CHAPTER ONE

INTRODUCTION
1.1 Background to the Study
According to Pearl & Joseph, (2012), Immunization is the process by which
an individual immune system becomes fortified against infection. It is a method of
protecting people against preventable diseases. They further stated that the method
involves the prevention of people that are susceptible to disease by the
administration or injection of safe and effective vaccines. Vaccine is any
preparation intended to produce immunity to a disease by stimulating the
production of antibodies (Emdex, 2006). Vaccines are made in the laboratory by
growing the germ and weaken them such as Virus or Bacteria in such a way that it
allows the recipient to develop an immune response without developing any
symptoms of the infection.
According to Ayo, (1998) the expanded program on immunization was
launched after the Alma-Ata conference in Geneva,1979, the ultimate aims of the
program is to reduce the morbidity of disease for which vaccines are available. EPI
was renamed to National program on immunization (NPI), it was charged with the
responsibility of preventing children against preventable diseases. Later National
Immunization days was launched in 1996, now it has become a series of yearly
program since 1996 to date. It is charge with the responsibility of boosting routing
immunization.
Immunization, vaccination or inoculation is a method of stimulating
resistance into the human body system to specific diseases using a micro-organism,
such as bacteria or viruses which have been modified or killed. Those treated
micro-organisms do not cause the diseases but rather trigger the system or
mechanism that continuously guard a particular disease causative agent in which
the immune system immediately respond defensively (Lucas & Gilles, 2004).
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 Immunization is one of the major public health strategies to avoid childhood
illnesses and mortality. Without the same, more than five million children would
die each year because of diseases that could have otherwise been prevented
through vaccination (Arooj, 2013). Regardless of interventions made to boost
immunization services, about 27 million children less than one year were not
vaccinated globally against measles or tetanus (Bates & Wolinsky, 2014). As a
result, 2-3 million children are dying annually from easily preventable diseases,
and many more fall ill (Arooj, 2013). In spite of the fact that approximate global
routine measles vaccination coverage was 82% in 2007, about 23.2 million
children remained unvaccinated of which 15.3 million (65%) are from eight
countries in Africa (Burton, 2009). In developed countries, where there is proper
management of immunization data and adequate reporting of diseases, most
vaccine preventable diseases are low, deaths caused by measles complications
dropped by 74 % worldwide and by 89 % in sub-Saharan Africa in the year 2012
to 2013 (Diekema, 2014). Worldwide, diphtheria, tetanus pertussis (DTP) coverage
rose to about 82 % by the end of 2008 (Etana & Deressa, 2012). Polio is about to
be eradicated (Maina, Karanja & Kombich, 2013). All the same, absolute numbers
of children less than one year that were not vaccinated are highest in highly
populated developing countries (Maurice & Davey, 2009. The Division of
Vaccines and immunization (DVI) Expanded Programme on Immunization’s (EPI)
policy prescribes that children get vaccinated with Bacillus Calmette-Guerin
(BCG) and Oral Polio Vaccine (OPV) at birth; three doses of Pentavalent vaccine
and OPV at 6, 10 and 14 weeks of age; and measles vaccine at 9 months of age
(Burton, 2009).
Similarly, according to Thompson (1997), immunization is the action of
artificially stimulating an immune response in a host. Immunization or vaccination
in started since 1967 when World Health Organization (WHO) launched Small Pox
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vaccination on a global scale for the eradication of small pox infection. Expanded
programme targeting the six (6) childhood killer diseases. These are Diphtheria,
Pertussis, Tetanus (DPT); poliomyelitis and tuberculosis (WHO, 1998).
In 1989, Expanded Programme on Immunization was renamed Routine
Immunization an agency under the Ministry of Health (MOH) charged with the
responsibility of effective control through immunization and provision of logistics
and vaccines for the following childhood vaccines preventable diseases that is
cerebrospinal meningitis (CSM), Diphtheria, Tetanus, Hepatitis B, Measles,
Poliomyelitis, Pertussis and Tuberculosis (NPI, 2002).
JAIPUR: The state has a challenging task to increase full immunization coverage
to more than 90% at a time when the health workers have to face difficulties in
persuading parents to get their children immunized in some areas of at least five
districts.
There is a Prime Minister's call to increase the full immunization coverage to more
than 90% by December 2018. Health authorities face difficulties to immunize
children in some parts of Alwar, Jaipur, Barmer, Jalor and Barmer. "In these
districts, there are individual families in some areas where we encounter difficult
situation, if we insist such people to get their children vaccinated," a senior health
department official said. For such areas, the health authorities will focus more on
increasing the immunization coverage by vaccinating children left out earlier from
routine immunization days.
Health department officials said that at present, the immunization coverage in the
state is 83%. But, recently released National Family Health Survey (NFHS-4)
shows that the percentage of fully immunized children (12-23 months) is 54.8%. In
such a situation, when health workers have to face refusals, health department will
prepare a strategy to fully immunise 90% of children in the state.

