Coverage Evaluation Survey - 2002 - IPPI, Routine Immunization and Maternal Care - National Report_0

8/8/2019 Coverage Evaluation Survey - 2002 - IPPI, Routine Immunization and Maternal Care - National Report_0

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CES-02 INDIA - FINAL REPORT

Coverage Evaluation Survey - 2002

IPPI, Routine Immunization and Maternal Care

National Report

Department of Family Welfare,Ministry of Health and Family Welfare

Government of India, Nirman Bhavan, New Delhi

Organized by Unicef, India Country OfficeFunded by USAID and Japan Governmen


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TABLE OF CONTENTS

1 EXECUTIVE SUMMARY ......................................................................................................................................7

INTRODUCTION.........................................................................................................................................................17

2 INTRODUCTION ..................................................................................................................................................18

2.1 RESEARCH OBJECTIVES ...................................................................................................................................19

2.2 RESEARCH DESIGN..........................................................................................................................................20

2.2.1 Universe....................................................................................................................................................202.2.2 Respondents ..............................................................................................................................................20

2.2.3 Sampling Design.......................................................................................................................................21

Qualitative Sampling Design....................................................................................................................................23

2.2.4 Universe....................................................................................................................................................232.2.5 Respondents ..............................................................................................................................................24

2.2.6 Sample Distribution..................................................................................................................................24

2.2.7 Weights .....................................................................................................................................................24

2.2.8 Recruitment, Training and Fieldwork.......................................................................................................25

DETAILED FINDINGS ...............................................................................................................................................26

QUANTITATIVE .........................................................................................................................................................26

3 RESPONDENT PROFILE ....................................................................................................................................27

3.1 PRIMARY CARE TAKER....................................................................................................................................27

3.2 PRIMARY CARETAKERS EDUCATION ..............................................................................................................28

3.3 EDUCATION OF THE FATHER.............................................................................................................................293.4 BACKGROUND CHARACTERISTICS OF THE SAMPLE COVERED ..........................................................................30

4 INTENSIFIED PULSE POLIO IMMUNIZATION.............. ........... ........... .......... ........... ........... .......... ........... ...31

4.1 DISTANCE OF THE PPIBOOTH..........................................................................................................................314.2 COVERAGE BY DOSES.......................................................................................................................................33

4.3 COVERAGE ACROSS STATES ..........................................................................................................................35

4.4 COVERAGE BY ROUNDS....................................................................................................................................364.4.1 Reach by rounds by age categories ..........................................................................................................37

4.5 COVERAGE BY ROUND ACROSS STATES ..........................................................................................................38

4.6 IPPI COVERAGE OF CHILDREN ABOVE 5 YEARS OF AGE ..................................................................................394.7 ZERO DOSE CHILDREN.....................................................................................................................................40

4.7.1 Zero dose children by age cohorts............................................................................................................42

4.8 ZERO DOSE CHILDREN BY STATES ..................................................................................................................43

4.9 PLACE WHERE DOSAGE WERE ADMINISTERED ...............................................................................................434.9.1 Place of administration of doses by States................................................................................................45

4.10 REASONS FOR NOT RECEIVING ONE OR MORE DOSES ......................................................................................46

4.10.1 Reasons for non compliance amongst campaign zero dose children........................................................494.10.2 Reasons for non compliance among lifetime zero dose children ............................................................51

4.11 SOURCE OF KNOWLEDGE .................................................................................................................................524.12 ADVICE ON VACCIANTION OTHER THAN POLIO ................................................................................................56

4.13 PERCEPTION REGARDING THE IMPORTANCE OF ROUTINE IMMUNIZATION.......................................................57

4.14 KNOWLEDGE ABOUT THE SYMPTOMS OF POLIO LIKE DISEASE.........................................................................584.15 KNOWLEDGE REGARDING THE PLACE TO REPORT THE OCCURRENCE OF POLIO..............................................59

5 NUTRIENTS...........................................................................................................................................................60

5.1 VITAMIN ASUPPLEMENT.................................................................................................................................60

5.2 IFA SUPLLEMENT ...........................................................................................................................................63


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6 ROUTINE IMMUNIZATION...............................................................................................................................65

6.1 ROUTINE IMMUNIZATION SESSIONS .................................................................................................................65

6.2 IMMUNIZATION CARD ......................................................................................................................................686.3 ROUTINE IMMUNIZATION SESSIONS BY STATES ..............................................................................................69

6.4 BCGVACCINATION .........................................................................................................................................70

6.5 DPTVACCINATION ..........................................................................................................................................71

6.6 OPVVACCINATION .........................................................................................................................................73

6.7 MEASLES VACCINATION..................................................................................................................................75

6.8 FULLY VACCINATED .......................................................................................................................................776.8.1 Vaccines received across States................................................................................................................79

6.8.2 Correlation of Coverage with Access to Immunization Service................................................................816.8.3 Timeliness of Immunization ......................................................................................................................82

6.9 PLACE OF IMMUNIZATION................................................................................................................................83

6.9.1 Source of immunization services across states .........................................................................................85

6.10 REASONS FORNON COMPLIANCE ....................................................................................................................86

7 INJECTION SAFETY ...........................................................................................................................................88

7.1 INJECTIONS SAFETY .........................................................................................................................................887.2 INJECTION SAFETY ACROSS STATES .................................................................................................................89

8 MATERNAL CARE...............................................................................................................................................90

8.1 AGE AT FIRST PREGNANCY ...............................................................................................................................90

8.1.1 Pregnancy wastage and children surviving..............................................................................................918.1.2 Pregnancy details across states ................................................................................................................92

8.2 ANTENATAL CARE ...........................................................................................................................................938.2.1 ANC across states .....................................................................................................................................95

8.2.2 ANC Service Provider...............................................................................................................................95

8.3 ANCSERVICE PROVIDER BY STATES..............................................................................................................968.3.1 Components of Antenatal Care.................................................................................................................97

8.3.2 Components of Antenatal Care by state....................................................................................................98

8.3.3 TT Immunization.......................................................................................................................................998.3.4 TT Coverage by State..............................................................................................................................100

8.4 IRON FOLIC ACID (IFA)SUPPLEMENT...........................................................................................................1018.4.1 IFA coverage by state .............................................................................................................................1028.4.2 Source of receiving IFA ..........................................................................................................................103

8.4.3 Source of receiving IFA tablets by State.................................................................................................1048.5 NIGHT BLINDNESS .........................................................................................................................................105

8.6 NIGHT BLINDNESS ACROSS STATES ..............................................................................................................106

8.7 KNOWLEDGE ABOUT COMPLICATIONS DURING PREGNANCY.........................................................................1068.7.1 Knowledge about Complications during Pregnancy by State.................................................................109

8.8 KNOWLEDGE ABOUT THE PLACE OF CONSULTATION FOR PREGNANCY COMPLICATIONS...............................110

8.9 COMPLICATIONS EXPERIENCED DURING PREGNANCY ....................................................................................112

8.10 COMPLICATION EXPERIENCED DURING DELIVERY..........................................................................................115

8.11 PLACE OF DELIVERY AND ASSISTANCE AT DELIVERY ...................................................................................1168.11.1 Nature of delivery ...................................................................................................................................120

8.11.2 Delivery Details across States ................................................................................................................1218.11.3 Clean Delivery Practices at Home..........................................................................................................122

8.11.4 Clean Delivery Practices at home by States ...........................................................................................124

8.12 POSTNATAL CARE..........................................................................................................................................1258.14 INITIATION OF BREAST FEEDING....................................................................................................................127

8.14.1 Initiation of Breast feeding by state ........................................................................................................1298.15 IMMUNIZATION STATUS OF INFANTS..............................................................................................................130

8.15.1 Immunization Status of Infants by State..................................................................................................131

9 HIGH-RISK DISTRICTS....................................................................................................................................132

9.1 PULSE POLIO IMMUNIZATION.........................................................................................................................132

9.1.1 PPI Coverage..........................................................................................................................................1329.1.2 Dosage received......................................................................................................................................133


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9.1.3 Zero dose cases.......................................................................................................................................134

9.1.4 Reasons for not receiving one or more IPPI doses.................................................................................1359.1.5 Source of Knowledge ..............................................................................................................................136

9.1.6 Nutrients .................................................................................................................................................138

9.2 ROUTINE IMMUNIZATION...............................................................................................................................139

9.2.1 Routine Immunization Sessions...............................................................................................................1399.2.2 Routine Immunization Coverage.............................................................................................................140

9.2.3 Source of Immunization ..........................................................................................................................141

9.2.4 Reasons for Non Compliance..................................................................................................................143

9.2.5 Injection safety........................................................................................................................................1449.3 MATERNAL CARE ..........................................................................................................................................145

