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IMMUNIZATION
Report on knowledge, attitudes and
practices - Implementers
FEBRUARY 1988
2. i
-
f 4 i
•Prepared for UNITED NATIONS CHILDREN'S FUND
By INDIAN MARKET RESEARCH BUREAU
DELHI
IMRB/RI/HV/40396
BflW
Indian Market Research Bureau
CONTEXTS
Page
No.
NOTE ON THE REPORT
SUMMARY
i
iii
detailed findI\GS
1.0
IMMUNIZATION
1.1
The immunization schedule
1.1.1
Awareness of vaccines
1
1.1.2
Details regarding each vaccine
4
1.2
Diseases prevented by vaccines
1.3
Symptoms of diseases and perceptions
1.3.1
Polio
1.3.2
Diphtheria
1.3.3
1.3.4
Pertussis
Tetanus
1.3.5
1.3.6
Tuberculosis
Measles
2.0
PRACTICE-RELATED KNOV/LEDGE
2.1
Contraindications
2.1.1
Cough and cold
2.1.2
Diarrhoea and vomiting
Fever below 100°F
2.1.3
2.1.4
2.1.5
2.1.6
2.2
2.3
Eever above 100° F
Malnut rition
16
18
20
22
24
25
27
29
30
31
31
Skin diseases and boils
32
32
33
Maintainence of vaccines
34
Number of recipients needed to
open a vial
39
D
D.
Indian Market Research Bureau
Page
No.
2.4
Left over vaccines
42
2.5
Case-studies
45
2.5.1
45
2.5.2
Multiple vaccines at a time
Measles vaccine
3.0
PROGRAMME
3.1
Targets
53
3.1.1
Coverage targets
3.1.2
Period for targets
53
54
3.2
Appraisal of own centre
58
3.2.1
59
3.2.2
Reasons for excellent - very good
Reasons for 'good' rating
62
3.3
Special training for immunization
65
4.0
UNDERSTANDING THE PEOPLE
4.1
Decision makers in the family
69
4.1.1
Immunization of the child
TT for pregnant woman
69
4.1.2
4.1.3
48
70
Taking the child to a doctor in
the village
71
4.1 .4
Taking a child to a town doctor
72
4.1.5
Taking the child to a local faith
healer
73
Peoples' attitudes to immunization
74
4.2
Indian Market Research Bureau
APPENDICES
Posters
Appendix I
Appendix II
Mother & dead child
Father and child
Appendix III -
Polio boy standing
Appendix IV
Polio boy crawing
-
Appendix V
TB-node on neck
Appendix VI
Appendix VII -
TT-bandaged head
TT-tube in nose
Appendix VIII -
Questionnaire
Indian Market Research Bureau
Page
No.
4.3
Assessment of overall attitudes
of the people
78
4.3.1
Analysis of statement 1
4.3.2
Analysis of statement 2
78
79
4.4
Refusals
85
4.4.1
Profile of the refuser
87
4.4.2
Reasons for refusal
88
4.4.3
Possible methods of persuasion
90
4.5
Attitudes of the implementers
92
4.5.1
Implementers attitude to his work
92
4.5.2
Understanding the attitudes of the
people
94
4.5.3
Knowledge regarding immunization
Practices
97
102
4.7
Bringing the child for immunization
Keeping track of due dates
5.0
PRACTICE RELATED ISSUES
5.1
Preservation of vaccines for out
reach sessions
5.1.1
Transportation
106
5.1.2
Placement of vaccines during an
immunization session
108
4.5.4
4.6
99
103
5.2
5.2.1
Sterilization
Place
110
5.2.2
Method
111
5.3
Availability of consumables
114
110
Indian Market Research Bureau
Page
No.
5.3.1
DPT vaccine
114
5.3.2
TT vaccine
115
5.3.3
OPV vaccine
115
5.3.4
Measles vaccine
115
5.3.5
Vaccine cards
5.3.6
BCG vaccine
116
117
5.4
Posters/Tin plates
5.4.1
5.4.3
Receipt of posters/tin plates
Type of posters received
Rating of posters
122
5.5
Problems in practice
126
5.5.1
No problems
126
5.5.2
Obstacles to the work
127
5.6
Areas of improvement
129
6.0
MEDIA
6.1
Main sources of information for
villagers
133
Information regarding national
happenings
133
Information regarding district
level happenings
134
Information about happenings in
neighbouring villages
135
Information regarding health teams
visit
137
5.4.2
6.1.1
6.1.2
6.1.3
6.1.4
6.2
6.3
Mass media
Messages that would convince
119
121
139
141
BfflW
Indian Market Research Bureau
NOTE ON THE REPORT
The report has been divided into six major sections.
These are :
Immunization
Practice-related knowledge
Programme
Understanding the people
Practice related issues
Media
In each section, comments have been made for all res
pondents as a whole.
Where relevant, specific details
have been provided for districts, metros, doctors,
workers, types of health centres and specific districts
or metros.
Complete data is available in computer printouts.
The top breaks used have been clubbed together in 3
different printouts, as follows :
A
Total
District
B
. Metro
. Doctor
. Worker
Total
Government hospital/dispensary
9
. Private practitioner/dispensary
categories
C
PHO . PHS
. Performance
Total
12 individual districts
.
individual metros
Indian Market Research Bureau
ii
All through the report, districts have been marked
with a special sign to indicate performance category.
Three signs have been used. These are :
*
Good performance district
Medium performance district
o
Poor performance district
The performance levels of each of the 12 districts
are as follows :
Good +
Hamirpur
Gwalior
Nanded
Anantpur
Medium
Allahabad
Iddukki
Puri
Kheda
Poor o
i
Bharatpur
Madurai
!
Nadia
Purnia
e
Indian Market Research Bureau
SUMbMARY
w
Indian Market Research Bureau
iii
1.0
IbfUJNIZATION
1.1
The immunization schedule
The five vaccines that comprise the immunization
schedule were well known to implementers.
Within
these, DPT and OPV vaccines were the best known
(96% and 94% respectively of all respondents
mentioned these spontaneously).
With help, all 5 vaccines were recognized by over
95% of all respondents as being part of the
schedule.
Awareness levels in the North zone
were marginally lower than those in the other
zones.
Detailed knowledge pertaining to each of the
vaccines was as follows :
No. of
doses
Target
recipient
TT
2 dose
(80%)
Pregnant
woman (99%)
BCG
1 dose
(98%)
Child aged
below one
year (96%)
Before
3 months
age (85%)
DPT
3 doses
(92?o)
Child age
below one
year (97%)
3 months
(63%)
1 month
(69%)
OPV
3 doses
(85%)
Child aged
below one
year (98%)
3 months
(63%)
1 month
(73%)
Measles 1 dose
(98%)
Child aged
below one
year (95%)
9 months
(67%)
Earliest
age
Interval
Indian Market Research Bureau
iv
1.2
Diseases prevented by the vaccines
Implementers had correct knowledge with regard to the
diseases prevented by each vaccine.
The only weak
link was that about 15% of the respondents did not
spontaneously associate the DPT vaccine with prevention
of tetanus.
1.3
Symptoms of diseases and perceptions of seriousness
Polio was associated with paralysis of the affected
limb, fever and headache.
Over 65% of all respon
dents believed that polio was very serious; another
36% felt that it was serious.
Diphtheria was associated with swelling and/or a white
membrane in the throat and fever, cough and cold.
74%
of all respondents believed that diphtheria was a very
serious disease; 24% felt that it was serious.
Pertussis was associated with constant coughing and a
whoop during the cough,
42% of respondents considered
the disease to be very serious while 47% felt that it
was serious.
Tetanus was associated with the body becoming rigid,
the jaw getting locked and with convulsions.
84% of
all respondents believed that this disease was very
serious.
Indian Market Research Bureau
V
Tuberculosis was associated with persistent cough
and fever, weight loss and fatigue.
42% considered
TB to be very serious whereas 45% considered it to
be serious.
Measles was associated with fever, rash, cough and
watery eyes.
35% of the respondents felt that the
disease was very serious while 45% felt that it was
serious.
14% said that it was not serious.
2.0
PRACTICE RELATED KNOWLEDGE
2.1
Contraindications
Fever, cough and cold and diarrhoea/vomiting were
seen as contraindications to vaccination.
Fever of
over 100°F was seen as a contraindication for DPT
vaccine (95%), OPV vaccine (63%) and measles (63%).
Diarrhoea and vomiting were seen as contraindications
for the OPV vaccine by over 75% of all respondents.
TT was one vaccine that was relatively unhindered
by contraindications.
24% of all respondents
believed that there were no contraindications to the
TT vaccine.
Skin diseases and boils were seen as contraindications
for DPT, BCG and measles vaccines by nearly one-third
of all respondents.
Malnutrition, on the other hand
was mentioned as a contraindication by only 18% - 20%
of all respondents.
Indian Market Research Bureau
vi
2.2
Maintainence of vaccines - Temperature
Only 44.6?o of all respondents could state the correct
temperature at which vaccines would need to be stored
namely, +4°C to +8°C, 29% gave an incorrect answer
while 26% said that they did not know, Correct
responses came more from doctors than from workers.
The error was made mainly on the side of lower tem
peratures, including temperatures at freezing point
and below.
Very few respondents spoke of storing
vaccines at temperatures higher than +8°C.
2.3
Number of recipients needed to open a vial
On an average, implementors said that 6 recipients
would be needed for them to open a ten-dose vial.
There was a difference in the responses given by
doctors and workers.
32?6 of doctors said that one
child would be sufficient reason to open a 10 dose
vial.
The mean was 5.1 children.
Workers, on
the other hand, tended to wait for larger numbers and
required an average of 7.1 children in order to open
a 10-dose vial.
There was a difference in the
responses between PHC and sub-centre respondents.
At the PHCs the single largest response favoured one
child as being sufficient for opening a 10-dose vial;
at the sub-centre, the response centred around 8
children.
JM D
D
Indian Market Research Bureau
vii
2.4
Left-over vaccines
If more than | a vial of vaccine was left over, both
doctors and workers would tend to put it back for
re-use.
If less than | a vial was left over, doctors
would tend to throw it away while workers would tend
to put it back.
DPT and TT vaccines would have a greater chance of
being put back in the refrigerator while measles and
BCG vaccines would tend to get thrown away.
OPV
vaccines were not clearly in any one category but,
in the final analysis, would stand a greater chance
of being put back than of being thrown away.
2.5
Case-studies
A couple of hypothetical situations were studied to
obtain an insight into the extent to which correct
immunization practices had been understood.
In one case, respondents were asked to assume that a
child's third dose of DPT/OPV had been delayed to the
age when the child would also be eligible for the
measles vaccine.
Respondents were asked if they would
give all three vaccines together under the circumstances.
50% of the respondents said that they would do so, 45%
said that they would not do so.
Willingness to give 3
vaccines together was higher at the district level
than at the metro level.
RD
w
Indian Martel Research Bureau
Vlll
The main reason for not being willing to do so was the
fear of unusually strong side effects or other
reactions.
The other situation pertained to the measles vaccine.
Respondents were asked if, in a situation where the
parents of a child said that the child had already had
an attack of measles, they would give the measles
vaccine nevertheless or refrain from doing so.
so.
73%
of all respondents said that they would not give a
measles vaccine under those circumstances, the main
reason being that natural immunity would have been
developed with the measles attack.
3.0
PROGRAMME
3.1
Targets
71% of all respondents said that the immunization
target was that 75% of all eligible infants and pregnant
women were to be vaccinated in that year.
64% of the respondents were aware that these targets
had to be maintained for the future.
The others either
felt that these targets were only for 1987 (21%) or
did not know.
Indian Market Research Bureau
ix
Within those who did not know that the immunization
programme was of long-term duration, only 43% were
aware that it would be a continuous process.
The
others assumed varying durations ranging from 2 years
to 20 years.
3.2
Appraisal of own centre
16% of respondents rated their own centre’s performance
as being excellent, 30% said their performance was very
good while 42% felt that it was good.
8%rated their
performance as being fair to poor.
There were two types of explanations given for the
ratings; one was a justification of the rating per se
while the other was an explanation of the performance.
Positive ratings were justified by respondents on the
basis of a good proportion of the target having been
achieved and ’many' children having been vaccinated.
Good-excellent performance was spontaneously attri
buted to the following factors :
cooperation received from the people
positive attitudes of workers
regular supply of vaccines.
The factors that were spontaneously mentioned to explain
a negatively rated performance were :
Indian Market Research Bureau
X
lack of education/understanding among the people
and the need for extensive persuasion
infrastructural problems
fear of side effects
3.3
Special training
53% of all respondents (7O?6 of workers at the district
level) said that they had received special training
for immunization.
Of those who said that training had been received,
almost all (93%) expressed satisfaction with the
training.
The training manual had been seen by 62% of all res
pondents; illustrations were recalled by an additional
4% .
Only 48% of all respondents currently possessed
the manual.
The large majority (83%) agreed that the
manual would be useful.
Awareness and current possession
of the manual was higher amongst workers than amongst
doctors.
4.0
UNDERSTANDING THE PEOPLE
4.1
Decision makers in the family
The decision maker in the family on the subject of
getting a child immunized was seen as being the mother
Indian Market Research Bureau
xi
by 75% of all respondents,
On the subject of giving
the TT injection to a pregnant woman, 59% said that the
woman concerned would take the decision while 23%
felt that her husband would be the decision-maker,
11%
felt that the female elder in the family would be the
decision maker.
If a child had to be taken to the village doctor (or a
nearby doctor), 49% felt that the decision would be
taken by the mother while 36% felt that it would be the
father's decision.
If, however, a child had to be
taken to a doctor in the town (or a doctor who lived
far away), 61% felt that the decision would be taken by
the father.
Decisions to take a child to the local faith healer
were believed to be taken mainly by the women in the
family - the elder women (45%) or the child’s mother
(27%).
4.2
People's attitudes to immunization
A child’s parents were seen to be unambigously in
favour of immunization,
of all respondents.
This was the opinion of 93%
Grandparents however, were seen to favour immunization
by only 59% of all respondents.
17% felt that grand
parents were opposed to immunization while 19% felt their
attitude was one of indifference.
MB
Indian Market Research Bureau
xii
The others in the village who were clearly seen to be
in favour of immunization were the school teacher
(92%), the village midwife (83%) and the village
chief (82%).
Village elders were seen to have a
favourable attitude by only 75% of the respondents.
The faith healer was believed to be clearly opposed
to immunization (39%) or indifferent to it (14%).
Workers felt more strongly than doctors that
elders were opposed to immunization. Assuming that
workers are closer to people and therefore have a
better understanding of the situation, it would be
prudent to tailor communication such that it reaches
out to and convinces the older generation.
4.3
Assessment of overall attitudes of the people
In terms of awareness of immunization, 88% of the
respondents believed that most people in their
territory were aware of immunization.
81% also said
that most people were cooperative and willing.
However, when negative statements were read out,
they were not opposed strongly.
Thus, 55% of the
respondents agreed that some people were indifferent
and 53% agreed that people had to be coaxed.
The
contradiction implicit in this tendency to
agree with positive and (to a lesser extent)
1WJ
Indian Market Research Bureau
xiii
negative statements reveals a higher level of dis
content than was willingly admitted to.
We conclude
that there was in fact greater resistance to immu
nization than would be immediately apparent.
4.4
Refusal
On being directly questioned, over 50% of the respon
dents said that some people did refuse vaccinations.
There was a slightly higher level of refusals reported
by district level workers.
The persons who refused vaccinations were predominantly
described as people who were illiterate or uneducated.
Backward classes, labourers and poor people were other
descriptions used to describe the typical refusers.
The most important reasons attributed to such
refusals were :
lack of education and belief in vaccines
fear of fever and/or adverse reactions
traditional beliefs.
Implementers felt that if people had to be effectively
persuaded on the subject of infant immunization, this
would have to be done by means of education through
personal contact and documentary films.
U K\j
Indian Market Research Bureau
xi v
4.5
Attitudes of implementers
Implementer attitudes were measured by means of a
senes of statements which respondents could agree or
disagree with. The statements, and the proportion of
respondents who expressed agreement with that statement,
are being presented below
% who
agreed
Attitude to work
1.
2.
3.
4.
5.
6.
7.
Convincing people to get their child
immunised is frustrating work
27
This job involves important and useful
work
99
Working with illiterate people can be
boring and tiring
41
I would prefer to work in a town rather
than in a village
40
People here do not really believe that
vaccinations can prevent disease
14
People suspect that vaccinations are
not given for the prevention of disease
but some other motive
16
Once a child has been vaccinated people
will come forward on their own to get
their next child vaccinated
89
Knowledge regarding immunization
8.
TT and DPT vaccines should not be
allowed to freeze
75
[WE
Ho
Indian Market Research Bureau
XV
% who
agreed
9.
Keeping vaccines at room tempera
ture for 2-3 hours is okay
24
Practices
10.
11.
The cold chain system beyond HQ
is very weak and breaks down easily
45
Most vaccines loose potency because
it is impossible to maintain them
at the correct temperature
62
99% of all respondents revealed that the child was
normally brought for immunization by the mother.
Mothers kept track of due dates on the basis of immuni
zation record cards or on the basis of fixed days which
would be advertised.
Alternately, workers took the
responsibility of reminding parents on the due date or
actually taking the vaccination to the house of the
child.
The former (mother-oriented) memory system was
more prevalent except for three districts - Purnia,
Nadia and Nanded where the latter (worker-oriented)
memory system was more prevalent.
In metros, the onus
of remembering dates rested almost entirely with the
mother.
5.0
PRACTICE RELATED ISSUES
5.1
Preservation of vaccines for outreach sessions
Two out of three respondents transported vaccines to
outreach session well protected in ice.
The responses
Indian Market Research Bureau
xvi
given by the balance one-third could be interpreted
It is difficult therefore to reach a
either way.
clear conclusion on this issue.
During the session, 82% of the respondents reported
preservation practices that would be acceptable.
These were of keeping the vial in a cup of ice, on
top of an ice-pack, on a plastic bag filled with ice
or back in the vaccine carrier itself.
The remaining
18% respondents reported practices that would not be
acceptable such as putting the vial on the table, in
a cup of water or in the shade.
5.2
Sterilization
Needles and syringes were sterilized by some respon
dents at the health centre and by others at the out
reach camp.
measure.
Both practices were reported in equal
The majority (77%) sterilized instruments
before the session while others, (20%) did so during
the sessions.
Sterilization was mostly ’achieved1 by boiling the
instruments. The error however lay in the under
standing of time required to achieved sterilization.
Inquiry revealed that 50% of all respondents boiled
instruments for 20 minutes or less and these 20 minutes
included the time taken for water to reach boiling
point.
Only 15?6 used the autoclave method for
sterilization.
E.'dB.
Indian Market Research Bureau
xvii
5.3
Availability of consumables
There appeared to be no problems in terms of availa
bility of consumables.
The two items in which some
availability problems were reported were vaccine
cards and the BCG vaccine.
Over 20% of respondents
in 6 out of 12 districts reported irregular supply of
the vaccine.
5.4
Posters/tin plates
80% of all respondents (91% - 95% at the PHC and PHC
levels, respectively) reported receipt of tin plates
and posters.
Doctors and workers in districts
reported that an average of 117 posters/tin plates had
been received.
In metros, on the other hand, an
average of 23 posters/tin plates were reported
received by each respondent.
There were wide
variations in numbers received between districts.
Some districts such as Bharatpur0 and Allahabad* reported
high receipts (an average of 335 and 245 respectively)
while others reported considerably lower receipts (6 in
Gwalior*,10 in Nanded*).
There were seven basic pictures and messages,
Data on
posters/tin plates received revealed that the types
were equally distributed.
Respondents were asked to rate each poster on a scale
ranging from poor to excellent.
The two pictures that
IMH D
D
Indian Market Research Bureau
xviii
received the highest rating both pertained to polio.
It is hypothesized that the combination of familiarity
of the disease and the dread of disability made these
posters most effective.
The second highest rating was received by two posters toother and dead child' and 'tetanus picture of infant
with bandaged head'.
The lowest ratings were given to three posters Tetanus - child with tube in the nose', 'TB-node
on neck' and 'Father and healthy child'.
This rating bears out the hypothesis that posters,
in order to be effective, need to have three
characteristics - familiarity, probability of
occurence and dread as perceived by the target
audience.
5.5
Problems in practice
One out of three respondents said that they had no
problems that caused any obstruction to their work.
The others however did speak of problems. The first
five problems that were mentioned were as follows,
in order of frequency of mention
xW
Indian Market Research Bureau
xix
Transportation problem
Resistance from people
Problems regarding vaccine supplies
Cold chain maintainence
Shortage of workers
5.6
Areas if improvement
Upon being asked, respondents ranked possible improve
ment areas as follows :
information to people about immunization
supply of vaccines
cold chain maintainence
Doctors spoke more in terms of cold chain maintainence,
supply of vaccines and system of travel; workers
wanted improvement in the system of travel, supply of
vaccines and in reduced ratios of people : Centres.
6.0
MEDIA
The main sources by which people in villages heard
of happenings outside their village differed by the
type of news in question.
National happenings were heard of through national
media. These were the radio (87%), newspapers (65%)
and television (52%).
BfflB
Indian Market Research Bureau
XX
District level happenings were heard of mainly
through the newspaper (52%) followed by the radio
(38?i). Word-of-mouth, particularly in terms of news
brought by travellers, accounted for an additional
20% of the reported sources.
Personal contact either with travellers or visitors
from neighbouring villages accounted for most of the
news that was received about events in neighbouring
villages. News about events in nearby villages was
disseminated by means of announcements, proclamations
made by village elders or chiefs and by means of
posters and leaflets.
Information regarding the visit by a health team was
given by health workers or the ANNS, Visits were
announced over megaphone; the services of village
chiefs were also taken for the purpose. In addition,
notices, pamphlets or posters were sometimes used.
