DOI: 10.

18410/jebmh/2015/595

ORIGINAL ARTICLE
ASSESSMENT OF KNOWLEDGE ABOUT IMMUNIZATION OF UNDER
FIVE CHILDREN AMONG MOTHERS ATTENDING OUTPATIENT
DEPARTMENT OF PEDIATRICS IN A TERTIARY CARE HOSPITAL IN
KOLLAM, KERALA
Ahmad Nadeem Aslami1, Athira T. K2, Ankitha K. Salim3, Athira V. Pillai4, Asha T. J5, Bency S6,
Anas S7, Ahemmed A8

HOW TO CITE THIS ARTICLE:

Ahmad Nadeem Aslami, Athira T. K, Ankitha K. Salim, Athira V. Pillai, Asha T. J, Bency S, Anas S, Ahemmed
A. ”Assessment of Knowledge about Immunization of Under Five Children among Mothers Attending
Outpatient Department of Pediatrics in a Tertiary Care Hospital in Kollam, Kerala”. Journal of Evidence
based Medicine and Healthcare; Volume 2, Issue 29, July 20, 2015; Page: 4191-4200,
DOI: 10.18410/jebmh/2015/595

ABSTRACT: BACKGROUND: Immunization is the most cost effective public health intervention
to reduce childhood morbidity and mortality. Thousands of children can be saved from vaccine
preventable diseases each year by immunization. The knowledge of mothers’ is an important
factor for better immunization coverage. Less knowledge affects decision making regarding
immunization. OBJECTIVES: To assess the knowledge about immunization of under five children
among mothers attending outpatient department of paediatrics in a tertiary care hospital in
Kollam, Kerala and to find out the association of the knowledge level of mothers with some
selected variables. MATERIAL AND METHODS: A Cross sectional study was done among
mothers of under five children attending the OPD of pediatrics in a tertiary care hospital in
Kollam, Kerala from 1st to 30th May, 2014. The sample size was 210 and simple random sampling
was used. Statistical analysis was done and chi-square test & percentages were calculated.
RESULT: 93.8% of mothers knew that vaccines are beneficial for their child. 58% were aware
about the side effects of few vaccines. 50% of mothers believed that as polio is eradicated from
India, there is no need to give polio vaccine. 35% of mothers acquired knowledge regarding
immunization through health workers. All of them had knowledge about polio vaccine but only
half of them knew about rotavirus vaccine. 60% mothers believed that multiple vaccines are
beneficial although 26% hold their view that it has no benefit at all. 39.5% of mothers’ had
adequate knowledge about immunization. It was positively associated with education, working
class and high socio-economic status of mothers. CONCLUSION: There are several loopholes in
the mother’s knowledge regarding immunization. Many of them had no knowledge about optional
vaccines. There is a need to improve knowledge regarding immunization among general
population. Adequate information about completing the schedule and correct knowledge about
optional vaccines should be given to mothers.
KEYWORDS: Knowledge, Immunization, Mothers of under five children, Kerala.

INTRODUCTION: Immunization is considered as the most cost effective and safest public
health intervention to reduce childhood morbidity and mortality although its full potential is not
reached yet. Many under five children die from vaccine preventable diseases (VPD’s) each year.1
The burden of infectious diseases has been reduced primary due to immunization. Life

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ORIGINAL ARTICLE
expectancy is also increased due to vaccination.2 Immunization prevents diseases like diphtheria,
measles, pertussis, pneumonia, polio, rotavirus diarrhoea, rubella, tetanus and many more.3
The knowledge of parents are important factors for better immunization coverage.4
Studies did previously show misconceptions on parent’s knowledge towards childhood
immunization. Mother’s educational status and knowledge was clearly associated with coverage of
immunization.5 Less knowledge among mothers bring negative attitude and fear which leads to
affect immunization status of their children. So, physicians must clearly communicate the benefits
and risks to the mothers and try to increase the acceptance.6
Nowadays parents are in doubt of safety and necessity of routine childhood immunization.
A false belief that vaccines can cause autism was very much prevalent among parents in USA.7
Knowledge is necessary to take any decision. Mothers’ knowledge can help them to take
proper decision regarding immunization of her child. Keeping these facts we did a study with the
objective to assess the knowledge about immunization of under five children among mothers
attending outpatient department of paediatrics in a tertiary care hospital in Kollam, Kerala, to find
out the association of the knowledge level of mothers with some selected variables and to impart
health education to mothers regarding childhood immunization.

