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 Table of Contents  
Year : 2023  |  Volume : 4  |  Issue : 1  |  Page : 13-17

Study of coverage and barriers of immunisation among children of age 12–23 months in urban areas of Rishikesh

1 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Radiation Oncology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission26-Jul-2022
Date of Decision09-Sep-2022
Date of Acceptance10-Sep-2022
Date of Web Publication23-Feb-2023

Correspondence Address:
Dr. Pradeep Aggarwal
Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_99_22

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Background: Ensuring high immunisation coverage and its acceptance among the beneficiaries are crucial for a healthy society. Hence, this study aimed to estimate vaccine coverage and barriers of immunisation among children of age 12–23 months in urban areas of Rishikesh, Uttarakhand. Aims: To estimate the immunization coverage rate among children of age 12-23 months in urban area of Rishikesh. Objectives: To identify the barriers towards immunization in children of age 12-23 months in urban area of Rishikesh. Materials and Methods: A community-based cross-sectional study was done in urban areas of Rishikesh for 1 year, including 210 children, using the WHO's 30 × 7 cluster sampling technique to collect data on immunisation status. Results: About 92% of the children were fully immunised. Bacillus Calmette–Guérin has the highest coverage rate (99.5%), whereas the coverage was the lowest for the measles vaccine (93.8%). Full immunisation coverage was found to be statistically significant with the education of the respondent, socio-economic status (SES) of the family and birth order of the child. Additional vaccines uptake showed a significant association between SES of the family and the place of vaccination. Conclusion: There were significant variations in childhood immunisation coverage across socio-economic and demographic factors. These findings emphasize on the need for regular monitoring and evaluation of immunisation coverage to achieve the benefits of vaccination in all strata of society.

Keywords: Barriers, children, immunisation coverage, monitoring, urban area

How to cite this article:
Asha T J, Singh M, Aggarwal P, Sharma N, Narayanan AU, Anjali M, Namitha R S. Study of coverage and barriers of immunisation among children of age 12–23 months in urban areas of Rishikesh. J Med Evid 2023;4:13-7

How to cite this URL:
Asha T J, Singh M, Aggarwal P, Sharma N, Narayanan AU, Anjali M, Namitha R S. Study of coverage and barriers of immunisation among children of age 12–23 months in urban areas of Rishikesh. J Med Evid [serial online] 2023 [cited 2023 Jun 3];4:13-7. Available from: http://www.journaljme.org/text.asp?2023/4/1/13/370398

  Introduction Top

Immunisation is the process of making a person immune or resistant to contagious diseases, usually through vaccination.[1] Vaccines have had a huge impact in reducing morbidity and mortality attributable to vaccine-preventable diseases since their introduction as a public health intervention.

In many nations, there are significant variations in vaccination coverage in urban regions, with poorer coverage among the urban poor. In less densely populated remote regions, disease transmission can be prevented with a lower vaccine coverage rate; however, in metropolitan areas, the coverage rate must be significantly higher. Immunisation is a multisectoral activity with significant variation in coverage globally due to demographic, socioeconomic and political factors.[2] Therefore, in this prevailing scenario, it is crucial to study barriers to full immunisation coverage, which will help planners to implement immunisation programme in a better way to achieve >90% coverage.

  Materials and Methods Top

A community-based cross-sectional study was conducted in urban areas of Rishikesh from 1 May, 2020 to 30 April, 2021, after receiving an approval from the Institutional Ethics Committee, through No: 185/IEC/PGM/2020, All India Institute of Medical Science, Rishikesh. The aim of the study was to estimate the immunisation coverage rate among children of age 12–23 months in urban areas of Rishikesh and to identify the barriers towards immunisation in children of age 12–23 months in urban areas of Rishikesh. Furthermore, we aimed to determine the association between socio-demographic variables of respondents and barriers towards childhood immunisation.