In terms of the overall penetration and credibility
of mass media, the radio ranked highest followed by
cinema.
66% of the implementers said that radio was
most likely to reach village people and 73% said that
the people believed in the news given by the radio.
Cinema was believed to reach people (42%
of the
implementers said so) and was credible (56%). Posters
had higher reach than newspapers but newspapers were
more credible than posters.
Indian Market Research Bureau
xxi
Messages that would convince
Finally implementers were asked for their suggestions
on messages that would convince people to get their
child immunized.
The main suggestions were as follows :
explain advantages of vaccination
give health education to parents
name the diseases that can be prevented and
explain these
explain the consequences of not vaccinating a
child
Indian Market Research Bureau
DETAILED FINDINGS
Indian Market Research Bureau
1.0
IMMUNIZATION
1.1
The immunization schedule
1.1.1
Awareness of vaccines
All respondents were asked to talk of the immunization
schedule as known to them. They were assisted by a
series of questions, starting with a question on the
names of the various vaccines that would form part of
the immunization schedule.
Spontaneous mention of vaccine names were as follows :
(Base : 312)
Rank
Name
Total
Highest mention
O'
'0
1
DPT
96.2
PHC = 100%, South zone
99%
2
OPV
94.2
PHC = 97%, North zone
97%
3
Measles
87.8
PHC = 98%, West zone
97%
4
BCG
83.3
PHC = 98%, West zone
92?6
5
TT
79.2
Govt Hospitals South zone = 90%
6
Others
39.4
PHS - 53%, East zone = 56%
88%
Ref : Tables B-8, C-9
BCG was spontaneously mentioned more often by workers
than by doctors at the district level (90% workers :
80% doctors).
The
inverse was true for the metros
(57% workers : 7O?6 doctors).
TT was spontaneously mentioned as part of the schedule
by only 79?o of all respondents.
Doctors, especially
Indian Market Research Bureau
2
at the metro level, mentioned TT more often than
workers.
(80% doctors : 78% workers;
At the
metro level the ratio was 74% doctors : 62%
workers).
In the South zone 90% of all respondents mentioned
TT; the figures for the other three zones are
North zone - 79%; East zone - 79%; West zone
75?6.
Other vaccinations (over and above these five)
were mentioned as part of the schedule by 39?6
of all respondents.
This implies inaccurate
knowledge and probably, some guesswork.
Other
vaccinations were mentioned significantly more
often by workers (76%) than by doctors (24%).
They were also mentioned more often in the
East zone districts.
Respondents were then prompted on
the vaccines
that they had not mentioned to see if they
were at all aware of the vaccine as being part
of the immunization schedule.
Total awareness of vaccines was as follows :
Name of
vaccine
(Base : 312)
Total
-
TT
97.4
Remarks
Low amongst metro workers : 81?6
Low in Hamirpur* (85%) and
Nanded (95?6)
hmw
Indian Market Research Bureau
3
Name of
vaccine
Total
BCG
95.8
Low in North zone : 86% and
amongst private practitioners : 81%
DPT
98.4
Low amongst metro workers : 95%
Remarks
Low in Hamirpur* (85%) and Nadia0 (96%)
OPV
99.0
Low amongst metro workers (95?o)
Government hospitals 97%)
Measles
95.5
Low amongst private practioners (85%),
metro workers (81%), Hamirpur* (80%),
Nadia0 (92%)
Ref : Tables B-9, C-9
The factors that emerge as being significant are :
Metro workers do not seem to be fully conversant
with the immunization schedule.
Hamirpur implementers, inspite of belonging to a
"good category” district, reveal a surprising
lack of awareness.
The South, East and West zone districts emerge
as being more aware of the vaccines in the
immunization schedule than the North zones.
D
D
Indian Market Research Bureau
Total Awareness
North
South
East
West
O'
/0
%
O'
/O
O'
'0
TT
95
100
100
99
BCG
86
100
99
97
OPT
95
100
99
100
OPV
100
99
99
100
Measles
93
99
96
100
Vaccine
Ref: Table C-9
1.1.2
Details regarding each vaccine
a/
Tetanus Toxoid
i/
No. of doses
TT
80% of all respondents said that TT vaccine was
a 2-dose course.
There were wide variations in the understanding
of the number of doses.
93.5% of PHC respondents and 94.5% of PHS respon
dents spoke of tetanus as being a 2-dose course
In contrast, only 40% of private practitioners
mentioned 2 tetanus doses; 44.7% of them mentioned
3 doses.
This emphasis on 3 doses was revealed by 50% of
all respondents in Iddukki .
spoke of 3 doses.
In Gwalior*, 18%
However, in all other districts,
Indian Market Research Bureau
5
over 80% of all respondents thought of TT vaccine in
terms of 2 doses.
In metros, however, TT was not always thought of in
terms of 2 doses.
59.3% of doctors and 35% of workers
in metros spoke of 2 doses; 47% of workers in metros
spoke of 3 doses.
In summary the views on TT doses were as follows :
2 doses
80% of all respondents particularly from
districts, from PHCs and PHSs.
3 doses
13.8% of all respondents, particularly
from Iddukki ; workers in four metros and
some private practitioners thought of TT
in terms of 3 doses.
1 dose
Mentioned by only 6?6 of all respondents.
Greater emphasis on one dose in Bharatpur0
and Allahabad
districts, amongst doctors
and workers in metros and amongst private
practitioners.
The widespread perception amongst implementers of TT
as a 2-dose vaccine was in contrast to the understanding
held by mothers who thought of TT essentially in terms
of 3 doses.
U t\\J D)
Indian Market Research Bureau
6
ii/
Target recipient
TT
On this subject there was little or no argument.
99?o of all respondents said that the TT vaccine was
for pregnant women.
women.
The three respondents who
did not specify were 2 doctors from the East zone
and one worker from a metro.
b/
BCG
i/
No. of doses
BCG
BCG was predominantly seen as a one-dose vaccine
(98.3%).
Only a couple of workers at the PHC/PHS
level mentioned 2 doses.
ii/
Target recipient - BCG
96% of respondents said that the BCG vaccine was
meant for a child aged below one year. 11.7% said
it was for a child above one year.
There is
therefore an overlap of 7.7% which is the proportion
of respondents who mentioned both below 1 year and
above 1 year.
These were mostly from Gwalior*
(41% overlap) Nanded*(23.8% overlap), and
Purnea
(17.4% overlap).
Private practitioners
and workers in metros mentioned both age groups
more often than others.
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Indian Market Research Bureau
7
Looking at this in conjunction with the earlier
statement, namely that BCG was seen as a one-dose
vaccine by 98% of all respondents indicates clearly
that respondents were not thinking in terms of
booster doses.
They were instead revealing a
lackadaisical attitude where their response would
have been that either below one year or above one
year would be a suitable age for the BCG vaccine.
iii/
Earliest age
BCG
The majority of the respondents believed that BCG
vaccine was to be given by the age of 3 months
(85.3%).
Half of all respondents said the vaccine
was due before 2 months of age; 35.5% said it was
due at 3 months.
Government hospitals and private practitioners were
in favour of BCG at below 2 months age; PHC and
PHS respondents were in favour of the age of 3 months.
Over two-thirds of respondents from Allahabad+,
Purnia0, Pun+ and Nanded* were in favour of BCG at
3 months.
At the district level, doctors (61%) spoke of BCG
before 2 months while workers (48%) spoke of BCG
at 3 months; in the metros, both doctors (82%) and
workers (74%) spoke of BCG being due before the age
of 2 months.
Indian Market Research Bureau
8
c/
DPT
1/
No. of doses - Dpj
DPT vaccine was known to be a 3 dose vaccine.
was stated by 92% of all respondents.
This
In Nadia0 and
Hamirpur* districts a few respondents mentioned 4
doses.
However, their numbers were small.(3.6%). Four
dises, when mentioned were usually from PHCs
at the district level.
Workers at the metro level, particularly in Calcutta
mentioned 5 doses of the DPT vaccine.
Target recipient
- DPT
The target recipient was mostly seen as a child
below one year (96.7%).
In the metros, (and to
some extent in the districts) there was additional
mention of a child above one year.
(%)
Total
District
Metro
Doctor
Worker
307
96.7
260
96.9
47
95.7
114
96.5
96.9
14.3
11.9
27.6
17.6
12.4
Base: All aware
of DPT
Both below
1 year and
above 1 year
193
Ref : Table A-16
All doctors from metros who were aware of DPT mentioned
the pre-one year old as the target recipient.
In addition,
29.6% mentioned the post-one year old too.
>TD
LSLW
Indian Market Research Bureau
9
Mention of the older age group points to an awareness
and inclusion of the booster does as part of the
However, the majority of
immunization schedule.
all respondents did think of the immunization schedule
as only the basic schedule and not the booster doses.
iii/
Earliest age
- DPT
The earliest age, as stated by 62.9% of all respon
dents, was 3 months.
22.8% of the respondents spoke
of an age of less than 2 months.
These were more
from metros and from government hospitals.
In
Hamirpur* Madurai0and Kheda+districts, respondents
mentioned the starting age as being less than 2 years.
Base: All aware Below
of DPT vaccine 2 months 3 months
Over 3
months
O'
zO
O'
zO
0'
zO
Hamirpur*
17
70.6
23.5
5.9
Madurai 0
Kheda+
24
45.8
37.5
16.7
22
59.1
36.4
4.5
Metros
47
36.2
53.2
6.4
Districts
260
20.2
64.6
11.2
Ref : Table C-17
In Anantpur*, 29.2% of all respondents gave the
starting age as 4 months.
11/
Interval between 2 doses
DPT
68.8% of all respondents at the district level and
89% of all respondents at the metro level stated that
the correct interval between 2 doses was one month.
Indian Market Research Bureau
10
(%)
Base: All aware Total
of DPT vaccine
307
One month
72.0
Two months
12.4
Over 2
months
13.1
Dist rict
260
68.8
Metro
47
89.4
13.1
8.5
15.3
0.0
Major variations
South
West
AnantGwaIddukki
pur*
Nanded* Kheda lior
24
24
21
22
22
41.7
0.0
61.9
63.6 72.7
41.7
0.0
36.4
16.6
100.0
38.4
27.3
Ref : Table A-18, C-18
As is apparent, the
knowledge in South and West zones
pertaining to the interval between 2 doses of
the DPT
vaccine was very different from the national average.
90% of private practitioners
were in favour of a one-
month interval as
compared 67°6 at the PHC/PHSs and 71?6
at the government health centres.
d/
OPV
1/
No. of doses
OPV
Most government related health
personnel saw OPV as a
3 dose vaccine, Private practitioners
and respondents
from the metros were however,
divided in their opinions
between three and five doses.
The details are as follows :
(%)
3 doses
84.5
Disttrict
262
89.3
5 doses
11.7
6.9
38.3
Others
3.8
3.8
4.3
Base: All aware
of OPV vaccine
*
Total
~3O9
Mainly 4 doses
Metro
47
57.4
Doc
tor^
114
74.6
18.4
7.0*
Major variations
WoIddu- Madu- Bom- Calrker kki+
rai° bay cutta
195
24
24
24
12
90.3 58.3
79.2
33.3 41.7
7.7
37.5
2.0
4.2
20.8
66.7 50.0
8.3*
RD K
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Indian Market Research Bureau
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Target recipient
OPV
The pre-one year old was seen by 98.4% of all res
pondents as being the target recipient.
16.2% spoke of
the post-one year old too, referring to the booster
doses.
(This could account for the 5 or 4 doses
mentioned by some respondents).
Less than one percent
of all respondents spoke of the target recipient as
the post-one year old only.
Higher mention of both age groups came from private
practitioners, and from Gwalior* and Nanded*in the
West zones.
The details were as follows :
(%)
Base: All
aware of OPV
vaccine
Child below
1 year
Child above
1 year
Total
Dis
trict Metro
Do
ctor
Wor
ker
Major variations
GwaPur- Bomlior* Nanded* nia° bay
309
262
47
114
195
22
21
24
12
98.4
99.3
93.6
98.2
98.5 100.0
100.0
95.8
91.7
16.2
13.0
34.0
19.3
14.4
52.4
25.0
75.0
45.5
Ref: Tables A-20; C-20
iii/
Earliest age
Opinions with regard to the earliest age were divided.
The majority (62.5%) said that the starting age was 3
months; 23% mentioned an age of 2 months or less while
D
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Indian Market Research Bureau
12
14.5% gave an age above 3 months as the starting age.
The details were as follows :
(%)
Total
Base; All aware
aware of OPV vaccine 309
Upto 2 months
23
3 months
62.5
4 months+
14.5
District
262
Metro
47
19.5
Worker
42.6
Doctors
114
24.6
61 .4
40.4
58.8
64.6
19.1
17.0
16.6
13.3
195
22.1
(%)
Base: All aware of
OPV vaccine
Upto 2 months
Hami rpur*
3 months
30
Major differences
Anant
pur*
Kheda+ Nanded*
22
23
21
9
59
5
65
36
57
4 months+
10
26
20
60
5
38
Bom
bay/
12
64
Cal
cutta
12
9
17
27
25
58
Ref: Tables A-21; C-21
The tendency in the North zone was to start earlier, at
2 months or before that.
vi/
Interval between 2 doses
OPV
The interval between 2 OPV doses was mostly seen as being
Private practitioners and metro respondents
were more wholly in favour of a one-month interval. In
one month.
some districts, particularly in the South zone, the
responses favoured a two-month interval.
Details were as follows :
umbi
Indian Market Research Bureau
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(%)
Major differences
Govt
Hospitals
99
71
Interval
Base* :
One month
Total
309
72.8
Dis
trict Metro
262
47
70.2 87.2
2 months
12.9
13.4
10.6
18
Over 2
months
14.3
16.4
2.2
11
Anantpur*
23
Iddukki+
24
46
42
100
Mad
urai-0 Kheda
24
22
75
64
23
36
12
Ref: Tables A-21 . B-21, 0-21
H
good category” district were
surprising as the majority stated that the interval
between 2 OPV doses would be 3 months or more.
There were no real variations in responses given by
doctors and workers.
75% in the former category and
71% in the latter placed the interval at one month.
v/
Measles
i/
No. of doses - Measles
Measles was predominantly seen as a one dose vaccine.
This was stated by 97.7% of all respondents.
There
were no real variations by district/metro, doctors/
workers or by type of centre
ii/
Target recipient - Measles
The target recipient was largely seen as being the
child aged less than one year (95.3%).
However, 14.4%
also mentioned that the vaccine was to be given to a
child aged over 1 year.
28
1
* All aware of OPV vaccine
Responses from Anantpur? a
*
Nanded
21
71
Since an overlap of 10% is
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14
incongruant with the earlier statement of measles being
a one-dose vaccine, this overlap connotes uncertainity
or flexibility rather than booster doses.
Measles injections for a child above the age of one
year were mentioned by private practitioners
and in
There were no real variations between
district and metros or between doctors and workers.
some districts.
The details were as follows :
(%)
Major differences
Govt
Gwa lan
Hospi
lior* ded* Purnia 0 tals
22
21
23
96
Private
practi
tioners
Total
Dis
trict
Metro
Base
298
256
42
Below 1
year
Above 1
year
95.3
96.1
90.5
100
95
83
96
45
93
14.4
14.5
14.3
45
62
26
8
20
*
All aware of measles vaccines
Ref: A-24, B-24, C-24
iii/
Earliest age
Measles
Two-thirds of the respondents
mentioned 99 months
months as the
respondents mentioned
The remaining one-third
mentioned both earlier and later ages.
ages. The
lhe average
age for the measles dose.
age mentioned across the country was, however, 9.1
months.
The variations across centres and respondent
groups
become clearer if looked at in terms of the average
age mentioned.
BW
Indian Market Research Bureau
15
Average age (Months)
Base: All aware of measles vaccine; figure in brackets
Total
9.1
(298)
District (256)
9.1
Doctors
(109)
9.3
(42)
9.2
Workers
(189)
9.0
Metro
Govt hospitals(96) 9.3
PHO
(63) 9.1
PHS
(94) 8.9
Private
practitioners (45) 9.2
Variations within districts and metros were as follows :
Higher age
Allahabad*(15) 9.6
Lower age
Iddukki
(23) 10.0
Purnia0 (23)
Puri+
(22)
Madurai 0
(24) 9.5
Kheda
(22)
8.8
Bombay
(12)10.0
Delhi
(11)
8.5
8.2
8.8
Ref: Tables A-25; B-25; 0-25
Indian Market Research Bureau
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1.2
DISEASES PREVENTED BY VACCINES
The questions asked to respondents in this context
was "What are the diseases prevented by each of these
vaccines ?
Each vaccine was mentioned and respondents
were asked to name the diseases.
The answers were predominantly correct.
Total
responses are given below :
Name of vaccine
(Base : 312)
Disease prevented
TT
Tetanus
96.5
BCG
TB
97.1
OPV
Polio
99.0
DPT
Tetanus
84.9
Diptheria
95.2
Whooping cough
97.1
Measles
97.1
Measles
% mention
Ref : Tables A—31 to A-35
TT vaccine was credited with preventing whooping cough,
diptheria by a handful of respondents, mainly doctors
from both districts and metros.
BCG and OPV were fairly clearly associated with TB
and Polio respectively.
Indian Market Research Bureau
17
The knowledge that DPT provided protection against
tetanus was somewhat weak, particularly amongst workers,
at both state and metro levels.
Data from private
practitioners and PHS' showed lower than average
awareness of tetanus prevention through DPT.
Measles vaccine was strongly associated with
of measles.
prevention
Only four respondents from the districts
confused the vaccine with prevention of tetanus.
W
Indian Market Research Bureau
18
1.3
SYMPTOMS OF DISEASES AND PERCEPTIONS OF SERIOUSNESS
1.3.1
Polio
a/
Symptoms
The most important symptoms of polio were paralysis
of the affected limb (82.4%) and fever and pain in
the head (68.3J6).
The latter was mentioned more often by doctors. The
former was mentioned more often in the districts and
by workers.
The details are as follows :
(%)
Symptoms
Total
Base: All res
pondents
312
Fever/headache 68.3
Doc Wor
tors kers
North
Zones
South East
West
48
73
115
82
197
60
57
56
72
93
70
71
65
45
District
Metro
264
67
Paralysis of
limbs
82.4
81
90
77
85
63
83
89
86
Pain in limb
34.9
33
46
38
33
19
42
43
25
Difficulty in
standing/
walking
9.6
10
6
9
10
12
7
7
15
Ref: Tables A-A6, C-36
In the North zone,
zone, there were several symptoms
mentioned.
In the South zone (including Madras
metro) responses were focussed more clearly around
fever/headache (100% mention in Anantpur? Madurai0
and Madras) and paralysis of the limb(s).
Indian Market Research Bureau
19
In the West and East zones paralysis of the affected
limb was the main symptom mentioned.
It was mentioned
by all respondents in Bombay, Gwalioi* and Nanded*and
Calcutta.
While fever/headache were mentioned by 71%
of the respondents in the East zone, it was mentioned
by less than 45% of respondents in the West zone,
The
other symptoms that were mentioned were :
difficulty in walking/standing - 9.6%
limbs become weak/thin - 7.1%
high fever and vomiting - 6.1%
weakness - 6.1%
b/
Seriousness
Polio was considered serious or very serious by over
98?6 of all respondents.
More respondents in metros
and in the worker group considered polio to be very
serious disease than in the districts.
The details
are as follows :
(%)
Base:*
Very serious
Total
312
65.4
District
264
64
Metro
48
71
Doctor
115
62
Worker
197
68
Serious
32.7
34
27
37
31
North
Base*:
57
Very serious 58
Serious
40
* All respondents
Delhi
12
75
South
72
68
Madras
12
92
East
70
73
Cal
cutta
12
92
25
31
8
27
8
65
59
Bombay
12
25
39
67
West
Ref: Table A-37, C-37
w
Indian Market Research Bureau
20
Attitudes towards polio in the West zone were clearly
less anxious than those in the East and South
1.3.2
zones.
Diphtheria
a/
Symptoms
The main symptoms of diphtheria
Total
Base: All respondents
312
Swelling in the
throat
64.1
Dis
were as follows :
(%)
trict. Metro
264
48
Doctor
115
Worker
197
62
75
69
61
White membrance
in throat
57.7
55
71
67
52
Fever/cough/cold
fits
50.0
51
44
59
45
Child cannot eat
39.1
39
40
34
Ref: Table A-38
42
Doctors were clearly more conversant with symptoms of
diphtheria than workers, Similarly, there was more
familiarity with the symptoms in the metros than in the
districts.
Within districts,
the diphtheria
there was greater familiarity with
symptoms in Puri+, Nadia0, Anantpur*
and Madurai0.
In the city of Bombay, respondents
were more conversant with the symptoms of diphtheria
than in other cities.
Apart from those mentioned above, other symptoms of
Indian Market Research Bureau
21
diphtheria that were mentioned were :
difficulty in breathing - 15.7%
pain and swelling, white tissue in throat - 9.3%
difficulty in speaking - 4.2%
b/
Seriousness
The majority (74%) considered diphtheria to be a very
serious disease. The detailed breakup was as follows :
(%)
Doc Wortor
ker
115
197
78
72
Base: All respondents
Very serious
Serious
T otal
312
74.0
23.7
District
264
74
20
26
Not serious
1.6
2
2
1
Ref : Table A-39
2
24
Metro
48
73
23
Clearly, there were not many variations between per
ceptions of seriousness in districts and metros.
Doctors considered the disease to be marginally more
serious than workers did.
Within districts, diphtheria was considered more
serious in Gwalior4",Madurai
,Madurai 0 , Nadia0, Iddukki+,
Puri
and Nanded* than the others.
Within metros,
diphtheria got a higher seriousness rating in Delhi,
followed by Madras, Calcutta & Bombay, in that
order.
