Vaccination coverage and vaccine hesitancy among vulnerable population of India

ABSTRACT

Vaccination coverage in India has improved from 44% to 62%, an increase of 19% over a span of 10 y (2006–2016), the inequity continues among the vulnerable people belonging to tribal groups and migrant population. In order to leave no one behind strategy, their vaccination coverage, reasons for low coverage were analyzed from available literary sources through this review article. A systematic search for relevant articles was conducted and articles published in various journals over the past 5 y were included. The vaccine coverage among the vulnerable population ranged from 31% to 89% from various studies. It was found that parents’ education status, income of the family and lack of awareness of the schedule were the most important reasons for vaccine hesitancy. Introduction of cash assistance integrated into other national program, digitalizing vaccination cards, involvement of local healers are few strategies suggested in this article.

KEYWORDS:

• Vaccination
• tribal
• migrants
• NFHS
• under five
• rural India

Introduction

It all began with the efforts of Edward Jenner, an English physician and the pioneer of vaccination for small pox, which led to the discovery of world’s first vaccines, the most impeccable contribution to public health till date, saving millions of lives every year. Vaccination is considered as one of the most innovative public health interventions till date. Between 1999 and 2013, the estimated national vaccine coverage among children gradually increased by 17% for Bacille Calmette–Guerin (BCG) vaccine; 16% and 24%for DTP1 (Diptheria, Tetanus, Pertussis) and DTP3, respectively; 25% for the third dose of oral polio vaccine(OPV); and 27% for the first dose of measles vaccine. The vaccine coverage was progressing till 2010, after which there has been a stagnant state till 2013.¹

Hence, in 2014, India’s Ministry of Health and Family Welfare launched Mission Indradhanush (MI), to target the underserved (remote rural- urban slum dwellers), vulnerable (migrants), resistant, and inaccessible populations (hilly areas). It covered entire country in phases leading to 6.7% increase in full vaccination coverage. In October 2017, came the Intensified Mission Indradhanush (IMI) to accelerate progress with the aim to reach 90% full vaccination coverage in districts and urban areas with persistently low level of vaccination status. IMI differed from MI in that it was a multi sectoral approach to cover high risk population.² According to National Family Health Survey 4 (NFHS-4) 2018, 62% of children are fully immunized. 78.4% children of 12–23 months age have received 3 doses of DPT vaccine. 81% received measles and 72.8% children received 3 doses of polio and all these improvements have occurred after the introduction of IMI.³ Population-based coverage studies were conducted in 190 IMI districts and found the proportion of fully vaccinated children to be 69% which is a 18.5% increase from pre-IMI estimate.²

As per census 2011, 31.8% of India’s population lives in urban areas. In 2017, it was 33.5% which is an increase of 2.8% per year. Most of them are migrants from rural areas for a varied reason and form a larger part of urban slums. In order to focus on urban area with increased reach out to a larger population, to decrease the vulnerabilities and build better data system, it is imperative that we focus on equitable services to these urban slum dwellers. Similarly, 8.6% of India’s population is tribal. The vaccination status among tribal population of the entire nation is still on research phase and is hard to reach a complete data on them.⁴

From Table 1 it is seen that, overall the vaccination coverage has improved from 44% to 62% a 19% increase over a span of 10 y. But when seen categorically, the urban population has better coverage than the rural one, likewise general category better than schedule caste/schedule tribe and people in highest wealth quintile better than lower levels. The districts in tribal areas showed 56% coverage. The vaccination coverage remains lowest among the north eastern states of Nagaland (35.7%) and Arunachal Pradesh (38.2%). Hence, vaccine coverage has not met the criteria of equity since the migrants, tribal, slum dwellers remain to be the vulnerable population and hard to reach core for coverage. Apart from that, the issue of hesitancy which is a delay in acceptance or refusal of vaccines despite availability of vaccination services tends to remain as a priority area of work to improve the coverage among all.

Table 1. Showing full vaccination coverage percentage change in NFHS-3 & NFHS-4 report.

	Full vaccination (%)
NFHS	2005–2006	2015–2016	Change (%)
Place of residence
Rural	39	61	23
Urban	58	64	6
Social group
Scheduled tribe	31	56	25
Scheduled caste	40	63	23
Other backward classes	41	62	21
None of them	54	64	10
Wealth quintile
Lowest	24	53	29
Second	33	61	28
Middle	47	64	17
Fourth	55	67	12
Highest	71	70	−1
All India	44	62	19

Objectives

1. To find the vaccine coverage and reasons for hesitancy among the vulnerable populations of India using data available from previous 5 y.

2. To recommend alternate strategies to improve the vaccine coverage among the vulnerable population.

Methodology

A systematic search for relevant Indian research articles was conducted. Articles published in English language in various journals over the past 5 y (2014–2019) were searched using free text, thesaurus, MeSH terms in google scholar, PubMed central and Embase. MeSH like vaccination coverage, vulnerable population, vaccine hesitancy, India were used.

