Priyobrat Rahkhowa : The impact of COVID-19 pandemic on parental health-seeking behaviour for childhood immunisation: Experience from local health facilities in Assam

Item

Title: Priyobrat Rahkhowa : The impact of COVID-19 pandemic on parental health-seeking behaviour for childhood immunisation: Experience from local health facilities in Assam
extracted text: 2021-22
n
Community Health Learning Programme
A Report on the Community Health Learning

Priyobrat Rajkhowa

Experience

School of Public Health Equity and Action
(SOPHEA)

Society for Community Health Awareness Research and Action

The impact of COVID-19 pandemic on parental health-seeking behaviour for
childhood immunisation: Experience from local health facilities in Assam
ABSTRACT
Introduction
Immunisation is one of the most remarkable public health interventions. Due to the low immunisation
coverage, a substantial number of children dies due to vaccine-preventable infections (VPD) in India.
Assamese children have consistently demonstrated low rates of routine childhood immunisations,
which can increase the number of children's death. The COVID-19 pandemic has further had a
significant impact on health care and disrupted health care services. Fear of infection, social distancing
norms, and other infection control measures have all had a negative impact on health-seeking
behaviour and regular visits to health care institutions. As a result, this study was conducted to look at
some of the possible effects of the COVID-19 pandemic on routine immunisations and health-seeking
behaviour in Assam.
Objectives
The study's objectives were to understand the health-seeking behaviour of parents/guardians in
immunising their child during this ongoing COVID-19 pandemic and to identify the felt needs of the
parents and guardians concerning child routine immunisation during the ongoing COVID-19
pandemic.
Methods
A qualitative study design with in-depth interviews was employed, and parents/guardians were invited
to participate with consent. The in-depth interviews were tape-recorded, transcribed verbatim, and
analysed using thematic analysis.
Findings
Delay/low health-seeking behaviour related to the fear of the COVID-19 pandemic, visiting a health
centre is more likely to contract the virus and face social stigma, afraid of being separated from own
children if tested positive for COVID-19, lack of good health facility leading to the disruption of health
services, the positive impact of routine childhood immunisation on adult COVID-19 vaccination,
reduced anxiety and fear leads to a resurgence of health-seeking behaviour.
Conclusions
This study assessed the enabling and constraining factors that affect access to health care and child
immunisation in Assam. Stakeholders and government entities should carefully examine all factors
affecting access to these services. As a result, efforts can be further tailored to promote public
knowledge of the potential advantages of immunisation, reduce the risk of immunisation dropout,
increase immunisation coverage in Assam, and lower child mortality.
Keywords: Children, COVID-19, Health seeking, Immunisation, Pandemic.

BACKGROUND
Immunisation is one of the most important public health measures, having controlled several lifethreatening infectious diseases and protecting millions more from illness. (1). India's immunisation
coverage is 76.4 %, and there is significant regional heterogeneity in routine immunisation throughout
the country's states (2,3). Due to the low immunisation coverage, about three-quarters of the 826,000
deaths in children aged 1 to 59 months were estimated to be due to vaccine-preventable infections such
as diarrhoea, pertussis, measles, meningitis, and pneumonia (4). According to the National Family
Health Survey 5 (NFHS-5) report, children in Assam, India's North-East region, have continually
demonstrated poor rates for routine childhood immunisations, with 66.4 % (2,5). The COVID-19
pandemic has negatively influenced all aspects of life, including health services, which have been put
on hold and has acted as an added determinant of low immunisation acceptancy (6–8). In Assam, one
of the significant causes of vaccination dropout was a lack of information among parents or guardians
(5). Because primary health care services, including immunisation, have been disrupted, women and
children are at risk for vaccine-preventable diseases (VPDs) such as measles, rotavirus, and tetanus
(9,10). Fear of infection, social distancing norms, and other infection control measures have all had a
negative impact on health-seeking behaviour and regular visits to health care institutions (11,12). All
other preventative health measures have been pushed to the side as the primary focus of public health
has shifted to preparing for and containing the COVID-19 pandemic in the country. Over the same
period, the number of fully immunised children declined (13). Any flare-up of VPDs will exacerbate
the strain on already overburdened healthcare systems. Therefore, it is essential to understand
parents’/guardians' felt needs and their health-seeking behaviour towards immunising their children
during this ongoing COVID-19 pandemic. Understanding these factors will eventually help minimise
the possible lacunas and barriers to immunisation coverage by implementing appropriate health
interventions. Past epidemics have taught us about the indirect effects, which may be far more
destructive to one's health. Therefore, this qualitative study is being undertaken to explore some of the
potential impacts of the COVID-19 pandemic on routine immunisations in Assam.
Research question
Do the disruptions in India's routine immunisation services due to the COVID-19 pandemic lead to a
decrease in parental health-seeking behaviour for child immunisation in Assam?
AIM
To understand the health-seeking behaviour of parents/guardians in immunising their child during this
ongoing COVID-19 pandemic.
SPECIFIC OBJECTIVE
To identify the felt needs of the parents and guardians in Assam concerning child routine immunisation
during the ongoing COVID-19 pandemic.