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Indian Market Research Bureau
22
There were no major variations in familiarity with
the disease or in the perceptions of serious by type
of health centre.
1.3.3
Pertussis
a/
Symptoms
The two main symptoms of pertussis that were
mentioned were that the child keeps coughing and
that there is a whoop during the cough.
The
mention of the whoop came significantly more
from metros than from districts and from doctors
than from workers.
Within types of doctors, this
symptom was mentioned more often by doctors in
government hospitals and the private practitioners.
The main symptoms mentioned were as follows :
(S)
Total
Dist r ict
Metro
Doctor
Wor
ker
North
South
East
West
57
72
70
65
72.1
71.9
65.3
78.6
66.2
83.5
64.0
50.9
72.2
62.9
83.1
43.8 •
53.0
49.7
50.9
43.1
55.7
60.0
22.3
22.9
27.0
19.8
21.1
23.6
18.6
26.2
14.4
6.3
7.0
16.8
10.5
8.3
34.3
3.1
Base:
Child
keeps
coughing
312
264
48
115
197
70.2
70.5
68.8
67.0
Whoop
during
cough
71.2
67.8
89.6
Vomiting
a fter
cough
51.0
52.3
Fever
22.4
Watery/
reddish/
shut eyes 13.1
Ref : Table A-40; C-40
rrnKB
Indian Maricet Research Bureau
23
Other symptoms mentioned were
face becomes red - 6.7?6
difficulty in breathing cough - 3.2%
In the North zone,apart from other symptoms, the
fact that the face became red was mentioned by 15%
of the respondents.
b/
Seriousness
The disease was considered to be serious by 47% of
the respondents and
respondents.
very serious by 42% of the
While the disease was considered
serious, it received a lower seriousness score than
other diseases such as polio and diphtheria.
It was
considered to be more serious than measles and TB.
Almost all respondents in Gwalior
pertussis to be very serious,
(96%) considered
Two out of three
respondents in Nanded* felt the same,
In Hamirpur*
and in Madurai0, over 50% believed that the disease
was serious. On the whole, workers believed that
the disease was very serious (45%) more than
doctors did (37%).
Indian Market Research Bureau
24
1.3.4
Tetanus
a/
Symptoms
The main symptoms of tetanjs that were mentioned
were that the body would become rigid, the affected
person would get convulsions and the jaw would get
locked.
Doctors mentioned lock jaw more often
while workers mentioned that the body becomes rigid.
The main symptoms mentioned and differences by
different categories of persons or places were
as follows :
(%)
Total
312
District
264
Metro
48
Doctor
115
Worker
197
72.4
72.3
72.9
60.9
79.2
Lock-jaw
66.7
67.8
60.4
82.6
57.4
Convulsions
61.9
61 .4
64.6
75.7
53.8
Fever
16.7
18.2
8.3
16.5
16.8
Base: All respondents
Body becomes
rigid
Ref : Table A-42
Lockjaw was mentioned more by doctors at the district
level, mainly in PHCs.
There appeared to be greater
familiarity with the disease in some districts than
in others in that several symptoms were mentioned
by a majority of the respondents. These districts
were Anantpur*, Puri+, Gwalior*, Kheda+, Nanded*
and Hamirpur*
IMH D
D
Indian Market Research Bureau
25
Other symptoms that were mentioned were
neck/face/lips become rigid - 6.1%
unable to swollow/digest/eat - 4.2%
difficulty in breathing - 1.9%
b/
Seriousness
The disease was clearly in the very serious category
with an overall seriousness score of 2.8.
84%
of all
respondents considered the disease to be very serious.
92% of the respondents in metros believed that this
disease was very serious as compared to 83% of the respon
dents in the districts.
It was considered most
serious in the North zone, particularly in Bharatpur0
and Gwalior* districts.
It was also considered very
serious by respondents in Gwalior* and Nanded*
districts.
91% of private practitioners categorised
the disease as being very serious as compared to 8O?6
of the respondents in government hospitals and
dispensaries.
1.3.5
T.B
a/
Symptoms
The main symptoms of tuberculosis as given by the
respondents were persistent cough and fever, child would
lose
weight and look
tired.
There were variations
in the viewpoints between doctors and workers as well
as between districts and metros.
Indian Market Research Bureau
26
Symptoms
Total Districts
Base: All respondents
Persistent cough/
fever
312
Metro
Doctors
Workers
264
48
115
197
88.5
90.2
79.2
93.9
85.3
Child loses
weight
63.5
61.7
72.9
74.8
56.9
Child looks tired
39.4
37.9
47.9
40.0
39.1
Ref: Table A-44
There was greatest familiarity with TB in the three dis
tricts of the South zone and in Puri
and kheda^'districts.
Enlarged lymphnodes and glands in the neck were only
mentioned by 9% of all respondents.
These respondents
came largely from the three districts of Purnia°, Nadia0
and Nanded*.
Other symptoms that were mentioned were :
spits blood from the mouth - 9.6%
weakness - 4.8%
chest pain/ribs pain - 4.5?6
TB was considered serious rather than very serious and
received an overall seriousness score of 2.3 out of 3.
Doctors tended to consider the disease just serious
whereas workers classified it as very serious.
The ratings on seriousness were as follows :
Indian Market Research Bureau
27
(%)
“372”
Dist rict
264
Metro
48~
Doctors
115
Workers
197
41.7
40.5
47.9
29.6
48.7
Gwa- NanNadia0 Puri+ lior* ded*
24
22
22
21
54
50
91
62
Serious
45.2
46.2
* All respondents
39.6
51.3
41.6
46
Total
Base*:
Very
serious
1.3.6
50
9
Ref: Table A-45; C-45
Measles
The main symptoms of measles as stated by the respondents
were fever, rash, cough and watery eyes,
There were no
major differences in symptoms mentioned by district
versus metro or by doctor versus worker.
In Hamirpur*, Anantpur* and Puri , there was higher
familiarity with the symptoms of measles,
On the whole
respondents were considerably more familiar with the
symptoms of mealses than they were with symptoms of the
other vaccine-preventible diseases.
The differences by district/metro or by doctors/workers
were as follows :
(?□)
Symptoms
Base: All respondents
Fever
Total
95.8
District
264
96.6
Metro
48
91.7
Doctor
115
96.5
Worker
197
95.4
Rash
90.7
90.9
89.6
92.2
89.8
Cough
43.6
43.6
43.8
46.1
42.1
Watery eyes
37.8
38.3
35.4
36.5
38.6
Body becomes reddish
14.4
15.9
6.3
13.9
14.7
Ref: Table A-46
Indian Market Research Bureau
33
28
b/
Seriousness
Measles received the lowest seriousness rating
amongst all 6 diseases with as many as 14% of the
respondents saying that the disease was
was "not serious".
35% said that the disease was very serious while 49?6
felt that measles was serious.
For comparison purposes, the scores received by the
other diseases were as Follows :
(%)
(Base : 312)
Very
serious
Serious
Not
serious
Mean
scores
Polio
65.4
32.7
1.6
2.6
Diphtheria
74.0
23.7
1.6
2.7
Pertussis
42.0
47.4
7.4
2.4
Tetanus
84.0
13.5
0.6
2.8
TB
41.7
45.2
12.8
2.3
Measles
34.9
49.4
14.1
2.2
(Ref: Tables A-37, 39, 41, 43, 45, 47)
It was interesting to note that doctors considered
measles non-serious more than workers did; similarly,
more
respondents from districts considered the disease
to be non-serious as compared to metro
level
respondents.
In Anantpur* and Iddukki+, over one
third of the respondents said that measles was not
In Allahabad+, 20% said that it was a
non-serious disease.
serious.
HD
w
Indian Market Research Bureau
29
2.0
PRACTICE-RELATED KNOWLEDGE
2.1
CONTRAINDICATIONS
Respondents were asked if there were any situations or
circumstances when a child should not be given vaccinations.
Responses by vaccination type, are given below,
These
give the overall picture for all the vaccines,
Each
vaccine will then be studied for perceptions regarding
contraindications and differences, if any, by districts
and metros, within districts and by type of respondent.
(?o)
Vaccine type
DPT
OPV
TT
BCG
Measles
Cough/cold
54.2
48.7
27.6
39.4
39.7
Diarrhoea/
vomiting
54.5
75.3
33.0
40.7
44.2
Fever less
than 100° IF 54.5
46.8
35.3
41.3
47.8
Fever more
than 100® IF 74.7
63.1
50.3
57.1
62.8
Malnu
trition
19.6
19.9
15.4
17.9
17.6
Skin disease/
boils
35.3
29.5
23.7
32.1
32.1
Others
15.7
13.8
9.6
11.9
13.8
None
3.2
2.6
24.4
12.2
5.8
Don't Know
2.9
3.2
17.3
13.8
10.9
Contra
indications
Base :
All respondents - 312
Ref: Tables A-54, 55, 56, 57, 58
Indian Market Research Bureau
30
Contraindications were most strongly associated with
DPT and OPV vaccines. 94% of the respondents mentioned
some contraindication or the other in connection with
those vaccines.
The lowest association of contra
indications was with the TT vaccine where only 38% of
the respondents mentioned any and as many as 24% said
that there were no contraindications for TT.
The health circumstances that were strongly associated
with avoiding vaccines were high fever (over 100°F)
diarrhoea and/or vomiting
fever below 100°F and
cough/cold, in that order.
Skin diseases and boils
were seen as contraindications by about a third of all
respondents for most vaccines.
We will study each of the contraindications in detail :
2.1.1
Cough and cold
This contraindication was mentioned by 61.2% of all
respondents.
It was mentioned more often at the metro
level (67%) than at the district level (60%).
Cough and cold was most commonly seen as a contra
indication for the DPT vaccine, followed by the OPV
vaccine.
39% of the respondents believed it to indicate
that measles and BCG vaccines should also not be given.
Only 28% were opposed to giving TT vaccine when the
patient had a cough or cold.
66% of the workers mentioned cough and cold as contra
indication as compared to only 53% of the doctors.
In
metros, 76% of all workers mentioned cough and cold in
this context.
Indian Market Research Bureau
31
2-1 -2
Diarrhoea and vomiting
There were seen to be contraindications by 77% of all
respondents.
The vaccine that was most commonly seen
to be banned under the circumstances was OPV followed
by DPT.
The rationale was possibly that OPV being an
oral vaccine would be rendered ineffective by the
presence of diarrhoea or vomiting.
55% of all respondents felt that DPT could not be
given during diarrhoea/vomiting ,
of all respon
dents felt the same with regard to the measles vaccine
and ^i1?o felt the same way with regard to BCG.
Diarrhoea/vomiting was seen as a contraindication
more often by doctors (80%) than by workers.
Doctors
in metros were more unanimous in their ban on vaccines
during diarrhoea/vomiting with 85% of them citing it
as a contraindication.
2-1.3
Fever below 100° F
59% of all respondents mentioned this situation as a
contraindication, with the main ban being on the DPT
vaccine, followed by measles, followed by OPV, BCG
and TT.
Workers mentioned low fever as a contraindication more
often than doctors (62% versus 54%).
Respondents in the
four metros believed that low fever was a contraindication
significantly more often than respondents in the districts
(69% verus 57%).
Indian Market Research Bureau
32
2.1.4
Fever above 100° F
This was quoted as a contraindication by 80% of all
respondents.
It was seen as a signal for not giving
DPT vaccine (75%),measles (63%), OPV (64%), BCG (57%)
and TT (50%).
In the metros, as many as 93% of all doctors mentioned
fever above 100° F in this context.
At the district
level, though, high fever was mentioned as a contra
indication by more workers (81%) than doctors (74%).
As with other contraindications, there was a greater
belief in not giving vaccines during high fever
amongst metro respondents than amongst district
respondents.
2.1.5
Malnutrition
Malnutrition was not a widely recognised contra-
indication for immunization,
Only 24% of all respon-
dents mentioned it, and these respondents came mainly
from the districts. There was no real difference
between doctors and workers on this score.
Malnutrition was seen as a contraindication for almost
all vaccines in equal proportions.
20% of the respon
dents mentioned OPV and DPT vaccines, 18% mentioned
BCGj and measles and 15% mentioned the TT vaccine.
Indian Market Research Bureau
2.1.6
Skin diseases and boils
40% of all respondents mentioned this condition,
making it a more widely recognized contraindication
than malnutrition.
Larger proportions of workers (43%)
mentioned that skin diseases/boils would be an
indication to not vaccinate than doctors (35%).
As
with malnutrition, skin diseases and boils were
mentioned more often at the district level (42%)
than in the metros (27%).
For each vaccine, there were some respondents who
said that there were no contraindications meaning
that the vaccine could be given under any circum
stances .
The details are as follows :
No contraindication
(%)
Total
Base:All respondents 3'1 2
DPT
3.2
Doctor
115
4.3
Worker
197
2.5
District
264
3.8
Metro
48
Nil
OPV
2.6
3.5
2.0
3.0
Nil
IT
24.7
31.3
20.8
22.0
39.6
BCG
12.8
19.1
9.1
10.2
27.1
Measles
6.1
9.6
4.1
5.7
8.3
Ref: Tables A-54, 55, 56, 57, 58
TT was the one vaccine that was believed to be
permissible under any circumstances by one out of four
respondents.
BCG was also seen to be relatively free
of the constraint of contraindications as compared to
DPT, OPV and measles, each of which had some contra
indication or the other, in the opinion of almost
all respondents.
Indian Market Research Bureau
34
2.2
MAi:;TAINE,\CE OF VACCINES : TEMPERATURE
The objective of the question on temperatures at
which vaccines should be maintained was to check if
respondents were aware of the •;-4°C to +8°C
temperature range at which all vaccines would
ideally need to be preserved.
The correct answer, namely that vaccines should
be kept at the centre or clinic at a temperature
that ranged from +4°C to 4-80C.,came from 44.6% of all
respondents.
26.3,o said that they did not know
the answers
while 295a gave an incorrect answer.
i or reasons of clarity we will divide responses
for this analysis, i.e respondent type analysis,
into 3 segments, correct responses, incorrect
responses and "don't know" responses.
The correct responses more came from doctors
than from workers both at metro and district
levels, with district level doctors scoring a
slight edge over metro level doctors.
The
■Ldon't know" responses came mainly from workers
particularly at the district level and, within
Incorrect
them, particularly at the sub-centres.
responses came equally from both groups.
Indian Market Research Bureau
35
The broad break-up of responses is as follows :
Total
Doctors
Workers
312
115
197
Base :
0;
Correct
Incorrect
Don't know
44.6
29.1
59.1
29.6
36.0
29.0
26.3
11.3
35.0
____ Total
District Metro
Base :
O'
/O
Doctors
District Metro
Workers
District Metro
264
48
88
27
176
21
%
O'
/0
O'
%
O'
'0
%
Correct
44.7
43.8
61 .4
51.9
36.4
33.3
Incorrect
26.5
43.7
26.1
40.7
26.7
47.7
Don’t know
28.8
12.5
12.5
7.4
36.9
Ref: Table A-59
Clearly there were more wrong notions held by respondents
at the metro level, both doctors and workers.
19.0
The major mistake at the metro level was that respondents
believed that vaccines were to be frozen.
Thus, out of the
48 respondents in metros, 7 believed that vaccines were to
be maintained at 0°C, another 7 responded by saying that
vaccines were to be kept at freezing point or in deep
freeze and 3 spoke of temperatures that were below —10°C.
Thus, metro level responses can be accounted for as
follows :
D
D
Indian Market Research Bureau
36
Metro
Doctors
Workers
Nos.
Nos.
Metro
No.
0'
Base :
48
100
27
21
Correct
21
43.8
14
7
Don't know
6
12.5
2
4
Belov/ —10°C
3
6.3
1
2
Freezing point/
deep freeze
7
14.6
3
4
At 0°C
7
14.6
4
3
Above +8°C
1
2.1
1
\ot specified
3
6.3
2
/O
1
Ref: Table A-59
A metro-wise analysis reveals that respondents were best
informed in Bombay,
The metro wise break-up of responses
is as follows :
Bombay
Nos
Calcutta
Nos
Delhi
Nos
Madras
Nos
Base
12
12
12
12
Correct
9
2
8
2
Don’t know
0
1
1
4
Below -10°C
0
1
Freezing point/
0°C
2
8
Above +8°C
0
Not specified
1
2
1
3
1
2
Ref: Table C-59
Indian Market Research Bureau
~51
In Calcutta, the belief in keeping vaccines at freezing
point seemed to be widely prevalent.
In Madras and
Calcutta, the proportion of correct answers was very
poor.
At the district level, the highest proportion of correct
responses came from the West zone, particularly from
Kheda+and Nanded* districts (73% and 67% respectively).
Two other districts had a higher-than-average score of
correct answers. These were Gwalior* (50%) and Bharatpur0 (5O?o). The lowest proporportion of correct
(2O.8?6), Purnia
Purnia 0 (33.3%)
responses came from Madurai0 (20.8%),
and Puri+ (36.4%).
There appeared to be a correlation between knowledge
on this subject and the performance categories.
Poor
74
Good
Medium
87
83
O'
zO
0'
/0
?□
Correct
49.4
49.4
36.2
Don't know
25.3
27.7
33.0
Base :
30.8
22.9
25.3
(Ref: Table B-59)
At the district level, errors were once again mainly
with regard to lower temperatures.
Incorrect
Indian Market Research Bureau
38
District
level
Base :
Belov/ 4°C :
- 20°C to -10°C
0°C
Freezing point/
deep freeze
+1°C to +4°C
Above 8°C
District
Doctors
Workers
264
88
176
C'
0'
%
12.1
10.2
13.1
4.5
2.3
5.7
1 .1
2.3
0.6
5.7
10.2
3.4
3.0
1.1
4.0
Ref : Table A-59
Indian Market Research Bureau
39
2.3
NUMBER OF RECIPIENTS NEEDED TO OPEN A VIAL
One deterrant to complete immunization of a child
would be non-receipt of the vaccination after a
mother had taken the trouble to take her child to
the doctor or health centre.
One of the several
reasons for which a child would be sent back would
be an insistence on the part of the doctor that
sufficient numbers should be present to
the opening of a vial.
justify
In order to check if indeed such constraints
operate, respondents were asked to specify the
number of children due for DPT vaccine that he/
she would need before opening a 10-dose DPT vial.
19.6% of all respondents said that they would open
a vial if even 1 child was present; 17% said that
10 children would need to be present. The remaining
63% of the responses were for varying numbers, as
given in the table on the following page.
8% did not give an answer to this question,
Of
those who did give an answer, the frequency
distribution was as follows :
W
Indian Market Research Bureau
40
Respondents who answered :
T otal
No. of
Children
No.
.3
Base :
287
100
No.
0'
1
61
21.2
2
7
2.4
3
0
4
7
2.4
5
44
6
Doctors
Workers
102
185
O'
%
32.3
15.1
2.9
2.2
26.0
2.9
2.2
15.3
41.3
18.6
13.5
27
9.4
50.7
10.8
8.6
7
23
8.0
58.7
4.9
9.7
8
36
12.5
71.2
5.9
16.2
9
9
3.1
74.3
2.0
3.8
10
53
18.5
92.8
15.7
20.0
20
7.0
99.8
3.9
8.6
More than 10
Cumulative
%
/□
23.6
23.6
yrr
Mean
tTT
Ref : Table A-66
Median
4-5
6-7
The average (mean) was 6.2 children needed while the
median was at 6.0.
There was an appreciable difference in the responses
given by doctors and workers.
32.3% of all doctors felt that the presence of one child
was sufficient reason to open a vaccine vial.
The
mean lay at 5.1 children while the median requirement
was 4-5 children.
The mode was clearly at one child.
J
Indian Market Research Bureau
41
By contrast, the mode in the analysis of worker
responses lay at 10 children (2O?6 of all responses)'
The median was at 6-7 children while the mean value
was 7.1 children.
Only 15% of the workers said that
one child provided sufficient reason to open a ten-dose
vial.
Analysis of the data by the health worker categories
and private practitioners revealed that the knowledge
at the level of primary health centres was most in
keeping with desired norms, as is clear from the
averages given below :
Govt hospital/
dispensary
PHC
PHS
Private
practitioner
6.5
children
5.3
children
6.8
children
5.9
children
Median
6-7
5-6
7
7
Mode
10
1
8
1
Mean
Ref: Table
B-66
Indian Market Research Bureau
42
2.4
LEFT-OVER VACCINES
On the whole, the instinct of preserving seemed
to emerge stronger than that of throwing away or
Presuming that the decision to keep
or throw away would vary by the quantity of
destroying.
vaccine left over in a vial, respondents had been
asked to talk of their action with regard to less
than half-a-vial of vaccine being left over after
an immunization session and more than half a vial
of vaccine being left over.
The responses were as follows :
(?o)
Less than ? vial
Total Doctors Workers
More than | vial
Total Doctors Workers
Base: Ail respondents
Throw away
312
39.1
115
197
43.5
36.5
312
18.6
115
197
23.5
15.7
Put back
40.4
36.6
42.6
55.8
48.7
59.8
Depends on the
vaccine
12.2
13.9
11.2
14.4
17.4
12.7
Others
3.2
5.6
4.5
0.8
6.7
Don't know
5.1
4.1
6.7
9.6
5.1
6.0
Ref: Table A-67
Of those who said that they would put the vaccines
back in the refrigerator, a few (26-30%) explained
that they would mark it or place in a separate
container before putting back in the refrigerator.
IME®
Indian Market Research Bureau
43
The decision to keep back or to throw away would vary
by the type of centre to which the respondent belonged.
If more than half a vial was left over
over,, 66% of the
respondents at a PHC and 61% at a sub-centre would tend
to put the vaccine back.
Assuming inadequate equipment for
prolonged cooling at the sub-centre, the majority decision
to put the vaccine back causes concern.