MATERIAL AND METHODS:

Study Design: A descriptive hospital based cross sectional study.
Setting of the Study: Outpatient department (OPD) of paediatrics in a tertiary care hospital in
Kollam, Kerala.
Study Population: Mothers of under five children attending the OPD of paediatrics.
Duration of Study: 30 days.
Sample Size: In a pilot study done prior to the study with 50 subjects show expected
percentage of the awareness of importance of immunization to be 75. The required sample size
was 200, for precision= 6% and desired confidence level 95%.
Sampling Technique: Simple random sampling. Mothers of first 10 under five children who
were registered in OPD on every day from 1st to 30th May, 2014 till our sample size was over.

INCLUSION CRITERIA: Mothers of under five children who are available at the time of data
collection and who gave consent.

EXCLUSION CRITERIA: Mothers of children more than five years of age and those who did not
gave consent to participate in the study.

Tools and Instruments: A pretested, structured questionnaire was used in the survey. The
proforma contained demographic variables and standard knowledge questionnaire on knowledge
of mothers of under five children regarding immunization.

Survey Technique: Survey was carried by third year undergraduate students as a part of their
project. They were properly trained in the interviewing technique and trained to ask questions in
local Malayalam language.

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ORIGINAL ARTICLE
Socio-economic Status: We used updated Modified BG Prasad classification for April 2013.

Ethical Consideration and Permission: Ethical clearance was obtained from the Central
research Committee of our college. Permission was obtained from the concerned authorities
(Medical Superintendent and Head of the Department, Paediatrics) to conduct the study.
Informed consent was taken from study participants. Data was kept confidential under principal
investigator.

STATISTICAL ANALYSIS: Data collected was entered in Microsoft Excel work sheet. Analysis
was done using SPSS Version 16. Percentages were used to find out various frequencies and chi-
square test was done to find out association between qualitative variables in the study. P values
were kept significant at the level 0.05.

RESULTS: 210 mothers who visited the paediatrics OPD were interviewed using a pretested
questionnaire.

Socio-demographic Profile of Mothers: Table 1 shows that among the 210 mothers, most of
them (45%) were less than or equal to 25 years of age. Religion wise, Muslims were in majority
(53%). 53% of mothers belonged to nuclear families. Nearly 48% of mothers were having
education more than or equal to 12th Standard. In our study population, nearly 63% of the
mothers were housewives. According to Socio-economic status, nearly 55% were of High class I.
When enquired to mothers about the decision maker in family regarding immunization of child,
40% told us that it is them although nearly 56% hold the view that both parents decide.

Particulars Frequency (%)

Age group (years)
≤ 25 94(44.8)
26-30 73(34.8)
31-35 31(14.8)
≥ 36 12(5.7)
Total 210
Religion
Hindu 81(38.6)
Muslim 111(52.9)
Christian 18(8.6)
Type of family
Nuclear 112(53.3)
Joint 98(46.7)
Education
≥12th Std 101(48.1)
<12th Std 109(51.9)

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Employment status of mothers
Housewife 132(62.9)
Working 78(37.1)
Socioeconomic status
class I 115(54.8)
class II 31(14.8)
class III 20(9.5)
class IV 27(12.9)
class V 17(8.1)
Decision maker
regarding immunization
Mother 86(40.1)
Father 7(3.3)
Both 117(55.8)
Table 1: Socio-demographic characters
of the study population (N=210)

Knowledge of Mothers Regarding Immunization: Table 2 shows that 93.8% of mothers

knew that vaccines are beneficial for their child. Nearly 22% mothers believed wrongly that there
are different vaccines for boys and girls. 38% told us that if one dose is missed, there is no
benefit of taking the vaccine later which is actually not correct. Only 107 mothers knew about
rotavirus vaccine and among them only 47.7% knew that it protects from severe diarrhoea.
Nearly 50% of mothers had incorrect information that as polio is eradicated from India, there is
no need to give polio vaccine. 89.5% knew that vaccine card is important and it helps in
monitoring child’s growth.