9.3.1 Pregnancy details ...................................................................................................................................145

9.3.2 ANC received..........................................................................................................................................146

9.3.3 ANC Service Provider.............................................................................................................................1469.3.4 Details of ANC........................................................................................................................................148

9.3.5 TT Coverage ...........................................................................................................................................149

9.3.6 IFA tablets ..............................................................................................................................................1509.3.7 Source of receiving IFA tablets...............................................................................................................151

9.3.8 Night Blindness.......................................................................................................................................152

9.3.9 Knowledge about pregnancy complication.............................................................................................1539.3.10 Birth Attendance .....................................................................................................................................154

9.3.11 Clean Deliveries .....................................................................................................................................155

9.3.12 Postnatal checkups .................................................................................................................................1569.3.13 Breast Feeding practice..........................................................................................................................157


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Fact Sheet

S.NO. INDICATORS COVERAGE (%)

NATIONAL RURAL URBAN

1 IPPI Coverage by Rounds2nd December 2001(NID) 93.6 92.7 96.4

20th January 2002 (NID) 96.1 95.7 97.32 Coverage for At least 2 Doses 95.6 95.2 96.7

3 Campaign Zero Doser 2.9 3.3 1.6

4 Life time Zero Doser 0.9 1.1 0.5

5 Booth Coverage by Round

2nd December 2001(NID) 85.5 84.5 88.6

20th January 2002 (NID) 85.4 84.3 88.7

6 Advised on Vaccinations Other Than Polio duringPPI sessions

20.5 20.6 20.2

7 Knowledge on Importance of Routine Immunization 81.4 80.2 85.1

8 Immunization Session at least once a month on aparticular day

51.5 51.2 52.2

9 Immunization Site not very far 71.1 70.5 72.710 Possession of Immunization Card 53.8 48.5 68.9

11 Coverage by Antigens

BCG 74.0 69.0 88.3

DPT1 70.6 65.4 85.3

DPT2 67.1 61.4 83.2

DPT3 63.8 58.0 80.5

OPV1 75.1 70.6 88.0

OPV2 71.5 66.5 85.8

OPV3 68.3 63.0 83.5

Measles 61.4 55.4 78.3

DPT Booster 43.2 39.1 54.812 CoverageFully Vaccinated 56.6 50.3 74.4

Partially Vaccinated 23.6 26.1 16.7

Not Vaccinated 19.8 23.7 8.9

13 Vitamin A Coverage11 dose 26.0 23.2 34.1

2-3 doses 11.1 10.9 11.9

4+ doses 2.3 2.3 2.4

14 IFA Coverage Among U5 Children 10.3 10.5 9.8

15 Ante Natal Contact in First Trimester 42.6 36.7 55.9

16 At least 3 Ante Natal Contacts 55.0 45.7 76.3

17 Components of ANCAbdominal Check-up (at least 3 times) 35.5 27.7 53.3

Weight taken (at least 3 times) 32.4 25.0 49.4

BP Check-up (at least 3 times) 32.6 25.3 49.2

18 TT2/Booster Coverage 78.3 74.6 86.9

19 IFA Coverage (90+ consumed) 13.6 11.2 19.3

20 Prevalence of Night Blindness 11.9 14.5 6.0

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Base: All children above 9 months


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S.NO. INDICATORS COVERAGE (%)

NATIONAL RURAL URBAN

21 Knowledge of Pregnancy complications 69.8 66.6 77.2

22 Experience of Pregnancy complications 52.3 50.2 56.9

23 Service delivery point visited during pregnancycomplication2s

81.4 77.4 89.4

24 Place of Delivery

Govt. Health Institution 25.2 18.8 39.8

Private Health Institution 23.5 17.1 38.1

Home 51.0 63.7 22.1

Others 0.2 0.3 0.0

25 Delivery Assistance at institution3

Govt. Doctor 42.2 44.1 40.2

Pvt. Doctor 42.3 40.5 44.1

Nurse/LHV 12.3 12.4 12.3

ANM 2.0 1.5 2.5

26 Delivery Assistance at Home4

Govt. Doctor 1.0 1.1 0.7

Pvt. Doctor 5.0 4.7 7.2

LHV/Nurse 3.9 3.5 6.7 ANM 4.1 3.9 5.6

Trained Dai 11.4 11.3 12.1

Untrained Dai 43.2 43.7 39.8

Friends/Relatives 29.4 29.7 27.3

27 Caesarian Section 8.9 6.2 15.1

28 At least 3 Post Natal Check-up 18.6 14.1 28.5

29 Breastfeeding within 2hrs. of delivery 28.9 26.9 33.6

30 Percentage of women who fed colustrum 60.0 56.9 66.9

31 Knowledge of number of times visited for RoutineImmunization

Less than five 10.4 9.7 11.9

Five to six 14.5 12.6 18.6 More than six 10.5 8.3 15.5

Would go whenever are asked to 15.0 14.4 16.4

Don't know 48.5 53.9 36.1

32 Safe Injection Practices during Immunization 48.1 41.3 67.5

2Base : All women who had experienced a complication during pregnancy

3Base: All women who delivered had an Institutional delivery

4Base: All women who delivered at home


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1 EXECUTIVESUMMARY

BACKGROUND

The Government of India launched the Pulse Polio Immunization Program, in an effort to eradicatePolio from the country and to free children from the danger of this dreaded disease. To achieve thisobjective, children below the ages of 5 years are administered supplementary Polio drops duringNational Immunization Days (NIDs). Besides these, some High-risk states have been identified,depending on the consistent occurrence of wild polio cases, where additional doses are administeredon SNIDs. The program is now in its seventh year of implementation. The Government of India hadentrusted UNICEF to assess the reach, coverage and peoples response to this program each year.Routine immunization being one of the four pillars of polio eradication, this opportunity was utilized toassess the coverage level of routine immunization. In addition, maternal care component was alsoincluded in this evaluation.

UNICEF engaged professional research agency through competitive bidding to carryout Coverage

Evaluation Survey for IPPI, RI and Maternal Care.

APPROACH

The CES was conducted in 18 states covering around 85% of the countrys target population. Inaddition, 4 districts and 6 cluster of districts of UP and Bihar were also evaluated to understand thereasons for non-compliance of some of the families. The evaluation covered three broad areas of IPPI,Routine Immunization and Maternal Care. This is the executive summary of the national, stateand district findings.

SAMPLE SIZE

In select major states, a total of540 clusters were selected using random cluster sampling technique.Of these, 270 were Rural clusters and 270 were Urban clusters. In these clusters a total of

10800 mothers/ primary care takers of children up to the age of 5 years, born between 27 thJanuary 1997 to 26th Jan 2002 for IPPI.

4320 mothers/ primary care takers of 12-23 months old children, born between 27th January 2000-26th January 2001 for Routine Immunization.

4320women whose pregnancy of at least 28 weeks completed/terminated between 27/1/2001 and26/1/2002 were interviewed for Maternal Care.

In specially identified districts, a total of 360 clusters (210 - Rural and 150 Urban) were selected. Inthese clusters a total of

7200 mothers/ primary care takers of children up to the age of 5 years for IPPI.

2880 mothers/ primary care takers of 12-23 months old children for Routine Immunization.

2880women whose pregnancy of at least 28 weeks completed/terminated between 27/1/2001 and26/1/2002 were interviewed for Maternal Care.

Data was collected during the month of July and August 2002.


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NATIONAL AND STATES FINDINGS

INTENSIFIED PULSE POLIO IMMUNIZATION

REACH AND COVERAGE OF IPPI:

Reach is defined as the proportion of the eligible children who had received at least one dose of OPVthrough the IPPI campaign. Overall 97.1% of the children were reached during the campaign. Thecoverage for at least 2 doses was 95.6%. Analysis by age cohort revealed that coverage wassignificantly higher among older children ( 4+ months old 94-97%) as compared to 0-3 monthschildren (86%), indicating risk to younger infants.

It is observed that the coverage for at least two doses was significantly higher in Andhra Pradesh,Delhi, Karnataka, Madhya Pradesh, Punjab, Tamil Nadu and Uttaranchal (around 97%). However thiscoverage in states like Assam, Jharkhand and Rajasthan is much lower (80-88%) than the nationalaverage level thus indicating a need for large scale concentrated efforts in these states to minimise therisk of re-emergence of polio.

COVERAGE BY ROUNDS:The national coverage significantly increased from 93.6% in December 01 NID to 96.1% in January 02.The improvement in January round was mostly in rural areas and among Muslims, which could beattributed to intensive mobilisation efforts among minority community. The same had also led toimprovement in coverage among children of illiterate parents.

Over the two rounds, coverage increased by 2 points, which is significant in AP and Bihar, whiledropped by 3 point in Jharkhand in January NID compared to December.