Base
Less than 12 vial
Govt
hospi
Pvt
tal
PMC PHS prac.
More than
vial
Govt
hospi
Pvt
tals
PHC PHS prac.
102
53
102
63
94
53
%
%
%
63
94
O'
/O
%
?0
?0
O'
zO
Throw away
41
5-5
38
43
18
19
15
26
Put back
39
54
39
28
54
65
61
40
Depends on
the vaccine
15
11
11
11
20
10
13
13
Others
1
Don’t know
4
17
7
3
1
21
11
2
1
Ref : Table B-67
As we have seen, 12% of the responses in case less than
1
2
vial was left over and 14% in case of more than 1 a
vial was left over depended on the vaccine in question.
The vaccines that would tend to be put back were DPT and
TT.
The vaccines that would tend to get thrown away were
measles and BCG.
OPV would have a greater probability of
being put back than being thrown away.
Indian Market Research Bureau
44
Decision by vaccine
Base: Those whose decision
would depend on the vaccine
DPT
(Base : 47)
Put back
Throw away
OPV
v-------
0'
/O
■0
83
64
9
Measles
TT
6
32
81
75
17
BCG
13
75
Ref: Table A-69
The sample size is too small for any meaningful
analysis by doctors and workers. However, one feature
that emerges strongly is that no doctor spoke of
putting back a measles vaccine,
17 out of the 20
doctors said that they would throw it away. While 3
workers spoke of putting the measles vaccine back,
21 out of the 27*workers also said that they would
throw it away.
*
Those not accounted for said "don't know"
Indian Market Research Bureau
45
2.5
CASE-STUDIES
A couple of hypothetical situations were presented
to the respondent and he was then asked to talk of
the action that he would take in such a situation.
The first one was with regard to giving multiple
vaccines at a time to a child.
The other was with
regard to the measles vaccine.
2.5.1
Multiple vaccines at a time
The question asked was as follows :
We have spoken about the ideal immunization
schedule.
However, take a case where a child was
late for his third DPT Polio vaccine and was eligible
for the measles vaccine.
In such a case, would you
give him all three together ?"
50% of the respondents said that they would.
would not and 5% did not know,
Wo
The details were
as follows :
(%)
T otal
Base: All respondents 312
Yes
50.3
No
44.2
Don't know
5.4
Doctor
115
48.7
Worker
197
51.3
District
264
53.8
Metro
48
31.3
48.7
41.6
40.5
64.6
2.6
7.1
5.7
4.2
Ref: Table A-48
Higher willingness to give all 3 vaccinations together
in the districts appears to be a function of the UIP
efforts.
However,inter district variations were wide.
Indian Market Research Bureau
^6
Four districts where a high proportion of people said
that they would give all three vaccinations together
were :
Base
Said yes
Nadia0
24
83.3%
Bharatpur0
22
77.3%
Anantpur*
24
75.0%
Hami rpur*
20
65.0%
The districts were a higher-than-average proportion
of people said that they would not give all three
vaccines together were :
Said no
Puri+
22
77.3?o
Kheda+
22
68.2%
Iddukki4-
24
54.2%
Gwalior
22
50.0%
Ref: Table C-48
Amongst metros, respondents in Delhi were emphatic
that they would not give three vaccines together with
92% of the respondents saying 'no’, In Calcutta, two
out of three respondents said 'no'.
In Bombay and
Madras, 50% of the respondents said ’ no' .
The mam reason, for not giving three vaccines at a time
was that the side-effects could be unusually strong
(34.8%).
There was also the fear that there could be
other reactions (21%) though the nature of these
other reactions was not specified.
Two other reasons
Indian Market Research Bureau
1^1
mentioned by over 10% of the respondents were that
the body would be too weak to resist multiple vaccines
(12.3%) and that, if multiple vaccines were given at
a time they would be ineffective with the result that
the child would not get immunized (10%).
An analysis of these four main reasons by type of
respondent reveals the following :
Total
138
Doctor
56
Worker
82
District
Metro
Base: Who said 'no' .
107
31
Unusually strong side
effects
34.8
28.6
39.0
37.4
25.8
Other reactions
21.0
16.1
24.0
22.4
16.1
Body too weak to
resist multiple
vaccines
12.3
17.9
8.5
13.1
9.7
Child would not be
immunized
10.1
16.1
6.1
5.6
25.8
Ref: Table A-49
The figures that have been underlined serve to highlight
the type of worker and location where this view was more
strongly held.
The question on the reasons for not giving multiple
vaccines was an open-ended one with the result that a wide
range of responses were received.
The other responses
are listed below along with the percentage frequency of
that response.
Indian Market Research Bureau
48
(Base : 138)
?6 who gave
the reason
Reasons
The mother will object, will
not understand
4.3
At least one month gap necessary*
4.3
Multiple vaccines cannot be given
4.3
If side effects occur, it would be
difficult to locate reasons for the
side effect
2.2
If child late, then earlier
DPTs invalid
1 .4
Cause pain
1 .4
No .instructions to that effect have
been received
1 .4
Take up (effectiveness of vaccine)
reduced
0.7
Vial (presumably measles vial)
opened only if enough children
present
0.7
Question possibly misunderstood
Ref: Table A-49
2.5.2
Measles vaccine
Two questions were asked with reference to the
measles vaccine.
a/
The first question concerned the respondent’s own
personal view with regard to the advisability of
preventing measles.
IBfflH D
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49
The overwhelming view was in support of the prevention
of measles.
91?6 of all respondents believed that
measles should be prevented,
100% of the workers in
metros favoured prevention.
In contrast, as many as
15% of the doctors in metros felt that
measles should not be prevented. There were no
major variations by doctors and workers on the whole
and in districts.
The negative responses revealed interesting patterns.
In the metros, 17% of the doctors in Calcutta and 8%
each in Bombay and Delhi were not in favour of the
prevention.
Amongst the districts, the highest
negative opinion came from Madurai (33.3%).
By
contrast, 100% of the respondents in Madras had been
in favour of preventing measles.
Some negative
opinion was also expressed in Kheda+, Iddukki
and
Bharatpur°and Puri4’ districts.
Those who expressed the belief that measles should not
be prevented (23 respondents) iwere asked for the
reasons for this negative reaction,
Since the
number of respondents were few the range of reasons
given are being listed below in order of frequency
of mention.
Indian Market Research Bureau
50
F requency
b/
Because measles cannot be prevented
7
Vaccine not really effective
5
Measles is not a serious disease
4
Preventing measles could be harmful
2
Complications of vaccinations serious
1
One attack of measles gives natural
immunity
2
Not specified
2
The other areaof inquiry with regard to measles was as
follows :
ii
If a mother/father said that her child had already had
measles, would you still give the measles vaccine or would
you refuse ?"
73% of all respondents said that they would not give the
vaccine, 23% said that they would give while 3.5% did not
know. The details were as follows :
(%)
Total
Doctors
Workers
District
Metro
Give
23.1
22.6
23.4
25.4
10.4
Not give
73.4
75.7
72.1
71.6
83.3
Dont Know
3.5
1.7
4.6
3.0
6.3
There were no real differences in the responses given by
doctors and workers though doctors were somewhat more
likely to not vaccinate a child who had reportedly already
had an attack of measles.
Indian Market Research Bureau
51
Between districts and metros though there was a clear
Only 10% of the respondents in metros would
difference.
give a measles vaccine in this situation as compared to
25% of the respondents at the district level.
This
difference seems to reveal, once again, the effect of
DIP training.
There were wide variations within districts, too.
The
districts where respondents favoured giving a vaccine
nevertheless and those where respondents preferred to
not give the vaccine have been listed separately below.
Average
I!
would give"
25.4%
% who would
give
% who would
not give
Gwalior
63.6
Purnia0
4.2
\‘anded*
57.1
Allahabad+
6.7
Hami rpur
35.0
iddukki’
8.3
Madurai 0
33.3
Puri
9.1
Bharatpur0
27.3
Kheda
9.1
Anantpur* = 25%
Nadia0
25%
Ref: Table C-52
The reason for not giving a vaccine was common to the
vast majority of those who said they would not give
namely,that natural immunity would have got developed
by that one attack of measles - 82.5% (Base : 229).
The other reasons given by small numbers of respondents
were as follows :
Indian Market Research Bureau
O 1^7
52
%
1.
Child may suffer from fever/get reaction
5.7
2.
Vaccine can worsen the condition*
4.4
3.
People recognize measles (♦ • believe report) 2.2
4.
Would refuse after verifying by asking
for symptoms
1.7
5.
Instructions already given to that effect
1.7
6.
Unless he is in the 9-12 month age group
1.3
*
Question apparently not understood.
The reasons given by a few respondents such as reasons
3, 4 and 6 indicate that the refusal would not be
blind but based on well-thought-out reasons and are
therefore reassuring.
Interestingly, more of these
responses came from workers than from doctors.
Indian Maricet Research Bureau
53
3.0
PROGRAMME
3,1
TARGETS
3.1.1
Coverage Targets
The UIP districts had been selected for intensive
immunization attention with the clearly defined
target of having 75% of all eligible infants and
pregnant women immunized in 1986.
That target was
to be maintained and improved upon in the years
that followed.
In order to see if respondents
were aware of these targets, each respondent was
asked to mention the percentage of eligible infants
in their territory that were to be vaccinated in
1987.
Since only the districts were in fact bound by
these targets, it would only be reasonable to
look at data originating from districts for this
study and not the metros.
District
Total
Doctors
Workers
PHC
PHS
264
88
176
63
94
%
%
%
%
%
Below 70%
11.7
11.3
12.0
12.7
8.6
75%
7.6
3.4
9.7
9.5
11.7
Above 75%
63.2
61.3
64.2
63.5
64.9
Not specified
17.4
23.9
14.2
14.3
14.9
Base :
Ref: Table A-94
The proportion of respondents who did not answer this
guestion can be read as those who did not know the
Indian Market Research Bureau
56
17.8% said that they did not know the answer. Details
are given in the table below :
Total
Doctors
Workers
169
57
112
C'
?0
%
Base* :
/O
For 1-2 years
3.6
3-5 yrs or upto 1990
15.8
15-20 years or upto 2000 AD
10.7
7.7
12.3
8.0
5.4
A continuous process
42.6
33.3
47.3
For the duration of our
working life
7.1
5.3
8.0
Till 100?o target achieved
10.7
17.5
7.1
*
5.4
Ref :Table A-96
District level respondents who had said that immuni
zation levels were to be maintained for the future.
An understanding of the continuous nature of this
programme (as expressed by statements 4 and 5 above)
was expressed by 100% of the respondents in Hamirpur*.
The details by district were as follows :
Continuous
process
For as long
as we are
working
Total
Dl<
Others
Hamirpur*
100.0
100.0
Bharatpur0
Allahabad*
73.7
73.7
20.0
10.0
70.0
Anantpur*
Iddukki-i-
20.8
5.3
10.5
20.0
20.8
15.8
58.3
26.3
20.9
42.1
Madurai0
35.0
25.0
60.0
5.0
35.0
26.3
Ref : Table C-96
mi
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51
Conti
nuous
process
For as long
as we are
working
Total
DK
Purnia0
60.0
20.0
80.0
20.0
Nadia0
27.3
18.2
45.5
27.3
Puri+
54.5
Gwalior*
Kheda+
55.6
21 .4
Nanded*
63.6
54.5
11.1
7.1
66.7
Others
27.2
45.5**
28.5
11.1
7.1
63.6
27.3
22.2
64.4
** All said upto 1990
Ref: Table C-96
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58
3.2
APPRAISAL OF OWN CENTRE (DISTRICT)
42% of all respondents said that the immunization
performance of their centre had been good, 30/o
said that it had been very good while 16% said that
the performance had been excellent.
The differences in appraisal by doctors and workers
were as follows :
Districts
Total
Doctors
Workers
264
88
176
%
%
%
Excellent
16.3
13.6
17.6
Very good
30.3
32.4
Good
Fair
41 .7
7.2
0.8
26.1
45.5
9.1
6.3
6.3
2.8
Base :
Poor
Don't know
3.8
39.8
5.7
Ref : Table A-75
The perception of respondents in the district and the
status of the district as per reported levels of
immunization were at variance.
The details are as per the table given on the next
page.
Indian Market Research Bureau
59
Rating of immunization performance
(Mean Score ; Max = 5)
Good districts
3.2.1
Medium distircts
Poor districts
Hamirpur*
3.9
Allahabad-;-
3.7
Bharatpur0
4.1
Anantpur*
4.0
Iddukki+
3.5
Madurai0
3.5
Gwalior*
2.6
Puri +
3.3
Purnia0
3.6
Nanded*
2.6
Kheda+
2.7
Nadia0
2.8
Ref: Table C-75
Reasons for excellent-very good rating/performance
a/
The reasons as understood by the respondents fell into
two broad categories.
There were those who gave a
justification of their self-assessment of very goodexcellent performance.
These were broadly as follows :
i/
ii
A good proportion of the target has been
achieved" = 39.9%
%
Doctors
41.2
Workers
39.2
%
District
36.6
Metro
53.3
Ref : Table A-76, C-76
Other centres where respondents expressed satis
faction that a good proportion of targets had been
achieved were Kheda+ (66.7%), Purnia+ (54.5%),
Hamirpur* (47.1%) and Gwalior* (40.0%).
W
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60
ii/
"Because many children had been vaccinated": 11.8%
The gist of this statement is the same as the one
quoted above, though this statement is less precise
than the earlier one.
25?6 of the respondents who
had rated their centre's performance as being very
good to excellent in Allahabad+ and Puri+, gave
this justification.
iii/
The other statements that explained the rating
were :
"No complaints of vaccinated child getting the
disease" :
3.9%
I!
No complaints/problems" : 2.6%
!l
Satisfactorily met all conditions like
cleanliness and care"
care : 1.3%
b/
The other category of responses were those where respon-
dents sought to explain the factors that had contributed
to this very good/excellent performance.
1/
The first credit went to people whose positive
attitudes to vaccination were believed to be a
major contributory factor to the centre's success
in this sphere.
"People are willing and cooperative.
They are aware of and believe in vaccinations".
This statement (or part thereof) was made by 24.8%
of all respondents.
Keeping in mind that the
Bffl Q
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61
question was an open-ended one, spontaneous responses
of this nature serve to highlight the importance
of
creating a positive attitude in people in order to
make the EPI successful.
A large proportion (73%) of these responses came
from the three districts of the South zone namely
Anantpur*, Iddukki+, and Madurai0 followed by
North zone districts.
other zones
the
Only one district each in the
Puri+ and Nanded* had this comment
made by a couple of respondents each.
ii/
"Workers are cooperative/work as directed/work with
interest" : 11.1%
This statement came as much from workers as from
doctors, but was made mainly in the districts, with
particular reference to the three districts in the
South zone.
iii/
"Cold chain system properly maintained" : 8.5%.
This was mentioned by one or two respondents each in
Hamirpur*, Allahabad+, Anantpur*, Purnia0, Gwalior*
Kheda+, and Nanded*.
iv/
"We educate people on health, keep track of
immunizations due" : 7.8%
This statement, interestingly, came entirely from
workers.
One third of these respondents came from
Indian Market Research Bureau
62
Purnia0.
The other districts where workers spoke of
health education and follow-up were Nanded*, Allahabad+
Hamirpur* and Madurai0.
v/
"Regular supply of vaccines" : 6.5?6
Credit was given to the system by workers, mainly from
districts and a couple of doctors.
Of all respondents
who made this statement, over 50% came from Anantpur*
district.
The other districts where one respondent
each spoke of regular supply of vaccines were
Hamirpur*, Anantpur+, Madurai0 and Gwalior*.
: 3.3%
vi/
"We sterilize syringes properly"
vii/
"Polite behaviour with people" : 1.3%
viii/
"Regular vaccination schedule & timing
it
: 1.3%
3.2.2 Reasonsfor "good" rating
Of those who had rated the performance of their centre as
being "good", 73% gave positive justifications for the
rating whereas 27% gave negative justifications.
This can be
explained by the angle from which the respondent was viewing
the response.
73% believed that a "good" rating was positive
and superior to a "fair-poor" rating.
rat ing.
27?6 felt that a good
rating was a compromise and gave reasons to explain why the
performance could not be rated "very good" or excellent".
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63
Positive : (Base : 90)
Reasons that explained rating
:
Achieved good proportion of the target
21.6%
Because many children vaccinated
5.4%
No complaints/problems
2.7%
No complaint of vaccinated child getting
the disease
2.0%
Reasons that explained good performance :
People are willing/cooperative/aware of/
believe in vaccinations
20.9%
Workers are cooperative/work as directed/
work with interest
6.1%
We educate people on health/keep track of
vaccines
3.4%
Ref : Table A-78
All other reasons, as given in numbers 5-8 in section 1 a'
above, were mentioned by 2-3 respondents each.
3.2.3
Reasons for negative rating
(Includes negative reasons given for ’’good” rating plus
reasons for fair and poor ratings.)
The reasons given here were varied and, as such, each
statement did not have the support of large numbers of
respondents.
However, they reveal the problems as
perceived by implementers and, are therefore important
in the total understanding of the immunization task.
KD
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Indian Market Research Bureau
64
The fact that the most frequently mentioned reason,
both positive and negative pertained to the attitude
of people emphasises, once again, the importance of
information, education and communication to develop
positive attitudes.
People uneducated/refuse to understand
Conditions not ideal/infrastructural
problems (mostly East zone)
8.1%
People afraid of side effects/fever
6.1%
People need lots of persuasion/are
not convinced
5.4%
Coverage could be higher/v/as higher
earlier
5.4%
Numbers
Poor cold chain maintainence
3
Need better supplies
3
Staff not cooperative/sincere
2
Cannot be done scientifically
2
Insufficient coverage through outreach
2
dissatisfactory/insufficient
1
Training
Communication/explanation difficult
1
Propaganda/ publicity/awareness
insufficient
1
Limited number of patients
1
Pressure of
1
other govt, programmes
Indian Market Research Bureau
65
3.3
SPECIAL TRAINING FOR IMMUNIZATION
In response to a direct question on whether special
training for immunization had been received or not,
53?6 said that they had been given special training
while 47% said that they had not. The proportions
were inversely related between doctors and workers
as follows :
Total
Doctor
Worker
Yes
53.2
33.0
65.0
No
46.8
67.0
35.0
It is relevant to look at doctor and worker
responses by district and metro :
District
Doctor
Worker
Base
Metro_____
Doctor
Worker
88
176
27
21
O'
'0
O'
'O
O'
/O
O'
'O
Yes
35.2
69.9
23.8
No
64.8
30.1
25.9
74.1
76.2
Ref : Table A-70
It would appear that the chief recipients of
the training were workers at the district level.
68% of the respondents at the sub-centres and
63.5% at the health centres said that they had
received special training.
By comparison, only
45% at the government hospital and only 30% of
the private practitioners said so.
Indian Market Research Bureau
66
Of those who said that special training had been received,
38% said that it was very satisfactory and another 55%
said that it was satisfactory.
with the training.
Thus 93%
were satisfied
The districts where a high level of
satisfaction was expressed were Allahabad , Anantpur*
and Kheda+.
The districts were satisfaction expressed
4-
.0
was lower than the national average were Iddukki , Madurai ,
o
Puri , Gwalior* andNadia .
In other districts the level of
satisfaction expressed was in keeping with the national
average. (Ref : Table A-71, C-71).
Of the few respondents (11 numbers) who rated the training
as "not satisfactory" or "very unsatisfactory", the
complaints were as follows
:
Nos.
Insufficient training to give
injection
3
2)
Need a refresher course
1
3)
Insufficient training on overall
schedule
1
4)
Training period too short
1
5)
No training on persuading villager
1
1)
4 respondents had not specified the areas of,
dissatisfaction.
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The training on immunization had included a manual which
had been distributed to all UIP districts.
Respondents
were shown a copy of this manual, both the cover and
the inner pages (since covers had differed by period and
place).
They were asked if they had ever seen the
manual, or at least the illustrations.
illustrations,
They were then
asked if they currently had the manual with them and
whether the manual was useful. The responses to each of
these questions are presented in the table given below :
(%)
Base :
Ever seen
manual
Total
312
Those who said H Yes"_____
Doctor
Worker
District
115
197
264
Met ro
48
61.9
44.3
72.1
68.9
22.9
Ever seen
illustration
66.0
54.8
72.6
73.5
25.0
Currently have
48.4
33.0
57.4
54.9
12.5
Useful
83.0
77.4
86.3
85.6
68.8
Ref : Table A-73
Once again, wide differences emerge between doctors and
workers.
Intra-district data reveals that district
level workers were the main recipients of the training.
80% of them had seen the manual and 64% currently had it
with them.
Responses on the usefulness of the manual clearly have
to be interpreted to mean not just actual usefulness but
also perceived potential usefulness since 83% of all
respondents felt that the manual was useful when only
62% had ever seen it.
Indian Market Research Bureau
68
The manual, where available, was available in the
following languages.
Languages
District
North
22?o
67% , English
Hamirpur
Hindi
Bharatpur
Allahabad
Hindi 87?6 , English 13%
Hindi 67%, English 33%
South
Iddukki
Not specified
Malayalam 80%, English 20%
Madurai
Tamil
Anantpur
74% , English
26%
East
Purnia
Hindi 65%, English 35%
Nadia
Bengali 80%, English 20%
Puri
Oriya 83%, English 17?6
West
English 20%
Gwalior
Hindi 80%
Kheda
Gujarati 67%, English 33%
Nanded
Marathi 83%, English 17%
Ref : Table C-74
The main languages in which
on a national basis were :
Hindi
English
the manuals were avaialbe
32%
22?6
Indian Market Research Bureau
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4.0
UNDERSTANDING
THE PEOPLE
As we have already seen, cooperation in the people
or the lack of it plays an important role in the
success of the immunization programme.