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Now, directions have been issued to all reproduction and child health officers to
keep a check on each and every child in their respective areas.
According to Dr SN Mittal, Director Family Welfare, Health department officials
from Jaipur will visit the areas where it is needed to increase immunization
coverage. "We held a meeting of RCHOs on Saturday in which we tried to find out
gaps in achieving our goal of fully vaccinating 90% of children in the state. We
have a task in hand to achieve the target in December 2018," That’s why my
emphasis is on the household that do attend Nims University Hospital where
Vaccines are administered.
1.2 Statement of the Problem
The ideal requirement demands that community should perceive routine
immunization as a social support toward preventable diseases. It is also expected
that health care providers should educate mothers on the importance and benefit of
vaccination to their children at the age of 0 – 5 years during the antenatal visits.
However, the researcher observed in the area of the study that people exhibits
somewhat negative response towards the routine immunization services perhaps
due to misconceptions. It is against this statement that the researcher intends, or
norms to investigate the attitude of people towards routine immunization services
among the household owners attending Nims University Hospital.

1.3 Objective of the Study

The purpose of this research work is to find out the knowledge and attitude
of people towards routine immunization services in household owners attending
Nims University Jaipur
1. To investigate the reason for rejection or having non-compliance during the
implementation of the immunization.

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2. To examine the misconception of people Towards Routine Immunization
Services some part of Jaipur.
3. To compare and contrast the effect of the program before and after the revised
launching of the program.
4. To find out the role of the Authority in Routine Immunization program
1.4 Research Questions
1. What is the knowledge and attitude of people attending Nims Hospital towards
routine immunization services?
2. Are people of Chandwji Distrist of Jaipur aware that routine immunization is the
legitimate right of every child 0-59 months?
3. Is Chandawaji District and the communities assisted in the running of the
routine immunization?
1.5 Significance of the Study
The findings of this research work would be useful to other researchers who
might be interested in similar study. The finding will also reveal the
knowledge and attitude of people towards routine immunization on the six
(6) selected childhood killer diseases on the Routine Immunization. They are
diphtheria, pertussis, tetanus, poliomyelitis, tuberculosis and measles. It will
contributes to the existing knowledge on immunization.
Those to benefit include the following:-
1. Nursing Mothers: through interaction with the healthcare personnel during
the visit of health facilities for antenatal care (ANC).
2. Under Five Children: when they are fully immunized they will become
more resistance to the six (6) killer diseases
3. Researcher: this category of people will benefit through using the records
available at hospital for ANC visit, health department and other health
agencies.
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 4. Health Workers: they can benefit through workshops, seminars and
conferences organized by government and other non-governmental
agencies.
5. Policy Makers: it will help them to know the next level of action after
proper evaluation of the available records.
1.6 Scope of the Study
The research is delimited to the knowledge and attitude of people towards
routine immunization Chandwaji District. It is further delimited to people who
attends Nims University Hospital for routine check or seeking medical care.
1.7 Limitation of the Study
This research on knowledge and attitude of people toward routine immunization is
limited to Chandwaji District, in Japur- Rajasthan State.
1.8 Operational Definition of Terms
-Knowledge and Attitude: mean the people behavior towards routine
immunization in Chandwaji District, Jaipur
-Routine Immunization: - taking children to hospital for vaccination from
0 – 5 years for vaccination.
- Immunization: mean administration of vaccines in to human body.
- Vaccines: means prepared weakened or inactive microorganism.

CHAPTER TWO
REVIEW OF RELATED LITERATURE
2.1 Introduction
This study is on the knowledge and attitude of people toward routine immunization
reviewed related literature concerning routine immunization services, and it consist
the following sub headings.
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2.2 Concept of vaccines and routine immunization.
2.3Factors influencing routine immunization services in rural and urban areas.
2.4 Studies on people attitude towards routine immunization program.
2.5 Summary and uniqueness of the study.
2.2 Concept and Meaning of Vaccines
Vaccine is a biological preparation that improves immunity to a particular
disease .Edward Jenner, demonstrated in 1798 cowpox as a vaccine that can
prevent smallpox in humans. Today the term ‘vaccine’ applies to all biological
preparations, produced from living organisms that enhance immunity against
preventable disease. Vaccines are administered in liquid form, either by injection,
by oral routes. Vaccines are composed from living organisms that have been
weakened, usually from cultivation under sub-optimal conditions (also called
attenuation), or from genetic modification, which has the effect of reducing their
ability to cause diseases, (Richard 1999).
2.2.1 What does the vaccine contained?
Vaccines are formulated (mixed) with other fluids (such as water or saline),
additives or preservatives, and sometimes adjutants. Collectively, these ingredients
are known as the excipients. These ensure the quality and potency of the vaccine
over its shelf-life. Vaccines are always formulated so as to be both safe and
immunogenic when injected into humans. Vaccines are usually formulated as
liquids, but may be freeze-dried (lyophilized) for reconstitution immediately prior
to the time of injection.
Preservatives ensure the sterility of the vaccine over the period of its shelf-
life. Preservatives may be used to prevent contamination of multi-dose containers.
When a first dose of vaccine is extracted from a multi-dose container, a
preservative will protect the remaining product from any bacteria that may be
introduced into the containers. (Steven, 1988)
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2.2.2 How do vaccines work?
When inactivated or weakened disease-causing microorganisms enter the
body, they initiate an immune response. This response mimics the body’s natural
response to infection. But unlike disease-causing organisms, vaccines are made of
components that have limited ability, or are completely unable, to cause disease
when inactivated or weakened disease-causing microorganisms enter the body,
they initiate an immune response. This response mimics the body’s natural
response to infection. (Fisher, 2004)
2.2.3 Impact of vaccines on diseases
Vaccines have one of the greatest impacts on public health. Their impact on
reducing human mortality, Vaccines are provided to individuals to protect them
from disease, but they play an even greater role in protecting entire populations
from exposure to infectious diseases. In the 20 th century, vaccines have reduced the
morbidity among susceptible children against preventable diseases; the prevention
of disease has had an enormous impact on economic development by limiting the
cost of curative care.www.vaccinesummit.org/.
2.2.4 Vaccine efficacy
Vaccine efficacy is the reduction in incidence of a disease amongst those
who have been vaccinated relative to the incidence in the unvaccinated. Because
biological are inherently variable, individuals do not respond identically to
vaccines. Vaccines may fail to induce immunity in a few individuals. But the most
effective vaccines induce a protective immune response in > 95% of individuals. If
a high level of vaccination coverage is achieved with an effective vaccine, disease
transmission can be interrupted. When disease transmission is interrupted, even
those individuals who were not vaccinated, or who were vaccinated and did not
develop immunity, will be protected from disease. Smallpox was eradicated by