IPPI COVERAGE OF >5 YEARS:

At national level, among those children who received OPV doses during IPPI campaign, 9% were

above 5 years of age.

ZERO DOSE CHILDREN:

Overall 2.9% of children had not received any dose during 2001-02 IPPI cycle, while 1% had neverreceived OPV drop. Among 0-3 months children, 11.9% were zero doser, while 3.5% among 4-6months and 1.8% among 7-11 months. The overall zero dose proportion among under 1 year was5.2%. In other age groups 2-3% of the target children were Zero dosers.

Out of the total children unreached during 2001-02 IPPI cycle, 0-3 months children alone contributed24% of the total Zero dose cases. Children under 1 contributed 37% of zero doser, while contributionfrom rest of the age cohort was between 15-18%.

The proportion of Zero dose case during current campaign was reported to be significantly higher, thanthe national level, in Assam (11%) and Rajasthan (8%). However, in the states of Karnataka, Punjab,Madhya Pradesh, Tamil Nadu and Uttaranchal the proportion of Zero dosers was significantly lower(


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Majority of the respondents (82%) got their children Polio drops administered only at the booth. Nearly11% children received PPI doses at home. The HtH campaign benefited higher proportion of childrenin rural areas, among Muslim, non-SC/ST, illiterate and young children of 0-3 months age. Analysis bystate revealed that sizeable proportion of children in Uttar Pradesh (24%), Rajasthan (22%), Bihar(19%), Delhi (17%), Uttaranchal (17%), Haryana (15%) and Jharkhand (16%) received all OPV dosesat home.

REASONS FOR NOT RECEIVING ONE OR MORE IPPI DOSES:

Overall 6.1% children missed one or more PPI dose. Of these equal proportions were from Rural andUrban areas. For these children, Lack of motivation" was the main reason for non-compliance (61%).This included reasons such as "No one came to my house" or "There was no one to take the child tothe booth", indicating an overall inertia towards the programme. Also a belief that the child was tooyoung exists and is the highest for the 0-3 months age cohort. The other reasons that got mentionedwere lack of awareness (39%) i.e. "not aware of place of booth or when they would come home".

SOURCE OF INFORMATION:

Overall, interpersonal communications were mentioned by 78% of the people. Amongst these, Health

Workers (42%) were most active informants followed by Anganwadi workers (28%) andRelatives/friends (19%). Teachers too seem to be active informants with 15% respondents mentioningthem as source of information.

In Karnataka and Assam nearly 92% of the respondents mentioned interpersonal sources as source ofinformation. The other states where the mention of interpersonal sources was significantly higher thanthe national average were Gujarat, Haryana, Jharkhand, Kerala, Madhya Pradesh, Maharashtra,Rajasthan and Tamil Nadu.

Overall, Mass media reached 46% of the target population. Amongst the mass media methods,Mike/Drumbeating (24%) emerged to be the major source of information followed closely by TV (22%).Radio was mentioned by 8% of the respondents whereas Newspaper/Magazine and Wall paintingswere mentioned by 5%.

In Punjab nearly 90% of the population was reached by mass media, whereas in West Bengal andDelhi, nearly three fourth of the respondents were reached by this. The reach of mass media was quitelow in the states of Bihar, Gujarat and Jharkhand.

PERCEPTION REGARDING THE IMPORTANCE OF ROUTINE IMMUNIZATION:

Overall 81% of the respondents reported that in addition to polio drops during IPPI campaign, othervaccination was also necessary. Only 21%, of the respondents reported that during the PPI campaignthey were advised on the need of other vaccination.

KNOWLEDGE ABOUT THE SYMPTOMS OF POLIO LIKE DISEASE (AFP) AND REPORTINGNEED:

37% mentioned weakness of limbs, while around 7% of respondents referred no movement of limbs asthe symptom of polio like disease. Another 8% mentioned fever followed by sudden weakness of limbsas the symptom. 44% of the respondents were not aware of any symptom. Percentage of suchrespondents was significantly higher in rural areas, among SC/ST and illiterate population.

Nearly two third of the respondents mentioned that they would report the Polio case in the close byGovt. /Municipal Hospital followed by 29% who said that they would report in the close by Private


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hospital /Private Clinic. PHC/Sub centre was mentioned by only 14% of the respondents.

NUTRIENTS

VITAMIN A SUPPLEMENT:

Close to 40% of the children in age group 9-59 months have received at least first dose of Vitamin A.The proportion of such children was significantly higher in Urban areas, among Christian, ST andliterate parents compared to Rural, Muslim, SC and illiterate.

Amongst those who received Vitamin A, 66% received only one dose, 28% 2-3 doses, while 6%received more than 4 doses. Analysis by age revealed that 34 to 42% of the children in different singleyear age cohort have received at least first dose of Vitamin A. Among total 12-23months childrensurveyed, 12% received 2-3 doses, while among older age cohort, 2-3% received 4 or more doses.

IFA SUPPLEMENT:

At national level only 10% of children in age group 9-59 months have ever received IFATablets/Syrups. Among these, only 3% had consumed more than 100 tablets in last one year.

ROUTINE IMMUNIZATION

AVAILABILITY OF IMMUNIZATION SERVICES:

In 82% of the clusters, key informants reported that Routine Immunization session was held within thecluster/area, while 76% (75% in Rural and 80% in Urban) of the respondents reported this. Thispercentage was significantly higher than previous year (62%) indicating the improved efforts in thecorresponding years. Only 52% of the respondents reported that at least monthly session wasorganised on a particular day in their cluster.

In Madhya Pradesh, 100% respondents reported that RI sessions were held in their cluster/area,followed by Chattisgarh (96%) and West Bengal (97%) respectively. Percentage of such respondentswas lowest in Bihar (33%).

AVAILABILITY OF IMMUNIZATION CARDS:

Overall, 54% of the respondents mentioned that they have an Immunization Card or some writtendocument. Presence of Immunization cards was high in Kerala (96%) and West Bengal (94%). Theevidence of RI services being availed (Immunization cards) was found with around one third of therespondents in UP (27%), Rajasthan (32%) and Bihar (33%).

BCG VACCINATION:

Overall 74% of children had received BCG, and 75% of them had scar. Only 64% of those who wereadministered the BCG had received it in the first month of birth while 29% received it within 2-6 monthsafter birth.

DPT VACCINATION:


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71% of children had received DPT 1 while this figure fell to 67% for DPT 2 and 64% for DPT 3. Thedrop out ratio from the first to the third dose was close to 10%.

Close to 66% of the children received DPT1 within 1 -2 months after birth. The proportion whoreceived all three doses of DPT with a gap of one month was about 65%.

OPV VACCINATION:

Overall, 75% of children in age 12-23 months received OPV1 dose under Routine Immunization. Theproportion of OPV2 came down to 72% and further down to 68% for OPV3. The drop out ratio fromOPV1 to OPV3 was 9%.

Close to 66% of the children received OPV1 within 1 -2 months after birth and the proportion ofchildren who received the OPV with a gap of one month was 65%.

MEASLES VACCINATION:

Overall, 61% of the children in the age group of 12-23 months were given the measles vaccination.Close to 88% of them received the measles vaccination at the recommended age of 9-12 months.

FULLY IMMUNISED

Overall, 57% of the children had received all vaccines, while 50% received all vaccines beforecompletion of 12 months of age. These proportions increased significantly compared to previous year(fully vaccinated increased from 50% to 57% while fully vaccinated by 12 months of ageincreased from 44% to 50%). Analysis by background characteristics revealed that significantlyhigher proportion of children from Urban areas (68%), belonging to Hindu families (51%) and literateparents (55-86%) received all vaccines before 12 months compared to Rural (44%), Muslim (40%) andilliterate (27%).

The results showed strong correlation between access and utilization of services. Percentage of fullyvaccinated among those who reported at least monthly session in their cluster/area was 67%, which

was 33% among those who had reported less than monthly sessions in their cluster/area.In states like Andhra Pradesh, Madhya Pradesh, Kerala, Delhi, Karnataka, Maharashtra, Punjab,Tamilnadu and West Bengal more than 70% children were reported to be fully immunised. However, inonly four states, namely Tamilnadu, Maharastra, Karnataka and Kerala more than 70% wereimmunised before 12 months.

In Rajasthan (20%), Uttar Pradesh (27%), Bihar (13%) and Jharkhand (26%), less than one third of thechildren were fully immunised.

Compared to the previous year, percentage of fully vaccinated children increased significantly inAndhra Pradesh (42% to 72%), Karnataka (60% to 81%), Madhya Pradesh (50% to 77%), UttarPradesh (46% to 59%) and West Bengal (56% to 78%) while declined in Rajasthan (30% to 20%).