LITERATURE REVIEW
The COVID-19 pandemic has posed several unique challenges in vaccinations and immunisation
programs and set the stage for many countries' potentially serious population health effects.
Immunisation and other primary health care services have been disrupted, leaving the vulnerable
group, i.e. children, at risk of vaccine-preventable infections (8). The WHO and UNICEF highlighted
widespread interruptions in vaccination services in nations throughout the world, with an estimate of
80 million children under the age of one living in countries where routine immunisation services were
disrupted and at risk of contracting a vaccine-preventable illness (14,15). Previous epidemics have
shown that even short disruptions in routine immunisation services can result in secondary public
health emergencies, such as outbreaks of vaccine-preventable illnesses, resulting in increased
morbidity and death (16). In 2020, 23 million children missed out on basic immunisations due to
routine immunisation services, which is 3.7 million higher than in 2019 (17). The Indian national
immunisation program is one of the world's largest, reaching nearly 26 million children and 29 million
pregnant women each year (18). The child immunisation coverage in India is below the desired level,
62% (19). Due to the ongoing pandemic, there is a halt in expanding immunisation services that may
lead to further negative impacts on childhood immunisation coverage in India (20).
METHODS
Study design
A qualitative study design was used to explore the health-seeking behaviour and felt needs of
parents/guardians in immunising their child during this ongoing COVID-19 pandemic. This study also
highlighted the enabling and hindering factors in immunising children. In-depth telephonic interviews
were conducted to capture the collective details of the participants' experiences on immunising their
children and receiving their health services during the COVID-19 pandemic.
Study setting
This study enrolled parents or guardians with at least one child under five years of age. Using
snowballing and purposive sampling techniques, we selected the initial possible interviewees who
attended a local health and wellness centre or Anganwadi Centre in Assam from 15th January to 20th
February 2022. As this study followed snowballing and purposive sampling, each participant recruited
for the study was asked to refer other potential participants; therefore, this study was also able to
capture the viewpoints of parents/guardians in the neighbouring districts from the initial district, Jorhat,
Sivasagar and Dibrugarh. The inclusion criteria for study participants was (i) Patients/guardians with
at least one child under the age of five, (ii) Participants who can speak either English or Assamese and
(iii) Residents of Assam. The current study reached the saturation principle after the 16th in-depth
interview when no new developing themes were identified. Each in-depth interview lasted 6-9 minutes
on average. Two community health officers helped out in identifying and recruiting the study
participants.
Study participants
All parents/guardians who participated in the study were purposively selected to ensure age and
educational background variation. We included participants who were fluent either in the Assamese
language or English. In this study, we invited 30 parents/guardians of children to participate, and 16
of them voluntarily agreed to participate in the study. All the in-depth interviews were conducted from
15th January to 20th February 2022. The women were in the age range 24–50 years. Most of them were
homemakers. All the participants spoke Assamese.
Data collection
Prior to conducting an in-depth telephonic interview, we prepared a list of the potential candidates
based on a Health and wellness centre record in Assam. We drafted an interview guide containing