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achieving sufficient immunization coverage to prevent transmission of disease to
unvaccinated non-immunes (susceptible).
2.2.5 Routine immunization can be described as a process whereby children
receive the recommended vaccination as it scheduled in an appropriate period. The
value of routine immunization services is commonly to assess its ability to reduce
the burden of disease and its consequences, which has an economic impact on the
individual or society and the national health system, (Harley 2010).
A key component to disease preventive measures among infant worldwide is
immunization which is design to improve children health and reduce morbidity and
mortality, also the effecting means for promoting health in the community, (Isyaku
& Aminu 2012).They further stated that, it is estimated to save 3millions lives
from vaccines preventable disease particularly in Africa where infant mortality is
high.
Nigerian Bulleting of Epidemiology volume(2) of 1992 reported that in
1970 , five (5)millions of the world children dead each year and some children
become disable or blind after suffering from preventable disease, with introduction
of immunization in developed countries millions of death due to preventable
disease have been control.
2.3 Factors Influencing Routine Immunization in Urban and Rural Area
 Household income
 Parental education
 Religious and Minority groups
 Migration
 Gender- base equity
 Women’s role and power
 War and Civil unrest
 Traditional healers
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  Urban vs. Rural place of residence
 Program Accessibility
 Financial factors
 Governance
 Information, Misinformation and the internet
 Religious, Cultural and personal Beliefs
 Immigration
 Complementary and Alternative Medicine
 Financial Factors
2.3.1 Household income was shown to play a major role in access to care, as
many indirect costs associated with immunizations, such as transportation to
clinics, were more tolerable for households with higher incomes. In this regard, a
cross-sectional study conducted in Delhi, India, demonstrated that a secure and
salaried job held by the head of household was associated with higher probability
of children being immunized. These findings indicate that poor living conditions
are associated not only with reduced immunization rates, but also with increased
incidence of disease, which in turn raises the overall burden placed on an existing
poor health care infrastructure. (Watkins 2009).
2.3.2 Parental Education
Parental education in general, and about vaccines in particular, was
described in multiple studies to be associated with higher child immunization rates,
suggesting that education of parents plays a significant role in this regard. In a
cross-sectional survey conducted in Delhi, India, maternal education was found to
play an important role in the use of health care services as well as full
immunization of children. In another cross-sectional survey conducted in Pakistan,
maternal educations as well as parents being fully informed about vaccinations
were associated with full immunization of their children. Furthermore, general
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health knowledge was improved among both men and women who have had
access to higher education, suggesting the key role education plays in healthy
behaviors including childhood immunizations. Lack of education can potentially
lead to misconceptions about vaccines. In this regard, a study conducted in Uganda
found that reduced participation in National Immunization Day for polio was due,
at least in part, to concerns that vaccines may cause malaria or contain
contraceptives. (Oladekun, 2009).
2.3.3 Religious and Minority Groups

Religious and cultural factors have been shown to affect immunization rates
among different populations in low-income countries. Differences in religious
affiliation were found to be associated with differences in immunization rates in a
study conducted in Nigeria, where immunization rate was 66% among Christians
but only 32% among Muslims. In addition, increased childhood mortality and
poorer health were seen among Muslims as compared with Christians in studies
from the Middle East and Africa. Lower immunization rates among certain
religious groups could be due to several factors such as marginalization and
alienation from the surrounding society, limited access to social programs, and
respect for their religious leaders’ opinions. In this regard, certain religious leaders
have cited vaccinations as a sin against God (Watkins, 2009).
2.3.4 Migration
Belonging to a community was shown to have a strong positive association
with full immunization coverage. In this regard, war related migration was found
to be associated with increased rates of childhood mortality in Angola. The same
study also showed that decreased access to age-appropriate immunizations was one
of the disadvantages of migrant families as compared with non-migrant families.
The transient nature of the refugee population and the lack of full vaccination