PLACE OF IMMUNISATION:

Govt. /Municipal hospitals were the most frequently accessed source for Immunization services with37% accessing them. PHC/ UHFWC were accessed by 16% of the respondents and Private hospitalsby (10%). Outreach sessions catered to 32% of the respondents.

In Karnataka, Kerala and Maharashtra, 50-60% of the respondents accessed Govt./ MunicipalHospitals, while in Assam (51%), Chattisgarh (73%), Haryana (58%) and Punjab (50%), majority got


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their child vaccinated in outreach sessions. Private sector contributed significantly in Delhi (21%) andKerala (25%).

REASONS FOR NON COMPLIANCE:

Overall 33% of the eligible children did not receive all vaccines and the main reason mentioned waslack of awareness. This includes reasons such as- not aware of the need of all vaccinations (58%),and not aware of time /place of vaccination (28%).

For 12% of the children, lack of motivation was the main reason for not completing the primaryvaccination. Fear /rumour of side effects (4%) and fear of getting diseases (6%) were the two majorobstacles which were mentioned and this fears were higher amongst Muslims.

Looking across states, in Jharkhand, Karnataka, Madhya Pradesh, Rajasthan and Haryana, 75%-85%of the non-compliers were not aware of the need of all vaccinations.

SAFE INJECTION PRACTICES

It was surprising to note that despite large supply of sterilisation equipment, only 5% of the respondentsreported the use of Autoclave / double rack steriliser. Overall, 42% mentioned the use of Disposable

syringes, while only 7% reported Boiling in a saucepan for at least 20 minutes.At national level after disposable syringes, the next most common practice followed was cleaning thesyringes and needles in once boiled water (13%). It is a concerning issue. Even the use of disposablesyringes does not ensure injection safety.

Use of disposable syringes was more than 70% in Delhi and Haryana, between 60-70% in Jharkhand,Punjab, Rajasthan and Uttaranchal, while it was lowest in Madhya Pradesh (18%). Use of equipmentsupplied under immunization programme (autoclave and double rack sterilizer) were reported by morethan 10% of the respondents only in Gujarat, Karnataka, Maharashtra and West Bengal. In AndhraPradesh, Assam, Karnataka and West Bengal, more than 15% of the children were vaccinated bysyringes and needles boiled in saucepan for 20 minutes.

Across states, Unsafe injection practises were reported by more than one fourth of the respondents in

Tamilnadu (34%), Uttaranchal (27%) and Uttar Pradesh (30%) closely followed by Bihar (24%). Thisproportion was lowest for Gujarat and Punjab at 2%.

MATERNAL CARE

ANTENATAL CARE:

Overall, 77% of the women received at least one antenatal check up (ANC1). This was significantlyhigher in Urban areas (91%), among non-ST/ST (79%) and women staying with their own parents

(87%). Year of schooling shown strong correlation with the ANC1 coverage. It increased from 61%among illiterate to 97% among women of 15+ years of schooling.

Nationally, 42% of the pregnant women received check up in first trimester, while 55% received it alleast thrice. Compared with the previous years data, ANC3 coverage remained more or less the same.

ANC3+ was over 80% in Andhra Pradesh, Karnataka, Kerala and Tamil Nadu. Whereas, it was lessthan 30% in Bihar, Rajasthan and Uttar Pradesh.

Amongst the women who had received ANC, 44% accessed Private physicians, while 37% Govt.


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doctors. ANM catered to 12% and LHV 11% of those women.

COMPONENTS OF ANTE NATAL CARE:

Nearly 63% of the women confirmed that the fundal examination was done during ANC visit. Amongstthese 56% had this thrice or more. Overall, blood pressure of 58% of the pregnant women waschecked and among these, 56% was checked at least thrice. The weight of 51% of the respondentswas taken and was taken at least thrice for 64% of them. Overall only 21% of the women hadundergone all these three check-ups at least thrice. Data revealed that location, caste and religioninfluenced quality and frequency of antenatal check-ups.

TT IMMUNISATION:

78% of the respondents received TT2/Booster, which was significantly higher in urban (87%)compared to rural (75%). Data revealed that ST, Hindu and Muslim women were poorly covered.

Among the vaccinated women, 49% accessed the Govt. health services for TT Immunization while29% utilised Private health services. Both Govt. and Private facilities were equally accessed in Urbanareas.

In West Bengal, Tamil Nadu, and Kerala the proportion receiving TT2 booster was more than 90%. InRajasthan, Uttar Pradesh, Jharkhand, Andhra Pradesh and Bihar, less than 70% of pregnant womenwere protect against tetanus.

In states like Andhra Pradesh, Karnataka, Punjab and Kerala more than 40% of the respondentsreported to have received TT immunization from private physicians. Interestingly, in Bihar close to onefifth of the respondents mentioned Chemists.

IFA SUPPLEMENTS:

65% of the pregnant women received IFA tablets, which was significantly higher in Urban areas (76%),among Hindus (67%), those staying with own parents (72%) and educated (64-91%).

Countrywide, only 19% of the beneficiaries received the recommended number of 90-100 tablets and14% consumed it, indicating the need of proper follow-up and counseling. Consumption of more than90 tablets was highest among women (47%) with 15+ years of schooling. Among the study states, thiswas highest in Kerala (59%) distantly followed by Delhi (34%) and Tamil Nadu (32%).

Majority (70%) of the respondents received it from Government health/ICDS centres. Among thevarious government health/ICDS centres, 35% received from hospital followed by outreach sessions(21%) and PHC (10%). Around 6% of the pregnant women received IFA tablets from AWCs.

KNOWLEDGE ABOUT COMPLICATIONS DURING PREGNANCY:

More than 30% of the respondents reported Severe Weakness (34%), Swelling of face/feet (32%)

as the pregnancy complication, followed by Severe headache (10%), Bleeding/spotting (7%) andVery high fever (7%). Around 30% were not aware of any pregnancy-related complications

Awareness of pregnancy related complications were high in Tamilnadu, Madhya Pradesh, Karnatakaand Maharashtra (86-97%), and low in Delhi, Uttaranchal and Uttar Pradesh (50% or less).

KNOWLEDGE ABOUT PLACE OF CONSULTATION FOR PREGNANCY COMPLICATION:

For consultation during pregnancy complication, Government doctors were mentioned maximum


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(44%) followed by Private doctors (36%). A distant third was ANM/LHV/Nurse (9%). More than 9% ofwomen mentioned that they would not consult anybody.

COMPLICATION EXPERIENCED DURING PREGNANCY

More than half of the women had pregnancy complication. The percentage of such respondents wassignificantly higher in urban (57%) compared to rural (50%). 17% reported that they had swelling offace/feet and 24% had severe weakness. High fever and severe headache was reported by 9%, while3% had abnormal representation.

43% of these women consulted a Private Doctor, while 28% visited Govt. doctor. ANM and LHV/ Nursewere consulted by 8% of the respondents. Overall 18% did not consult anybody.

PLACE OF DELIVERY AND ASSISTANCE AT DELIVERY:

Institutional deliveries were accounted for 49% of the total deliveries, while 51% at home. Govt.hospitals and Private hospitals contributed equally. Institution delivery was significantly higher in urban(78%) and among educated women (45-94%) compared to rural (36%) and illiterate (25%). This couldbe because of low accessibility to health institutions and ignorance regarding the importance ofinstitutional delivery.

Most of the home deliveries were conducted by untrained dai (43%) followed by relatives and friends(29%) and trained dai (11%). Skilled birth attendant conducted hardly 14% of the home deliveries.

In states like Delhi, Kerala Maharashtra and Tamilnadu more than 70% of the deliveries wereinstitutional. However in Bihar and Uttar Pradesh, the institutional deliveries were less than 20%.

POST NATAL CHECKUPS:

Only 19% of the women reported that they were checked at least three during postnatal period, while52% had no such opportunity. The PNC3 coverage was 43-47% in Kerala, Karnataka and Tamil Nadu.

BREAST FEEDING:

Only 29% of respondents initiated breast feeding within 2 hours of birth. An additional 26% initiatedwithin 2-24 hours. However, there was a substantial segment comprising 16%, who initiated only after72 hours. Overall, 60% of the women fed colostrum to their newborns.

A large majority in Tamil Nadu (87%) had initiated breastfeeding within 2 hours of birth. It is surprisingthat despite 100% institutional deliveries in Kerala, only 62% initiated breastfeeding within 2 hours.

HIGH-RISK DISTRICTS FINDINGS

In addition to the 18 states, 6 very high-risk districts: Moradabad, Rampur, Badayun, Bareilly, Bhagalpur and Muzaffarpur and

4 Cluster of high-risk districts

Cluster A - Muzaffarnagar, Meerut, Bulandshar & J.P. Nagar

Cluster B - Sultanpur, Faizabad, Basti, Gonda

Cluster C - Jamui, Banka, Lakhisarai, Munger

Cluster D - Madhubani, Darbhanga, Sitamarhi

were identified from UP and Bihar based on the wild polio cases.