In an effort
to understand the role played by family members we
asked implementers to talk of the decision makers
in the family on health care, on people's attitudes
with regard to immunization and reasons for rejecting
immunization, if at all rejected.
These questions
also sought to assess the extent to which implementers
were alert to and aware of the attitudes and reser
vations or problems of people in their territory.
4.1
DECISION MAKERS IN THE EAMILY
Respondents were asked to name the family members
who would be the decision makers with regard to the
following aspects of health care.
4.1.1
Immunization of the child
75% of all respondents said that the decision to
get the child immunized would be taken by the mother
of the child.
27% of all doctors felt that this
decision would be taken by the father while only
19% of the workers expected that the father would
do so.
Indian Market Research Bureau
70
There was not much difference in responses
between districts and metros.
Total
Doctors
Workers
District
Metro
115
312
Base :
Decision of
0'
immunisation
/0
Mother of child74.7
197
264
48
O'
/0
O'
/O
O'
'0
0'
'0
69.6
77.7
74.2
77.1
Father of child21.8
27.0
18.8
22.0
20.8
Elder(Male)
1.3
0.9
1.5
1.5
Elder(Female)
1.6
0.9
2.0
2.0
The role of family elders was
on this subject.
The doctors who felt that
fathers would be the decision makers came
mainly from districts.
In metros, there was
greater consensus that the mother was the
decision maker.
4.1.2 TT for pregnant woman
There was an interesting division of opinion on
this score between districts and metros.
In the
districts some implementers felt that the concerned
woman would not be the decision maker,
The decision
to take the pregnant woman for the TT injection would
be taken by the husband or the family elder-female
(presumably the mother-in-law),
In metros, most
implementers believed that the woman concerned would
herself take the decision.
Indian Market Research Bureau
71
(?o)
Total
Doctor
Worker
District
Metro
Base :
312
115
197
264
48
Mother of child (i. e.
woman concerned)
58.7
59.1
58.4
55.7
75.0
Father of child
23.4
19.1
25.9
25.8
10.4
Family elder (male)
2.2
3.5
1.5
2.3
2.1
Family elder (female)
10.6
10.4
10.7
11.7
4.2
Others
1.9
4.3
0.5
2.3
Ref : Table A-84
It does seem peculiar that if a woman can be the decision
maker for her child's immunization, she should
be passive
with regard to immunization for herself.
The answer could
lie in the traditional self-effacement that women in India
are conditioned into practicing which makes her neglect aspects
of her own health care.
This conclusion is further supported
by the fact that the woman in the metro, who is less tradition
bound and more independent, was seen as the decision maker
more often than the district level woman.
It also reveals
that the fact that the TT injection protects the child is
not fully understood.
4.1.3 Taking a child to a doctor
in the village
For metro respondents, this question was altered to read
"taking the child to a doctor in the neighbourhood".
Only half of all respondents felt that this decision would
be taken by the mother (49.4%).
At the metro level, two
out of three respondents (66.7%) said that the mother would
be the decision maker.
The role of men seemed to become
more important in this decision of taking a child to the
Indian Market Research Bureau
72
doctor with almost 40?o of the respondents either saying
that the decision maker would be the father of the child
or the grandfather.
Total
Doctors
Workers
District
312
115
197
264
48
%
?0
%
?0
%
Mother of child
49.4
47.0
50.8
46.2
66.7
Father of child
35.6
35.7
35.5
38.3
20.8
Family elder(Male)
4.2
7.0
2.5
4.5
2.1
Family elder (Female) 5.4
3.5
6.6
6.4
Others/Don't know
6.9
4.6
4.6
Base
5.4
Metro
10.4
Ref : Table A-84
While responses from doctors and workers were very similar,
there was greater confidence in the role of the mother in
metros.
4.1.4
Taking a child to a town doctor
In metros, this was asked as ti taking the child to a doctor
in distant part of the city".
In districts, two out of three respondents said that the
father would be the decision maker.
In metros, respondents
continued to feel that mothers would be the decision makers.
However, one third of the doctors in metros felt that the
father would be the decision maker, as compared to only 19?6
of the workers in metros who felt so.
D
D
Indian Market Research Bureau
73
Total
Doctors
Workers
District
Metro
312
115
197
264
48
%
?0
O'
'0
%
%
Mother of child
30.1
31.3
29.4
23.9
64.6
Father of child
60.9
57.4
62.9
67.0
27.1
Family elder (Male)
3.5
5.2
2.5
3.8
2.1
Family elder (Female)
2.2
1.7
2.5
2.7
0
Base
Ref : Table A-84
4.1.5 Taking child to local faith healer
This was clearly seen to be the
domain of the grandmother,
followed by the mother and the grandfather.
The father of
the child, according to implementers, had little role to
play in this decision.
Total
Doctors
Workers
District
Metro
312
115
197
264
48
O'
O'
'0
%
%
%
Mother of child
26.6
29.6
24.9
21.6
54.2
Father of child
4.2
7.8
2.0
4.9
Family elder (Male)
11.5
8.7
13.2
12.9
4.2
Family elder (Female
45 .2
39.1
48.7
50.8
14.6
Base
Ref : Table A-8
Metro respondents believed once again that the mother would be
the decision maker.
In metros, therefore, most implementers clearly
believed that child health related decisions would be taken by
the child's mother.
In districts, the father and grandparents
appeared to have a larger role to play.
Indian Market Research Bureau
74
4.2
PEOPLE'S ATTITUDES TO IMMUNIZATION
Respondents were asked for their opinion with regard
to
the attitudes of people with regard to immunization.
Attitudes of those people who could directly or
indirectly influence the mother were covered,
The
overall responses for each of the influencer groups
covered were as follows :
(Base : 312)
(%)
Perceived as being
In favour
Against" Tndifrerent
Dk/us
Father of child
92.6
1.6
3.2
2.6
Mother of child
93.3
2.6
2.2
1.9
Paternal
grandfather
59.3
16.7
18.9
5.1
Paternal
grandmother
59.0
17.6
18.9
4.5
Village chief
82.4
1.0
7.4
9.3
Village elders
74.7
3.8
10.9
10.6
School teacher
91.7
0.6
2.6
5.1
Faith healer
19.6
39.4
13.5
27.6
Dai (midwife)
82.7
2.9
4.2
10.3
Ref : Table A-85
In the opinion of the respondents, except for the
faith healer, and, to some extent the grandparents,
none would be against immunization,
appears to be interesting is that
One pattern that
n
elders" appeared to
be less in favour of immunization than
than others.
others. If this
is looked at in conjunction with other data from depth
Indian Market Research Bureau
interviews where support or opposition from family elders
did seem to account for some difference between a child
being partially or fully immunized, it becomes clear that
communication needs to be aimed at elders such that negative
attitudes be changed. These negative attitudes tend to
be of two types - either they are opposed to interference
with nature or they intrinsically lack faith in the efficacy
of the injections. Communication would need to illustrate
that prevention is possible and that newer medical inventions
do call for different practices which were not the norm
in earlier generations but they can help avoid needless
disabilities and deaths which were, in fact, the norm in
earlier generations.
A table on the differences between doctor and worker opinions
is given below
:
Base
In favour of
Doctor Worker
115
197
O'
/O
O'
Father
93.0
Mother
Against
Doctor Worker
115
197
Indifferent
Doctor Worker
115
197
O'
/0
O'
'O
0'
'O
O'
'O
92.4
0.0
2.5
3.5
3.0
92.2
93.9
0.9
3.6
4.3
1.0
Grandfather
59.1
59.4
22.3
57.4
59.9
23.4
24.3
27.0
15.7
Grandmother
Village chief
7.0
7.8
74.8
66.1
86.8
0.9
0.9
1.0
5.6
8.7
14.8
14.2
6.6
8.6
89.6
17.4
92.9
20.8
0.0
3.5
2.0
36.5
1 .0
41.1
14.8
12.7
73.0
83.3
3.5
2.5
6.1
3.0
Village elder
School teacher
Faith healer
Dai (Midwife)
/O
79.0
Ref Tab;e : A-85
Indian Market Research Bureau
76
The percentages short of 100 are accounted for by the
"don't know" response. V/orkers appeared to feel more
strongly than doctors that grandparents were opposed to
immunization.
Doctors felt that grandparents, along with
other village elders and the faith healer, were merely
indifferent. To the extent that workers, being closer
to v illage folk in terms of socio-economic profile would
have their finger on the pulse, it would be prudent to
assume that the older generation
are actively opposed
rather than indifferent to immunization and tailor
communication accordingly.
Differences in opinion between district and metros
are expressed below :
In favour of
District Metro
Base
264
Against
District Metro
Indifferent
District Metro
48
264
48
264
48
%
0'
/0
?o
%
0'
'0
Father of child 91.7
97.9
1.9
3.8
Mother
92.8
95.8
3.0
2.3
2.1
Grandfather
54.9
83.3
19.3
2.1
20.8
8.3
Grandmother
54.5
83.3
20.5
2.1
20.5
10.4
Village chief
86.4
60.4
1.1
8.0
4.2*
Village elders
77.7
58.3
4.5
11.7
6.3*
School teacher
92.8
85.4
0.8
2.7
2.1
Faith healer
20.1
16.7
44.3
12.5
14.8
6.3**
Dai (Midwife)
85.6
66.7
3.0
2.1
4.2
4.2
0'
/□
35% said
I!
don't know" at the metro level
** 65% said "don't know"
at the metro level
Ref : Table A-85
ERffil
Indian Market Research Bureau
77
Much of the belief in negative attitudes was at the
district level rather than at the metro level.
Metro
respondents appeared to see very little opposition to
immunization since, in their opinion, the people in the
tBrritory were either in favour of or indifferent but
not against immunization.
Mffl DJ
Indian Market Research Bureau
78
4.3
ASSESSMENT OF OVERALL ATTITUDES OF THE PEOPLE
Four statements were read out to respondents.
They
were asked to state if,in their opinion, the statement
was true for most people in their territory,for some people
or for none.
The statements
4.3.1
are being analysed below :
Statement
H
People are aware of immunization H
Total • Doctors
Base :
312
115
Workers
197
District
264
Metro
48
Most
88.1
82.6
91 .4
88.3
87.5
Some
10.6
14.8
8.1
10.6
10.4
1.3
3.0
None
Don't know
0.5
1.1
2.1
Ref : Tables A-86, B-86, 0-86
There seemed to be a consensus of opinion on this score.
88% of the respondents were of the opinion that most people
in their territory were aware of immunization.
There were only 3 districts where more than 15% of
the respondents felt that some people were not aware of
immunization. These were Bharatpur0 (18.2%), Nadia0 (16.7%)
and Gwalior* (18.2%). In 4 districts, over 90% of the
respondents said that people were aware of immunization.
Indian Market Research Bureau
79
These were :
Hamirpur* (100%), Purnia (91.7?6), Puri+ (5.5%)
and Nanded* (90.5%).
Respondents at
sub-centre were most confident about high
levels of awareness amongst the people. 93.6% said that
most people were aware of immunization. Private practitioners,
on the other hand, were not as confident. Only 75.5% of the
private practitioners said that most people were aware of
immunization. 18.9% felt that some were aware while others
were not aware.
It is significant that not a single respondent said that
none of the people were aware of immunization.
4.3.2
Statement :
ii
People are cooperative and willing"
On this statement, too, 81% agreed that most people were
cooperative and willing. Once again, not a single respondent
said that none of the people were cooperative.
These were, however interesting differences between metros
and district and between the opinions of doctors and
workers.
Indian Market Research Bureau
80
Base :
Total
Doctors
312
Oz
zO
District
264
Metro
115
Workers
197
O'
zO
0'
z0
%
%
48
Most people
81.1
74.8
84.8
79.2
91.7
Some people
None
17.3
21.7
14.7
19.3
6.3
1 .6
3.5
0.5
1.5
2.1
Don't know/
Can’t say
Ref: Tables A-86, CB-86,
:
C-86
Workers were clearly more satisfied with the extent of
cooperation received whereas one out of 5 doctors had
reason to believe that while some people were cooperative,
others were not.
There was s clear difference between
metro and district
At the metro level, 91.7% of all respondents said that most people were cooperative and
willing.
At the district level, as many as 19% of all respondents
felt that not all respondents were cooperative.
perceptions too.
Dissatisfaction with cooperation came mostly from the
primary health centre respondents.
High____
Cooperative
Most
Some
O'
zO
Oz
zO
Hamirpur*
100
0
Bharatpur0
Iddukki+
91
92
Low
Cooperative
Most
Some
Oz
zO
0/
/O
71
29
9
Purnia0
Nadia0
50
8
Gwalior*
59
46
41
_ JWd;
Indian Market Research Bureau
81
4.3.3
Statement
"People are indifferent but do not resist"
The negative statement brought on negative to middling
responses.
However, the interesting facet of
this
statement is that while respondents were unwilling
to disagree with a positive statement, they did not
oppose a negative statement with equal strength. The
interpretation is that attitudes of the people to
immunization were not as cooperative and willing as
initially agreed by the respondents; their agreement
with the statement would include a measure of politeness;
the truth is likely to be closer to their reactions
to the negative statements.
(?o)
Total
Doctors
Workers
Districts
Metros
Base :
312
115
Most
17.9
20.0
197
16.8
264
20.5
48
4.2
Some
54.5
52.2
55.8
57.6
37.5
None
23.1
20.0
24.9
19.3
43.8
Don't know
4.5
7.8
2.5
2.7
Ref Table A-86
14.6
Over half of all respondents said that some people were
indifferent but did not resist immunization,
21% at the district
level felt that this statement was true for most people in
their territory, 44% of the metro respondents however
felt that this statement was not true for any people in their
territory. Clearly, there was greater cooperation from people
in the metros.
Indian Market Research Bureau
82
The districts which reported that most people
were indifferent were Bharatpur0 (46?o),
Allahabad (53?o) and Anantpur+ (33?6). The
districts which reported that none of the
people were indifferent were Madurai0 (75?o)
Purnia0 (38%), Puri+ (38%), Puri+ (22%) and
Nadia0 (21%).
An interesting observation here is that dis
tricts which were reportedly not performing
well in terms of achievement of targets
reported a relatively low level of indifference.
Assuming target achievement reports are
accurate, this could mean that implementers
did not have their fingers on the pulse and
were not sensitive to the feelings of people
in their territory vis-a-vis immunization.
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83
4.3.4
Statement : "People resist immunization and have to be
coaxed"
Over
half of all respondents agreed with this statement,
too, saying that some people resisted immunization.
One out of three respondents felt that this statement
was not true for any respondents in their territory. The
details were as follows
(%)
Total
Doctors
Workers
Districts
Metros
Base :
312
115
197
264
48
Most
7.7
3.5
10.2
9.1
Some
53.2
47.8
56.3
58.3
25.0
None
33.7
41.7
28.9
27.7
66.7
5.4
7.0
4.6
4.9
8.3
Don't know
Ref: Tables A-86, 0-86
In keeping with the trend revealed earlier, resistance
was not reported in metros to the same extent to which
it was reported in districts,
The districts which
reported high resistance (i.e. responded - most people
resist immunization) were Allahabad
(27%), Anantpur* (29%)
and Nadia0 (29%). The responses from Anantpur are difficult
to explain since Anantpur otherwise emerges as an aware and
involved district.
A large number of district respondents said that some
people resisted immunization. These were
Hamirpur*
80%
Anantpur*
47%
Bharatpur0
77%
42%
Allahabad
Iddukki+
75%
Madurai 0
13%
Gwalior*
56%
Puri+
77%
Purnia0
68%
Nanded
33%
Kheda
82?o
Nadia0
50%
Indian Market Research Bureau
84
There appeared to be no pattern by reported target achievement
levels. The districts which
reported least resistance were
Madurai0 (75?6) and Nanded* (67%).
An analysis of the responses by type of health centre shows
that respondents at the PHC and PHS levels reported higher
resistance than those at the headquarters,
reported least resistance.
Base :
People resist immuni
zation
Most
Some
None
Meanscore
(Max = 3)
Private practitioners
Government
hospitals
102
PHC
63
O'
'0
O'
>0
O'
/□
O'
O'
/O
8.8
47.1
7.9
9.6
1.9
63.5
60.6
39.6
0
25.0
40.2
27.0
24.5
45.3
66.7
1.6
1.8
1.7
1.3
1.2
PHS
94
Private
53
'0
Metro
level
48
Ref : Table B-86
The pattern indicates that as urbanization increases,
cooperation tends to increase.
MB
Indian Market Research Bureau
85
4.4
REFUSALS
The last statement was verified once again by means
of a direct question that sought to understand if
parents of eligible children ever refused vaccinations
even when efforts were made to persuade and convince
them.
Once again, responses were coded as most, some, and
none refuse.
The details are given below :
(%)
Refusals
Total
Doctors
Workers
Districts
Metros
Base :
Most
312
2.9
115
0.9
197
4.1
264
3.4
48
0
Some
50.0
45.2
52.8
56.4
14.6
None
47.1
53.9
43.1
40.2
85.2
Ref : Table A-87
In keeping with earlier reporting patterns, metro
respondents stated that by and large, none of the parents
refused vaccinations,
in agreement
uver
Over nan
half or
of an
all doctors were
with that statement.
Workers, particularly
at the district levels, reported some refusals.
By giving a score of 3 to the statement that "most
refuse”, 2 to the statement " some refuse" and 1 to the
statement "none refuse", the mean scores arrived at result in
the following table.
W
Indian Market Research Bureau
86
Mean score
(max = 3
: Most refuse; min = 1 : None refuse)
Overall
1.56
Doctors
1.47
Workers
1 .61
Government
PHO
1.63
PHS
1.69
Private
1.32
District
Metro
1.63
1.15
1.51
Districts
North
South
Hamirpur* : 1.35
Allahabad4" : 1.9
Bharatpur0 : 1.7
Anantpur*:1.25
Iddukki + :1.6
Madurai0 : 1.4
East
Puri
:1.8
Nadia0 :1.7
Purnia0 : 2.1
West
Gwalior* ; 1.9
Nanded*
Kheda
: 1.4
: 1.6
Ref : Tables B-87, C-87
Indian Market Research Bureau
87
4.4.1
Profile of the refusers
The profile of the people who refused vaccinations,
as perceived by the implementers, was as follows :
(Base = 165)
Description
Who gave this
description
O'
/0
Illiterate/uneducated
69.1
Backward classes
18.2
Labourers
17.6
Poor people
14.5
Orthodox people
8.5
Muslims
8.5
People with blind faith in God or
in faith healers
7.9
Farmers/cultivators
5.5
People who had a bad experience
with immunization
4.2
Elderly people
3.6
Anybody - does not differ by caste,
education, social status
3.6
Ref : Table A-88
Clearly, one dominating feature that seemed to set
the "refusers" apart in the opinion of the imple
mentor was lack of education or literacy.
Other
features such as poverty and backwardness could be
additional but
would, by that very fact, include
illiteracy.
Indian Market Research Bureau
88
It must be remembered that the question on the profile
of the refuser was an open-ended one.
The responses
received were spontaneous.
4.4.2
Reasons for
refusal
In the opinion of those who were implementing the
programme, the main reasons for refusing permission
to immunize a child were as follows
% who gave this reason
Total
Doctors
Workers
165
53
112
Lack of education
and belief in
38.8
vaccines
47.2
34.8
Fear of fever
27.3
11.3
34.8
Fear of adverse
reaction
20.6
18.9
21 .4
Traditional beliefs/
customs
17.6
18.9
17.0
Fear of pain/
swelling
6.7
3.8
8.0
Bad experience
with vaccination
5.5
11.3
2.7
Don't see need to
vaccinate healthy
child
5.5
3.8
6.3
Wage loss due to
fever because of
vaccines
5.5
3.8
6.3
Base
Reasons
.
Ref : Table A-89
D
D
Indian Market Research Bureau
89
Other reasons, given by a couple of respondents each
were
because child will cry (workers)
people do not understand benefit (doctors)
vaccination time inconvenient (doctor/worker)
fatalistic (worker)
prefer to go to private doctor (worker)
afraid that it may be family planning
injection (worker)
Once again, these responses were open-ended and
spontaneous.
The reasons may be supported by
relatively small numbers but serve to illustrate
the range of reasons
that could exist that result in
vaccination services being refused.
The ranking of
reasons in terms of the frequency of mention serves
to indicate the extent to which each reason was
spontaneously believed in.
However, since the
research design was qualitative in nature, the
ranking serves only as an illustration and need
not necessarily reflect the relative importance of each
reason as being true for the relevant universe.
UtAJD)
Indian Market Research Bureau
90
4.4.3
Possible methods of persuasion
A few methods were suggested by the respondents, once
again on a spontaneous basis.
Base : 165
Methods
1.
2.
3.
These were as follows :
% who suggested
Total
Doctors
Person-to-person contact
and education
54
64
49
Education through
documentary films
39
39
39
Local leaders should
be involved
19
25
16
4
4
4
7
2
4
4.
Economic
5.
Make vaccination
compulsory/use force
help
Workers
Ref : Table A-90
The main focus of the methods suggested revolved around
education of the target audience.
The important point
to be noted here is that both suggestions pertaining to
education involved audio-visual communication - one was
person-to-person where the trainer would be physically
present to explain, answer, interact and demonstrate.
The other was through documentary films.
We believe that respondents were trying to emphasise
(but
could not articulate the same) that communication
had to be active, something that reached out and held
the attention of the target audience.
Thus, they were
referring to dynamic, aggressive methods of communication
rather than inert, passive methods (for example, the
print medium, posters, banners).
JBffl D
D
Indian Market Research Bureau
91
Implicit in the choice of these type of active media
could be an understanding that the rural/semi-urban
parent did not have the education and therefore the
understanding or interest to absorb the importance
or the scope of immunization, A passive medium could
get ignored, The medium had to grab the attention
and convince.