open-ended questions followed by probing questions based on subjects drawn from relevant literature
to conduct the in-depth interview, which was based on topics drawn from relevant literature. The topics
explored the participants' thoughts about the need for routine immunisation services during the first
wave of the COVID-19 pandemic, their health-seeking behaviour, and the barriers or facilitators for
immunisation. The participants were informed about the study's objectives and technique and the
benefits and drawbacks of their involvement during the conduct of the in-depth telephonic interview.
Following that, they confirmed their verbal consent to participate. The in-depth telephonic interview
lasted from 6 minutes to 9 minutes. Interviews continued to be held until no further information was
obtained, and the first author perceived that data saturation had been achieved. The conversations were
tape-recorded when the participants agreed, transcribed verbatim and translated from Assamese to
English.
Data analysis
The collected data were transcribed verbatim and translated from Assamese to English. The transcripts
were read numerous times before being thoroughly examined. Because this was a more exploratory
study, thematic analysis was adopted for data analysis (21). Initially, codes and themes were manually
prepared by segmenting the transcripts and categorising the codes identified during the in-depth
interview. Following that, the data was reorganised to fit the emerging themes. The third phase was
to combine codes with more sub-themes and themes, and the relationship between the created codes,
sub-themes, and themes was discovered using an inductive methodology. To ensure that no relevant
or crucial data was missed, the datasets were re-read to check that the created themes matched the
original datasets.
Ethical considerations
An ethical committee approval was obtained from the SOCHARA Institutional Scientific and Ethics
Committee (SISEC). Prior to data collection, verbal informed consent was obtained from the recruited
participants, and the women were guaranteed their right to withdraw at any moment during the study.
Participants were invited to share only the information with which they were comfortable. The
participants' confidentiality was protected by conducting each in-depth interview without asking for
the participants' names, which would otherwise have been their vital identifying data. The participants
were informed and consented that the in-depth interview was taped. They were told that the recordings
would only be used for research reasons, and those individual participants would not be identifiable.
There was no remuneration/incentives for the participants to minimise compulsion and bias. We asked
all the participants about their willingness to participate in this study. After receiving consent and
confirming their willingness to participate, the interviews were conducted. Only after receiving the
informed consent for audio recording was utilised for preparing transcripts of the minutes of the indepth interview was noted to prepare the study transcripts.

RESULTS
A total of 16 interviews with 14 parents and 2 guardians were conducted, and their gender, occupation,
ethnicity and level of education are presented in Table 1. Four primary themes emerged from the indepth interviews. The first theme was individual dread of the COVID-19 pandemic, which influenced
parents' and guardians' decisions to postpone seeking medical help and utilising health services. There
were two sub-themes that arose, and each sub-theme is discussed in detail, with actual comments from
survey participants. The second concern was the lack of good health facilities, which resulted in the
disruption of health services, and it emphasised the need to strengthen the health system for all health
services to run smoothly. Participants in the third theme discussed how routine immunisation
positively impacts the adult on accepting the COVID-19 vaccine. Finally, due to reduced worry and
dread, individuals expressed their switch to health-seeking in the fourth theme.

Code
SP1
SP2
SP3
SP4
SP5
SP6
SP7
SP8
SP9
SP10
SP11
SP12
SP13
SP14
SP15
SP16

Gender
F
F
F
F
F
F
M
F
F
F
F
F
F
F
F
M

Age
24
31
26
29
24
25
36
25
27
50
30
30
28
26
55
50

Occupation
Homemaker
Self-employed
Homemaker
Public sector job
Homemaker
Homemaker
Public sector job
Homemaker
Private job
Homemaker
Homemaker
Self-employed
Homemaker
Homemaker
Homemaker
Farmer

Education
Secondary
Secondary
Secondary
Graduate and above
Secondary
Secondary
Graduate and above
Secondary
Graduate
Primary
Secondary
Graduate
Secondary
Secondary
Primary
Secondary