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INTENSIVE PULSE POLIO IMMUNIZATION

The PPI coverage at least two doses was significantly higher than national average in Bareilly, clusterA, Bhagalpur, Muzaffarpur and cluster D, indicating the effectiveness of the extra efforts done in theseareas. The house to house activities benefited significantly higher proportion of children in thesedistricts. Around 50% of the children in UP districts received all doses at home, except in cluster A,where 70% children all doses at booth. In the districts of Bihar, people accessed both the approachesin different rounds.

Despite all the extensive efforts, around 3% of the target children were unreached during the currentcampaign in Rampur and cluster B. In Cluster D (0.5%), Bhagalpur (0.7%), Bareilly (1.4%) and clusterC (1.4%), it was significantly lower than the national average.

Lack of awareness of place and time was mentioned as the major reason for non-compliance in thedistricts of Bihar, while in Uttar Pradesh, lack of motivation was the major constraint. Interpersonalcommunication could be helpful in overcoming these constraints. The study showed that this was themajor source of information, except Rampur and Cluster A. In these districts, mass media had widerreach. Among the different mass media methods, miking and drum beating contributed most.

Nutrients

In Bareilly, clusters A and B, Bhagalpur and Muzaffarpur, significantly higher proportion of childrenreceived vitamin A compared to their state average. However, the coverage was less than 20% in UPdistricts and less than 25% in Bihar districts. Data revealed that less than 4% of the children hadreceived two or more doses.

IFA coverage was abysmally low. Only 3-8% of the children in these districts had ever received IFAsupplementation.

ROUTINE IMMUNZIATION

Accessibility of immunisation services in both the states, particularly in Bihar is a major concern. InBhagalpur, Muzaffarpur, Moradabad, Rampur, Clusters A and B, only around 30% of the respondentsreported that at least monthly session on a particular day were organized in their cluster/area, while inclusters C and D, less than 3% of respondents reported that.

Slightly less than half of the respondents showed immunisation card or any written immunisationdocument in Bhagalpur (45.5%) followed by Muzaffarpur (42.5%), Cluster A (36.6%). It was lowest incluster B (20.5%) and Badayun (17.8%).

Only around one forth of the children were fully vaccinated in Bareilly, Muzaffarpur, Clusters A and B.In other study district, less than 20% of the children received all primary vaccines. The most frequentlymentioned reasons for non-compliance was lack of knowledge on the need for all the vaccines. Thisproportion was particularly high in cluster D (82.7%) and Badaun (81.1%) and lowest in Moradabad(38.4%). In Bareilly, half of the non-compliers (49%) were unaware of the place/time of vaccination.Efforts to improve accessibility and strong IEC are the need of hour.

In Bhagalpur, Clusters C and D, more than 60% of the respondents reported that disposable syringeand needle were used for vaccinating their child. This was around 50% in Bareilly, Cluster A andMuzaffarpur. Use of autoclave/double rack steriliser was hardly mentioned.


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MATERNAL CARE

Among the study districts, cluster A (61%), Rampur (66.0%) and Bareilly (64.2%) did fairly good withalmost two thirds of respondents having at least one Antenatal Check-up. ANC3 coverage variedbetween 11% to 28%, significantly lower than the national average of 55%. In U.P, governmentfacilities (65%) were more accessed than the private (35%). In Bihar, however, the Private doctor werethe service providers in almost three fourth of the cases.

On the components of ANC, only in cluster A, BP and weight of more than 10% of the women were

checked at least thrice during pregnancy. In other districts, it was ever less.

TT2/booster coverage was more than 50% in all the study districts except Badayun and Moradabad.Unlike national trend, contribution of private sector was more for TT vaccination in these districts.

The receipt and consumption of more than 90 IFA tablets was in the range of 3.5 to 22% and 2 to 14%respectively. The proportion of women who consumed more than 90 tablets was significantly lowerthan those received it in Moradabad and Cluster C.

In Bhagalpur, Clusters A and D, more than 20% of the deliveries were institutional. It was hardly 7% incluster C. Majority of the deliveries were conducted by untrained dais in these study districts.Surprisingly, in cluster B, 35% of the respondents reported that they have been checked thrice duringthe postnatal period. The PNC3 coverage was 19% in Rampur and 16% in cluster A. In other districts,coverage was less than 10%.

Less than 8% of the newborns were breastfed within 2 hours of delivery, while more than 40% werefed after 24hours of delivery in all these districts.


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INTRODUCTION


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.

2 INTRODUCTIONImmunization against infectious diseases is one of the key inventions of the last century and asignificant success of modern medicine. Generations of todays healthy adolescents/adults owe theirlives to the fact that they were immunized as children and protected against life threatening diseases.The material and human progress so many societies have made rests heavily on public healthimprovements, of which immunization is the lynchpin.

In India immunization history goes back to the era of vaccine against small pox in late 1940s.However, a formal program under the name of Expanded Program of Immunization (EPI) waslaunched in 1978. This gained momentum in 1985 under Universal Immunization Program (UIP) fullysupported by UNICEF. The main objectives of this program were universal immunization, reduction inmortality and morbidity due to VPDs, obtain self-sufficiency in vaccine production; establish a wellfunctioning cold chain system and introduction of district level monitoring system. This was merged inChild Survival and Safe Motherhood (CSSM) in 1992-93. Since 1997, immunization activities are animportant component of national Reproductive and Child Health (RCH) program.

Immunization services are provided through a network of sub-centers, Primary Health Centers (PHC)

and Community Health Centers (CHC) in Rural areas. In Urban areas, most of the governmenthospitals and postpartum centers provide the immunization services. All states have fixedimmunization days especially for the outreach sessions. Villages having more than 1000 population arescheduled to be visited at least a month. The fixed immunization day is a major gain of UIP during1985-90. This has been subsequently used to provide other primary care service package whichincludes Antenatal Care, IFA and Vitamin A supplementation, Contraceptive distribution, Nutritioncounseling etc. The immunization schedule under the UIP program currently includes vaccinationsagainst childhood Tuberculosis (BCG), Diphtheria, Pertusis, Tetanus (DPT), Measles and Polio. Forthe above diseases except Polio, the current immunization strategy seeks to contain and provideindividual immunity to the child, while for Polio the efforts are on to eradicate the scourge.

Polio eradication has been one of the goals of World Summit of Children (1990) and India being a

signatory to the Summit goals ventured additional efforts to eradicate Polio. Learning from the LatinAmerican experiences and realizing that the strategies followed until 1995 would not be able toeradicate Polio in India, the Government of India (GOI) launched Pulse Polio Immunization (PPI) i.e.,having two National Immunization Days (NIDs) every year beginning from December 1995. The aimwas to interrupt the circulation of wild Poliovirus by immunizing all targeted children simultaneouslyover a short period of 1- 4 days during low transmission season.

Till 1998, the PPI Campaign approach was to immunize targeted children at fixed booths on two NIDsheld 4-6 weeks apart. Although number of Polio cases declined, transmission of wild Polioviruscontinued. In year 1998-99, in addition to the two NIDs, third round of PPI was introduced in High-Riskpockets. Additionally, an action research was carried out during the same year at the request ofMoHFW to find out the impact of offering of OPV drops at home to those who did not turn up at the

booth. Findings of the research were encouraging and concluded that House to House approach hadadded value. This led to the intensification of the program in the year 1999-2000 in terms of number ofNIDs (four rounds) and sub-NIDs (two rounds) and adoption of mixed strategy of booth and House toHouse immunization. Data on virologically confirmed wild Polio cases in the following year clearlyreflected the impact of the intensification as the number of confirmed wild Polio cases dropped from1124 (1999) to 268 (2001). Based on the epidemiological situation during 2001-02, one SNID (14 thOctober 2001) was carried out in UP, Bihar, Delhi, WB and in some parts of Maharashtra, Gujarat and


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Karnataka, in addition to the two NIDs (2nd December 01 and 20th January 02).

Research findings in 2001 from the Process Evaluation, coverage evaluation study and other IPPIstudies indicated a need for a substantial shift in the communication/social mobilization strategy forPolio eradication, especially in relation to the hot 4 districts of Uttar Pradesh - Rampur, Moradabad,Bareilly and Badayun. UNICEF responded by recruiting, training and deploying a Social MobilizationCo-ordinator (SMC) in 10 High-Risk districts in UP. UNICEF also recruited and trained block levelmobilizers (BMCs) for the four hot districts. At grass root level, around 2000 Community Mobilization

Co-ordinators (CMCs) were identified in a total of 20 districts to mobilize reluctant families in theirvillage/mohalla. This strategy was well appreciated and decided to be sustained and further expand in2002.

