Pediatric vaccination in rural Udaipur, India: The impact of agency, local perceptions, and social determinants of health on maternal health-seeking behaviors and current coverage Open Access

Abstract

As one of the most effective preventative public health measures, pediatric immunization significantly reduces global morbidity and mortality due to vaccine-preventable diseases. Though under-five mortality rate in India has sharply decreased over the years, low coverage still burdens many rural remote regions. Furthermore, pediatric immunization has recently reached a "plateau", in which the same increase in supply no longer translates to the same increase in coverage. Coverage in rural Udaipur is particularly low - nearly half that of national full immunization rates. Public and global health experts must reorient vaccination strategies to address the gross health inequities that exist in rural India. The aims of this study were to determine the current state of coverage and knowledge and to illuminate how local agency and perceptions of immunization influence the spectrum of maternal health-seeking behaviors in rural Udaipur district. Data were collected in conjunction with Seva Mandir, a non-governmental organization serving rural and tribal communities through development programs. In five Seva Mandir villages (two health intervention; one non-health intervention) and three non-intervention villages, thirty-three mothers with children between the ages of nine months and five years were interviewed about their health-seeking behaviors, experiences with immunization, and basic demographics. Contrary to the "spillover" hypothesis, in which non-health development programs would positively influence vaccine uptake, the worst vaccine knowledge and coverage was observed in non-health intervention villages. Though there was a relatively high level of general immunization awareness, very few mothers could name any vaccines or vaccine-preventable diseases. Even though mothers reported satisfaction with government services, interviews revealed that health workers provided very little information, suggestive of a paternalistic patient-provider relationship. While the most common reason for immunizing children was because an authority figure had instructed to do so, the most common reason for not immunizing children was because they did not understand why it was so important. With no inhibitory community beliefs or fear of side effects, the phenomenon of passive acceptance observed in these communities indicates a large clinical gap in communication. Future study must address factors that contribute to passive acceptance of immunization in these communities, including imbalances in the patient-provider relationship and the lack of agency that this brings about. Future intervention must focus on the improving services and attendance at the anganwadi, the main site of pediatric immunization in rural Udaipur.

Table of Contents

TABLE OF CONTENTS

INTRODUCTION................................................................................................................................ 1

Vaccination as a Critical Public Health Issue

BACKGROUND................................................................................................................................... 2

Current Vaccination Policies, Rural Health Infrastructure, and Seva Mandir

Current Vaccine Coverage

Predictors of Vaccination

Vaccine Behavior

FRAMEWORK & HYPOTHESES........................................................................................................... 24

METHODS......................................................................................................................................... 27

Site of Study

Study Population

Data Collection: Semi-Structured Interviews

Quantitative Data Analysis

Qualitative Data Analysis

RESULTS.......................................................................................................................................... 38

Study Site and Population Descriptive Statistics

Vaccine Knowledge and Coverage, by Intervention Status

Relationship between Vaccine Coverage and Social Determinants of Health

Relationship between Vaccine Knowledge and Social Determinants of Health

The Translation of Vaccine Knowledge to Coverage

Logistic Regression Models

Multi-Level Chi-Squared Tests

Location of Vaccination

Source and Extent of Information

The Spectrum of Vaccine-Related Behaviors and Underlying Factors

Local Perspectives and the Healthcare Patient-Provider Relationship

DISCUSSION.................................................................................................................................... 68

Overall Coverage and the Intervention Effect

Education, Health Literacy, and Vaccine Coverage

The Anganwadi

Accessibility

Local Perceptions of Vaccination

The Patient-Provider Relationship

Gender and Vaccination

Agency, Autonomy, and Formation of Health-Seeking Behaviors

LIMITATIONS................................................................................................................................... 90

Linguistic and Cultural Barriers

Limited Sample Size

Potential Bias and Confounding

Study Ethics

CONCLUSION................................................................................................................................... 94

APPENDICES.................................................................................................................................... 98

Excel Spreadsheet Formatting and Coding

REFERENCES.................................................................................................................................... 101

About this Honors Thesis

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School	Emory College
Department	Anthropology
Degree	BS
Submission	Honors Thesis
Language	English
Research Field	Anthropology, Cultural Health Sciences, Public Health South Asian Studies
Keyword	Vaccine Coverage Seva Mandir Agency Vaccine Knowledge Health-seeking Behaviors India Immunization Social Determinants of Health
Committee Chair / Thesis Advisor	Worthman, Carol, Emory University
Committee Members	Flueckiger, Joyce, Emory University Hadley, Craig, Emory University

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