SL. Correct
Knowledge Question
No Response (%)
1 Vaccine is beneficial 197(93.8)
2 Vaccination should start at birth 178(84.8)
3 There are different vaccines for males and females 46(21.9)
4 Not all vaccines prescribed by doctors is useful 107(50.9)
5 Vaccines should always be taken on its due time 195(92.8)
6 If one dose is missed, there is no benefit if taken later 80(38.1)
7 Child with fever should not get any vaccine 65(30.9)
8 Vitamin A must be given to children less than five years of age 151(71.9)
9 Rota virus vaccine protects from severe diarrhea (n=107)
*
51(47.7)
10 There are some side effects of few vaccines 122(58.1)
11 Polio is eradicated form India, so no need to give vaccine 106(50.5)
12 Vaccine card also helps in monitoring child’s growth 188(89.5)
Table 2: Knowledge of mothers regarding immunization (N=210)

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Source of Knowledge: Figure 1 tells us that 35% of mothers acquired knowledge regarding
immunization through health workers. The percentage of mothers who got knowledge from
media, anganwadi centres and hospitals were 32%, 29% and 25% respectively.

Fig. 1: Source of Knowledge of Mothers Regarding Immunization (N=210)

Knowledge of Mothers Regarding Individual Vaccines/VPD’s: When asked about

individual vaccines, 87.6% knew about BCG and they also knew that it protects from Tuberculosis
[Table 3]. The knowledge regarding diphtheria, pertusis, tetanus was 71.9%, 72.9% and 91.9%
respectively. 84.8% knew about measles vaccine. Only 73.3% of mothers knew about varicella
and 65.7% were aware of typhoid vaccine. Figure 2 shows us the awareness of mothers
regarding benefits of multiple vaccines. 60% mothers believed that multiple vaccines are
beneficial although 26% hold their view that it has no benefit at all.

Vaccines/ VPD’s Yes (%)

Tuberculosis/BCG 184 (87.6)
Diphtheria 151 (71.9)
Pertussis 153 (72.9)
Tetanus/ TT 193 (91.9)
Measles 178 (84.8)
Polio 210 (100)
Hepatitis B 197 (93.8)
Pneumonia/ HiB 155 (73.8)
Rotavirus 107 (50.9)
Varicella/ Chickenpox 154 (73.3)
Typhoid 138 (65.7)
Table 3: Knowledge of Mothers Regarding Individual Vaccines/ VPD’s

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Fig. 2: Awareness of Mothers about Multiple Vaccines given to Child

Knowledge Level of Mothers: We classified mothers according to their knowledge level [Table
4]. A scoring system was developed for each question. Those who scored more than or equal to
60% were labeled as having adequate knowledge while those scoring less than 60% were having
inadequate knowledge. 83 mothers (39.5%) had adequate knowledge while 60.5% had
inadequate knowledge. We found that the knowledge level among those mothers who were
having high education level (12th Standard pass) was more as compared to those having less
education level (below 12th Std.) and the difference is highly significant. Working mothers had
better knowledge (52.6%) as compared to housewives (31.8%) and this difference is also
significant. The mothers who were of high socio-economic status (Class I and II) were having
significantly better knowledge as compared to mothers belonging to lower class (Class III, IV and
V).

Factors Knowledge Level

Statistics
Education Adequate (%) Inadequate (%) OR C.I. of OR
≥ 12th Std. 58 (57.4) 43 (42.6) 4.53 2.49 – 8.22
χ 2 = 26.09, DF = 1,
<12th Std. 25 (22.9) 84 (77.1) 1 -
p < 0.0001
Total 83 (39.5) 127 (60.5) - -
Occupation
Working 41 (52.6) 37 (47.4) 2.37 1.33 – 4.22 χ 2 = 8.33, DF = 1,
Housewife 42 (31.8) 90 (68.2) 1 - p = 0.003