Since 1995, UNICEF has been entrusted with the task of conducting the Process Evaluation andCoverage Evaluation Survey to validate the process followed and coverage reported for thecampaign each year, by Min. of Health and Family Welfare, GoI.

Sustaining high level of routine immunization is one of the four corners of Polio eradication strategy.Therefore, this year the opportunity of PPI household survey is being utilized to evaluate the RoutineImmunization and Maternal Health Care coverage. In order to assess and understand the perception ofBeneficiaries, Service Providers and Influencers regarding these interventions, qualitative research was

also carried out in states of Uttar Pradesh and Bihar only.

Quantitative study was carried out in 18 states where confirmed Polio cases were reported in last threeyears. Apart from that, 6 High-Risk districts and 4 cluster of districts from UP and Bihar were alsoidentified as particularly High Risk and thus a separate independent sample for these were studied.This document is the final report for All India.

2.1 RESEARCHOBJECTIVES

The research objectives for the study were to assess:

The reach and coverage of children below 5 years with the Oral Polio Vaccine (OPV) in the PPI

campaign from October 2001 to January 2002

Place of getting the OPV dose

Lifetime and 2001-02 cycle zero doser

Reason for non-compliance

Source of information

Knowledge of place and time of RI sessions

RI coverage amongst 12-23 months old

Place of routine immunization

Reason for non-compliance

ANC of women5 during their pregnancy which ended within the reference period

Components of ANC

Place of delivery and assistance

Complication

5All women whose pregnancy of more than 28 weeks completed/terminated in between 27/1/2001 to 26/1/2002


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Postnatal Check ups

Injection practices during immunization

The qualitative module was to assess the gap between the expectations, service and it's utilisation bythe community. This was undertaken only in High Risk with an aim to understand the factors thatinfluenced compliance and non-compliance with the above issues. The study also aimed to assess theeffect of IEC/Social mobilization in motivating the community for compliance.

2.2 RESEARCH DESIGN

A combination of both qualitative and quantitative research methodologies was adopted to meet theresearch objectives. The quantitative module was provided an assessment of important variablesrelated to the coverage with OPV, Routine Immunization and Maternal Care. The two modules wereconducted simultaneously.

The research methodology comprised of interviews. The questionnaires were largely structured withscope for a few open-ended questions (enclosed as annexure I). The survey was divided in to threemajor modules each catering to one of the three major objectives of assessing PPI, RoutineImmunization and Maternal Care Coverage.

Quantitative Sampling Design

2.2.1 Universe

A total of18 States were selected, viz. Uttar Pradesh, Bihar, Maharashtra, Karnataka, Assam,Gujarat, Haryana, Punjab, Rajasthan, Kerala, Madhya Pradesh, Delhi, Tamil Nadu, AndhraPradesh, West Bengal, Uttaranchal, Chhatisgarh and Jharkhand. Additionally,4 Cluster of districts: i) Muzaffarnagar, Meerut, Bulandshar & J.P. Nagar

ii) Sultanpur, Faizabad, Basti, Gonda

iii) Jamui, Banka, Lakhisarai, Munger

iv) Madhubani, Darbhanga, Sitamarhi

& 6 Individual districts: i) Moradabad

ii) Rampur

iii) Badayun

iv) Bareilly

v) Bhagalpur

vi) Muzaffarpur

were also covered2.2.2 Respondents

The respondents definition for each of the modules was different.

PPI Coverage: The information was obtained from households, which have at least one child below 5years and interviews were conducted with the principal caretakers of the eligible children. The childhowever should have been born between 27th January 1997 to 26th Jan 2002.


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Routine Immunization Coverage: - The interviews were conducted with the primary care takers of 12-23 months old children (born in between 27th January 2000 -26th January 2001).

Maternal Care Coverage: - Women whose pregnancy of more than 28 weeks ended in between27/1/2001 to 26/1/2002 were eligible to be interviewed under Maternal Care Module.

2.2.3 Sampling Design

Multi-stage cluster sampling technique was used for this study. In India, a total of 540 clusters wereselected. In order to have estimates for Urban and Rural separately for PPI, 270 clusters wereidentified from Urban and 270 from Rural areas.

For IPPI coverage, sample size of 200 was sufficient at 5% level of significance and absoluteprecision of 3% at 95% coverage level. Considering the design effect to be 1.5, sample size wasworked out to be 300. Since, for IPPI, analysis was planned separately for Urban and Rural areas,sample size of 20 per cluster (20*15=300) was taken. At national level, precision was 1%.

ForRoutine Immunization and Maternal Care components, sample size of 120 was sufficient at5% level of significance and absolute precision of 10% at 50% coverage level. Considering the designeffect of 2, sample size was worked out to be 240, i.e. 8 per cluster. At national level with the samplesize of 4320, precision was 2%.

Once the minimum number of clusters to be covered in the state and across Rural/Urban areas wereworked out, random cluster sampling methodology was used.

The villages comprised the primary sampling unit in Rural areas whereas a Municipal ward formed theprimary sampling unit in Urban areas.

Clusters were identified using PPS technique from the list of villages for Rural and list of wards forUrban. Due to non-availability of Census 2001, 1991 census list of villages and wards were used as theuniverse. In case of divided states/districts, districts (in case of state) and blocks (in case of districts),which were left or present in newly carved state/districts after division were taken for the sampling.

From each selected cluster or the primary sampling unit, four segments were selectedrandomly after listing all localities (lanes, mohallas etc).

In each segment 5 interviews were conducted with primary care takers of children under five years forthe PPI coverage Module. In case there was more than one child eligible in the household, theinterview was conducted only for the youngest. These 5 interviews were divided across the five agecohorts of (0-11 months, 12-23 months, 24-35 months, 36-47 months and 48-59 months). The samplewas divided equally across males and females in each cluster.

The primary care takers for the children in the age group of 12-23 covered for PPI module were alsothe respondents for Routine Immunization module. A total of 2 interviews per segment or8 per clusterwere conducted for the Routine Immunization module.

For the Maternal Care Coverage module, women whose pregnancy had completed/terminated in

between 27th

Jan 2001 to 26th

Jan 2002 were interviewed. Two interviews per segment or 8 perclusterwere conducted.

2.2.3.1 Sample sizes

A total of 10800 interviews were conducted with mothers/ primary caretakers of children up to fiveyears of age. In addition 4320 interviews were conducted with women whose pregnancy of more than28 weeks was completed/terminated between 27/1/2001 and 26/1/2002.


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These sample interviews were done in a total of 540 cluster with a distribution as shown below.

Sample Size Urban Rural Grand Total

PPI Component 5400 5400 10800

Routine Immunization 2160 2160 4320Maternal Care 2160 2160 4320

2.2.3.2 Rural Sampling

In the Rural areas, at the first stage, villages were selected according to PPS from the list of villagestaken from Census 1991.

At the second stage, each village was divided in to smaller segments. In larger villages, the segmentsof relative socio-economic homogeneity were identified in consultation with the village key informants.Four such segments were then randomly selected (Exhibit A). In smaller villages (of less than or equalto 200 households) complete village was divided into four segments taking socio-economic variationsin consideration.

At the third stage, within the selected segments, the house of any key personnel in that segment wasidentified. First household to be contacted was randomly selected with the help of random number

tables. Using the first selected house (identified house of the key personnel) as the starting point,random contacts according to the Right Hand Rule6 were conducted. If the contacted household hadany of the target respondents further forms were filled, else next household was contacted

6According to this rule, the household falling right to the starting point is the next household to be contacted.

Exhibit A : Showing segmentation and numbering of the segments for random selection

8

567

9

Hamlet 1

Hamlet 2

Hamlet 3 1

2

3 4


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2.2.3.3 Urban Sampling

In Urban areas, all wards of the state were listed and ward selection was done according to PPS. Atthe second stage, the selected ward was treated in a similar manner as the selected villages in theRural areas and segmentation and segment selection were undertaken. The third stage of selection ofthe respondent households in the selected segment was also similar to the one described for the Ruralareas.

Special cases in Urban sampling:

For the Urban sampling, as mentioned before, the wards were taken as the Primary sampling unit. Thewards were selected from the Census 1991. In many states the wards boundaries had undergonemajor reorganization since 1991. Since the sampling was undertaken based on the ward boundaries of1991, all efforts were made to identify the boundaries as they were then. This attempt had led to a fewspecial cases where the following actions were undertaken:

Case #1: Mohalla name guiding principle for ward: Ward boundary of 1991 was not availablebut it is known that so and so mohalla comprised the selected ward (say Rampur Mohalla wasward 10). In such cases the Mohalla was taken as the cluster and rest of the steps for selection ofhouseholds were followed. If there were more colonies/mohallas, all of them were taken into the

cluster sampling frame.Case #2:- 1991 Ward no. the guiding principle: If the selected ward (Ward 10 in 1991) hasbeen divided in to new wards say 10, 12, and 14 now, then the new wards (10,12 and 14) wereconsidered as parts of the cluster and rest of the steps were followed.