Cross references were searched and relevant articles cited. Gray literature was searched using WHO, UNICEF data.

Table

Inclusion criteria	Exclusion criteria
gVaccination coverage of children till 5 y in India	Beyond 5 y
Migrants, urban slum dwellers, tribal population	International studies
Within 5 y of search	Non-EPI (Expanded Program on Immunization) vaccines
Coverage of routine vaccination	Supplementary activities and camps

Since our target was to find the vaccine coverage and reasons for vaccine hesitancy among Indian children and their parents, respectively, international studies were excluded. In order to keep the updated coverage status and the present scenario for low vaccine coverage, search was restricted to last 5 y.

Results

After searching through the literature, fifteen relevant articles were screened, out of which ten were chosen based on inclusion criteria. The data from the 10 selected articles are presented in Table 2 which shows, that most of the studies have covered the age group of 12–23 months and have used cluster sampling technique for evaluation of vaccination coverage. They have found out the different reasons for low coverage in areas such as urban slums, tribal areas, rural area and migrant settlements.

Table 2. Showing finding of full vaccination (FV), partial vaccination (PV), & non-vaccination (NV) among various studies conducted across India.

			Age of children			Findings
Sl .No	Study	Year	Months	Sample size	Methodology	FV	PV	NV
1	Urban agglomeration, Kochi	2019	12 and 23 60 and 84	310 children 308 children	Cluster sampling	89%	10%	1%
2	Urbanized agglomeration, East Delhi	2019	13–24	350	Simple random	Timely 67.1% Delay of 4 weeks 19.7%	11.2%	2%
3	Internal migrants, Hyderabad	2018	24	768	Snowball sampling	66.7%	NA	NA
4	Migrants Delhi	2018	24	458	Cross-sectional	31% recent migrants, 53% settled migrants	NA	NA
5	Measles cover rural area, Bhopal	2017	17.7	210	Cluster sampling	92% measles	NA	NA
6	Mumbai slums	2017	12–23	550	Cluster sampling	73.1%	23.8%	3.1%
7	Urban, Maharashtra	2016	12–23	210	Cluster sampling	60.5%	39.5%	NA
8	Tribal area, Thane	2015	12–60	225	Cross-sectional	71.1%	17.8%	11.1%
9	Urban slum, Rewa	2014	12–23	210	Cluster sampling	72.4%	21.9%	5.7%
10	Slums, Kanpur	2014	12–23	210	Cluster sampling	52.38%	29.5%	18.1%

NA: Not Applicable.

In Geddam JB et al. study, it was found that a literate mother, more salary of HOF (Head of Family), better ANC (Ante Natal Care) visits were associated with better vaccination coverage. This study did not consider the hospital infrastructure, outreach, facilities, supply and other such crucial details influencing vaccination.⁵ Joy TM et al. found that less than 10 y education of mother and being in a nuclear family were the main reasons for partial vaccination. But the question of generalization arises as the number of primary sampling units (PSU) selected is not even ten percent of the available PSU.⁶ Vinu Cherian et al. found pain and fear of vaccination, bad past experience, fear of side effects, lack of vaccination card during vaccination day were the main reasons related to partial vaccination or a delay in vaccination. They have mainly focused on the importance of timely vaccination as a major setback to prevent the outbreaks of epidemics.⁷ Y.S. Kusuma et al. conducted a study on vaccination coverage among recent and settled migrants of Delhi and found that, settled migrants had better coverage than the recent migrants. Though the arbitrary cut off taken for classifying as recent or arbitrary is quiet long (10 y) and that those living for almost 8–9 y would not fulfill the reasons for non-vaccination as mentioned from the study. Lack of awareness of the vaccination schedule (14%) was the main reason, and 19%of recent-migrant mothers thought that the child had received all vaccines. Recent-migrant mothers were characterized by younger ages, low educational attainment and lower incomes and were mainly represented by the socioeconomically disadvantaged groups such as scheduled castes and other backward castes. The overall vaccination uptake was not satisfactory.⁸

Shailendra Meena et al. found that the main reasons behind noncompliance to measles containing vaccine (MCV1) vaccination was due to unawareness about Universal Immunization Programme, no information about Measles disease and its complication, being away from home on the session day and distance of session site from home.⁹

A study in urban area of Maharashtra also found a low vaccine coverage and the main reasons explaining this finding were literacy of parents and place of delivery which were significantly associated with vaccination of their children. Out of 210 children, only seven children of illiterate parents were fully immunized while 120 children of literate parents had full immunization and this difference was statistically significant.¹⁰