SES
I & II 71 (48.6) 75 (51.4) 4.10 2.02 – 8.31 χ 2 = 16.62, DF = 1,
III, IV & V 12 (18.7) 52 (81.3) 1 - p < 0.0001

Table 4: Association of Knowledge of Mothers with their Socio-Demographic Factors

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DISCUSSION: 40% of the mothers in our study told us that they are themselves the decision
maker in family regarding immunization of their child. A study done in Kashmir showed that 66%
of decisions regarding immunization of children were taken by mother’s themselves.8

Knowledge of Mothers Regarding Immunization: 93.8% of mothers knew that vaccines are
beneficial for their child. Similar results were reported in studies done in different parts of the
world.9-12
Usually administration of vaccines may be associated with some side effects like pain,
swelling as well as redness at the injection site. 13 58% of our study population was aware about
the side effects of few vaccines. Nearly half of mothers had incorrect information that there is no
need to give polio vaccine.

Source of Knowledge: Majority of mothers acquired knowledge regarding immunization

through health workers. Singh et al also find out in their study that major source of information
were health workers.14

Knowledge of Mothers Regarding Individual Vaccines/VPD’s: 87.6% knew about BCG

and they also knew that it protects from Tuberculosis. The knowledge regarding diphtheria,
pertussis, tetanus was 71.9%, 72.9% and 91.9% respectively. 84.8% knew about measles
vaccine. A study done in rural West Bengal showed that 62% named polio, 61% measles, 53%
TB but very few named diptherua, whooping cough and tetanus.15
Regarding polio vaccine 100% mothers had knowledge about it. Nearly 94% had
knowledge about Hepatitis B. A study done by Kapoor and Vyas found that 85% of mothers had
knowledge about polio although only 15% knew about Hepatitis B.16 Only three fourth of mothers
knew about varicella and two thirds were aware of typhoid vaccine.

Knowledge of Mothers Regarding Combined/multiple Vaccines: 60% mothers believed

that multiple vaccines are beneficial although 26% hold their view that it has no benefit at all.
There is a need for policy makers to make people understand that combined vaccines are
safe and equally effective than individual ones.17 8% of mothers labeled combined vaccines to be
harmful for their child. A study showed a quarter of parents believed that their child’s immunity
becomes weak as a result of too many vaccines given simultaneously.18

Knowledge Level of Mothers: 39.5% mothers had adequate level of knowledge regarding
immunization. A study done in Mangalore showed that 30% of mothers had poor knowledge
while 44% had average knowledge regarding immunization.19
Knowledge level was positively associated with education, working class of mother and
high socio-economic status. Higher educational level helps the parents to understand the
important educational messages well and they have better chances to understand about
immunization.20

CONCLUSION: The present study focuses on knowledge of immunization among mothers of

under five children. A better understanding of various issues associated with immunization among

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mothers is a big challenge for doctors and health workers. There are several gaps in the mother’s
knowledge regarding availability of vaccines for specific diseases especially optional vaccines.
Some of them had no knowledge about the diseases for which their child is immunized. Majority
of mothers have no knowledge about rotavirus vaccination. Half of the mothers are not ready to
give polio vaccination since it eradicated. There was a significant association between adequate
knowledge level of mothers regarding immunization level and the high educational status,
working status of mothers and high socioeconomic status of mothers.

RECOMMENDATIONS: Enhance the knowledge of people in general and mothers in particular

about immunization and vaccine preventable diseases by providing them health education. There
is a need to strengthen Information Education and Communication (IEC) activities to improve
knowledge regarding immunization among population. The role of media in the form of
advertisements in radio and television and involving famous film personalities and politicians to
encourage people for immunization activities is the need of the hour. Motivation of health
workers is necessary to disseminate information regarding immunization. Specific information
about importance of completing the schedule and knowledge about optional vaccines should be
given to mothers. Even though polio is eradicated from our country, there is a need to continue
routine immunization of polio. This should be aware to all the mothers. There is a lot more scope
for further exploring the area of research in immunization. Awareness and practice of mothers
regarding immunization should also be included in further studies.