Theme 1: Delay/low health-seeking behaviour related to the fear of the COVID-19 pandemic
The study participants' delays in seeking health services generated two sub-themes: (a) visiting a health
centre is more likely to contract the virus and face social stigma, and (b) afraid of being separated from
your family if tested positive for COVID-19.
(a) Visiting a health centre is more likely to contract the virus and face social stigma
Participants in the study expressed concern about being exposed to the virus because they were
unsure how their children would maintain social distancing and follow the COVID-19 protocol.
The majority of research participants said they had to go a considerable distance to get to the health
centre. Participants stated that accessing a health facility would subject them to societal
discrimination and that visiting a health institution would necessitate the COVID-19 test. It has
also been noted that if COVID-19 severity worsens, there is no treatment for COVID-19. As a
result, the participants believe it is preferable to use home cures rather than putting themselves in
the epicentre of COVID-19.
"…. brother had COVID-19, despite our efforts, we could not save him…."-SP4
"We had spent a lot of money and had to ask for donations; COVID-19 is dangerous"
"…. always had paracetamol at home…."-SP12
"…. stopped to leave the house…. scared and concerned for my child, used to run only
with whatever food was available…."-SP13
"…. family members had a fever, and we did not test for COVID-19 as we were
scared…."-SP10
"I don't want my neighbours to see me going to the hospital: they will not talk to me"-SP1
& SP5
"…. careful about our children, as it was a high risk to go for health facility…."-SP9
(b) Afraid of being separated from own family if tested positive for COVID-19
Delays related to fear of getting tested for the COVID-19 infection were expressed in the in-depth
interviews. Most of the participants (mothers) in the study stated that a positive COVID-19 test

result would prevent them from spending time with their children. This has been mentioned more
frequently by women whose families cannot live with them due to workplace differences.
"If I become positive in the covid-19 test, then who will take care of my child?"- SP4
Theme 2: Lack of good health facility led to the disruption of health services
Even in the local health institution, the study participants expressed the need for adequate healthcare
workers. Participants discussed how health priorities have shifted from routine health services such as
immunisation, antenatal care and other health services toward managing the COVID19 pandemic. As
a result, there is a severe shortage of healthcare personnel in the health centre. According to study
participants, healthcare staff, particularly Asha and grassroots workers, were overworked, yet they still
managed to help them whenever they needed it. Despite the hurdles in disruption of the health services,
the participants still acknowledged the health system for prioritising the interventions to stop the
COVID-19 pandemic.
"Asha forgot to give the vaccine (Routine child immunisation)"-SP5
"…. very limited staff and they were swamped during the first lockdown"-SP12
"…. limited health staff, my daughter, had to miss multiple Wednesday vaccine"- SP13
"Things were not available on time"-SP7
Theme 3: Positive impact of routine childhood immunisation on adult COVID-19 vaccination
All of the study participants were in favour of the COVID-19 vaccination. Participants talked about
how important immunisation is and how their childhood immunisation enabled their acceptance
towards the COVID-19 vaccine. Participants also expressed their willingness to vaccinate their
children if given. Participants were so anxious about protecting their child that they took the COVID19 vaccine to protect their child from COVID-19.
"Our family made the COVID vaccine a priority in order to keep our children healthy and prevent
from passing the sickness on to our children"-SP7
"My parents vaccinated me during my childhood, and they are very important. Therefore, I
vaccinated my son and also received both the doses of COVID-19 vaccine"-SP3
"Me and my husband took the COVID-19 vaccine so that we don't transmit it to our child"-SP8
Theme 4: Reduced anxiety and fear leads to a resurgence of health-seeking behaviour.
The study participants expressed how their fear, anxiety and concerns towards COVID-19 is restoring
to normalcy from the initial days of COVID-19 to now. The need for adequate healthcare workers was
expressed by majority of the participants. Participants discussed how health priorities have shifted
from routine health services such as immunisation, antenatal care and other health services and toward
managing the COVID19 pandemic. They indicated that healthcare practitioners are now paying equal
weight to all health concerns, not just COVID-19. This was attributed to the ability to have access to
a health institution and the restoration of immunisation services.
"Will have to learn to how to walk along with COVID-19 while saving ourselves, we will have to do
the necessary work"-SP4
"It took a long time to restore the services, but at least we are getting the vaccine now"-SP14

DISCUSSIONS
In the case of COVID-19, pandemic management became a high priority in order to prevent COVID19 infection from spreading. The purpose of this study was to evaluate parental/guardian healthseeking behaviour for child immunisation and health-seeking behaviour during the early stages of the
COVID-19 pandemic by looking at participants from local health facility in Assam. This study shows
how the priority of obtaining medical help shifted throughout COVID-19's initial countrywide
lockdown days and afterward. This study examines how fear, social process, and practical issues
influence parents' and guardians' health-seeking behaviour for their children and for themselves
(Figure 1).

