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Immunization in children is one of the best methods of preventing vaccine preventable diseases.With the onset of the COVID-19 pandemic,there have been disruptions in vaccine supply,its uptake and perception towards routine immunization, globally and in India. This study was planned to identify the challenges faced by the parents, the perceived barriers towards childhood immunization and perception regarding vaccination during the ongoing pandemic.
A cross-sectional study was carried out in the well-baby clinic, providing immunization services. The informants were parents/caregivers of under-five children accompanying their children to the well-baby clinic within the study period. Data was collected using a semi-structured interviewer administered questionnaire and analysed using Epi-info software and p value less than 0.05 was considered to be statistically significant.
Delay in immunization was noted in 62% of the children. The challenges stated by respondents for delay in immunization during this pandemic mostly were “fear about getting infected” (30%) and “someone instructed them not to take the child to the hospital if not ill” (13%). The most common perceived barriers were ‘no vaccination sites were open’ or ‘did not know where the baby can be vaccinated’. ‘Child should receive all vaccines’(99%) and ‘safety is more important than vaccination’ (83%)was the perception of respondents about immunization during the pandemic.
Though the respondents were aware of the need for timely vaccinations of their children, still a substantial delay was seen among majority of them due to fear of getting infected and unavailability of vaccines.
Childhood immunization has been one of the most important, cost-effective interventions to reduce the burden of vaccine preventable diseases (VPDs). With the onset of the current pandemic of COVID-19, the health system around the world and so also India, was affected greatly due to increased demand of healthcare workers dedicated for serving the patients affected by the disease. This, along with the lockdown restrictions led to a disruption of the routine healthcare services. Routine immunization services were also hampered in various parts of India including Odisha. As per the WHO advisory, the immunization service being an essential one, should have continued even during the period of pandemic.
The suspension and disruption of immunization services in India affected the strategies used by Mission Indradhanush to achieve and sustain full immunization of more than 90% for children by the year 2022.
As per the health management and information system (HMIS) of the National Health Mission (NHM), there was a significant decrease in routine immunization services showing that at least one lakh and two lakh children missed their BCG and pentavalent (DPT, Hib, Hep B) vaccines respectively in March 2020.
The fear and uncertainty during the pandemic may have also affected parent's perception towards vaccination, posing a barrier towards the proper provision of scheduled vaccination.
As this information is essential to improve resilience, reduce the population's fundamental vulnerability, to increase vaccine uptake and decrease an upsurge of VPDs; this study was planned for identifying the challenges faced by the parents with regards to immunization of their children, to find out the barriers to childhood immunization during the pandemic and to identify their perception regarding vaccination during the pandemic.
2. Materials & methods
It was a cross-sectional study carried out from June to September 2020 after getting approval from the institutional research and Ethics committee. The study was conducted in the well-baby clinic of a tertiary care hospital in Bhubaneswar, Odisha. The respondents included parents/caregivers of the under five children visiting the well-baby clinic by 30th September, 2020. Convenience sampling technique was used for selection of study participants; those who agreed to participate in the study and gave written informed consent within the time frame were included. Consent for the results to be published after analysis was also taken from the study respondents. A total of 128 respondents were contacted out of whom 106 agreed and satisfied the inclusion criteria; six of the respondents were previously included in the study (during their first visit within the time frame of the present study), so they were excluded during the subsequent visits; thus making a sample size of 100.
It consisted of questions to assess the socio-demographic details of the respondent, challenges and barriers to vaccination during COVID-19 and parental perception of immunization during the pandemic. The barriers for appropriate immunization during COVID -19 was assessed through the survey tool which had some open ended questions as well so that the parents’ perception could be better assessed.
Methodology: The respondents were contacted telephonically whose children had their vaccination scheduled during the study period, which is a usual practice of the current institute. The investigator first contacted the eligible parent and briefed them about the purpose of the study and seeked their support. After their consent, the investigator conducted a face to face interview. All efforts were made to include the parents/caregivers with children under-5 years of age. Confidentiality of all participants was maintained. At the end of the interview the parents/caregivers were briefed on the recommendations and importance of immunization during this period and how routine childhood immunization will help preventing the outbreak of other VPDs. Any query raised by the respondents were answered. They were encouraged to continue with the childhood immunization routinely as scheduled without further delay even with the continuation of the current pandemic.