A study in tribal population of Thane, Maharashtra found that there was a significant association between vaccination status and religion of the children, socioeconomic status, the place of delivery of the children and the presence of the vaccination card. Males and Hindu religion children had more complete vaccination compared to females and Muslim children. Literacy of fathers had significant impact. It was also found that dropout rate for females were higher than males similar to a study conducted in the slums of Kanpur. The authors have recommended health education, improved interpersonal approach and improving quality of health services will solve the problems of non-vaccination. The vaccine coverage in that area is only 71%, but still the authors have only given passive modes of intervention rather than action-oriented rigorous ones.¹¹

The commonest reason for incomplete vaccination/partial vaccination was found to be lack of knowledge of vaccination schedule by the parents among the slum population of Rewa.¹² From the above studies, the most common causes of vaccine hesitancy (VH) among the vulnerable population are depicted in Table 3

Table 3. Reasons for vaccine hesitancy.

Sl no.	Reasons	Percentage (%)
1	Parents education status	50
2	Income of the family	30
3	Lack of awareness of the vaccination schedule	30
4	Lack of vaccination card at the time of vaccination	20
5	Place of delivery of the child	20
6	Religion or caste	20
7	Fear and pain of vaccination	10
8	Fear of side effects	10

Discussion

From the different literature search, it is clear that the full and complete vaccination of children in India has not crossed 90%. There are differences in vaccine coverage among different states and union territories. Within each state there are differences in coverage rate between variable kinds of populations.

VH is prevalent in India since the time of availability of vaccines. Since the inception of polio campaigns to till date Measles-Rubella (MR) campaign, VH has affected the VCR (Vaccine Coverage Rates). Around seventy schools in Mumbai had to stop the campaign due to strong parental objections.¹³ VH is prevalent to an extent of 83% in families residing at slums of Siliguri, West Bengal as per Dasgupta et al. study.¹⁴ Looking overall, the top three common reasons for vaccine hesitancy are parents’ literacy, their income and their knowledge on the vaccination schedule. When looking at the causes for low coverage among the vulnerable population, the reasons have differed slightly. The following discussion will focus on the unique reasons existing among the specific vulnerable population.

The vaccination status among migrants vary broadly between 50% and 60% but is lowest among the recent migrants to an extent of 30%. The main reasons would be the lack of awareness about the locality and the fear of traveling alone by mothers. Similar to our findings are the ones from Awoh et al. systematic review on migrant children among low- and middle-income countries. They have found that there was discrepancy in coverage among rural and urban population and that less percentage of children of migrants were fully vaccinated.¹⁵

The recent migrants might not have updated their address and other details with the government offices, due to which the tracking of the due child becomes hectic for the ASHA (Accredited Social Health Activist). If there were systems of auto update of the new locality to the old register of anganwadi, the responsibility could easily be transferred to the new locality anganwadi.

Among three slum area vaccine coverage studies, it was found that almost Rewa (Madhya Pradesh) and Mumbai (Maharashtra) have 70% coverage, while in Kanpur (Uttar Pradesh) it was only 52%. It may be due to inter-state variation in infrastructure and running of the program. But the difference in the state-wise coverage is 53.6% and 51.1% in Madhya Pradesh and Uttar Pradesh, respectively (NFHS-4). The slum area people are the most difficult to capture for vaccination as the response in spite of repeated counseling may be poor. Majority of the response for non/partial vaccination was due to illiteracy or worry about loss of a day’s wage. Financial assistance/incentive for getting immunized may be likely to bring about a change. When the fear of loss of wage is erased from the minds of people, then the likely chance of bringing their children for vaccination might improve.

Full vaccination coverage for Maharashtra is 56.2%, while overall in India the tribal population’s coverage is 56%. A study from Thane, among the tribal population is found to be higher than that of national, state, and tribal population coverage. The reasons for a higher coverage as given by the study is that the locality of Thane which is considered to be peri-urban and that the state’s rural and tribal coverage is so low that it might have pulled the overall state’s coverage (56.2%) to lesser side. There were other related studies on tribal children’s coverage in Andhra Pradesh (AP), Odisha. The study in AP shows a full vaccination coverage of 63% and states that tribal population are dependent on public health services for all their needs. Hence, they have suggested increasing the physical access, infrastructure, quality of care as few methods to improve coverage.¹⁶ Similarly, the migrant tribal children in Odisha are 62% vaccinated till DPT1 while 0% are fully vaccinated.¹⁷

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions is called health literacy (HL).¹⁸ The positive relation between maternal health literacy and vaccination status among children has been proven in Johri et al. study among two underserved communities in India.¹⁹ But a systematic review by Lorini et al. concluded that the association between HL and vaccine acceptance is unclear.²⁰

Recommendation

WHO SAGE has given a working model regarding the most effective strategies to tackle VH. There are two major outcomes expected, which are to increase the vaccine uptake and to cause a psychological shift.

