-Feb-2020
Date of Decision02-May-2020
Date of Acceptance12-May-2020
Date of Web Publication22-Sep-2020

Correspondence Address:
Sivagami Alias Ashwini Kanagasabapathy
Department of Community Medicine, Indira Gandhi Medical College and Research Institute, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_130_20

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How to cite this article:
Kanagasabapathy SA, Manivel P, Vasudevan K. Immunization coverage among under-five children living along with a school student: A critical appraisal. Indian J Public Health 2020;64:311-2

How to cite this URL:
Kanagasabapathy SA, Manivel P, Vasudevan K. Immunization coverage among under-five children living along with a school student: A critical appraisal. Indian J Public Health [serial online] 2020 [cited 2020 Oct 30];64:311-2. Available from: https://www.ijph.in/text.asp?2020/64/3/311/295783



Dear Sir,

We have read the original article entitled “Immunisation coverage among under-five children living along a school student through child-to-child and child-to-parent Information, Education, and Communication Strategy.”[1] It is a very informative article in which they have studied if the immunization coverage improves through IEC to school students, which is a good administrative strategy, and an experimental study based on the above needs to be appreciated. Park mentions that “Every school child is a health worker.”[2] So, the strategy adopted by the authors might turn out to be a tremendous success. While reading the article, we had a few concerns regarding the methodology.

  1. The formula used for sample size calculation is the formula for cross-sectional study. Instead, the formula for randomized control trial could have been used[3]
  2. In [Table 2], the authors have compared pretest and posttest knowledge quotient scores of primary sampling units with immunization coverage percentage in rural and urban experimental groups before and after IEC strategy according to vaccination card. The tests used were Kruskal–Wallis test and Friedman test. The authors have used Kruskal–Wallis test considering the dependent variable as ordinal or continuous data and independent variable as two or more categorical groups. One of the important assumptions to do Kruskal–Wallis test is that there should not be any relationship between the observations in each group or between the groups themselves.[4] This assumption has been violated here, as the table compares the pretest and posttest scores of the same people. For comparing the continuous data of two related groups, the most appropriate statistical tests of significance are Student's paired t-test (if normally distributed) and Wilcoxon matched-pairs signed rank test (if skewed distribution).[3] The authors have used Friedman test which is used to test for the differences between related groups when the dependent variable being measured is ordinal or continuous data. One of the important assumptions to do Friedman test is that the same group should be measured on three or more different occasions.[4] This assumption has been violated here, as the table compares the pretest and posttest scores of the same people on two occasions. For comparing the continuous data of the same group measured on two different occasions, the most appropriate statistical tests of significance are Student's paired t-test (if normally distributed) and Wilcoxon-matched pairs signed rank test (if skewed distribution).[3] The authors have used nonparametric test. They must have assessed for normality and come to a conclusion of nonnormal distribution. So, here, instead of mean and standard deviation, median and interquartile range (IQR) would be appropriate. We intended to state that it is a skewed data, representing them as median and IQR would be more appropriate. Since the authors have compared pretest and posttest knowledge quotient scores using nonparametric test (Kruskal–Wallis test and Friedman test), we suggested a median and IQR as a better mode of representing the data. It would have been more appropriate if a comparison between the experimental and control group has been shown in the table. Six pairs of means have been compared but only three P values are given
  3. In the clustered bar chart, they have just mentioned the results of the experimental group pre- and post-IEC. Instead, the chart could have compared the immunisation coverage (IC) of the experimental and control group, which would have been more appropriate for an experimental study. The expectation from an experimental study is the effect size.[5] Had the multiple bar chart focused on comparing the experimental group and control group, the natural expectation from an experimental study could be met. One of the objectives mentioned in the article was to evaluate the outcome of the IEC strategy on immunization to school students on the current IC percentage. Since only the experimental group had received IEC and not the control group, the stated objective could be attained by comparing immunization coverage percentage among experimental and control group with pretest and posttest values separately
  4. It would have been even more informative if the components/domains of the questionnaire were detailed with explicit measurement strategy for the same
  5. In the qualitative part, the details of the method adopted and the details of the participants are not mentioned
  6. The duration of the study was 6 years (2012–2018), and during this study, Mission Indradhanush (2014) was launched. Under Mission Indradhanush, the government identified 201 high-focus districts across the country that has nearly 50% of all unvaccinated or partially vaccinated children in the country.[6] The authors have selected the rural areas where the baseline immunization coverage was around 50%, which is evident from [Table 2]. Between 2014 and 2018, India's annual immunization growth rate has risen to 4–6% as documented by the Integrated Child Health and Immunization Survey.[7] Had the authors shown in the results, the difference in immunization coverage between the experimental group and the control group, it would have proved that their intervention has improved the coverage. As it is not clearly mentioned in the results, the difference in coverage between the experimental and control group, the improvement in coverage that is shown in the experimental group could have been due to the effect of Mission Indradhanush
  7. The original article stated that “IEC strategy included structured training sessions on meaning of immunization, vaccine preventable diseases 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.”[1] Since much of the IEC strategy revolves around immunization cards among the intervention group, they tend to retain the card for a longer duration compared to the control group. Finally, the outcome was based on authentic recording in immunization cards issued by a medical facility to categorize a child as full, partial, or not immunized.[1] How many cards were missing in both the groups? This should come as baseline data to show that there is no significant difference between the two groups. The details regarding missing or retained immunization card status could have established the baseline similarity or difference between the intervention and control group.{Table 2}


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
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.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Park K. Parks Textbook of Preventive and Social Medicine. 25th ed. Jabalpur: Banarsidas Bhanot Publishers; 2019. p. 635.  Back to cited text no. 2
    
3.
Saha I, Paul B. Essentials of Biostatistics. 2nd ed. Kolkata: Academic Publishers; 2010. p. 66-115.  Back to cited text no. 3
    
4.
Bowers D. Medical Statistics from Scratch. 3rd ed. United Kingdom: John Wiley & Sons Ltd; 2014. p. 209.  Back to cited text no. 4
    
5.
Detels R, Beaglehole R, Lansang M, Gulliford MM. Oxford Textbook of Global Public Health. 6th ed. United Kingdom: Oxford University Press; 2015. p. 484.  Back to cited text no. 5
    
6.
National Health Mission, Tripura. Available from: http://tripuranrhm.gov.in/Guide lines.htm. [Last accessed on 2020 May 08].  Back to cited text no. 6
    
7.
National Health Mission. IMI_CES_Survey_Report. Available from: https://nhm.gov.in/New_Updates_2018/NHM_Components/Immunization/Guildelines_for_immunization/IMI_CES_Survey_Report.pdf. [Last accessed on 2020 May 08].  Back to cited text no. 7
    




 

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