The other methods suggested revolved around force,
either implicit as in involving local leaders or explicit as in
using force or making vaccination compulsory.
The
numbers in favour of the latter two suggestions were,
however, very few.
MW
Indian Market Research Bureau
92
4.5
ATTITUDES OF THE IMPLEMENTERS
A set of statements were read out to the respondents,
They were asked to agree or disagree with each of the
statements on the basis of their personal opinion,
beliefs or feelings. Each of the statements are
being set out below and the responses are being
analysed for each.
4.5.1
Statements regarding
a/
implementers attitude to his work
Statement :
"Convincing people to get their child
immunized is frustrating work"
27% of all respondents agreed with this statement.
Workers and district level respondents expressed
more frustration than doctors and metro level
respondents.
(?o)
Total
312
27.2
Doctors
115
19.1
Workers
197
32.0
District
264
29.9
Metro
Base
Agree
Disagree
72.1
80.0
67.5
69.3
87.5
Not speci
fied
0.6
0.9
0.5
0.8
48
12.5
Ref: Table A-103
These comments are consistent with those made
earlier that there was greater resistance from
district level parents than those in the metros.
One out of three workers expressed frustration.
Since agreement with the above statement would not
BfflM
Indian Market Research Bureau
95
reflect too well on the respondent it would be
realistic to assume that the level of frustration is
The fact that doctors
in fact higher than stated.
expressed low agreement could be a reflection of their
lesser role in the job of persuasion.
The highest
level of agreement came from sub-centre respondents
which supports the hypothesis of increasing resistance
with decreasing urbanization.
b/
Statement : "This job involves important and useful
work"
99% of all respondents agreed with this
statement, with the figure rising to 100% in the
metros.
There was clearly no dispute on the importance
and usefulness of this work.
c/
Statement : "Working with illiterate people can be
boring and tiring" -
For a socially unacceptable
statement, this received a high level of agreement at
41% of all respondents.
(%)
Base :
Agree
Total
312
41.0
Poet s
115
41.7
Workers
197
40.6
District
264
43.9
Metro
48
25.0
Disagree
58.3
57.4
58.9
55.7
72.9
Not specified
0.6
0.9
0.5
0.4
2.1
Ref : Table A-103
There was little difference between doctors and workers
in terms of their agreement with this statement. In the
metros, however, 73% of all respondents disagreed with
this statement.
Indian Market Research Bureau
3^
d/
Statement
"I would prefer to work in a town rather
than in a village”
40% of all respondents agreed with this statement.
More doctors than workers agreed with this statement.
(%)
Total Doctors Workers District Metro
Base :
312
115
197
264
48
Agree
40.4
52.2
33.5
39.4
45.8
Disagree
58.0
45.2
65.5
58.7
Not specified
1.6
2.6
1.0
1.9
54.2
Ref : Table A-103
It was significant that two out of three workers
disagreed with this statement indicating that they
were quite satisfied with the idea of working in
rural areas.
66.5% of the workers in districts
disagreed with this statement; 57% of workers in
metros also felt the same way.
Doctors on the other
hand expressed a higher desire to work in urban areas.
4.5.2
Statements regarding implementers understanding of
attitudes of the people
a/
:
Statement : "People here do not really believe
that vaccinations can prevent disease”
The majority disagreed with this statement. They
believed, therefore, that people had faith in the
concept of immunization.
The acceptance of immu
nization was, by that logic, a conscious aware
acceptance rather than an unthinking or cynical
compliance.
TB
Indian Market Research Bureau
95
(%)
Total
Base :
Doctors Workers
District
Metro
197
204
48
8.7
16.8
15.5
4.2
91.3
82.7
84.1
95.8
0.5
0.4
312
115
Agree
13.8
Disagree
85.9
Not specified
0.3
Ref : Table A-103
The differences between district and metro attitudes begin
to fall into a pattern. The understanding of and belief
in immunization was clearly higher in metros,
Workers in
metros were all in disagreement (100?o) with the statement,
19% of the workers in districts agreed with the statement
though only 9% of the doctors did so.
The higher agreement by workers could be a function of their close contact
with the people and therefore needs to be taken seriously,
Highest agreement came from respondents in sub -centre
villages.
b/
Statement : " People suspect that vaccinations are not
given for the prevention of disease but some other motive"
As with the earlier statement, over 80% disagreed with it,
reinforcing
the finding that the attitude of the average
receipient of immunization was neither skeptical nor
suspicious.
However, a higher percentage of workers in
districts agreed with this statement as compared even to this
the earlier one.
None of the workers in the metros agreed
with this statement.
(%)
Total
Base :
Agree
312
16.0
Doctors
115
10.4
Workers
1-97
19.3
District
204
17.8
Metro
48
6.3
Disagree
83.7
89.6
80.2
81.8
93.8
Not specified
0.3
0.5
0.4
Ref : Table A-103
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Thus, while suspicion regard immunization was not
a major problem, it would deserve some attention in
areas.
rural areas.
In sub-centre villages, 23.4% of
respondents (almost one out of every four) agreed
with this statement.
V/hile experience and the
percolation effect from urban to rural areas would
in time create greater confidence, it would be
necessary to be aware that, in small villages, some
suspicion and skepticism exists and would have to be
handled with explanations and patience.
c/
Statement :
ii
Once a child has been vaccinated, people
will come forward on their own to get their next
child vaccinated"
The idea behind this statement had been to see if.
in the opinion of implementers, parents understood
the benefits of immunization well enough to be self
motivated after an initial introduction.
89% agreed that this would be so.
Both doctors and
workers were in equal agreement on this score.
(%)
Total
Doctors
V/orkers
District
Metro
Base :
312
115
197
204
48
Agree
89.4
88.7
89.8
88.6
93.8
Disagree
9.9
11.3
9.1
10.6
6.3
Not specified
0.6
1.0
0.8
Ref : Table A-103
UMnw
Indian Market Research Bureau
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Only 10% of all respondents disagreed with this state
ment.
This faith in parents becoming self motivated
augurs well for the long-term functioning of the EPI
programme since, in the final analysis, persuasion
would have to stop and a demand for immunization services
from the target audience should begin.
14% of the respondents in sub-centre villages disagreed
with this statement, again confirming the conclusion
that parents in rural areas would need more attention
in order to help them overcome suspicion, doubt and
indi f ference.
4.5.3
Statements related to knowledge regarding immunization
a/
Statement
TT and DPT vaccines should not be
allowed to freeze ii
The correct answer to this statement would be in the
affirmative.
However, 24% of all respondents
disagreed with this statement revealing that, in
their opinion, freezing these vaccines would be
acceptable.
The proportion at 24?6 is disturbingly
high since freezing, if being actually practiced,
could be damaging a large proportion of vaccines.
This incorrect knowledge was more widely held in
metros, where 33.3% of all doctors and 23.8% of
workers disagreed with the statement.
Indian Market Research Bureau
98
(%)
Total
Doctors
Workers
District
Metro
Base :
312
115
197
264
48
Agree
74.7
84.3
69.0
75.4
70.8
Disagree
24.4
15.7
29.4
23.5
29.2
Not specified
1.0
1.5
1.1
Ref : Table A-103
The doctors who most widely agreed with this statement
were private practitioners (Agree - 79.2%).
The level
of agreement by type of health centre was as follows :
(%)
Base
Agree
Disagree
Govt hospital/dispensary
102
75
25
Primary health centre
63
79
21
Health sub-centre
94
69
29
Private practitloner/hospitai
53
79
19
Ref : Table B-103
The misconceptions therefore were higher amongst
implementers in the govt health network.
b/
Statement :
"Keeping vaccines at room temperature for
2-3 hours is okay"
Once again, this statement was clearly erroneous and
should have been disagreed with.
Instead, as many as
24% of all respondents agreed with this statement.
Agreement, and the misconception implicit within that,
came more from districts than from metros.
(?o)
Total
Doctors
Workers
District
Metro
Base :
Agree
312
23.7
115
22.6
197
24.4
264
25.0
48
16.7
Disagree
75.3
77.4
74.1
74.2
81.3
Not specified
1 .0
1.5
0.8
2.0
Ref : Table A-103
EMW
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99
It would appear that while implementers in metros
err on the side of freezing vaccines, at the district
level implementers err on the side of allowing vaccines
to become warm.
If this statement is looked at together
with the earlier question (Refer section 2.2) where 48%
of the implementers at the district level would not
throw away a half - used vial and 68% would not throw
away a vial of which less than half had been used, the
implications cause concern.
Chances are that one out of
8 implementers would put a vial back in the fridge after
having left it at room temperature for 2-3 hours and
re-use the vaccine from that vial.
4.5.4
a/
Statements regarding practices
Statement :
"The cold chain system beyond the HQ
hospital is very weak and breaks down easily"
45% of all implementers in the districts agreed with
this statement. 50% of the implementers in metros
agreed with this statement.
However, since the metro
respondents were not talking on the basis of experience
but on the basis of perceptions and hearsay, their
views are not of orimarv
primary concern.
(%)
Base :
Total
Doctors
Workers
PHC
PHS
264
88
176
63
94
0'
/0
Oz
zO
?0
O'
/O
%
Agreed
45.1
48.9
43.2
30.2
47.9
Disagreed
51.5
45.5
54.5
66.7
51.1
Not specified
3.4
5.7
2.3
3.2
1.1
Ref : Table A-103
*■
D
D
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Firstly, that
Two factors emerge from this analysis.
doctors spoke of cold chain breakdowns more than workers
did, albeit only marginally so.
so.
Secondly, breakdown
problems seemed to occur more at the sub-centre level
than at the primary health centre level.
but nevertneless an area
This is logical
that would need attention if
people in interior villages are to benefit from
effective immunization.
b/
Statement : "Most vaccines loose potency because it is
impossible to maintain them at the correct temperature"
The extent of agreement with this statement is a cause
for grave concern.
As many as 62?;, almost two out of
three implementers, agreed with this statement,
The
details vjere as follows :
(%)
Base :
Agree
Total
312
62.2
Disagree
36.2
Not specified
1.6
Doctors Workers District Metro
115
197
264
48
66.1
59.9
61 .0
68.8
32.2
38.6
37.5
29.2
1.7
1.5
1.5
Ref : Table
There was greater agreement at the metro level where,
2.0
A-103
pnma facie, there appears to be less cause for difficulty
in maintaining vaccines at correct temperatures.
The
agreement in metros came from doctors (74?;) than from
workers.
The same was true for districts.
Indian Market Research Bureau
101
An analysis by type of centre reveals the following :
(%)
Govt
hospitals
PHC
PHS
Private
Base :
102
63
94
53
Agree
62.2
72.5
50.8
67.9
Disagree
36.2
26.5
47.6
28.3
Not specified
1.6
1.0
1 .6
3.8
Ref : Table B-103
PHS respondents contradict themselves on this score.
While 4856 had agreed that the cold chain system breaks
down easily, an almost equal number did not agree that
vaccines lost their potency because of the same
problem. This could either mean that their under
standing of the cold chain was faulty, or their
understanding of vaccines and the maintainence of
vaccines potency was faulty or both.
Indian Market Research Bureau
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102
4.6
BRINGING THE CHILD FOR IMMUNIZATION
The child was normally brought for immunization by
the mother.
dents.
This was revealed by 99?o of all respon
Only 3 respondents said that the child was
normally brought by the father.
However, 76% of the respondents said that the child
would sometimes be brought by the father. 41% were
of the opinion that sometimes a grandparent brought the
child.
The father or grandparent accounted for most of those
occasions when the mother did not bring the child.
Some others who were spontaneously mentioned by a few
respondents, were, in order of priority.
Brother or sister of the child
9.3%
Women, other than mother
4.8%
Uncle
Aunt/Sister-in-law
4.5?6
Anganwadi/Health worker
1 .6%
4.5%
Ref : Table A-79
Iffl D
D.
Indian Market Research Bureau
103
A.7
KEEPING TRACK OF DUE DATES
The methods of keeping track as revealed by respondents
could be broadly divided into 2 categories :
those which did not involve actual implementer
participation and could be termed ’’parent-oriented ft
meaning that the onus of keeping track lay with the
parent.
.
In this category were three methods
Cards given to parents and referred to by them
for the due vaccination dates
Fixed days advertised
Parents check with worker
those which involved active implementer partici
pation and where parents play a relatively passive
role.
In this category were the following methods :
Parents are reminded
Parents are called on due date
Vaccination given at the house on due date
Worker goes to the house and fetches
The two categories were not mutually exclusive and
often co-existed.
However, there were differences
by district and these differences revealed the level
of active participation that implementers maintained
to ensure complete immunization.
0}
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Indian Market Research Bureau
104
A look at each district in terms of the broad
methods of keeping track of dates reveal the
following picture.
(%)
North
Base
(Nos.)
Parentoriented
Implementer
oriented
Overlap
Hamirpur*
20
65
40
5
Bharatpur0
22
59
45
4
Allahabad+
15
67
40
7
Anantpur*
24
92
21
13
Iddukki+
24
58
54
12
Madurai0
24
88
88
76
Purnia0
24
38
67
5
Nadia0
24
75
100
75
Puri+
22
73
50
23
Gwalior*
22
86
32
18
Kheda+
22
91
14
5
Nanded*
21
57
86
43
So jth
East
West
Ref : Table C-81
Barring a few districts, the majority of the districts
seemed to rely predominantly on parent-oriented methods
of keeping track of dates.
The overall dependence on the various methods listed
earlier was as follows :
D
Q
Indian Market Research Bureau
105
Total
District
Metro
O'
/□
C'
/O
O'
/O
81.3
Cards are given
71.5
69.7
Fixed days are advertised
Parents check v/ith worker
0.3
0.4
0.6
0.8
Parents are reminded
Parents are called on
due date
34.0
37.9
12.5
10.9
11.7
6.3
Vaccination given at home
on due date
2.2
2.3
2.1
Worker goes house-to house
and fetches
1.9
1.9
2.1
Ref : Table A-81
There was clearly greater intervention and effort made
by implementers at the districts than at the metros.
In the districts, there was also greater use of
simultaneous reminder methods than in the metros.
BW n
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5.0
PRACTICE RELATED ISSUES
5.1
PRESERVATION OF VACCINES FOR OUTREACH SESSIONS
5.1.1
Transportation
All respondents who ever moved out to outreach centres
to implement the EPI programme were asked a few questions
to establish whether vaccines were being transported to
outreach camps in a manner that would help preserve
their potency.
It was a question that was difficult to get an honest
response to since the correct answer would be known to
most respondents, The objective, however, had been to
ascertain the actual practice rather than test knowledge
of correct answer.
Respondents were therefore asked to
describe how they wouldI carry vaccines for an outreach
Interviewers 1were briefed to probe till they
understood the answer fully but to not prompt.
session.
The responses received were coded in
a code list that
had attempted to differentiate between responses that
included the mention of ice and those which did not.
Of those who gave any reply to this question (234
respondents), the responses were as follows :
iQMtOilH)
Indian Market Research Bureau
107
Those who said
-
only
%
Carry in vaccine carrier
26.5 *
Vials in plastic bag in carrier
In vaccine carrier with ice
In vaccine carrier with frozen ice
pack
1.3 *
25.6
24.8
With ice packs filled with cold
water
1.7
In thermos with ice
3.8
In an ice-box
5.6 *
Kidney tray
0.4
No special care required
0.9
Ref : Table A-61
The remaining 9.4% gave a combination of the above
responses.
The areas of concern surrounds those responses which
did not specifically mention ice or frozen ice packs
(Marked by an aesterisk * ).
It could be assumed that
the respondents meant to include ice when they used
words such as vaccine carrier or ice box.
If that
assumption were true, there would be no cause for
worry since almost 90% of the respondents would then
have been using acceptable methods of vaccine trans
portation.
If, however, it is assumed that non-
mention of ice or ice packs means non-use, there
would because for concern since in that case only 67%
of the respondents would have been transporting
vaccines as required.
w
Indian Market Reseaich Bureau
l!
108
5.1.2
Placement of vaccine during an immunization session
Proper preservation of vaccines requires that vaccines
be kept at a cool temperature (+4°C to +8°C) from the
time of manufacture to the time of injection,
It would
therefore be important for implementors to preserve
vaccines in a cup of ice during the session.
Out of the 261 respondents who were involved in outreach
camps (these included 12 private practitioners/workers
in private clinics)
40% put the vials in a cup of ice
during the session.
Another 28% attempted to keep the
vaccine cool by putting it on top of an ice pack or in
a plastic bag filled with ice during the session.
An
additional 13.8% put the vaccine back in the vaccine
carrier. Thus, 82% revealed practices that were correct
(or at least acceptable) as well as an awareness of the
need for special care of the vaccines during a session.
The details of these responses are as follows :
Base :
Acceptable practices
Total
PHC
PH5
Doctor
Worker
261
62
94
81
180
O'
'0
%
%
?0
%
1.
In a cup of ice
40.2
37.1 42.6
40.7
40.0
2.
On top of an ice pack
20.3
14.5 30.9
18.5
21.1
3.
Ice bag/plastic bag
filled with ice
8.0
8.1
6.2
8.9
9.6
Ref : Tables A-62, B-62
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Total
4.
Put back in carrier
PHC
PHS
Doctor
Worker
?0
O'
/O
%
%
0/
/O
13.8
25.8
10.6
8.6
16.1
Dubious practices
1.
On table/tray
8.8
8.1
8.5
7.4
9.5
2.
In cup with water
3s 1
1.6
1.1
2.5
3.3
3.
In shade
1.5
3.2
1.0
2.5
1.1
4.
In plastic cover
1.5
1.6
1.1
1.2
1.7
5.
Polio vaccine gets
put on ice
1.1
1.6
1.1
1.2
1.1
6.
At room temperature
0.8
7
Only one vial carried
out of the clinic
0.8
2.5
3.2
0
1.2
0.6
Ref : Table A-62, C-62
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5.2
STERILIZATION
5.2.1
Place
Needles and syringes were sterilized in equal measure
either at the health centre or at the outreach camp.
The other place was at the house of the child, though
this was mentioned by only a few respondents,
There
was not much difference in responses between doctors
and workers.
The details are as follows :
Place
Total Doctors Workers
Govt
Hospt
PHC
Pvt
PHS Hospt
Base
261
180
198
62
94
7
%
0'
zO
%
O'
/O
%
81
O'
/O
At centre
50.5
53.1
49.4
55.1
46.8
44.7 57.1
At camp
48.7
39.5
52.8
39.8
54.8
55.3 28.6
At house of child
3.1
2.5
3.3
5.1
1.6
1.1 14.3
Ref : Tables A-63,B-63
Only one respondent said that he used disposable
syringes and therefore did not sterilize the needles.
Instruments were mostly sterilized before a session
rather than during a session.
Only a small proportion
of respondents sterilized after a session to keep ready
for the next session.
D
Ivll D
Indian Market Research Bureau
111
T ime
Total
Doctor
Worker
Govt
Hospt
PHC
PHS
Pvt
Hospt
Base
261
81
180
98
161
94
7
/O
O'
zO
O'
zO
?0
?0
%
74.5
57.1
%
O'
Before session
76.6
75.3
77.2
74.5
85.5
After session
4.2
3.7
4.4
7.1
4.8
During session
20.3
17.3
21.7
19.4
8.1
5.2.2
Method :
28.7
28.6
Ref : Table A-64, B-64
The most common method of sterilizing instruments
was by boiling.
77.6% of all respondents used this method
The duration for which instruments were boiled
di ffered
14.3
however,
as follows :
Method
Total
Doctors
Workers
Base
312
115
197
O'
zO
O'
zO
O'
zO
77.6
67.0
83.8
1 - 10 minutes
13.5
12.2
14.2
11
20 minutes
36.2
22.6
44.2
21
30 minutes
24.0
27.0
22.3
45 minutes
3.2
5.2
2.0
60 minutes
0.6
0.0
1.0
Autoclave
15.4
21.7
11.7
Keep it in hot water
1.0
0.9
1.0
Use a sterilizer
0.3
0.9
Disposable : not sterilized
3.5
5.2
2.5
Not specified
2.2
4.3
1.0
Boiling
Ref : Table A-65
Almost 5O?6 of all respondents (35?o of doctors and 58%
of workers) boiled the instruments for less than 20
minutes.
Added to this is another finding which pertains
to the understanding of boiling instruction.
Some res-
Indian Market Research Bureau
112
pondents had mentioned that boiling time included time
Thus, if they
taken for water to reach boiling point.
were instructed to boil instruments for 20 minutes,
they would put the instruments in ordinary water, put
the pan on the flame and count 20 minutes from that
point onwards.
While it is not necessarily true that all implementers
interpreted boiling time in this manner, it would be
erring on the safer side to assume that all those who
claimed to boil for 20 minutes or less were not
achieving effective sterilization.
By that standard, sterilization methods could be
broadly broken up as follows :
Total
312
Base
Doctor
115
Worker
197
0'
0'
/O
O'
'0
46.7
59.1
39.5
(Boil less than 20 minutes,
Keep in hot water, use
sterilizer)
51.0
36.6
59.4
Not specified
2.2
4.3
1.0
/0
Effective
(Boil 21+ minutes, auto
clave, disposable)
Ineffective
Ref : Table A-65
Clearly, doctors reported more effective practices
than workers.
The overall picture however, causes
Indian Market Research Bureau
113
concern.
There appears to be a case for stronger
training in the area of sterilization of instruments
with particular emphasis on :
definition of duration of boiling
the importance of effective sterilization
rw w
Indian Market Research Bureau
114
5.3
AVAILABILITY OF CONSUMABLES
The majority of the respondents reported regular
supply of six items which were being studied.