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coverage may be further complicated by the use of multi-dose vaccines, as follow
up visits for multiple doses at the same centers is often not possible. Low
immunization coverage among migrant groups can lead to disease outbreaks which
affect both the immigrant population as well as the host country. In this regard,
measles outbreaks were described in several studies conducted among displaced
populations. Most of these outbreaks occurred in post-conflict circumstances,
where immunization status, nutrition, living conditions and refugee movements
contributed to the transmission, illness and death from the disease. The migration
of children between Burkina Faso and Cote D’Ivoire was found to contribute to a
measles outbreak in Burkina Faso which occurred despite supplementary measles
vaccination given to children in Burkina Faso shortly before the outbreak. (Gutter
1997)
2.3.5 Gender-based inequity
In many low-income countries women are dependent on men socially,
economically and culturally, and are at disadvantage compared with women in
high-income countries. This disadvantage may start at infancy and continue
throughout life. One of the manifestations of this disadvantage is lack of preventive
healthcare, particularly vaccinations, for females. According to health surveys
conducted in India between 1992 and 2006, girls had significantly lower basic
immunization coverage as compared with boys. (Gutter 1997).
2.3.6 Women’s Role and Power

The role of women in societal advancement has been investigated by several

studies. In many households in Uganda, for example, although mothers are the
primary caretakers of children, fathers often make decisions about participation in
government programs and their objections have often been identified as one of the
barriers to their children’s participation in vaccination programs. Two major

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factors appear to particularly affect the role of women in facilitating childhood
vaccination, education and social support. Although the education of both parents
was found to be important for healthy behaviors, maternal education in particular
has been cited as a key element in parental adherence to vaccination programs. In
this regard, a study conducted in sub-Saharan Africa demonstrated that women’s
literacy was positively associated with increased healthcare access and usage. In
Ethiopia, studies led to the recommendation to educate mothers on the importance
of family planning, breast feeding, and immunization programs in efforts to reduce
child morbidity and mortality. Social support for women, especially for mothers of
newborns, was also identified as an important element in shaping attitudes toward
health and care of children. In marginalized, extremely poor and hard to reach
areas, mobilization of social support networks, combined with education and
communication, were found to be effective in overcoming gender barriers and
resistance to vaccination programs. (Taylor 2000).
2.3.7 War and Civil Unrest
War and civil unrest have a deleterious effect on the physical and mental
health of individuals within a population, including the prevalence of vaccine
preventable diseases and the success of vaccination programs. As an example, a
high prevalence of Hepatitis B was found in populations of internally displaced
persons due to war in countries such as Pakistan, especially in rural environments.
Pakistan, which introduced the Hepatitis B vaccine in 2006, has had a substantial
population of internally displaced individuals due to the recent war on terrorism.
Such populations have multiple risk factors for Hepatitis B as well as other vaccine
preventable diseases, and are in great need of effective vaccination programs.
However, war and civil unrest have a negative impact on the infrastructure
necessary to deliver effective health services, including clean water, sanitation and
electric power supply to allow proper cold chain capacity. Delivery of vaccinations
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to rural areas becomes particularly difficult when transportation systems are
destroyed. In addition to destruction of transportation systems as a result of war,
destruction of communication systems such as radio and telephone networks
impacts vaccination programs due to an inability to inform the population of
National Immunization Days as well as vaccine and medical staff availability. The
consequences of war also present a challenge to vaccination program surveillance,
as measuring vaccination coverage and other health related metrics becomes
difficult in the face of communication and transportation systems malfunction.
Thus, in areas stricken by continual civil unrest and war, such as the Sudan, the
scarce and unreliable relief efforts, including vaccination, contribute to high
prevalence of disease. (Lawolyn n.d)
2.3.7 Traditional Healers
Traditional healers often serve as primary health care providers in
developing countries and mothers use their services for pediatric care to various
degrees. Traditional medicine may include herbal, spiritual or religious practices.
A study done in Haiti found that the use of traditional healers by mothers was
negatively associated with the vaccination rates of their children. Furthermore, in a
study done in Pakistan, the use of traditional healers was found to be a risk factor
for under-5 mortality. (sandhu1988).

2.3.9 Urban Vs. Rural Place of Residence

The 2011 Millennium Developmental Goals Report describes a higher rate
of mortality among children from rural households. It is thus important to explore
whether there are differences in routine childhood vaccination rates between urban
and rural communities in low-income countries.
A study conducted in Papua New Guinea demonstrated a significantly
higher rates of 3-dose DPT immunization at 6 month of age in urban as compared
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with rural communities. A study done in Kilifi district in Kenya found that
children from the Kilifi Township received pentavalent vaccine doses earlier than
children from rural areas. Another study done in Indonesia found significantly
higher rates of first-dose measles vaccination in urban as compared with rural
areas.
The differences in immunization coverage between urban and rural children
were linked to parental education, wealth, and the presence of a skilled birth
attendant. Additionally, misconception or lack of knowledge, health services
issues, challenges with regard to travel or transport and family-related logistical
issues were reported more frequently by rural residents as compared with urban
residents. However, urban communities are not always homogeneous with respect
to immunization coverage. Poor urban residents can represent a large proportion of
the population in low-income countries. They may also have high proportions of
migrants or people belonging to different ethnic groups. Thus these populations
may not enjoy the advantages of urban communities with respect to education,
proximity to health care services and ease of communication. (Rayman n.d).
2.3.10 Program Accessibility
Accessibility to immunization programs was shown to have an impact on
their utilization by various populations. A study conducted in Yemen demonstrated
that longer geographical distance and longer driving time were associated with
lower childhood immunization rates. A study conducted in a poor district in Kenya
showed that immunization rate ratios of the pentavalent vaccine decreased with
each kilometer of distance from vaccine clinics to homes. In this regard, a study
conducted in Burkina Faso demonstrated that mortality of children less than five
years of age increased by 50% when the walking distance to healthcare facilities
was longer than four hours, and a study conducted in Pakistan showed that
proximity to government healthcare centers led to increase in children’s
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immunization coverage. Another study conducted among the Bedouin Arabs in
southern Israel, many of whom have lived a nomadic lifestyle away from Maternal
and Child Centers, and are thus similar to populations in low-income countries,
demonstrated low infant immunization coverage prior to the establishment of a
population-specific intervention program.

