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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 24-28

Complete immunization coverage among children aged between 18 and 23 months in the rural area of Mon State, Myanmar


1 Department of Public Health, Ministry of Health & Sports, Myanmar
2 University of Community Health, Magway, Myanmar
3 Faculty of Medicine, SEGi University, Malaysia

Date of Submission01-Feb-2020
Date of Decision27-Feb-2020
Date of Acceptance02-Mar-2020
Date of Web Publication03-Nov-2021

Correspondence Address:
Win Myint Oo
Faculty of Medicine, SEGi University
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2773-0344.329029

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  Abstract 


Objective: To access complete immunization coverage among children aged 18-23 months living in the rural area of Mon State, Myanmar, and study the affecting factors.
Methods: A cross-sectional study was conducted in the rural area of Mon State in 2017. Totally 353 caregivers who had children aged 18 to 23 months were selected using multistage random sampling. Face-to-face interview was applied in data collection. Complete immunization status was defined according to the current practice of routine immunization in Myanmar. Chi-square test and multivariate logistic regression analysis were utilized in data analysis.
Results: Most of the caregivers were mothers (86.1%). Among 353 children, 293 [83% (95% CI 79.1-86.9)] had been immunized completely. The majority of caregivers had good levels of knowledge (77.1%) and attitude (71.4%) towards routine immunization. Some children (17.6%) had minor adverse events after immunization such as fever, pain and redness at the site of vaccination. Caregivers’ knowledge and attitude towards immunization, and the occurrence of adverse events after immunization in previous immunization session were significantly related to the status of complete immunization coverage (P<0.001).
Conclusions: Complete immunization coverage among children living in the rural area of Mon State stands at 83% and should be improved. Health education campaigns with appropriate strategies should be reinforced or strengthened to enhance immunization coverage.

Keywords: Complete immunization status; Immunization coverage; AEFI; Mon; Myanmar


How to cite this article:
Htike AZ, Myint Aung SS, Oo WM. Complete immunization coverage among children aged between 18 and 23 months in the rural area of Mon State, Myanmar. One Health Bull 2021;1:24-8

How to cite this URL:
Htike AZ, Myint Aung SS, Oo WM. Complete immunization coverage among children aged between 18 and 23 months in the rural area of Mon State, Myanmar. One Health Bull [serial online] 2021 [cited 2021 Dec 1];1:24-8. Available from: http://www.johb.info/text.asp?2021/1/1/24/329029




  1. Introduction Top


Immunization will be an effective measure for preventing disease if its coverage is sufficient enough. Nowadays, 2 to 3 million children deaths are prevented by immunization every year, globally[1]. In Myanmar, routine immunization coverage among children is still at unsatisfactory level[2-5]. The national coverage of Bacillus Calmette-Guerin (BCG), third dose of Oral Polio Vaccine (OPV3), third dose of Pentavalent vaccine or Diphtheria-Pertussis-Tetanus, Haemophilus influenza type B and Hepatitis B (DPT–Hib-HepB3), first and second doses of Measles vaccine (Measles1 and Measles2) in 2013 were 89%, 75.1%, 68.8%, 85.1%, and 78.1%, respectively[6]. In Mon State, coverage of BCG, OPV3, DPT–Hib-HepB3 and Measles 1 were 95.4%, 75.3%, 68.7% and 84.4%, respectively. Moreover, 2.3% of children did not receive any immunization and complete immunization coverage was only 64.4% in Mon State by the year 2015[7]. Besides, the determinants of childhood immunization in Myanmar remain poorly understood, with occasional outbreaks of vaccine preventable diseases such as Measles and Diphtheria[3],[4]. Therefore, this study was conducted to determine the complete immunization coverage and its determinants among children age of 18 to 23 months living in the rural area of Mon State, Myanmar.


  2. Subjects and methods Top


2.1. Study design, study area and participants

A cross-sectional study was done in the rural area of Mon State during 2017. Participants were caregivers for children aged 18 to 23 months who had been living in Mon State continuously for at least two years.

2.2. Sample size calculation and sampling procedure

Epi Info version 7 software was used in sample size calculation where an estimated proportion of complete immunization among children was assumed to be 65%[4],[5],[7], confidence level 95% and confidence limit (precision) 5%. So sample size required for the present study was 353 caregivers who have children aged 18 to 23 months.

Multistage random sampling procedure was applied in selecting the samples. In Mon State, there were two districts namely Mawlamyine and Thaton. Two townships were selected from Mawlamyine district and one township from Thaton district by using simple random sampling method. Then two village tracts were selected from each selected townships by simple random sampling. After that, participants were selected proportional to size of 18-23 months old children from each village tract by using simple random sampling procedure. Detail procedure is depicted in [Figure 1].
Figure 1: Sampling procedure applied in this study.

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2.3. Data collection and data analysis

The data were collected via face-to-face interview. Epi-data version 3.1 statistical software was used for data entry and validation, and STATA version 11.0 statistical package for data analysis. Chi-square test and multivariate logistic regression analysis with backward deletion strategy were utilized.