The order in terms of regularity of supply was as
follows :
% Who said it was regularly available :
(?o)
Total
District
Metro
Base :
DPT vaccine
312
90.7
264
91.3
48
87.5
TT vaccine
89.4
91.3
79.2
OPV
80.8
80.3
83.3
Measles vaccine
80.8
81 .4
77.1
Vaccine cards
72.1
73.5
64.6
BCG vaccine
63.8
63.6
64.6
Ref : Table A-26
It would be pertinent to look at this data by
district. (Ref Table C-26)
5.3.1
DPT vaccine
91.3% of all respondents at the district level
reported that they received regular supply of DPT
vaccines.
Only 7.2% felt that the supply was
irregular.
The districts which reported an above-
average irregularity of supply were Madurai0
(16-7% said irregular) and Gwalior* (13.6%).
Except for one respondent in Anantpur*, none
reported that the DPT vaccine had never been
received.
Indian Mai tel Rtscaxui 2-reau
115
5.3.2
TT vaccine
91.3% of the respondents in districts said that they
received a regular supply of the TT vaccine.
Irregular supply was reported from Madurai (20.8%)
and Nanded* (19%).
Three respondents in Madurai0
(12.5%) and one in Purnia0 said that the TT vaccine
had never been received.
This could, however, be
a reflection on their awareness rather than actual
supply.
5.3.3
OPV vaccine
Regular supply was reported by 80.3% of the district
respondents.
However, 17.8% said that the supply
was irregular which is higher than reported for
for DPT (7.2%) and TT (6.1%).
The factor that causes concern however is that the
district average of 17.8?6 was a result of some
districts which reported very high level of
irregularity.
These were Hamirpur* (60%),
Gwalior * (41%), Nanded* (29%), Purnia0 (29%)
and Madurai0 (21%).
3 out of these 5 districts
are high performance districts.
5.3.4
Measles vaccine
81.4?6 of the district level respondents said that they
received a regular supply of the measles vaccine.
Indian Market Research Bureau
116
(The supply in the metros was not quite as regular).
Complaints with regard to irregular supply or non
receipt were focussed around the South zone districts
and Purnia0. Details are as follows :
Irregular
Never
0'
'0
5.3.5
%
District average
11.0
4.5
South :
Anantpur*
Iddukki+
8.3
8.3
16.7
12.5
Madurai0
25.0
4.2
East :
Purnia0
20.8
20.8
West :
Nanded*
23.8
Cwalior*
18.2
Ref ; Table 0-26
Vaccine cards
73.5% of all respondents at the district level reported
that vaccine cards were regularly received. 7.2%
reported irregular supply.
The factor that causes
concern, however, is that 12.5% of all respondents said
that they had never received vaccine cards, There was
no difference between the"never received" claim made
by doctors and workers. At the district level, 12.5?6 in
each group said that these cards had never been received.
Thus, it is unlikely that the non-receipt complaint
could be based on non-awareness.
Indian Market Research Bureau
117
Complaints of non-receipt and irregular supply came mainly
from the following districts.
(%)
Irregular
Never
Not specified
Purnia0
29.2
50.0
8.3
Nanded*
4.8
47.6
4.8
16.7
25.0
Iddukki+
Allahabad+
26.7
6.7
Anantpur*
Madurai0
5.3.6
20.8
12.5
4.2
4.2
Ref : Table C-26
BCG Vaccine
The largest problem seemed to be in the area of BCG
vaccine supplies. At the district level, only 63.6%
claimed regular supply.
As many as 24.6% (one out of
every four respondents) said that the supply was irregular
while 7.2% said that it had never been received.
There were some patterns here that were different.
Firstly, as in the case of the measles vaccine, a greater
proportion of respondents in metros (16.7%) claimed that
they had never received the measles vaccine.
Secondly
at the district level, 17% of the doctors said that the
BCG vaccine had never been received as compared to only
2% of the workers who said so.
This was the only item
for which a larger proportion of doctors claimed nonreceipt.
The highest non-receipt complaints came from the South
zone districts followed by the East zone districts.
District-wise data is as follows :
Indian Market Research Bureau
118
_____ Supply of BCG Vaccine____
Regular Irregular Never Not specified
North :
South :
East :
West :
%
<0
Hamirpur*
50
30
Bharatpur0
68
23
5
5
Allahabad
68
7
13
13
Anantpur*
Iddukki+
54
17
29
33
58
8
Madurai0
46
38
13
Purnia0
Nadia0
42
83
46
13
Puri+
91
9
Gwalior*
Kheda+
86
14
77
71
9
Nanded
?0
0'
/0
20
4
17
5
20
9
9
Ref: Table 0-26
Anantpur, inspite of being a ii good performance " district
had close to 30% of respondents claiming that the BCG
vaccine had never been received. There is a discrepancy
between such a claim and high achievement of targets.
Indian Market Research Bureau
119
5.4
POSTERS/TIN PLATES
Posters and tin plates on the subjects of polio,
tetanus and TB had been made and distributed amongst
UIP districts.
Respondents were questioned with
regard to receipt
and use of posters/tin plates
and their opinion on each of the poster/tin plate
types.
5.4.1
Receipt of posters/tin plates
Almost 80% of all respondents said that they had
received these posters/tin plates.
This figure was
much higher at the PHC and PHS levels where an
affirmative response was given by 90.5% and 94.7% of
respondents respectively.
83.3% of the people in
government hospitals or dispensaries said that they
had received the posters.
In contrast only 32.1% of
private practitioners had received any posters.
There were differences between districts and metros
and between doctor and worker responses.
(%)
Base
Total
312
Doctor
115
Worker
197
O'
O'
zO
O'
/O
Yes
79.5
68.7
85.8
No
20.5
31.3
?0
District
264
Metro
48
84.8
50.0
O'
zO
14.2
15.2
50.0
Ref : Table A-97
All those who said that posters/tin plates had been
provided were asked to state the total number of posters
received.
Doctors said on an average, that 150 posters/
IMB
Indian Market Research Bureau
120
tin plates had been received while workers said that
closer to 90 posters had been received.
The figures
were higher where looked at specifically by district
and by metro.
____ District
Metro
Doctor Worker Total
Doctor Worker
Total
Average
numbers
received
34
170
95
117
53
7
Ref : Table A-98
There were wide zonal variations. In the North and South
zones, an
an average of 267 and 151 posters/tin plates were
mentioned by each respondent.
In the East and West zones,
an average of 46 posters/tin plates were mentioned.
Within zones too there were district-wise variations that
were wide enough to merit individual mention here.
Average number of
posters/tin plates
received
Hamirpur*
178
Bharatpur0
Allahabad+
335
245
Anantpur*
Iddukki+
50
100
Madurai0
291
Purnia0
Nadia0
Puri+
Gwalior*
Kheda+
74
25
42
6
138
Nanded*
10
Ref: Table 0-98
Indian Market Research Bureau
121
Barring Hamirpur*,' there seemed to be an inverse
relationship between the good performance districts
and the posters received by them.
Low performance
districts namely Bharatpur0 and Madurai0 reported the
highest receipt of posters
5.4.2
Types of posters received
There were seven basic pictures that were converted
into posters and tin plates and distributed amongst
health centres.
This study showed that each poster and tin plate had
been received by between 65-70% of all respondents of
There was considerable amount of multiple receipt.
Each respondent reported receipt of, on an average,
4.9 types of posters and 4.6 types of tin plates.
Interviewers had been asked to report on display of
posters and tin plates on the basis of actual sighting
of the same rather than by questioning the respondents.
Either posters or tin plates were reported to have
been displayed inside the health centre in 39-46% of
the interviews and outside the health centre in 32-35%
of the interviews.
Indian Market Research Bureau
122
Looking at display data specifically by type of picture
and type of health centre, the
the following picture
emerges.
Base: To whom
provided
Govt Hospt.
PHC
PHS
85
57
89
In
Out
?0
O'
.0
None
In
Out
None
In
Out
None
%
?0
0/
/O
0'
'0
?o
%
%
Mother & dead child
47
38
28
39
39
46
Father & child
39
26
40
47
37
31
44
39
42
Polio boy standing
39
25
52
48
41
28
46
37
49
Polio boy crawling
42
26
47
47
41
29
44
42
42
TB-node on neck
43
26
48
45
39
27
44
42
IT bandaged head
40
42
21
48
45
40
31
49
39
42
TT tube in nose
44
26
48
45
41
25
42
35
46
40
26
44
Ret : Table B-101
5.4.3
Rating of posters
All respondents were asked to rate the
posters on a 5-point
scale ranging from excellent to
poor. The ratings were given
a score such that an excellent rating would receive a score
of 5 while a poor rating would receive
a score of 14 The
ratings received by each of the six types of
posters/tin
plates on an overall basis are as follows :
Indian Market Research Bureau
123
Appendix
Number
Picture
I
Mother & dead child
3.5
II
Father and child
3.2
III
Polio boy standing
3.7
IV
Polio boy crawling
3?8
V
TB-node on neck
3.2
VI
TT-bandaged head
3.5
VII
TT-tube in nose
3.3
Mean Score
(Max = 5 = Excellent)
Ref : Table A-102
The differences are not wide.
However, they do reveal
a trend in terms of the type of pictures that were highly
rated by implementers.
a/
The top two
•
The highest ratings were given to the
two polio pictures (III & IVL
explanations for this.
There could be several
Firstly, direct interaction
with mothers of young children revealed that the fear
of disability was greater than the fear of death.
Secondly, polio was a widely recognised and feared
disease.
The poster therefore portrayed something
that was both known and feared; it would have aroused
dread and curiosity with regard to the purpose of such
a poster which in turn would serve as the mother's
point of introduction to immunization.
Another hypothesis is that the picture of a boy
suffering from polio would be more likely to strike
an answering chord in the viewer as she (the mother)
lufaBi Mar^zt Research Buieau
124
could have come across a lame child before.
This
disability would therefore appear real and possible.
The other pictures possibly do not arouse the same
fear since they fall outside the average rural mother's
range of experience.
Finally, we have stated a hypothesis in our analysis
of mother's attitudes and practices namely that the
mothers does not really understand the full scope of
immunization in the sense of the diseases against
which protection is provided and the gravity of these
diseases.
However, she knows and dreads polio and
possibly accepts or seeks out immunization to protect
her child from polio.
It is possible that implementers,
realizing this, gave higher marks to the posters that
highlighted polio and disability.
b/
The second two ;
The two pictures that were rated as being
next best (mean score 3.5) were the " mother and dead child HI)" and the ’’tetanus picture of an infant with
a bandaged
head - IV)”.
Once again, the explanation for these
pictures getting a
higher rating could lie in two factors - dread and
possibility.
The sight of a mother with a dead child would not be unknown
to the rural mother,
An infant with a bandaged head would
also fall within the realm of a mother's experience.
Thus,
she would identify with and dread these two possibilities,
The posters would possibly arouse in her the
necessary
combination of fear and desire to protect
w
Indian Market Research Bureau
125
c/
The last three :
The three posters that were rated
lowest on the rating scale were "Tetanus - child with
tube in nose - VII" (Mean score = 3.3), "TB-node on
neck - IV" (Mean score = 3,2), "Father and healthy
child - II" (Mean score = 3.2).
The fact that these received a lower rating than
the others bears out the explanation given earlier.
The pictures were either too unfamiliar to be real
(Pictures VII and IV) or too mild to be threatening
(Pictures IV and II).
The picture of an infant with a tube in the nose,
while dreadful, was removed from rural reality and
therefore would not arouse the fear that picltures
of a more possible/plausible situation could.
The picture of the node on the neck would most
probably not be understood by an illiterate audience
to be anything more threatening than a boil which
was too common-place to merit much thought.
The messages that were sought to be delivered by
the picture of a man carrying a healthy child namely,
the active role of the father and the rewards of
immunization were probably not received.
The picture
did not serve the function of creating interest in or
demand for immunization since it aroused no fear.
Indian Market Research Bureau
126
5.5
PROBLEMS IN PRACTICE
Respondents were asked to name the one problem which,
in their opinion, formed the main obstacle to their
work.
The question was asked
in an open-ended
format, allowing the respondent to spontaneously
mention
5;5.1
the problem that first surfaced in his mind.
No problems (Ref: Tables A-91, B-91, C-91)
A third of all respondents said that there were no
problems that obstructed their work, This figure
was lower in the districts (30.3%) but considerably
higher in the metros (50%). 2 out of 3 workers in
metros said that there was no problem.
This absence of problems was expressed to differing
degrees across districts, In Madurai0 district, 75%
of all respondents stated that there were no problems,
Given that the district belonged to the poor performance category, this claim rings false or speaks of
extreme inefficiency.
In Anantpur* district, 52.8?o of
all respondents, said that there were no problems.
The third district where over
over a third of the respondents
expressed "no problem", was Nadia0 in the East zone.
Barring these, less than 30?i of the respondents in
other districts said that there were no problems.
Indian Market Research Bureau
127
5.5.2
Obstacles to the work
(Ref: Tables A92. B-92, 0-92)
Implementers were asked to talk about the problems
that formed an obstacle to their work.
They were asked
to talk of the main problem and other problems.
All problems that were mentioned (the question was
open-ended) were weighted in terms of their being mentioned in the context of main or other problems.
The ten main problems that emerge as a result are as
follows :
Rank
1
Transporation problems
2
Resistance from people
3
Problems regarding vaccine supplies
4
Cold chain maintainence
5
Shortage of workers
6
Lack of faith/confidence in vaccination
7
Financial problems
8
Problems with
9
Difficulty in convincing people regarding
regard to sterilization
vaccination
10
Lack of sincerety in workers
11
Illiteracy in people
Other problem
areas that were mentioned were as
follows, in order of frequency of mention :
Indian Market Research Bureau
128
Problems regarding supply of other necessities
Problems of space
Workers not trained
Load shedding
Infrastructural problems
Payment unsatisfactory
Dishonesty (corruption, misappropriation)
Side effects of injections
Language problems
Mobile population therefore difficult to keep records
Unhygienic surroundings
Worker-public interaction
People go out of town and miss due dates
Non-availability of vaccine cards.
The purpose of listing all the problems in the order of
the frequency or order of their mention is to provide
an understanding of the range of problems that existed..
IMM
Indian Market Research Bureau
129
5.6
AREAS OF IMPROVEMENT
A list of six possible areas of improvement was
provided to the respondents.
They were asked to choose the one area which they
considered to be most important, if improvement in that
area could be guaranteed.
They were then asked to pick
the area of improvement that they considered was second
most important and then the third most important area.
The areas of improvement sought differed by doctors and
workers as well as between districts and metros.
On the basis of the total sample, the order in which
the six areas were ranked is as follows :
Rank
Improvement in the area of
Mean Score
(Max - 3)
1
Information to people about
immunization
1.52
2
Supply of vaccines
1.08
3
Cold chain maintainence
1.05
A
System of travel to villages
1.05
5
Greater number of immunization
centres per village/locality
0.95
6
Supply of consumables
0.39
Ref : Table A-93
All respondent groups were agreed on the two areas of
improvement that ranked first and last respectively.
Indian Market Research Bureau
150
The most important area where improvement was wanted
was with regard to providing information to villagers
or people about immunization.
Doctors and workers,
in districts and in metro ranked this area the most
important area where improvement was needed.
Clearly, providing information and education to the
people, namely communication, is the need of the hour.
The area which aroused the lowest sense of urgency
and was common to all groups was the supply of
consumables.
The most likely interpretation of this
is that there was no problem in this area and that
needles, syringes and other items required for immuni
zation are available in quantities that are perceived
as being adequate by the implementers.
The ranking of other areas differed considerably amongst
the four groups both in terms of the order and the mean
scores.
2
Doctors
Mean
score
Cold Chain
maintainence
1.21
Mean
score
Workers
2
System of travel
1.13
3
Supply of
vaccines
1.10
3
Supply of vaccines 1.06
4
System of travel
0.91
4
Greater number of
centres : people 0.98
5
Greater no. of
centre: people
0.89
5
Cold chain
maintainence
0.96
Indian Market Research Bureau
131
Each group was clearly looking at the areas of improve
ment based on the problems faced by them in the imple
mentation of the immunization programme.
Doctors
mentioned cold chain maintainence as the second most
important area in which improvement was needed,
possibly because they were accountable for the perfor
mance of their centre and understood the role of the
cold chain in effective immunization.
Workers on the
other hand laid stress on improvement in the system
of travel to the villages since immunization in
outreach areas would be likely to fall more often in
their lot.
Both doctors and workers independently placed supply
of vaccines as the third area in which improvement
would be desired.
In the fourth place, doctors felt that improvement in
the system of travel would be desirable while workers
opted for greater numbers of centres for a given
population.
Once again, it is apparent that the actual
burden of implementation fell on the workers who
probably felt that the load per centre was too high.
In the fifth place, doctors spoke of more centres for
a given population while workers mentioned improvement
in the cold chain system.
The latter is a cause for
concern since it indicates a non-appreciation of the
importance of the cold chain in the view of the workers.
Indian Martel Research Bureau
132
There were wide differences in the priorities between
districts and metros.
The areas of improvement are listed
separately as ranked by district and metro respondents.
District
Metro
1 . Provide information
to people about
1.56
immunization
1. Provide information to
people about immunization
1.31
2. Greater number of
centres : people
1.25
3. Supply of vaccines
1.14
4. Cold chain
maintainence
0.89
5. System of travel
0.69
6. Supply of consumables
0.54
2. System of travel
1.12
3. Cold chain
maintainence
1 .08
4. Supply of vaccines
1.07
5. Greater number of
centres : people
0.89
6. Supply of consu
mables
0.37
The problem areas in districts and metros become apparent
on the basis or
of me
the above rankings.
One striking aspect
is that in metros the second most important area of
improvement was considered to be a greater number of centres
for a given population.
The high density of metro population
possibly placed a greater load
per metro doctor or worker
than in the districts.
Indian Market Research Bureau
133
6
MEDIA
In every aspect of this KAP study, one objective
had been to inguireinto the means of reaching out
to village people.
In the case of implementors, we
asked them to talk about the main sources of infor
mation for various sorts of happenings, at national,
district and village levels. V/e also elicited
information about the formal media which, in the
opinion of the villagers, would be suitable for
communicating with villagers.
6;1
MAIN SOURCES OF INFORMATION FOR VILLAGERS
6.1.1
Information regarding national happenings
In the opinion of the implementors, the main sources
of information with regard to national happenings
were :
Media
?6 of implementors
who mentioned
Radio
86.7
Newspaper
TV
65.2
51.5
Ref : Table A-104
These three were clearly the main sources for
information about national level happenings, Other
sources mentioned by significantly smaller numbers of
respondents were :
Indian Market Research Bureau
134
Local heads
3.8%
Cinema/cultural programme
2.7?o
Working people coming to
village
2.7
Posters or magazines
1.9
There were some differences by district in the relative
importance of the first three media.
In Bharatpur0,
Allahabad+, Madurai0, Puri+ and Gwalior* TV seemed to
be an important source of information for villagers.
In the Northern districts of Hamirpui*, Bharatpur0and
Allahabad4; in Nadia and Puri+in the East and in Nanded*
district in the West, over 9O?6 of implementers mentioned
the radio as an important source of information about
national events.
The newspaper was mentioned by over 75% of all respon
dents in the three South zone districts and in Puri+
district of the East.
All three mass media are being reported on at length
in the next section.
6.1.2
Information regarding district level happenings
For this kind of information, the newspaper emerged as
being the most important medium, followed by the radio
and word of mouth.
BfW
Indian Market Research Bureau
135
Media
% of implementers
Newspaper
51.5
Radio
37.5
Travellers (traders, farmers etc)
15.2
Public meetings, word-of-mouth
TV
14.8
Social/village/health workers
Froii service people
(those going out of the village
for work)
12.1
9.8
6.1
Ref : Table A-105
There were district-wise differences. The newspaper as
a source was more frequently mentioned in Anantpur*; Puri+
Gwalior*, Madurai0 and Bharatpur0.
Public meetings and word of mouth communication was
mentioned in the East zone districts by one-third of the
implementers.
6.1.3
Information about happenings in neighbouring villages
The two main ways in which villagers got the opportunity
to hear of happenings in neighbouring villages were
through personal contact particularly with travellers,
or visitors from neighbouring villages and through
announcements.
Indian Market Research Bureau
136
o-
<0
62.5
Personal contact :
.
Person-to-person contact
30.3
T ravellers
21 .6
Visitors from neighbouring
villages
10.6
Announcements (particularly with
regard to fairs, markets etc.)
15.2
Local village worker or elder
9.8
Village pradhan
7.2
Posters
6.4
Newspaper
5.3
Propaganda by cinema
4.5
Events fixed by custom are known
3.1
Pamphlets are given
2.3
Relatives
3.8
Health worker, teacher, anqanwadi worker
dai, postman, chowkidar, purohit (temple
priest)
5.0
Ref : Table A-106
The last category clubs together all the persons who
become sources of information.
Health workers and teachers
play a marginally more important role than the others.
However, village leaders and village elders remain an
important source for news that are not likely to be covered
through mass media.
It is interesting to note that announcements, posters and
pamphlets together play an important role in generating
Indian Market Research Bureau
137
awareness. However, it must be remembered that infor
mation regarding fairs or market days etc. is information
that intrinsically has the potential to capture the
interest of villagers since it promises fun and
excitement. The message regarding immunization availa
bility would not have that pull. Thus, while this data
reveals that pamphlets and announcements do work, the
nature of the announcement must be borne in mind while
deciding on the media to be used.
6.1.4
Information regarding health teams visit
Implementers reported that the main source of information
regarding the health team's visit were as follows :
Health workers, A.N.M, Other workers
56.0%
Propoganda/Publicity/Megaphone
announcements
12.1%
Village chief/Pradhan
9.8%
Health worker visits houses
7.2%
Notice issued/Posters/Pamphlets
Fixed schedule for immunization
Panchayat
7 .'2%
4.9%
2.7%
Chowkidar
Teacher
2.3%
Village elders
2.3%
2.7?o
0D
D
Indian Market Research Bureau
138
reaching the villages are few and even those are not
seen by all villagers.