2.3 Ethical committee approval
The institutional research an Ethics committee approval was sought before the initiation of the study [****/****/IEC/350/2020].
2.4 Data management and statistical analysis
The data collected was entered into Microsoft excel sheet and analysed using Epi-info en-US version 188.8.131.52 software. Descriptive statistics was used for frequencies. Chi –square test and F-test wherever appropriate was used as the test of significance. A p value of less than 0.05 was considered as statistically significant.
Around 95% of the respondents were parents and 5% were caregivers. The caregivers were either uncles or grandparents. The total number of study participants were 100 out of which delayed vaccination was reported by 62. Table 1 depicts the socio-demographic characteristics of the study participants and its association with delay in scheduled childhood vaccination.
Table 1Socio-demographic characteristics of the study participants with vaccination status of the sampled population (n = 100).
The age of the respondent (p = 0.044) and age of the child (p = 0.022) were found to have a statistically significant association with delayed vaccination.
Fig. 1 depicts the barriers cited by parents to vaccination during COVID-19 pandemic that resulted in a delay in routine childhood immunization uptake.
The barriers stated by parents/caregivers’ for delay in immunization of their children during this pandemic were “fear about getting infected” (30%), “someone instructed them not to take the child to the hospital if not ill” (13%) and “COVID-19 patients might be present in the hospital” (12%). “Place of residence” (p value = 0.028), sex of the child (p = 0.042) were found to be statistically significantly associated with the cited barriers. There were multiple responses cited as barriers to routine immunization by the respondents.
Fig. 2 depicts the perception of parents/caregivers on immunization during the COVID-19 pandemic.
The above figure depicts that many respondents realized the importance of scheduled vaccination for their under-five children whereas some respondents did not have a clear idea about the same. Around 68% of the respondents considered that healthcare (HC) providers could be the potential source of infection.
Fig. 3 depicts the challenges faced by parents/caregivers for delayed immunization with respect to various rules and regulations laid down by the government during the four stages of lockdown.
Fear of getting infected (29.03%) and unavailability of vaccines (16.13%) were some of the common reasons cited by the respondents during the first phase of lockdown.
The present study consisted of respondents where 95% were parents and 5% were caregivers (which included either grandparents or uncles). A similar study done in Indonesia reflects a slightly different profile of the respondents with more than 78% being parents followed by other family members such as uncles, aunts and grandparents.
The present study found that around 62% of the study participants had a delay in the scheduled immunization for their children. A similar study done in Saudi Arabia by Mohammed Alsuhaibani et al. reported a delay of more than two weeks for routine childhood immunization in 47.8% of the respondents and a significant delay of more than a month in 23.4% respondents.
There were some socio-demographic factors like the age of the child which was found to be statistically significantly associated with delay in routine immunization of the under-five child in the present study. A study done in South East Asia and Pacific Region by Rebecca C. Harris et al. reported infancy and school entry age being most affected which was also found to be significantly associated with delayed routine childhood immunization.
In the current study higher age of the child, as well as higher age of the respondents, were found to have statistically significant association with delayed vaccination.
The barriers to routine immunization cited by parents had multiple responses among which ‘no vaccination sites open’ (29%), ‘didn't know where the baby can be vaccinated’ (13%) and ‘didn't have someone else who can take care of other children at home’ (10%) were the most commonly cited barriers. Another similar study done in Saudi Arabia among parents reported that the barriers cited for delayed routine immunization during the pandemic were the fear of contracting COVID-19 (60.9%) followed by time constraints (11.6%) and difficulties in scheduling an appointment (9.2%). Other reasons mentioned by parents were travelling during the vaccination time, vaccine unavailability or closed clinics (6.7%).