The study population included children aged 12–23 months and their parents residing in urban areas of Rishikesh. Children aged 12–23 months residing in urban areas of Rishikesh for at least 6 months were included in the study, whereas children on immunosuppressive therapy and respondents who did not give informed consent were excluded. The WHO's 30 × 7 cluster sample approach was employed.[3] In the Uttarakhand district of Dehradun, Rishikesh is a Nagar Palika Parishad city. The list of wards was obtained from Rishikesh Municipal Corporation. There are a total of 40 wards with a population of 106,320. The representative population in Rishikesh's urban areas was chosen using the cluster sampling technique, which is a form of the two-stage sampling method. In the first stage, database of wards in urban areas of Rishikesh was taken from Nagar Nigam, Rishikesh, and then 30 clusters were randomly selected according to population proportion to size.

In the second stage, seven study participants were chosen at random from each of the clusters. If all seven participants could not be found in a single cluster, the contiguous cluster was used until the desired number of participants was reached.

Description of selection of clusters

  • Step 1: A list of all the wards of Rishikesh was taken from Nagar Nigam, Rishikesh office
  • Step 2: The cumulative population was calculated and by dividing it by 30, i.e., the number of clusters, we obtained the sampling interval
  • Step 3: A random number having the same number of digits, but less than or equal to the sampling interval, was selected, which gave us the first cluster
  • Step 4: The random number plus sampling interval gave the second cluster (the cumulative population listed for that ward was equal to or more than the number we obtained by addition)
  • Step 5: Second cluster + sampling interval = third cluster and so on.

The procedure was continued until all 30 clusters were chosen. From each cluster, seven participants were selected from continuous households randomly. Only one study participant was chosen from each house. If there are more than one study participant from the same household, the eldest one was chosen. A total of 210 people were analyzed in the end.

Study tool

The WHO vaccination coverage cluster survey questionnaire on routine immunisation form of 12–23 months was used for data collection. For data collection on sociodemographic variables, attitude assessment and other vaccination barriers, a pre-tested questionnaire form was used. Before including their children, the mother provided written informed permission. The interview schedule was divided into the following sections: coverage of individual vaccines, information on socio-demographic characteristics, information on knowledge in immunisation and information on vaccine hesitancy.

Operational definitions

Fully vaccinated child

A child was deemed fully vaccinated, if he or she had gotten one dose of Bacillus Calmette–Guérin (BCG), three doses of diphtheria, pertussis, and tetanus (DPT), three doses of oral polio vaccine (OPV) and one shot of measles by the age of one.[4]

Partially vaccinated child

Any child who, by the age of 1 year, had gotten at least one dose of vaccine, but had not completed all doses.[4]

Unvaccinated child

If the child had never got any of the immunisations, by the time he or she was 1 year old.[4]

Full immunisation coverage (%)

Percentage of 1 year old who received one dose of BCG, three doses of polio, three doses of DPT and one dose of measles vaccine.[4]

Additional vaccines

Vaccines other than included in routine immunisation as per the National Immunisation Schedule.

Statistical analysis

For numeric variables, descriptive data were expressed as mean and standard deviation, whereas categorical variables were expressed as percentages and proportions. Chi-square test and Fisher's exact test for categorical variables are examples of appropriate tests of significance used to analyze association depending on the nature and distribution of variables. SPSS Version 23.0 was used to analyze the data (IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp. was used to analyze the data). P =0.05 is deemed statistically significant.

  Results Top

The current study examined the coverage, obstacles and determinants of childhood immunisation among 210 children aged 12–23 months in Rishikesh's urban districts.