Posters we hypothesize, would
be noticed by larger numbers because of their intrinsic
non routine nature as well as the association of posters
with news that directly concern the village.
However,
implementers felt that newspapers had marginally higher
credibility than posters.
TV followed after newspapers indicating that the reach
of TV is still not widespread.
Leaflets were believed to be more likely to reach
villagers than hoardings, possibly because the news
carried in leaflets would be perceived as being more
pertinent to the village than general-purpose hoardings.
We recommend from this data that the kind of media
vehicles that are most likely to reach the rural audience
would be those that
a/
depend on the audio-visual medium rather than
the printed word
b/
are perceived as having some news or information
that is pertinent to the people of that village.
In the latter case, the printed medium works since
word of the news carried in the poster/leaflet
would be spread by those are literate to the rest.
W
Indian Market Research Bureau
139
6*2
MASS MEDIA
Data was collected on the basis of media that reached in villages
and media that people were most likely to believe in.
The
objective of the latter question was to see if there were
perceived to be any differences in the credibility of
different media.
The eight media vehicles that were thus evaluated and
the ratings received were as follows :
Media
Reaches people
Believed in
O'
O'
Radio
66; 3
73.1
Cinema
42.4
55.7
Posters
38.6
48.9
Newspaper
37.9
53.8
TV
30.7
45.5
Leaflets
20.1
17.8
Hoarding
16.7
20.8
Magazine
8.3
13.6
/0
/O
Radio and cinema emerged as being the two media vehicles
that reach the village people and are believed in as well.
Both are based on audio communication (listening) rather
than on reading and therefore would logically have
appeal for illiterate people.
The two vehicles that were rated as next most likely to
reach villagers were posters and newspapers.
The order
of ranking suggests that the number of newspapers
Indian Market Research Bureau
140
reaching the villages are few and even those are
not seen by all villagers.
Posters we hypothesize,
would be noticed by larger numbers because of their
intrinsic non-routine nature as well as the association
of posters with news that directly concern the village.
However, implementers felt that newspapers had
marginally higher credibility than posters.
TV followed after newspapers indicating that the
reach of TV is still not widespread.
Leaflets were believed to be more likely to reach
villagers than hoardings, possibly because the news
carried in leaflets would be perceived as being
more pertinent to the village than general-purpose
hoardings.
We conclude from this data that the kind of media
vehicles that are most likely to reach the rural
audience would be those that :
a/
depend on the audio-visual medium rather
than the printed word
b/
are perceived as having some news or information that is pertinent to the people of
that village.
In the latter case, the printed
medium works since word of the news carried in
the poster/leaflet would be spread by those are
literate to the rest.
b)
Indian Market Research Bureau
U1
6.3
MESSAGES THAT WOULD CONVINCE
Finally, respondents were asked to give their sugges
tions with regard to messages that could most effectively
convince rural people on the need for immunization.
The largest number of.suggestions were in the area of
educating people with regard to health and the advan
tages of immunization.
Some of the suggestions in this
context were as follows :
%
Explain advantages of vaccination
23.1
Give health education to parents
19.7
Name and explain the diseases that
can be prevented
15.9
.
Explain consequences of not vaccinating
14.0
.
Explain that it protects children from
severe/fatal diseases
9.8
Explain that vaccine is the easiest
way to protect your child
6.1
.
This group accounted for 88.6% of the suggestions. Two
issues that emerge from these suggestions are :
1/
Implementers seem to strongly feel that there is a
gap in communication with regard to the fact that the
immunization course helps protect the child from some
serious diseases.
People do not know the diseases
which can be prevented, understand the severity of
diseaaes or really understand prevention.
Indian Market Research Bureau
142
2/
Implementers seem to feel that a combination of fear
appeal and reward appeal needs to be used to make an
impact.
The other suggestions were with regard to promises that
could be made and fears or misconceptions that could be
These were :
removed.
Makes children healthy and happy
6.1%
Explain that government gives
vaccination free
3.0%
Reduce fear of side effects
1.9%
A few respondents (5 to be precise) spontaneously said
that the current TV message was very good.
Respondents also had suggestions with regard to the
best media to be used.
These were :
Cinema
15.9%
Personal contact
12.5%
Leaflets/posters/pamphlets
9.5%
Radio
5.3%
TV
4.9?6
Mike/Megaphone
3.4%
Press
0.4%
An interpretation mentioned earlier has been revalidated.
That is that the medium used to communicate
the immunization message would need to be an active
medium rather than a passive one.
It would need to
reach out and grab attention and not expect to draw
attention.
Indian Market Research Bureau
APPENDIX I
VII
POSTERS
Indian Market Research Bureau
APPENDIX I
MOTHER AND DEAD CHILD
Indian Market Research Bureau
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APPENDIX V
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APPENDIX VI
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APPENDIX VII
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Indian Market Research Bureau
APPENDIX VIII
QUESTIONNAIRE
w02
Indian Market Research Bureau
IMRB/JN 40396/APRIL 1987
J
'I
1-10
IMMUKAP—IMPLEMENTER INTERVIEW
r
Name of Respondent
Name of village
Category
District Code
OR
Name of town
Address
District Code
Date
Name of interviewer
Sr. No. of interview
Backchecked :
1
'Unit’ Category
:
Name of Supervisor
Accompanied :
2
Metro
1
District Headquarter
PHC
3
PHS
:
Neither :
:
3
2
4
Without health centre
:
5
11
CLASSIFICATION DATA
1.
I
Health Centre Information Sheet No.
01
12-15
What would you say is your job with regard to immunization ?
What else ?
(IF MORE THAN ONE, NOTE ORDER OF MENTION UNDER RANK)
ANSWER PERTAINS TO :
Rank
Immunizing/vaccinating children
Health education
1
z
2
Keeping track/records
3
Maintaining cold chain and vaccines
4
Sterilizing and preparation
5
Others (specify
6
16-21
2.
Can you tell me the recommended immunization schedule ?
2a
What are’the vaccines given ?
(CODE UNDER COL. 2a) DO NOT PROMPT
ASK FOR EACH VACCINE CODED UNDER COL 2a
2c
What is the name used for this vaccine by the local people ?
2d
How many doses are to be given (CODE UNDER 2d)
2e
To whom is this vaccine to be given (CODE UNDER 2e)
2f
What is the earliest age at which it can be given ? (CODE UNDER 2f)
2g
(IF MORE THAN ONE DOSE) What should the interval
between two doses ?
(CODE UNDER 2g)
PROMPT ON VACCINE NOT CODED UNDER COL 2a;
2b
Does
IF YES CODE
vaccine also form part of the schedule :
UNDER 2b.
ASK
ALL
QUESTIONS
GIVEN
ABOVE
Q. 2c-g. PROMPT ON NEXT UNCODED VACCINE AND REPEAT
TILL YOU HAVE PROMPTED ON ALL UNCODED VACCINES.
UNDER
CONTINUE
2
2a/b
2e
2d
2f
2g
TT
BCG
22—76
DPT
OPV
Measles
Other
CODE BELOW FOR Q. 2
Vaccine
Name
2a
2b
2c
Spontaneous
Aided
Local Name
2d
2f
2e
2g
No.
To whom Earliest
of doses"'~S= ? ;
age
Interval
5. | c ( Mnths) (mths)
(j£r- <r-
Q.3a
TT
1
2
1
x
x
BCG
1
2
X
2
3
DPT
1
2
x
2
3
OPV
1
2
X
2
3
Measles
1
2
x
2
3
Others
1
x
X
2
3
x
X
x
Here are a list of consumable items that you need for a vaccination session. Is the supply of
these regularly available ? READ OUT EACH ITEM
Regular
supply
ITEMS
3b
X
Irregular
Never
received
BCG vaccine
1
2
3
TT vaccine
1
2
3
DPT vaccine
1
2
3
OPV vaccine
1
2
3
Measles vaccine
1
2
3
Vaccine cards
1
2
3
77-82
How many needles and syringes do you have that are usable ?
Needles (all sizes together)
:
Syringes
83—88
3c
What are the diseases that are prevented by these vaccines ?
(NAME VACCINE AND CODE) (IF LOCAL NAME DIFFERENT—REF. Q. 2 ABOVE—USE LOCAL
NAME)
Dip- Whooping Measles
Tetanus Polio theria cough
TB Others
TT
1
2
3
4
5
6
7
BCG
1
2
3
4
5
6
7
OPV
1
2
3
4
5
6
7
DPT
1
2
3
4
5
6
7
Measles
1
2
3
4
5
6
7
I
89—123
(MULTIPLE CODES FOR ONE VACCINE OR ONE DISEASE ARE ACCEPTABLE)
3
4.
For each of the d:.< ases, please answer the following (NAME ONE DISEASE AT A TIME AND
4a.
ASK) :
What are the major symptoms of this disease ? CODE UNDER COL. 4a.
4b.
On a scale of very serious, serious and not serious, where would you rate this disease ? CODE
III i~T?l
I
UNDER COL. 4b
•?
1 — 10
4b
4a.
>
Disease
Polio
Symptoms
Fever and pain in head
Pain IP limb
Paralysis o£afTected limb :
1
2
Very
Serious
Serious
Not
Serious
1
2
3
3
Others (SPECIFY)
Diptheria
Child cannot eat properly :
Swelling in throat
:
White membrane inthroat :
Any other(SPECIFY)
Child keeps coughing
:
Whoop during cough
:
Vomitting after coughing :
Any other (SPECIFY)
1
2
3
1
LL
17—22
3
2
23—28
1
3
2
4
5
Don’t know
Child looks tired
Child loses weight
Persistent cough & fever
Others (SPECIFY) |
1
2
29—34
1
3
2
3
I
4
5
Don't know
Measles
m
1
2
3
Body becomes rigid
Convulsions
Lock jaw
Any other (SPECIFY)
TB
3
2
1
1
2
3
4
5
Don't know
Tetanus
11—16
4
5
Don’t know
Pertussis
LI
4
5
Don’t know
1
2
Fever
Rash
Watery eyes
Cough
Eyes sensitive to light
Any other (SPECIFY)
1
3
2
3
4
N
5
41—46
Don't know
5.
I I
35—40
What are the local names for each of the following as understood by people here ?
READ OUT EACH ITEM.
Local
Tetanus
Polio
Diptheria
Whooping cough
Measles
TB
Umbilical cord
name
6a.
We have spoken about the ideal immunization schedule,
was late for his third DPT/Polio and eligible for
would you give him all 3 together ?
Yes
:
1
No
:
2
DK/CS
:
3
4
However, take a case where a child
the measles vaccine,
In such a case,
47
IF ’2’ CODED, ASK :
Why not ?
48-53
6b.
Do you personally believe that measles should be prevented by vaccination ?
Yes
:
1
No
2
DK/CS
3
IF ‘2’ CODED, ASK :
54
Why do you say so ?
55-60
6c.
If a mother/father said that her child had already had measles, would you still
give the measles vaccine or would you refuse ?
•
Give
1
Refuse
2
DK/CS
3
IF ‘2’ CODED, ASK :
61
Why would you refuse ?
62-67
7.
Are there any situations or circumstances (medical term : contraindications) when you should
refuse vaccination to a child ?
What
situation ?
------------------
For what vaccination ?
DRT
ORV
TT
BCG
Measles
Cough/cold
1
2
3
4
5
Diarrhoea/Vomitting
1
2
3
4
5
Fever below 100°F
1
2
3
4
5
Fever above 100°F
1
2
3
4
5
Malnutrition
1
2
3
4
5
Skin disease/boils
1
2
3
4
5
Others
1
2
3
4
5
No situations or circumstances
1
2
3
4
5
Don't know/Can’t say
1
2
3
4
5
68-112
5
8.
9.
At what temperature must vaccines be kept at the health centre/in your clinic ?
(DO NOT PROMPT)
-F4* to +8°C
1
Other (SPECIFY)
2
Don’t know
3
113
ASK PRIVATE PRACTITIONER/PRIVATE HOSPITALS :
Do you ever take vaccines to any place outside this clinic/hospital ?
Yes
1
2
No
3
DK
114
IF ‘1’ CODED CONTINUE, IF '2’ CODED MOVE TO Q.10e
ASK ALL EXCEPT THOSE WHERE '2' CODED IN Q.9
10a
10b
Can you describe how you would carry vaccines for an immunization session ?
(DO NOT PROMPT) (PROBE TO UNDERSTAND FULLY)
Carry in vaccine carrier
: 1
Keep vials in plastic bag in carrier
2
Carry in vaccine carrier with ice
3
Carry in vaccine carrier with frozen ice packs
4
Ice packs filled with cold water
5
No special care required
6
Don't know
X
Others (SPECIFY)
Y
115-120
How should vials be kept during an immunization session ?
In a cup of ice
:
1
Don’t know
3
On top of an ice pack :
2
Others (SPECIFY BELOW)
4
121-126
I I
10c
3
1-10
Where do you sterilize all needles and syringes for an outreach session ?
At health centre
1
At outreach camp
2
3
Others (SPECIFY)
u_
11-12
10d
lOe
11.
When do you sterilize them (SINGLE CODE)
Before the session
:
1
After the session to keep ready for next session
:
2'
During the session
3
Others (SPECIFY)
4
Which method of sterilization do you use (SINGLE CODE)
Boil for 1—10 minutes
1
Boil for 11—20 minutes
2
Boil for 21—30 minutes
3
Autoclave
4
Keep in antiseptic solution
5
Keep in hot water
6
Others (SPECIFY)
7
If you had a 10-doze DPT vial, what is the minimum number of children that you
would need before you opened the vial ?
Minimum number of children :
13-14
6
12a
What would you do if you had less than | vial of vaccine left over after a
session ? And what would you do if you had more than | vial of vaccine ?
Less than |
More than J
Throw it away
1
1
Put it back in refrigerator
2
2
Mark it and put it back in refrigerator
3
3
Depends on the vaccine
4
4
Others
5
5
Don't know
6
6
19-24
IF '4' CODED. ASK :
b
Which vaccine would you put back and which would you throw away ?
Put back
Throw away
DPT
1
2
OPV
1
2
Measles
1
2
TT
1
2
BCG
1
2
25-29
13a
Were you given special training for immunization ?
Yes
No
1
2
30
IF YES :
Today how satisfactory do you feel this training was compared to what you
need ? (SHOW CARD 'A')
Very satisfactory
1
Satisfactory
2
Not satisfactory
3
Very unsatisfactory
4
Don't know
5
31
IF ‘3’ OR ‘4’ CODED ASK :
Could you specify the areas in which the training was unsatisfactory ?
I
32-39
13b
SHOW MANUAL (OPEN AND SHOW SOME ILLUSTRATED PAGES)
Yes
No
Have you ever seen this manual ?
1
2
Have you seen these illustrations ?
1
2
Do you currently have it with you ?
1*
2
Is the manual useful ?
1
2
40-43
* SPECIFY LANGUAGE
7
SHOW CARD 'A*
How would you rate the Immunization performance of your centre ?
14.
! 1
: 2
: 3
: 4
: 5
: 6
Excellent
Very good
Good
Fair
Poor
DK/CS
44
What do you say so ?
45-52
15a.
Normally, who brings the child for immunization ?
Mainly
Sometimes
Mother of child
1
1
Father of child
2
2
Grandparent
3
3
Others
4
4
I
53-60
15b.
How does a parent keep track of due dates of vaccinations ?
Cards are given
: 1
Vaccinations given at the house on due date: 4
Parents are reminded
: 2
Others
: 5
Parents are called on due date : 3
ASK FOR ALL EXCEPT THOSE WHO CODED '4’ IN Q. 15b.
16a.
the due date ?
Do mothers usually bring the children on
i
All mothers bring child on due date
1
Most mothers bring child on due date
Some mothers bring child on due date
2
Most mothers do not bring child on due date
None of the mothers bring child on due date
4
5
6
3
Don't know/Can't say
IF ‘3’, *4’ OR
16b.
63
5' CODED :
What you think are the reasons for this ?
64-73
17.
In your opinion, who in the family mainly decides on :
(SINGLE CODE FOR EACH ITEM)
Family elder
Male Female
Mother of
child
Father of
child
Immunization of child
1
2
3
4
TT for pregnant weman
1
2
3
4
Taking child to a doctor in the village
1
2
3
4
Taking child to a town doctor
1
2
3
4
Taking child to local faith healer
1
2
3
4
ITEM
74-7S
18.
8
regard to the people in your region would
In favour of
Against
Indifferent
DK
Father of child
1
2
3
4
Mother of child
1
2
3
4
Grandfather of child (Paternal)
1
2
3
4
Grandmother of child (Paternal)
1
2
3
4
Village chief
1
2
3
4
Village elders
1
2
3
4
School teacher
1
2
3
4
Faith healer
1
2
3
4
1
2
3
4
Dai
79-87
19.
For each of the following, would j— -you say the statement is applicable for most
people in your territory, some people or none of the people"?
Most
Some
None
DK
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
People are aware of immunization
People are cooperative and willing
People are indifferent but do not resist
People resist immunization and have to be
coaxed
__
88-91
20a
Do any mothers/parents <ever refuse vaccine even when efforts
are made to
convince/persuade them ?
Most refuse
:
1
Some refuse
:
2
None
:
3
92
IF ‘1’ OR ‘2’ CODED IN 20a, ASK :
20b
Who are the people who refuse ?
20c
Why do you think they refuse ?
What features do they have in common ?
93-100
101-108
20d
In your opinion, what could be done by
persuade them ?
government or others to convince or
109-116
9
If you were asked to name one problem that forms the bipgest obstacle to your
work, which would you name ? (NOTE UNDER MAIN PROBLEM)
21.
What are the other problems that obstruct your work ?
□□
Main problem :
117-118
Other problems
119-126
I
SHOW CARD B :
22.
I
I
I
I
I
4
1-10
If Improvement could be guaranteed in any of the followingj areas, which would
the most
you pick as being I...
----- important ? And which would be second most
important ?
And third ?
Rank
Information to villages about immunization
Supply of vaccines
Supply of ^TComsumables (needles, syringes)
Storage of vaccines—cold chain maintenance
System of travel to villages—roads, transport
Greater number of immunization centres per village
11-16
23a
What % of the eligible infants in your territory have to be vaccinated in 1987.
%
23b
Will these levels of immunization have to be maintained for the future or is it
only for 1987 ?
Only for 1987
1
To be maintained for the future :
2
19
IF •2’, FOR HOW LONG :
I I
20-21
SHOW POSTER ALBUM
24a
A set of posters/tin plates had been made on the subject of immunization
Were these provided to you ?
Yes :
No :
1
2
22
IF YES, ASK Which ones ?
CODE UNDER COL. 24a
Mow many were there in all (approx) Total Number
I
24b
CHECK IF -DISPLAYED AND CODE UNDER COL. 24b.
DONE IN DISPENSARY OR CENTRE, CODE '3' UNDER 24b.
IF INTERVIEW NOT
I
23-25
24c
10
With reference to the ones you have, how would you rate them in terms of
their effect in making people willing to give Immunization (SHOW CARD).
24a
Please pick the phrase that most appropriately describes your rating of the
posters/fin plates,
Poster
24a
24b
PROVIDED
Displayed
Tin plate
Tin
name
24c
26-39
Yes
Exce-
Very
DK
llent
good
Good
Fair
Poor
Poster
plate
1
1 >
1
2
3
1
2
3
4
5
Father & child 2
2
1
2
3
1
2
3
4
5
Polio boy
3
3
1
2
3
1
2
3
4
5
4
4
1
2
3
1
2
3
4
5
TB-mode on
neck
5
5
1
2
3
1
2
3
4
5
TT-bandaged
6
6
1
2
3
1
2
3
4
5
7
7
1
2
3
1
2
3
4
5
Mother &
dead child
INSIDE OUT
SIDE
standing
Polio boy
cram
24b
40-53
24c
Lead
TT-tube in
nose
54-60
25
I have here a set of statements, As I read out each one, please tell me whether
you agree or disagree with the statement :
1.
Convincing people to get their child immunized is
frustrating work
2.
TT and DPT vaccines should not be allowed to freeze
3.
People here do not really believe that vaccinations
can prevent disease
Agree
Disagree
1
2
1
61
2
62
1
2
63
4.
This job involves important and useful work
5.
The cold chain system beyond the HQ hospital is very
weak and breaks down easily
1
2
64
1
r
65
6.
People suspect that vaccinations are not given for the
prevention of diseases but some other motives
1
J
66
11
7.
People have fears with regard to vaccination side effects.
Agree
Disagree
1
2
67
8.
1
Working with illiterate people can be boring and tiring
2
68
9.
I would prefer to work in a town rather than a village
2
1
69
10.
Keeping vaccines at room temperature for 2—3 hours is okay
2
1
70
11.
Once one child has been vaccinated, people will come
forward on their own to get their next child vaccinated
2
1
71
12.
Most vaccines loose potency because it is impossible
to maintain them at the correct temperature
1
2
72
FOR DISTRICT LEVEL INTERVIEWS ONLY
26.
What would you say is the main source of information for villagers in this district,
with regard to :
A
a.
National happenings :
73—78
b.
District level happenings :
79-84
c.
Neighbouring village incidents, fairs, melas, etc.
id
85—90
d
Health Team’s visit :
91—96
27
23.
In your opinion, what message would be best to convince people about
immunization. What should they be told to most effectively convince them ?
SHOW CARD ‘C*
For people in the villages, which of these media should be used :
a.
Which do people believe most in ?
b.
Which one would be most likely to reach them ?
b
a
Believe
a
Believe in
Reach them
Radio
1
1
Hoardings 6
TV
Newspaper
2
2
Leaflets
Magazine
3
4
3
4
Cinema
Others...
Posters
5
5
(Specify)
b
Reach them
in
7
8
9
6
7
8
9
105-122
- Media
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