2.3.11 Financial Factors

Morbidity and mortality from vaccine-preventable diseases occur primarily
in poor countries. It has been estimated that out of the approximately 162 million
Disability-Adjusted Life Years (DALYs) that have been lost around the world
from vaccine-preventable diseases, over 90% occurred in low-income countries.
Additionally, it was estimated that 87% of the 2.5 million deaths of children under
5 years of age worldwide have occurred in poor areas of the world. The
Millennium Developmental Goal No. 4 (MDG 4) calls for a two-thirds reduction in
the mortality of children under the age of 5 by the year 2015. In order to meet
MDG No. 4 in the poorest 72 countries of the world, an estimated US$ 11–15
billion are needed. Thus country-level financial factors have a substantial effect on
the ability to effectively immunize populations in low-income countries.
Historically, financial resources for vaccines in low-income countries have
been limited and inconsistent, however, in recent years substantial efforts have
been made to close the vaccination gap between high- and low-income countries.
In this regard, the GAVI Alliance, which was launched in 2000, has been
instrumental in supporting immunization efforts in low-income nations and
working toward closing the immunization gap between low- and high-income
countries. The GAVI Alliance is a public-private partnership that brings together
the World Health Organization (WHO), UN agencies, the World Bank, donor and
recipient countries, public health institutions, the Bill and Melinda Gates
16
Foundation, pharmaceutical manufacturers, and other members of the financial and
philanthropic community. Its support has been available to countries with gross
National Income per Capita of US$ 1,000 (and more recently of US$ 1500) or less.
The GAVI Alliance offers a new model in which eligible countries submit detailed
proposals which are evaluated by a panel of experts. Thus far, GAVI has been
instrumental in the introduction of new vaccines, enhancing the use of existing
vaccines and promoting reduction in vaccine prices. Future evaluation of GAVI’s
long-term efforts is required.
2.3.12 Governance
The role of country-level governance in the introduction of vaccines was
recently investigated in the context of new vaccine introduction to poor African
nations. In that study, country-level governance was found to be essential for the
early introduction of new vaccines. Country-level governance affects societies in
multiple ways and it is currently assessed yearly by the World Bank. Each
country’s performance is evaluated based on six governance components; these
are: political stability, government effectiveness, rule of law, control of corruption,
regulatory control and voice and accountability. Poor African counties with higher
governance scores were more likely to affect early introduction of at least one new
vaccine indicating the importance of governance in the implementation of
vaccination programs. Superior country-level governance was formerly
demonstrated to have a substantial impact on health-related investments in
developing countries. Country-level governance may also have an effect on the
infrastructure required for the successful implementation of vaccine programs,
such as the ability to reach distant locations, cold chain capacity, safe disposal of
used syringes and needles, as well as adequate numbers of trained personnel. In
fact, country-level governance was found to be a stronger predictor of the initial
introduction of new vaccines to poor African nations.
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2.3.13 Safety concern

It has taken over a decade for public health advocates to achieve a reduction
in negative vaccine perceptions, an effort which required resources that were
thought by some to have been better utilized for the development and delivery of
alternate vaccines.
The number of vaccines given to children presents another significant
concern for parents. The total number of inoculations given to an individual child
can consist of up to 26 injections by the age of 2.69 Even when several vaccines
are combined into a single injection, parents have expressed concern regarding the
ability of children’s immune system to handle multiple vaccines simultaneously
without becoming ‘overloaded’ and experiencing adverse side effects.

2.3.14 Information, Misinformation and the Internet

Information and misinformation transmitted through the media in general
and the Internet in particular compounds the problem of parental concern. This is
particularly due to vast quantities of unfiltered sources of information which are
difficult for laypersons to discern and refute. Increasing efforts toward education
may not be sufficient to address this issue, primarily as trust in medical and other
professional sources has been eroded among certain individuals and societal
groups. In this regard, perceptions that the interest of pharmaceutical companies is
primarily financial have contributed, at least in part, to the reduced trust in
vaccines as necessary components of health care. The website thinktwice.com, for
example, notes “30 tactics used by the medical profession to hoodwink the public,”
the website of the Center for Research and Globalization ‘globalresearch.ca’
questions the safety of vaccines in general and for infants and the elderly in
particular and the website childbirthsolutions.com explores “the contradictions

18
between medical science and immunization policy.” It is interesting to note that
media reports about vaccines have penetrated even some secluded populations that
are usually insulated from the direct influence of the media, such as Orthodox
Jewish communities.