To improve vaccination uptake, the top interventions showing largest positive effects were found to be: 1. directly targeting the unvaccinated or under vaccinated populations, 2. increase the knowledge and awareness on vaccination, and 3. easy accessibility to vaccination. In order to cause a psychological shift, education initiative in a tangible process was effective in changing the attitude of population. Overall a well-tailored health education approach, finds itself as the most effective strategy.²¹

According to Arede et al., to negate the effects of VH, children and adolescents have to be chosen as target population. They have suggested education and critical thinking approach via different modes of communication to promote positive attitude toward vaccination.²² In Shen et al. article on addressing VH, the role of counseling and various ways of doing it at primary care level has been described. Starting early, vaccinating child as default and various model statements to convince parents have also been enlisted.²³

Since the vaccination program is not providing any monitory incentives with the added disadvantage of parents losing a day’s wages, an introduction of cash benefit might show some good progress. Instead of adding a new cash assistance, it is easier to integrate with other national program and extend the time at which the beneficiaries receive them. For instance, the financial assistance under JSY (Janani Suraksha Yojana) which is given post-delivery has to be given to beneficiary only after the 9th month vaccination of the new born with measles vaccine.

The school admission of children should be mandated with the submission of fully immunized status card of the child. In order to save the loss of wage for a day, special permissions should be granted for the parents who are taking their children for vaccination. This has to be legalized into all government and private sectors as well as small-scale industries and employers of daily laborers.

When the family migrates from one place to other, there has to be an auto update of address to the child’s MCP (Maternal Child Protection) card which will be digitalized and linked with Aadhar or BPL (Below Poverty Line) card. So the responsibility of that child to be followed up will be automatically transferred to the anganwadi near the new locality and the ASHA of that anganwadi will pay a home visit to inform the new comers about the location of anganwadi, nearby health facility and the reminder about the next schedule.

To improve the acceptance of vaccines among tribal population, the local healers in tribal areas should be made a part of vaccination delivery system. They should be trained in vaccinating the children and will be made to encourage the population on the same. Every occasion/festive celebrated by the tribal village should be made into an opportunity to deliver the importance of vaccination. The health professionals should actively be involved in such events to make the tribal population feel at home.

When an eligible child who is supposed to receive a vaccine doesn’t receive it due to various reasons, it is called missed opportunity of vaccines (MOV) which is an emerging threat to be addressed adding to the poor vaccine coverage. Hence, multi-level strategies have to be implemented to have a check on the same. Starting from simple screening at entry level of hospital/clinic by providing the caregivers with a token to enquire about the vaccination status of the child followed by referral to a vaccination clinic if needed till house to house visit by health workers for checking the vaccination cards of eligible children. Every opportunity has to be carefully handled. When a mother visits a health facility for an ANC checkup, or when sibling accompanies the other for an illness, the entire family has to be considered as a whole for not missing a chance of vaccination of an eligible child.

Since HL in India has proven to be effective in improving VCR, it might be a useful add-on strategy. Indian government, under the Ministry of Health and Family Welfare (MoHFW) has launched the National Health Portal in 2014 which serves as a single point of authentic resource on health sector for providing HL to its citizens.²⁴ Recently, MoHFW has launched a guidance document for the states to improve full immunization coverage to 90%.²⁵ Also under National Health Mission through ASHA, the government has tried to improve the HL of the remotest populations. By conducting Village Health Days, campaigns, paying house to house visit, anganwadi centers activities; HL has found its way to the beneficiaries.²⁶ But the association between HL and VCR is still an area of research interest in India as less number of literatures is available.

To summarize, with strong political commitment, practical and feasible approaches to improve VCR are providing financial assistance, vaccination leaves/permissions to parents, digitalization of MCP cards. By inter-sectoral coordination with other ministries, mandatory submission of vaccination certificates for school admission, executing different programs under NHM (National Health Mission) to revamp HL are also attainable perspectives. It is the allegiance of the government, health sector, health professionals, teachers, parents, and every single individual to create and spread optimistic views on vaccination for the benefit of the country and the world from vaccine preventable diseases.

Author’s contributions

Table

	Contributor 1 Dr Karpaga Priya P	Contributor 2 Dr Vineet Kumar Pathak	Contributor 3 Dr Anjan Kumar Giri
Concepts	Yes	Yes	-
Design	Yes	Yes	Yes
Definition of intellectual content	Yes	Yes	Yes
Literature search	Yes	Yes	Yes
Clinical studies	-	-	-
Experimental studies	-	-	-
Data acquisition	Yes	Yes	Yes
Data analysis	-	-	-
Statistical analysis	-	-	-
Manuscript preparation	Yes	Yes	Yes
Manuscript editing	Yes	Yes	Yes
Manuscript review	Yes	Yes	Yes
Guarantor	Yes	Yes	Yes

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.