Practical issues

What people think
and feel

Distance to health
facility, lack of adequate
healthcare workers,
prioritization of health
services

Societal discrimination

Motivation
Readiness, willingness,
anxiety

Immunization and health
seeking
Schedule appointment,
accept immunization,
delay/refuse, visiting health
facility

Social Processes
Believes no cure for
COVID-19, fear of contracting
the virus, afraid of being
separated from family
Figure 1: Determinants of child immunization and health seeking behavior

The participants were left in a situation where they delayed seeking medical treatment owing to their
concern of a COVID-19 pandemic when the lockdown was deployed unexpectedly. Most parents and
guardians prefer not to seek medical help because they are terrified of catching COVID-19. However,
as immunisation services and other health services are restored, health-seeking behaviour has also been
restored. In India, the influence of COVID-19 has resulted in a decline in health-seeking behaviour,
according to a study. A study also highlights the decrease in health-seeking behaviour due to the impact
of COVID-19 in India (22).
Participants said that their personal experiences with COVID-19 pandemic-affected family members
and acquaintances significantly impacted their desire to visit health institutions. Many parents and
guardians were hesitant to seek medical attention for their children and themselves because they
believed the health centre was the source of the ailment. Fear of contracting the virus on the route to
the health facility was one of the reasons given by study participants as a contributing cause to the
delays. As a result, they choose to isolate themselves from others. They also had concerns about their
children's ability to maintain social distance and adhere to the COVID-19 protocol. A study also
underlines the effects of isolation and the level of fear of getting Covid-19, which is similar to our
findings (23). Delays in the provision of adequate access to health care were limited during the first
national lockdown, as visiting a health facility would necessitate the COVID-19 test. The fear of the
COVID-19 test stems from the fact that the results would hinder moms from caring for their children
since they are the only single person caring for their children, as the majority of women stated that
their spouse is working in a faraway city. The anxiety of undertaking the COVID-19 test was also
underlined in a study conducted in Eastern India (24).

During the pandemic, it was stated that healthcare staff were overworked as a result of the extensive
training on how to manage the COVID-19 pandemic. Long queues formed at health facilities as a result
of the severe shortage. As a result, individuals reported a delay in receiving health services for their
children, such as routine child immunisation. A study also points to the strain caused by a high
workload caused by a shortage of healthcare workers, similar to our study findings (25). Participants
stressed the importance of better health facilities, even in remote areas, and a greater health workforce
for better performance. They also stated that the defection of their anxiety and panic caused by
COVID-19 resulted in a return of health-seeking behaviour for routine childhood immunisation and
favourable perception of health beliefs.
RECOMMENDATIONS
According to our model, fear, societal discrimination, distance to the health facility, lack of health at
the grassroots level, and prioritising health services all negatively impacted parents' and guardians'
health-seeking behaviour for their children and themselves (figure 1). Because the majority of the
emphasised problems were psychological, during this pandemic, a positive psychological intervention
should have been targeted to increase immunisation services and improve health-seeking behaviour.
A comparable set of positive psychological interventions can be modified to avoid similar pandemic
management in the future. However, because of the factors affecting diverse cultures, geographical
areas, socioeconomic levels, and so on, these types of interventions cannot be pre-drafted and
implemented on a big scale. As the participants also highlighted concerns about healthcare
affordability, accessibility, awareness, and availability, any imbalance in one of these factors is enough
to cause a tight spot in the healthcare delivery system. As a result, it is suggested that when constructing
a plan for dealing with comparable obstacles, the framework given by Banerji D. be used to encompass
all components of SEPCE and handle these issues (26).
CONCLUSIONS
This study provides a comprehensive look at enabling and limiting factors on accessing health care
services and child immunisation in Assam. Fear of contracting COVID-19 was a substantial barrier to
health-seeking behaviour in this study. Other factors, such as disrupted health services, the limited
number of available healthcare staff, the need for staying away from family, the fear of getting the
virus in health facilities, and the attitude of healthcare professionals during the epidemic, all
contributed to the delay in seeking medical help. As this study highlighted a tight spot in the healthcare
delivery system due to an imbalance in affordability, accessibility, awareness, and availability, the
incapacitated healthcare system has been reflected through this study. In this regard, it is necessary to
strengthen the health system in order to make healthcare more affordable, accessible, and available, as
well as to raise public awareness about the importance of seeking medical help during a pandemic in
order to avoid obliterating the gains made in reducing poor health-seeking behaviour among
beneficiaries, particularly in resource-limited settings. The stakeholders and government entities
should carefully examine all the factors impacting accessing these services. Once the issues related to
the delivery of the health system are addressed, there would be another bottom down approach required
to motivate the target population by disseminating awareness programs. Therefore, strategies should
be tailored by adopting both bottom down as well as a top-down approach to raise public awareness
of the potential benefits, lower the risks of immunisation dropout, increase immunisation coverage in
Assam and reduce child mortality.