2.4. Variables of interest

Caregivers’ characteristics such as type (i.e., relation to the child), age, sex, education, occupation, and knowledge & attitude towards routine immunization or expanded programme on immunization (EPI), and attributes of children such as age, sex, birth order, place of birth and presence of adverse events after immunization (AEFI) during previous immunization session were considered as possible determinants. Variables with P≤0.25 in univariate analysis were selected as candidate variables in multivariate analysis.

Complete immunization was defined in the present study as a particular child had been completed all doses of vaccines as scheduled in EPI, Myanmar [a single dose of BCG, (3 doses of DTP-HepB-Hib, OPV, PCV), and two doses of Measles] at the time of data collection. The information on status of complete immunization had been obtained from vaccination card and/or registers.

Knowledge of caregivers on EPI was assessed using a questionnaire composed of 24 items and divided into good and poor categories. Caregivers’ attitude on EPI was also measured using a questionnaire composed of 15 items (5 point Likert scales) and categorized into two groups namely positive and negative.

2.5. Validation of questionnaires on caregivers’ knowledge and attitude towards immunization

Based on research questions/objectives and literature review, the structured questionnaire was developed to assess caregivers’ knowledge and attitude towards immunization. It was prepared in Myanmar language. The questionnaire was checked by experts from University of Public Health, Yangon and from Central Epidemiological Unit of Department of Public Health. Central Epidemiological Unit was responsible for implementation, supervision and monitoring of National EPI programme in Myanmar. Final version was developed after necessary correction has been made based on their opinions and suggestions. Then pre-test was performed on the caregivers in neighbouring township (n=30). The questionnaire was adjusted and corrected accordingly. Internal consistence or reliability was checked using Cronbach’s alpha. The coefficients of knowledge and attitude questionnaires were 0.88 and 0.77, respectively.

2.6. Ethical consideration

This study was approved by Institutional Technical and Ethnical Review Board of the University of Public Health, Yangon, Myanmar with the reference number “ITERV(2017)/RESEARCH/8”. Informed consent was taken from all participants. All information belonging to the respondents was kept confidential and was not shared to anyone apart from the research team.


  3. Results Top


Totally 353 caregivers who had children aged 18 to 23 months were included. Most of them were mothers (86.1%). Their mean age (SD = standard deviation) and range were 34.5 (9.2) and 18-63 years, respectively. Knowledge and attitude levels of caregivers towards EPI are shown in [Table 1]. Mean scores (SD) and range were 20.4 (3.2) and 4-24 for knowledge, and 57.7 (4.7) and 45-71 for attitude, respectively.
Table 1: Characteristics of the respondents including their knowledge and attitude towards the expanded programme on immunization.

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Characteristics of the children including their immunization status and the occurrence of AEFI are shown in [Table 2]. Complete immunization coverage was 83% (95% CI 79.1-86.9). The commonest age at which immunization has been completed was 18 months.
Table 2: Characteristics of the children including their immunization status and adverse events after immunization (AEFI).

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[Table 3] reveals the relationship between immunization status of children and characteristics of their caregivers. Only caregivers’ knowledge and attitude towards immunization were significantly associated with complete immunization.
Table 3: Immunization status of children according to characteristics of caregivers.

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The association between immunization status of children and their characteristics is shown in [Table 4]. The presence of AEFI during previous immunization and birth order were found to have a significant association with immunization status.
Table 4: Immunization status of children according to their characteristics.

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Based on the results of multivariate logistic regression analysis, caregivers’ knowledge and attitude towards immunization, and the occurrence of AEFI in previous immunization session were identified as determinants of immunization status among children aged 18-23 months. If caregivers had good knowledge or positive attitude towards immunization, the complete immunization coverage among their children would be about four times higher than their counterparts. Similarly, the coverage of complete immunization was about six times greater among children with no experience of AEFI during previous immunization compared to those with even minor AEFI [Table 5]. Although birth order had inverse relationship with immunization status in univariate analysis, this association became disappeared in multivariate analysis [Table 4] and [Table 5].
Table 5: Results of univariate and multivariate logistic regression analyses.

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  4. Discussion Top


Complete immunization coverage detected in the present study (83%) was higher than the Myanmar National figures reported by UNICEF (<80%)[4] and a study in 2015 (55.4%)[5]. This might be due to the fact that the result of this study was non-representative for the whole country. Time difference should also be considered because the present study was conducted in 2017. Similarly, complete immunization coverage determined in the present study was also higher than those found in previous independent studies done in Ethiopia (77.4% and 38.3%)[8],[9]. However, it is lower than complete immunization coverage among children in Malaysia (86.9%), Thailand (89.7%), Maldives (92.9%) and Nepal (87.1%)[10],[11]. The differences in time and place of study as well as utilization of different operational definitions of complete immunization should be taken into consideration.