Estimation of vaccine coverage

[Table 1] describes the distribution of study participants according to vaccination card. All study participants had received vaccination card, and among them, 209 (99.55%) had vaccination card with them at the time of the study. Coverage of individual vaccines showed that the highest coverage rate (99.5%) is for BCG and oral polio vaccine 0, whereas the coverage was the lowest for the measles vaccine (93.8%). About 92% of the children (193 out of 210) were fully immunised and the remaining 8% (17 out of 210) were partially immunised.
Table 1: Estimation of vaccine coverage (n=210)

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Majority (35.2%) of the respondents were educated up to high school. Most of them were homemakers (92.9%), while only 5.7% were employed. Almost everyone (99%) was Hindu by religion. More than half (54.3%) had joint type of family and the remaining (45.7%) to nuclear family type. 45.2% belonged to class IV socioeconomic status (SES) of modified Kuppuswamy's SES, 2020. 44.8% of children were of first-order birth, followed by 42.9% of second-order births. Only 12.4% of the children were of third order and higher [Table 2].
Table 2: Sociodemographic characteristics of respondent (n=210)

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100% of informants had faith in immunisation, and 98.1% had knowledge that vaccines can protect the child from diseases. The majority of parents (94.8%) were aware that their child had received all the required vaccinations. Sick child at the time of vaccination was the most common (76.4%) reason for vaccine hesitancy among the majority of the responders. Others include long-wait and closed facilities at the time of visit. Only a few (5.2%) informants had knowledge on additional vaccines. The remaining 199 had no information about the newer vaccines. All those who had heard of additional vaccines recommend newer vaccines (5.2%) for their children [Table 3].
Table 3: Assessment of knowledge on immunisation and vaccine hesitancy

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The study found that the respondent's education (Chi-square = 8.748, df = 2, P = 0.013) and the family's socioeconomic position (Chi-square = 7.127, df = 2, P = 0.028) had a statistically significant relationship with the child's complete immunisation status. Complete immunisation was not substantially related to occupation, religion or family type (P > 0.05). 95% of first-born children were completely immunised, and the association between birth order of child and immunisation status was statistically significant (Chi-square 8.322, df = 2, P = 0.016) However, gender, birth place, usual place of vaccination and distance to vaccination centre were not associated with complete immunisation [Table 4].
Table 4: Factors associated with immunisation status of children

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  Discussion Top

In our study, we found that 92% of people were fully immunised. However, this coverage reveals a higher percentage of beneficiaries who have received all immunisations as of the survey date, compared to the Uttarakhand National Family Health Survey-4 report.[5] This rise could be attributed to the active participation of all stakeholders in increasing awareness generation in the survey area. From 2008 (DLHS-3) to 2021, the state's full immunisation coverage has increased. There was a lot of heterogeneity in the coverage of individual vaccine doses. Other studies around the country have found a similar pattern in the percentage of children who have received all their vaccines. Similar to our study finding, studies done in other states of India to assess the vaccine coverage in urban areas by Vohra et al.,[6] Bhatt et al.,[7] Joy et al.,[8] Rakesh et al.[9] and Punith et al.[10] have reported similar high coverage rates with BCG having the highest of all routine vaccines and measles reported with the least coverage rates. Our study findings on full immunisation coverage in urban areas of Rishikesh were similar to the findings of a study in Kerala, which showed significant improvement in health and socio-economic variables. Individual vaccination coverage among children aged 12–23 months was as follows: 'BCG' had 98.7%, 'OPV zero dose' with 98.7%, 'hepatitis B zero dose' showed 97.7% and 'DPT 1st, 2nd and 3rd doses' with 99%, 98.7% and 98.4%, respectively. Measles had the least coverage of 95.8%.[8]

The most common explanation given by the most respondents in our study was that their child was unavailable on the day of vaccination owing to a sick child, followed by a closed health facility and a long-wait time. Singh et al.[11] from Bihar showed that the most prevalent reasons for partial or no immunisation are a sickly or sick child (27.5%), a lack of vaccination awareness or understanding (25.12%) and a closed health facility at the time of vaccination. Low awareness was the most common reason for incomplete or no immunisation, according to a study conducted by Latika Nath in Haridwar, Uttarakhand,[12] Vohra et al.[5] in the urban slums of Lucknow. Our study's findings, however, indicated that all mothers were aware of and supportive of childhood immunisation. This can be due to the high education and literacy among the urban population. Multiple factors impacting childhood immunisation in Uttarakhand have been identified by the state's department of medical health and family welfare.[13]