ANNEXURES
1. SISEC approval letter

21st December 2021

To Whomsoever it May Concern
Scientific and Ethical Clearance

The SOCHARA Institutional Scientific and Ethics Committee (SISEC) has reviewed all the
necessary documents submitted to SISEC for clearance on scientific and ethical aspects of the
research proposal titled “Impact of COVID-19 on parental health-seeking behaviour
specifically for routine child immunization in Assam.” by Priyobrat Rajkhowa, CHLP
2021 fellow. The SISEC found them satisfactory and hereby a provisional approval to carry
out the study as planned is issued. Reporting to SISEC on the progress needs to be done at
regular intervals and any adverse effect happening during the study should be intimated
immediately.

Dr Arvind Kasthuri
Chairperson- SISEC

2. Participant Information Sheet (PIS) for Telephonic Interview

Hello sir /ma’am, Namaskar. Are you (name)?
I am calling from SOCHARA, Bangalore.
I'm a CHLP fellow at SOCHARA. My name is Priyobrat Rajkhowa.
I have got your phone number from X-Health center/Anganwadi center/ (Person name)
We are conducting a study to ask and find out the understanding of health-seeking behaviour of
parents/guardians in immunising their child during this ongoing COVID-19 pandemic. We will be
asking you questions about the access to immunisation of your child during the Lockdown period. It
will require about 10-15 minutes in a single phone call for completing the study. Participation in this
study is voluntary, and you may refuse participation without giving any reasons for your decision. Any
information, including your name, address, test results, will be kept confidential and reviewed only by
the authorised personnel. Kindly provide permission for the audio recording of the telephonic
interview and for its use by the research team/authorised personnel for extracting the statements and
analysis for research and publication purposes. I would be grateful if you could tell me the date and
time when we can call, according to your convenience, to conduct the interview.
If you want the details of the study to be sent to you by surface mail/message/WhatsApp to decide
regarding participation, I shall gladly send the same to you.
If you have any questions about this form or any study related issue, you may also contact the following
person
Name: Janelle de Sa Fernandes
Mobile No.: +91-8884559387
If you have any queries regarding your rights as a research participant, you may contact the Member
of the SOCHARA, Bangalore at: chc@sochara.org

Serial No.

Call log record
(To be incorporated into the proforma of the project)
Coding Sheet for Name and Telephone Number
Participant code
Call Date
Call time
(First 2 and last 2
numbers of the
phone number)

(to be filed in a separate document)
(Should not be included in the proforma)

Call duration

Serial No.

Participant's name

Telephone No.
(to be destroyed once data collection is done / closure
report submitted to IEC)

3. INFORMED CONSENT FORM
Project title: The impact of COVID-19 pandemic on parental health-seeking for childhood
immunisation: Experience from local health facilities in Assam
I confirm I have read the Participant Information Sheet for the above study and its contents were
explained and I have had the opportunity to ask questions and received satisfactory answers.
I understand that my participation in the study is voluntary and that I have the right to withdraw at
any time without giving any reason, without my medical care or legal rights being affected.
I agree to take part in the above study. I confirm that I have received a copy of the Participant
Information Sheet along with this signed and dated informed consent form.

Name of the Research Participant:
Age of the Research Participant:
Address of the Research Participant:
Occupation:
Annual Income of the Participant:
(Indicate so if not ready to disclose)
Name & address of the nominee(s) and his relation to the Participant:
_________________________________________________________________________
__________________________
Signature of the research subject

_________
Date

__________________________
Name & Signature of the witness

_________
Date

_______________________________________________
Name & Signature of the person explaining the consent

_________
Date

4. Photographs

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