Case #3:- Neither the boundary nor the colonies comprising ward is known, guided by atleast 1 colony which was a part of selected ward : In certain situation, no one knew exactboundary of the selected ward nor was it clear which all colonies were included in the selectedward.In such cases, efforts were made to identify at least one colony, which did form a part of theselected ward. One common point/ well known point was identified in that colony and taking thatas the centre a boundary was made that consisted close to 800 houses in it. A common publicplace (such as School, Hospital/PHC, Temple/ religious place, Park, Bridge, well known

government offices etc.) was identified in the colony. From that point, a boundary was drawn thatcontained approximately 800\1000 houses. This boundary was considered as the selected clusterand rest of the steps for selection of households were followed

Case #4:- No past information at all guided by new ward boundary: As a last resort whenthe previous boundaries were not possible to identify, the current boundaries were used.

Case #5:- Ward too big : Some of the wards were too big exceeding 8000-10000 population. Insuch cases all colonies in the ward were taken as the given segments. Out of them 4 segmentswere randomly selected.

Qualitative Sampling Design

2.2.4 Universe

Ten individual and group of districts (mentioned in quantitative section) were taken for qualitativeresearch.


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2.2.5 Respondents

Parents of under 5 children

Service provider people involved in providing services on IPPI and RI ANM, male & femalehealth supervisors, Medical Officer, AWW, teachers, etc.

Influencer people who have influenced community to accept or not to accept polio drops during

IPPI campaign religious leaders, local doctor, Panchayat member, etc.

Polio afflicted families

SMCs and BMCs - Social mobilization co-ordinators involved at district and block level

2.2.6 Sample Distribution

For qualitative research, 7 clusters were selected from each of the individuals and group of districts. InUP, out of 7 clusters, 3 were randomly selected from the list of villages with CMC (1 from urban and 2

from rural), 3 (1 from urban and 2 from rural) from the list of non-CMC villages and one from the list ofvillages with virologically confirmed wild polio cases reported in 2001. In Bihar, 4 clusters were selectedfrom the list of villages while 2 from urban wards and one from the list of villages with confirmed poliocases reported in 2001. Focus Group Discussions (FGDs) and Depth Interviews (DIs) were used fordata collection. FGDs were conducted with parents of under 5 children and neighbours of polio afflictedfamilies, while DIs were conducted with service provider, influencer, polio afflicted family and socialmobilization co-ordinators. Guidelines were developed before hand for FGD and DI for differentsegments.

Thus a total of 70 FGDs and 190 DIs were conducted with beneficiaries, service provider, influencer,polio afflicted families and social mobilization co-ordinators across 10 geographical areas.

2.2.7 Weights

The Rural and Urban population and Male and Female population proportions of the 18 states wereused to weight the data so as to arrive at the India figures. The survey was conducted in 18 majorstates and the All India figures were generated on basis of them. Apart from these 18 states, additionalHigh Risk districts were covered in two states (UP and Bihar) so as to have separate estimates for theHigh Risk districts. These districts samples were not included while calculating the overall Nationalfigures so as to avoid double counting as their states were already covered through an independentsample.

For a state, the sample was divided across the various respondent categories. As mentioned insections above, for the PPI section, separate quotas were maintained for ages 0-11, 12-23, 24-35, 36-

47, 48-59 months across male and female children. From the 1991 census, the proportion of each ofthese age brackets in Rural and Urban areas of the state was calculated. Considering the age wiseproportions as given, we had multiplied them to Rural and Urban population in 20017. This gave us anestimate of the total number of children in Rural and Urban areas of a particular state in each of theseage brackets. The sample responses were projected to these universe numbers resulting in the statelevel picture. Similar steps were taken for the RI and Maternal care section based on the respondentdefinition of those sections.

7The total Rural and Urban population of the state was available from Census, 2001


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For national figures, the projection factors for a state were same as those used for the state levelestimates. Each states sample was projected to its state universe. Together all states totaled tothe national universe.

2.2.8 Recruitment, Training and Fieldwork

In order to maintain uniform survey procedures across the states and districts, two set of briefing notesfor supervisors and interviewers were developed. One of the notes was on sampling designed for thesupervisor and other one was on questionnaires for the interviewers. Initial training of qualitative teamsfrom Delhi, UP and Bihar was organized in Delhi. This was followed by pilot in Gaziabad district. Theguidelines were revised based on the feedback. For quantitative research Pilot was done in Jaipur,Lucknow and Gaziabad, followed by zonal briefing of field managers and state level briefing ofinvestigators. The data was collected in the month of July and August 2002.


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3 RESPONDENT PROFILE3.1 PRIMARYCARE TAKER

The responsibility of childcare generally lies with the mother, she being the primary care taker of the

child. In absence of the mother or when mother is not living there any other reliable resident of thehousehold (grandmother, aunt, elder sister, etc.), is normally the primary caretaker of the child. For thesurvey, the primary caretaker of the child was the respondent who answered the questions pertainingto the selected child.

Across All India, for nearly 94% of the children, mother herself was the primary caretaker. For nearly3% of children grandparents were the primary care takers whereas 2% were primarily looked after bythe father.

Table 1 Primary Caretaker

Base : All children

% across

Base Mother Father Grandparents Elder Sibling Aunt

ALL 10800 94.1 1.6 3.4 0.5 0.3

LOCATION

Rural 5400 93.8 1.7 3.5 0.5 0.2

Urban 5400 94.7 1.1 3.3 0.4 0.3

RELIGION

Hindu 8720 94.0 1.6 3.6 0.4 0.3

Muslim 1436 94.4 1.4 2.6 0.5 0.2

Christian 224 91.4 2.2 4.0 2.1 0.4

Sikh 342 93.7 0.4 4.8 0.1 0.6

Jain 62 100.0 0.0 0.0 0.0 0.0

Others 16* 100.0 0.0 0.0 0.0 0.0CASTE

SC 2335 94.8 1.4 3.3 0.3 0.1

ST 880 95.0 2.0 2.3 0.6 0.1

Others 7585 93.7 1.6 3.7 0.5 0.3

GENDER

Male 5400 94.1 1.8 3.4 0.5 0.3

Female 5400 94.1 1.3 3.5 0.4 0.3

AGE OF THE CHILD

0-3 Months 759 97.9 0.6 1.2 0.1 0.3

4-6 Months 640 97.0 0.7 2.1 0.0 0.2

7-11 Months 762 96.6 1.0 2.2 0.2 0.2

12-23 Months 2159 94.4 1.1 3.8 0.5 0.2

24-35 Months 2161 92.7 2.5 3.5 0.5 0.2

36-47Months 2158 93.4 1.2 4.5 0.7 0.3

48-59 Months 2161 93.5 2.0 3.4 0.5 0.3

* Base too low


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3.2 PRIMARYCARETAKERSEDUCATION

Literacy and educational levels are important indices of human development. Many of the positivehealth and other behaviours (such as health care for themselves and their families) often depend onliteracy and education levels. Literacy here is defined as the ability to read and write with understandingshort simple sentences.

At the aggregate level, 51% of the caretakers were reported to be literate, with Rural caretakersreporting a lower literacy level at 42% when compared to the 76% of the Urban caretakers. Accordingto 2001 Census the female literacy for All India is at 54%, which is well comparable to the estimatesfrom this survey for the All India.

Table 2 Primary Caretakers education

Completed years of schooling

Base : All

% across

Base Illiterate 1- 4 years 5-8 9-12 15+

ALL 10800 49.4 9.6 19.9 17.7 3.4

LOCATIONRural 5400 57.7 10.0 18.8 12.5 1.0

Urban 5400 24.2 8.3 23.3 33.3 10.6

RELIGION

Hindu 8720 49.8 7.7 20.7 18.0 3.7

Muslim 1436 50.5 20.7 14.8 12.7 1.1

Christian 224 25.8 9.9 17.4 37.3 9.1

Sikh 342 38.8 2.9 29.6 25.2 3.5

Jain 62 32.6 5.7 15.4 30.3 16.0

Others 16* 65.0 2.1 13.3 19.7 0.0

CASTE

SC 2335 57.8 9.3 19.3 12.6 1.0

ST 880 67.9 8.2 13.7 9.8 0.5

Others 7585 43.8 9.9 21.0 20.5 4.7

GENDER

Male 5400 48.6 9.4 20.6 17.9 3.3

Female 5400 50.1 9.8 19.2 17.3 3.5

AGE OF THE CHILD

0-3 Months 759 47.1 7.0 23.0 19.5 3.5

4-6 Months 640 46.4 7.7 24.8 18.0 3.1

7-11 Months 762 44.0 9.9 19.9 22.6 3.6

12-23 Months 2159 46.3 9.9 20.1 19.7 4.1

24-35 Months 2161 50.7 9.8 19.2 16.6 3.5

36-47Months 2158 50.0 10.8 18.8 16.7 3.6

48-59 Months 2161 52.2 9.1 19.6 16.3 2.7

*Base too low. The arrows indicate significant difference.