2.3.15 Religious, Cultural and Personal Beliefs

Religion-based and cultural beliefs have been reported as barriers to
vaccination programs in medium- and high income countries. An example of one
religious belief impacting universal immunization programs consists of the notion
that health is given to a person by God and God will determine health without the
need for medication. Another religious objection consists of the notion that some
vaccine viruses are grown in aborted fetal tissue cell lines.
In Israel, two measles outbreaks occurred in 2003 and 2004 within the Ultra
Orthodox Jewish community in Jerusalem. These densely populated highly
religious communities have been closed to outside influences which are perceived
as threatening to their religion. Effective outreach to these populations which
required involvement of their religious leadership emphasized the need for cultural
sensitivity when immunization programs are concerned.
The recently licensed Human Papilloma Virus (HPV) vaccine elicited
objection among certain societal groups because of personal beliefs. In this regard,
black and Asian mothers living in the UK expressed objection to the HPV vaccine
due to the sexual transmission of the virus and their belief that vaccinations could
encourage sexual activity among adolescents.
According to the Center for Disease Control and Prevention (CDC), US
states allow exemptions from vaccine requirements for religious reasons and 21 for
personal beliefs. One study found that children and adolescents receiving

19
exemptions from vaccinations were 35 times more prone to contracting measles as
compared with vaccinated individuals.
2.3.16 Immigration
Many immigrant groups are currently residing in middle- and high- income
countries. Immigration into these countries has led to demographical changes in
many of them. These populations, if under-immunized upon immigration or
thereafter, may contribute to outbreaks of vaccine preventable diseases in the host
countries. In this regard, inadequate vaccination was among the most common
health problems noted among African immigrants in Australia. A study conducted
in Catalonia found significantly lower prevalence of antibodies to the Rubella virus
in immigrant pregnant women as compared with indigenous pregnant women.
Children of foreign-born mothers living in the US were found less likely to
complete the full vaccination series by 18 month of age as compared with children
of US-born mothers. Several reasons were found to be associated with lower
immunization coverage among immigrants. A study conducted in Poland found
that low immunization levels among refugees were due to the use of different
health centers, postponement of vaccinations, and lack of health education among
immigrant parents. Language and cultural beliefs were described to impede many
routine health care practices among Chinese immigrants in Montreal, Canada. A
study conducted among parents in California found that socioeconomic status and
the utilization of traditional medicine constituted barriers to immunizations,
command of the English language, on the other hand was not perceived by these
parents to affect vaccination program participation. A study of Latino children in
Colorado found that sending appointment reminder cards in Spanish helped
improve immunization rates.
2.3.17 Complementary and Alternative Medicine

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 Complementary and alternative medicine (CAM) have grown increasingly
popular over the years, they include naturopathic, homeopathic, chiropractic and
anthroposophic medicine. Their popularity is due, at least in part, to the belief that
conventional medicine, including vaccine administration, is associated with greater
risk than benefit Thus, certain CAM practitioners advise patients against
immunizations, and several studies demonstrated lower vaccination rates among
CAM pediatric patients, with higher rate of vaccine-preventable diseases. In
addition to the belief that vaccines are associated with greater risk than harm, a
strong philosophical reasoning plays a significant role in the choices made by
certain CAM patients. Anthroposophy, for example, is a philosophical approach
that is applied to several areas of life including medicine and education.
Antroposophical medicine used for pediatric care has been particularly popular in
certain European countries. Parents practicing anthroposophy believe in the mental
and physical strengthening effects of natural infections like measles. Several
measles outbreaks originating in anthroposophic communities and schools in
Europe highlight the role of these philosophical beliefs in immunization uptake.
2.3.18 Financial Factors
Despite the relative wealth of high- and medium-income countries, financial
factors do affect vaccinations in these countries. In the US, disparities in income
that have affected immunization rates led to the establishment of the Vaccines for
Children program (VFC). This state-operated federal entitlement program provides
funding for recommended vaccines to children from low socioeconomic status.
2.4 Studies on Peoples Attitude toward Immunization Program

Mohler (1997) stated that, the World Health Organization (WHO), believe
that the control of preventable diseases through routine immunization services is
necessary condition for social and economic development. He further stated that

21
the routine immunization service was in view of reducing the mortality rate among
children to all state of the federation.
Marley (1975) observed that most of the children only 60% have chance of
surviving to the age of 5 years due to the infection of preventable diseases. The
national program on immunization was launched in 1979 and revised in
1984,where other state were expected to commence lunching to all local
governments headquarters to control the spreading of preventable diseases. In
Jaipur, following the implementation of immunization program, the incidence of
preventable disease was 97% lower in 2006.
The implementation of immunization programs varies from country to
country. All countries provide basic immunization services through the public
sector. The private sector plays an important role in offering many of the same
vaccines, and several others, to segments of population that access healthcare
outside of the public sector.
2.4.1 Implementation of immunization in Europe