The perception of parents regarding immunization in the present study depicted that around 99% of the parents considered that childhood immunization should continue during the pandemic, 83% of them considered that safety is more important than immunization during the pandemic and around 31% of the respondents considered that routine immunization may provoke COVID-19 disease. These findings of the present study are similar to the findings of a study done in England by Sadie Bell et al.
The present study had the novelty of studying the challenges faced by parents/caregivers during the four phases of lockdown in the state of Odisha. There were multiple responses for each lockdown depending on the local restrictions. The most common challenge faced by the respondents during the first phase of lockdown were ‘fear of getting infected’ and ‘absence of Government vaccines during that period’. The challenges during the second phase of lockdown were ‘fear of getting infected’, ‘someone's instruction/advice not to take the child to the hospital if he/she is not ill’ and ‘police would ask on the way’. Similar results were reported by Leena R. Baghdadi et al. depicting that ‘fear of getting infected’, ‘travelling on the due date of vaccination’, concerns about vaccine efficacy and safety’ were the major contributors to delay in routine childhood vaccination.
Delayed vaccination was seen in those with older children (more than 2years), among mothers who were 31–40 years old and among those respondents who were illiterate. Although the parents and caregivers had a perception that children should receive all the vaccinations during the pandemic, but lack of knowledge and information on vaccination sites being operational and unavailability of vaccines were the cited barriers. The challenges faced during the first phase of lockdown were fear of getting infected and unavailability of government supply of vaccines.
6. Implication for further scope
The present study helped identify barriers for delayed vaccination during the pandemic. These barriers were addressed by appropriate counselling, so that their misconceptions would be addressed. These identified challenges and barriers can help in making guidelines for future crisis management. Healthcare providers can help in reviewing, planning and implementing strategies to remove them leading to proper implementation and avert suspension of routine services in future. Information about parental barriers to immunizations can lead to targeted interventions to minimize these obstacles at the individual and community level and to help the country achieve our national and state goals. With the ongoing pandemic routine childhood vaccinations should smoothly continue to prevent the outbreak of any other VPDs. Adequate and proper management by the health system to address the existing context-specific barriers and challenges at the system, community and individual level will help in improving the work performance of HCPs.
Further research on the methods to have a continuous uptake of routine immunization among under-five children and methods to reach a greater proportion of parents/caregivers for avoiding delay in scheduled vaccination may be planned. Health planning and management on this aspect of routine immunization including sufficient provision of vaccines and adequate HC personnel may be helpful to overcome the crisis due to the pandemic.
What is already known about the topic: Vaccine hesitancy among parents has been studied at various levels of healthcare.
What the study adds: This study aimed at identifying the challenges faced by parents during various stages of lockdown which is new of its kind and none of its kind have been reported from this part of the country. In case of any epidemic or pandemic the identified factors may be considered for keeping a continuous provision as well as uptake of the routine childhood immunization.
Limitations: It is a hospital based study and the results may not be generalized.
Each enlisted author has substantially contributed as per the journal's requirements. Each author has actively participated in the in the conceptualization and designing of the study, acquisition of data, analysis and interpretation of the data, drafting of the manuscript and final approval of the version of manuscript which is submitted.
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
CRediT authorship contribution statement
Krishna Mishra: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, &, Visualization, Validation, Final draft preparation Acceptance of the final draft submitted. Ipsa Mohapatra: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, &, Visualization, Validation, Final draft preparation Acceptance of the final draft submitted. Partha Sarathi Mohapatra: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, &, Visualization, Validation, Final draft preparation Acceptance of the final draft submitted. Smriti Madhusikta: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, &, Visualization, Validation, Final draft preparation Acceptance of the final draft submitted. Pragyan Parimita: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, &, Visualization, Validation, Final draft preparation Acceptance of the final draft submitted.
Declaration of competing interest
The authors acknowledge all the study participants who spared their time to participate in the survey. The authors also thank the staff of the well-baby clinic who contacted the parents telephonically.
Guiding Principles for Immunization Activities during the COVID-19 Pandemic, Interim Guidance.