Comparing across the background characteristics of religion and caste, illiteracy was significantly loweramong Christian and Sikh. It is lowest among non-SC/ST followed by SC


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& ST. Around 11% of urban respondent had 15+ year of schooling, which is significantly higher thanrural (1%). Higher proportion of Hindu respondent had primary education (5+) when compared toMuslim.

3.3 EDUCATION OF THE FATHER

Going by the traditional difference between male and female literacy, the education levels of fatherswere better than mothers/primary caretakers. The overall literacy level amongst fathers at 73% is wellcomparable with the Census 2001 provisional figures for male literacy (76%) for All India.

It is observed that there is a significant difference between the literacy levels among the fathers in theRural areas when compared to the Urban areas. The fathers in the Urban areas were more educated(88%) than the fathers in the Rural areas (68%) particularly for higher level of schooling. Significantlyhigher proportion of Muslim fathers (37%) were illiterate than Hindu (25%). Similarly, higher proportionof SC/ST fathers was illiterate as compared to others.

Table 3 Fathers education

Completed years of schooling

Base : All% across

Base Illiterate 1- 4 years 5-8 9-12 15+

ALL 10800 26.8 10.2 22.2 30.2 9.6

LOCATION

Rural 5400 31.8 11.5 22.7 26.8 6.2

Urban 5400 11.5 6.5 20.7 40.5 20.0

RELIGION

Hindu 8720 25.3 9.3 22.3 31.9 10.4

Muslim 1436 36.8 16.1 21.0 19.5 5.2

Christian 224 16.1 9.9 21.5 38.0 13.3

Sikh 342 20.9 5.2 33.3

33.7 7.0Jain 62 18.8 5.1 12.6 36.1 23.7

Others 16* 14.9 1.9 6.1 33.6 1.0

CASTE

SC 2335 33.4 11.4 24.7 23.7 5.8

ST 880 34.5 15.1 23.1 22.1 4.0

Others 7585 23.4 9.1 21.2 33.6 11.8

GENDER

Male 5400 26.8 10.5 22.1 29.8 9.9

Female 5400 26.8 10.0 22.3 30.6 9.3

AGE OF THE CHILD

0-3 Months 759 21.6 10.5 21.8 32.6 12.9

4-6 Months 640 25.7 10.1 20.8 34.9 8.3

7-11 Months 762 22.9 8.6 22.9 35.2 10.3

12-23 Months 2159 24.2 9.2 25.1 30.9 10.1

24-35 Months 2161 28.7 11.1 21.5 28.6 9.6

36-47Months 2158 27.3 10.0 21.9 29.8 9.4

48-59 Months 2161 28.8 10.7 21.7 28.5 8.8


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*Base too low

3.4 BACKGROUNDCHARACTERISTICS OF THE SAMPLE COVERED

The following table compares some of the key sample distribution characteristics with the nationalproportion according to 1991 census. The difference in SC population could be because ofmisclassification.

Table 4 Sample Coverage for All India

Sample

Base : All

% down

Base IPPI 2002

(% of the sample)

Census 1991

(% of population)

ALL 10800 10800 Census

RELIGION

Hindu 8720 80.7 82.0

Muslim 1436 13.3 12.0

Christian 224 2.0 3.0

CASTE

SC 2335 21.6 16.0

ST 880 8.1 8.0

Others 7585 70.2 76.0

* Base too low


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4 INTENSIFIED PULSE POLIO IMMUNIZATION4.1 DISTANCE OF THEPPIBOOTH

Across India, Polio drops during the current campaign was administered at the booths on the first day.

In addition, house to house vaccination activities were taken up in subsequent 5-6 days in UttarPradesh, Bihar, Delhi, West Bengal and in few districts of other states with confirmed wild polio casesin 2001. Booths are organised within the village/ ward/ colony/ area in such a way that it is accessibleto the families of about 250 children. It was hypothesised that distance between the booth and homemay be a barrier for administering the Polio drops, especially in areas with no HtH activities.

Table 5 Distance of the PPI booth

Distance of the PPI booth

Base : All

% across

Base Within Walking distance Not very far Too far DK/CS

ALL 10800 84.5 11.4 3.0 1.1

LOCATION

Rural 5400 82.5 12.9 3.7 1.0

Urban 5400 90.6 6.8 1.1 1.6

RELIGION

Hindu 8720 84.5 11.4 3.0 1.0

Muslim 1436 82.8 12.3 3.2 1.7

Christian 224 90.9 8.5 0.1 0.5

Sikh 342 89.2 5.3 4.2 1.2

Jain 62 93.5 3.2 1.9 1.4

Others 16* 99.5 0.0 0.5 0.0

CASTE

SC 2335 88.2 9.0 1.9 0.8ST 880 78.2 15.5 5.1 1.3

Others 7585 84.2 11.6 3.1 1.2

GENDER

Male 5400 85.1 11.1 2.8 0.9

Female 5400 83.8 11.6 3.2 1.4

EDUCATION OF PARENTS

Both literate 6350 86.9 9.5 2.5 1.1

Both illiterate 1735 82.3 13.3 3.0 1.4

One of them literate 2681 82.2 12.9 3.9 1.0

Not Specified 34 95.7 4.1 0.0 0.2

*Base too low

Overall, 85% of the population said that the booth was within walking distance and nearly 3% of therespondents felt that the PPI booth was too far from their residences.

It can be observed that only 1% of the respondents in the urban areas reported that the booth was toofar. In the rural areas however, a significantly higher proportion (4%) of respondents felt the distancewas too far and thus access of services was not a big concern.


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Across the religion, the proportion of respondents reporting the booth was too far was not significantlydifferent, whereas, considering the caste, ST (5%) expressed concern of proximity of the booth.Further, illiterate parents felt the booth to be too far (3-4%) probably because of the lack of urgency orknowledge of importance for the additional OPV drops.

The segregated data by urban and rural revealed that religion has significant influence on theperception of distance of booth location while in rural areas, caste and literacy shown its influence. InUrban areas a significantly lower proportion (88%) of Muslims mentioned that PPI booth was withinwalking distance as compared to Sikhs (98%). In Rural areas significantly higher proportion of SC(88%) and literate households (84%) reported that the booth was within walking distance.

Table 6 Distance of the PPI booth- Rural and Urban Comparison

Distance of the PPI booth

All Rural Urban

% across Base WithinWalkingdistance

Base WithinWalkingdistance

Base WithinWalkingdistance

ALL 10800 84.5 5400 82.5 5400 90.6

RELIGION

Hindu 8720 84.5 4359 82.5 4361 90.8

Muslim 1436 82.8 690 81.2 746 87.8

Christian 224 90.9 111 87.7 113 96.9

Sikh 342 89.2 224 86.9 118 97.7

Jain 62 93.5 14* 100.0 48 89.7

Others 16* 99.5 2* 100.0 14* 98.8

CASTE

SC 2335 88.2 1321 87.9 1014 89.5

ST 880 78.2 589 76.2 291 88.9

Others 7585 84.2 3490 81.6 4095 91.0

EDUCATION OF PARENTS

Both literate 6350 86.9 2460 84.4 3890 91.0

Both illiterate 1735 82.3 1266 81.4 469 90.0

One of them literate 2681 82.2 1656 81.0 1025 89.1

Not Specified 34 95.7 18* 98.0 16* 79.1

*Base too low


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4.2 COVERAGE BY DOSES

During year 2001-02, children in different states had 2-4 opportunity of getting additional doses of OPV.Analysis of coverage by background characteristics revealed that coverage for at least two doses wasmarginally higher in urban area compared to rural. Significantly lower proportion of Muslim childrenreceived two doses (93.5%) compared to Hindu (96%). Genderwise desegregated figure showed thatcoverage for at least two doses was same for boys and girls. The major variation was observed for

different age cohorts. The coverage was significantly lower among 0-3 month age cohort, whil

Documents

Coverage Evaluation Survey - 2002 - IPPI, Routine Immunization and Maternal Care - National Report_0