The European region is very diverse and immunization policies vary

considerably from country to country. Some countries, such as Germany, have a
decentralized public health system where the states are responsible for the
implementation of immunization (as is the case in the US). In Germany, the costs
of immunization are covered mostly by statutory insurance provided by employers.
Other European countries, such as the UK, have a strong, centralized,
comprehensive health system that includes responsibility for immunization. In the
UK, the national government provides for all recommended vaccines to the public
at no cost. The national government is also responsible for disease surveillance and
monitoring and encouraging vaccination coverage.
2.4.2 Implementation of immunization in the Asia-Pacific Region

22
 The Asia-Pacific region is very heterogeneous. Countries in the region span
all classes of economic development. As a result, approaches to immunization are
widely varied. Unlike Europe, the region does not have a centralized regulatory
body to license vaccines. But the Japan Pharmaceuticals and Medical Devices
Agency and the Ministry of Health, Labor, and Welfare is a signatory to the
International Conference on Harmonization with the US and Europe. This is
intended to encourage the standardization of the requirements for vaccine licensing
between the three regions.
The Asia-Pacific region does not have a regional vaccination support
program, such as the one administered by the Pan-American Health Organization
in Latin America. Most countries in the region rely on national expert
immunization committees to recommend vaccines. Most countries then provide
recommended vaccines at no cost through public sector health outlets. However
recommendations for vaccines vary considerably between countries in the region.
Ironically, some of the lowest-income countries in the region recommend the
greatest number of vaccines.
2.5 Summary and Uniqueness of the study
Although a lot of research has been carried out on the people knowledge and
attitude toward routine immunization services, the writer combined different
opinions of various authors in reviewing the literature in which the concept and
meaning of vaccines and immunization and the factors that influence routine
immunization program in rural and urban area were reviewed.
This study is unique based on the fact that, the research will be carried out in
Chandwaji District.

23
 CHAPTER THREE
RESEARCH METHODOLOGY

3.1 Introduction
The study is on the knowledge and attitude of people towards routine
immunization services in Chandwaji District with emphasis on people attending
Nims University Hospital Jaipur. This chapter deals with Research Design,
Population of the Study, Sample and Sampling Techniques, Data Collection
Instrument, Data Collection Procedure and Method for Data Analysis.

3.2 Research Design

The design to be adopted for this study will be survey research design
According to Njodi and Bwala (2010). This research design is a systematic way of
action which provides the necessary information to a specific population on current
status of one or more variables. The survey is found suitable for this study because

24
it will collect and organize data at a particular point of time with the intention of
describing the nature of existing condition.

3.3 Population of the Study

The population of the study includes all men and women who attended hospital
for routine immunization check or medical care totaling 5,022 according to data
record in (2016).

3.4 Sample and Sampling Technique

The sample for this study was 100 respondents which are selected using
random sampling method from the population of the study.

3.5 Data Collection Instrument

The instrument for data collection in this study will be self-developed
questionnaire. The questionnaire consists of two (2) sections, labeled A-B. Section
A deals with demographic information of the respondents, while Section B will
access information on people attitude towards routine immunization services.

3.5 Data Collection Procedure

An introductory letter will be obtained from Public Health and Community

Medicine Department, Nims University Jaipur seeking for permission to conduct
the study. Questionnaire was distributed to the respondents and retrieved back after
two weeks to enable the respondents makes good and appropriate choice on the
questions provided.

3.6 Method of Data Analysis

Frequency count and percentage will be used to organize and describe the
demographic characteristics of the respondents. The same statistics will be used to
analyze the research questions.
25
 CHAPTER FOUR

DATA PRESENTATION, ANALYSIS AND DISCUSSION OF RESULTS

4.1 Introduction
This study is on the knowledge and attitude of people toward routine immunization
service, in Chandwaji District. Therefore this chapter deals with analysis and
discussion of Result by using questionnaires as the instrument for data collection
Result and Discussion
One hundred (100) copies of questionnaire were distribution to the
respondents and only ninety five (95) copies were returned and analyzed.
They are presented in the table below
4.2 Age of the respondents
Respondents Percentage
a. 15 – 24 years 24 22.5%
b. 25 – 34 years 26 27.5%
c. 36 – 44 years 28 32.5%
d. 45 years and above 17 17.5%
Total 95 100%
From the table above, is indicated 22.5% of the respondents believe that
routine immunization is vital aspect to their children, 27.5% agreed that routine
immunization reduce the menace of preventable disease to our children. While
32.5% containing the highest percentage against routine immunization which
believe that the vaccines are unsafe to administer to our children and finally 17.5%
shows the least portion of routine immunization to our children.
4.3 Occupation of the respondents
Respondents Percentage

26
 a. Civil servant 36 37.5%
b. Self employee 35 34.5%
c. House wives 24 28%
Total 95 100%
The above table, shows that 37.5% were civil servant and 34.5% were self
employed while 28% were house wife which is believe that routine immunization
to our is a major thing to be considered and it is a free and safe to our children with
is the preventive agents infections disease.
4.4 Gender
Respondents Percentage
a. Male 71 65.5%
b. Female 24 34.5%
Total 95 100%
From the above table, 65.5% were male respondents while 34.5% were
female based on the masculine gender. 71 male respondents said that routine
immunization services improve the health condition of their children. While 24
female respondents believe that, routine immunization will prevent child mortality
and morbidity.
4.5 Educational Background of the Respondents
Respondents Percentage
a. Primary 38 39.5%
b. Secondary 18 16.5%
c. Tertiary 11 10.5%
Other 28 33.5%
Total 95 100%