The present study revealed the presence of significant association between complete immunization and the knowledge and attitude of caregivers towards immunization. This finding was consistent with those of studies conducted in Myanmar[4] and Ethiopia[8],[12]. However, complete immunization did not have any significant association with age, sex, education, occupation and type (relation) of caregivers, and children’s age, sex and place of birth in this study. Maternal age[5], education[8-10] and occupation[9],[10], and place of birth[12] were found to be associated with complete immunization in the studies done in Myanmar[5], Malaysia[10] and Ethiopia[8],[9],[12] whereas age of mothers and sex of children were not in a Malaysian study[10].

Although a significant inverse relationship between birth order and complete immunization has been observed in univariate analysis, this association became disappeared in multivariate analysis. Birth order of a child has been reported as a factor associated with complete immunization in some studies[13-15]. Differences in socioeconomic status, knowledge and attitude towards immunization among study population might be responsible for these findings.

Conflict of interest statement

The authors claim that there is no conflict of interest.

Authors’ contributions

All authors designed the study, searched the literatures, took part in data collection and management, performed the statistical analysis and interpreted the results of data analysis. Author Htike AZ wrote the protocol. Oo WM prepared the first draft of the manuscript. All authors read and approved the final manuscript.



 
  References Top

1.
WHO. Immunization coverage. [Online] Available from: https://www. who.int/news-room/fact-sheets/detail/immunization-coverage. [Accessed on 1 August 2019].  Back to cited text no. 1
    
2.
CEPI, DOPH, MOHS, Myanmar. Expanded program on immunization multi year plan 2017-2021 revised January 2016. [Online] Available from: http://www.nationalplanningcycles.org/sites/default/files/planning_ cycle_repository/myanmar/myanmar_cmyp_2017-2021.pdf. [Accessed on 16 September 2019].  Back to cited text no. 2
    
3.
WHO, SEARO. EPI Fact Sheet, Myanmar 2017. [Online] Available from: http://www.searo.who.int/immunization/data/myanmar_2017.pdf. [Accessed on 11 October 2019].  Back to cited text no. 3
    
4.
UNICEF. Myanmar. Immunization. [Online] Available from: https://www. unicef.org/myanmar/health-and-nutrition/immunization. [Accessed on 11 October 2019].  Back to cited text no. 4
    
5.
Nozaki I, Hachiya M, Kitamura T. Factors influencing basic vaccination coverage in Myanmar: Secondary analysis of 2015 Myanmar demographic and health survey data. BMC Public Health 2019; 19(1): 242.  Back to cited text no. 5
    
6.
DOPH, MOHS, Myanmar. Annual public health statistics report 2013. [Online] Available from: mohs.gov.mm/su/IyLOf2. [Accessed on 5 November 2019].  Back to cited text no. 6
    
7.
MOHS, Myanmar. Myanmar demographic and health survey 2015–2016. [Online] Available from: https://dhsprogram.com/pubs/pdf/FR324/ FR324.pdf. [Accessed on 5 November 2019].  Back to cited text no. 7
    
8.
Girmay A, Dadi AF. Full immunization coverage and associated factors among children aged 12-23 months in a hard-to-reach areas of Ethiopia. Int J Pediatr 2019; 1924941. doi: 10.1155/2019/192494.  Back to cited text no. 8
    
9.
Tamirat KS, Sisay MM. Full immunization coverage and its associated factors among children aged 12-23 months in Ethiopia: Further analysis from the 2016 Ethiopia demographic and health survey. BMC Public Health 2019; 19(1): 1019. doi: 10.1186/s12889-019-7356-2.  Back to cited text no. 9
    
10.
Lim KK, Chan YY, Noor Ani A, Rohani J, Siti Norfadhilah ZA, Santhi MR. Complete immunization coverage and its determinants among children in Malaysia: Findings from the National Health and Morbidity Survey (NHMS) 2016. Public Health 2017; 153: 52-57.  Back to cited text no. 10
    
11.
Restrepo-Méndez MC, Barros AJD, Wong KLM, Johnson HL, Pariyo G, Franca GVA, et al. Inequalities in full immunization coverage: Trends in low- and middle-income countries. Bull World Health Organ 2016; 94(11): 794-805.  Back to cited text no. 11
    
12.
Meleko A, Geremew M, Birhanu F. Assessment of child immunization coverage and associated factors with full vaccination among children aged 12–23 months at Mizan Aman Town, Bench Maji Zone, Southwest Ethiopia. Int J Pediatr 2017; 7976587. doi: 10.1155/2017/7976587.  Back to cited text no. 12
    
13.
Mukungwa T. Factors associated with full immunization coverage amongst children aged 12–23 months in Zimbabwe. Afr Popul Stud 2015; 29(2): 1761-1774.  Back to cited text no. 13
    
14.
Schaffer SJ, Szilagyi PG. Immunization status and birth order. Arch Pediatr Adolesc Med 1995; 149(7): 792-797.  Back to cited text no. 14
    
15.
Gavrielov-Yusim N, Battat E, Neumann L, Friger M, Balicer RD. Birth order and private voluntary immunization–A study of 110 902 children. Vaccine 2012; 30(2): 442-447.  Back to cited text no. 15
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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