Children in metropolitan regions, children with educated moms and children from wealthy families are more likely to have received all the required vaccines than other children. The proportion of completely immunised children varies just slightly by gender. The present study to find the barriers of complete immunisation has also observed similar findings as factors contributing to it. While immunisation services are free of cost, lack of parental knowledge or income loss can be contributing factors. Complete vaccination cover was shown to be more common in good homes; however, partial and non-immunisation were found to be more common in economically disadvantaged or weaker homes.

This study supports prior research that shows a link between a better socio-economic level and higher immunisation rates. Corsi et al.[14] stated that with a greater number of children in the household, there are higher chances that the younger child's health would be neglected.

The introduction of newer or optional vaccines has a dismal track record in developing countries. Deepali et al.[15] did a study in Maharashtra, finding that total knowledge and understanding of newer vaccines were quite low, with only 32.5% of the total respondents knowing anything about them.

  Conclusion Top

Urban areas of Rishikesh stand out with high rates of complete immunisation coverage compared to other areas of the district, Dehradun, and the state, Uttarakhand, reflecting the quality of services provided and success of systematic outreach approaches which helped in increasing accessibility to routine immunisation services.[5] Like other studies, in various settings, the importance of parental education in improving child health and SES of the family was found to be significant determinant of complete immunisation. Factor like children with low birth order has to be given special attention to identify high-risk group for low childhood immunisations. Coverage of optional vaccines was found to be very low compared to routine vaccines


Address community queries, negative information and fear of adverse events related to vaccines and immunisation programme at all levels to assure and mobilise beneficiaries. Formal media briefings to encourage positive messages for the community to access vaccine and to stay up to date on the latest vaccine recommendations.

Limitation of the study

It was difficult to conduct research during the continuing COVID-19 pandemic and throughout the lockdown period. Construction sites, temporary settlements, brick kilns and slums comprising residents from several other regions dwelling in Rishikesh's urban areas were not included in the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

WHO | Immunization. Available from: https://www.Who.int/topics/immunization/en/.[Last accessed on 2021 Dec 11].  Back to cited text no. 1
GATHER Compliance: WHO/UNICEF Estimates of National Immunization Coverage (WUENIC); 2018. Available from: https://cdn.who.int/media/docs/default-source/immunization/immunization-coverage/gather_checklist.pdf?sfvrsn=6611a56a_6. [Last accessed on 2021 Dec 11].  Back to cited text no. 2
WHO | Immunization. The EPI coverage survey. Available from: https://www.Who.int'documents'MLMModule7. [Last accessed on 2021 Dec 11].  Back to cited text no. 3
WHO | Full Immunization Coverage among One-Year-Olds (%) (Health Equity Monitor). Available from: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/3317. [Last accessed on 2021 Nov 04].  Back to cited text no. 4
National Family Health Survey-4; 2015-16. Available from: http://rchiips.org/NFHS/UT_FactSheet.pdf. [Last accessed on 2021 Dec 11].  Back to cited text no. 5
Vohra R, Vohra A, Bhardwaj P, Srivastava JP, Gupta P. Reasons for failure of immunization: A cross-sectional study among 12-23-month-old children of Lucknow, India. Adv Biomed Res 2013;2:71.  Back to cited text no. 6
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Punith K, Lalitha K, Suman G, Pradeep BS, Jayanth Kumar K. Evaluation of primary immunization coverage of infants under universal immunization programme in an urban area of Bengaluru city using cluster sampling and lot quality assurance sampling techniques. Indian J Community Med 2008;33:151-5.  Back to cited text no. 10
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  [Table 1], [Table 2], [Table 3], [Table 4]


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