27
 From the above table, shows that 38 respondents which represent as 39.5%
received primary education while 18 respondents i.e 16.5% have secondary
education than 11 respondents i.e 10.5% attended tertiary institution and finally 28
respondents i.e 33.5% persue adult and non formal education .
Therefore, all the respondents agreed that routine immunization plays
fantastic role in their community and believed that, routine immunization will
boost child in the community.
Table 4.6: knowledge and Attitude of people towards routine immunization
services and the effects on the children in Chandwaji District.
S/N Items Response Respondents Percentage
6 Do you prefer to prevent 49 52%
your children from
infectious disease
46 48%
through routine
immunization (RI)
Total 95 100%
7 Do you find it convenient 56 59
to use the nearest health Yes
facility to immunize your 39 41
child? No
Total 95 100%
8 Are you comfortable to 39 41
take your child for Yes
routine immunization
56 59
every session due to its
No
preventive effect?

28
 Total 95 100%
9 Will you feel happy if 49 52
your child started Yes
immunization schedule at
46 48
birth and finished before
No
1 year?

Total 95 100%
10 Do you always bring 45 47
Yes
your child for routine
immunization as 50 53
schedule? No

Total 95 100%
11 Are you bringing your 60 63
child for routine Yes

immunization service to
35 37
ensure healthy growth?
No

Total 95 100%
12 Do you agree that 49 52
Yes
immunization service is
46 48
free and safe to our No
children? Total 95 100%
13 Do you also believe that 63 66
Yes
routine immunization can

No

29
 prevent child mortality 32 34
and morbidity?
Total 95 100%
14 Does routine 40 42
Yes
immunization boost child
55 58
immunity? No

Total 95 100%

CHAPTER FIVE
SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Introduction
This study is on the knowledge and attitude of people toward routine immunization
service in Chandwaji District, Jaipur. Therefore, this chapter deals with summary,
conclusion and recommendation of the research work.
5.2 Summary
This study was conducted to investigate the attitude of people towards
routine immunization services and the effects on the children in Chandawji
District, Jaipur in Rajasthan state. Survey design was use to collect the needed
research data regarding the study. The population of the study consists of male and
female in Study area. To obtain the information a self-developed questionnaire was
used by the researcher.
A total number of one hundred (100) copies of questionnaires were
distributed to the respondents , and ninety five (95) copies were duly filled,
returned, and analyzed using simple frequency count and percentage, the findings

30
of the study revealed that the people of Chandwaji have negative attitude towards
routine immunization services.

5.3 Conclusion
The findings of this study in a nutshell, based on revealed that, the people in
the study area have negative knowledge and attitude toward routine immunization
services.
5.4 Recommendations
Based on the findings it was recommended among other things that:-
Government should developed strategies to educate people on the importance of
routine immunization services. So also, Government should provide enough and
trained personnel for routine immunization services. Nevertheless, Government
should organized seminars for health workers to effectively educate the general
populace on important of routine immunization services.
Government should set aside some laws and guidelines on proper vaccination
schedules. Government should appropriate action to insure that parent take their
children to immunization centres at regular interval.
Public enlightenment campaign on routine immunization and the use of mass
media should be encouraged.
Community based organizations should be involved in routine immunization
activities. Government should improve routine immunization service delivery in
order to achieve desired goal.
So also, Government should provide enough logistics to maintain the cool chain
system. Advocacy visit to community leaders, sensitization and social mobilization
should be intensified

31
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Appendix
QUESTIONNAIRE

Dear Respondents
I am an Undergraduate Student studying Public Health, in the Department of
Public Health and Community Medicine, Nims University Jaipur Rajasthan.
carrying out a research on “Knowledge and Attitude of People Toward Routine
Immunization Services in Household members attending Nims University
Hospital, Jaipur. All information given will completely be used for academic
purpose and remain highly confidential.
35
Please Tick (√ ) the option appropriately.
The paper consists of two (2) Sections:
Section A “Demographic Information of the respondents”
1. Age
a. 15-24 years
b. 25-34 years
c. 35-44 years
d. 45 years and Above

2. Occupation
a. Civil Servant
b. Self Employee
c. House Wife

3. Gender
a. Male
b. Female

4. Educational Background
a. Primary
b. Secondary
c. Tertiary
d. Others

36
Section B: “Knowledge and Attitude of People towards Routine Immunization
Services in Chandwaji District Among Respondents.”
S/N ITEM YES NO
5 Do you prefer to prevent your children
from infection diseases through routine
immunization (RI)?
6 Do you find out it convenient to use the
nearest health facility to immunize your
child?
7 Are you comfortable to make your child to
routine immunization every session due to
its preventive effect?
8 Will you feel happy if your child started
immunization schedule at birth and
finished before 1 year?
9 Do you always bring your child for routine
immunization as schedules?
10 Are you bringing your child for routine
immunization service as it ensures healthy
growth ?
11 Do you agree that immunization services
are free and safe for our children?
12 Do you also believe that routine
immunization can prevent child mortality
and morbidity?
13 Does routine immunization boost child

37
immunity?

38