LIMITATIONS: This study was limited to mothers coming in OPD of one tertiary medical
college, so we cannot generalize it to the mother of whole state. Future researches on the topic
are needed from different places of the state and country. Primipara as well as multipara mothers
were included in the study. Multipara mothers have better knowledge due to their past
experience with immunization of their children.

REFERENCES:
1. Immunization Handbook for Medical officers; Dept. of Health & Family Welfare, Govt. of
India; 2009.
2. Andre FE, Booy R, Bock HL, Clemens J, Datta SK, John TJ, et al. Vaccination greatly reduces
disease, disability, death and inequity worldwide. Bull World Health Organ 2008; 86: 140-6.
3. World Health organization media centre. Immunization coverage Fact sheet 2013 No378
reviewed April 2015.
4. Jheeta M, Newell J. Childhood vaccination in Africa and Asia: the effects of parents’
knowledge and attitudes. Bull World Health Organ 2008; 86: 419.
5. Siddiqi N, Siddiqi AE, Nisar N, Khan A. Mothers’ knowledge about EPI and its relation with
age-appropriate vaccination of infants in peri-urban Krachi. J. Pak Med Assoc. 2010; 60:
940-4.
6. Kimmel SR, Burns IT, Wolfe RM, Zimmerman RK. Addressing immunization berriers,
benefits, and risks. J Fam Pract 2007; 56: S61-9.

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DOI: 10.18410/jebmh/2015/595

ORIGINAL ARTICLE
7. Smith MJ, Woods CR, Marshall GS. Parental vaccine concerns in Kentucky. J Ky Med Assoc
2009; 107: 342-49.
8. Hamid S, Andrabi S A H, Fazli A, Jabeen R. Immunization of Children in a Rural Area of
North Kashmir, India: A KAP Study. Online Journal of Health and Allied Sciences 2012; 11:
1-4.
9. Bernsen RM, Al-Zahmi FR, Al-Ali NA, Hamoudi RO, Ali NA, Schneider J, et al. Knowledge,
attitude and practice towards immunizations among mothers in a traditional city in the
United Arab Emirates. Journal of Medical Sciences 2011; 4: 114-21.
10. Asim M, Malik N, Yousaf H, Gillani, Habib N. An assessment of parental knowledge, belief
and attitude toward childhood immunization among minorities in rural areas of District
Faisalabad, Pakistan. Mediterranean Journal Journal of Social Sciences 2012; 3: 153-9.
11. Mollema L, Wijers N, Hahne SJ, van der Klis FR, Boshuizen HC, de Melker HE. Participation
in and attitude towards the national immunization program in the Netherlands: data from
population-based questionnaires. BMC Public Health 2012; 12: 57.
12. Borras E, Dominguez A, Fuentes M, Batalla J, Cardenosa N, Plasencia A. Parental knowledge
of paediatric vaccination. BMC Public Health 2009; 9: 154.
13. Kimmel SR. Vaccine adverse events: separating myth from reality. Am Fam Physician 2002;
66: 2113-20.
14. Singh MC, Badole CM, Singh MP. Immunization coverage and the knowledge and practice of
mothers regarding immunization in rural area. Indian J Public Health 1994; 38: 103-7.
15. Mandal S. Basu G, Kirtania R, Roy SK. Care Giver’s knowledge and Practice on Routine
Immunization among 12-23 months children in a Rural Community of West Bengal. IOSR
Journal of Dental and Medical Sciences (IOSR-JDMS) 2013: 6: 105-11.
16. Kapoor R, Vyas Sheetal. Awareness and knowledge of mothers of under five children
regarding immunization in Ahmedabad. Healthline 2010; 1: 12-5.
17. Hilton S, Petticrew M, Hunt K. ‘Combined vaccines are like a sudden onslaught to the body’s
immune system’: parental concerns about vaccine ‘overload’ and ‘immune-vulnerability’.
Vaccine 2006; 24: 4321-7.
18. Gellin BG, Maibach EW, Marcuse EK. Do parents understand immunization? A national
telephone survey Pediatrics 2000; 106: 1097-102.
19. Jose J, Lobo MR, Nisha K, Shilpa GS, Umarani J. Awareness on Immunization among
Mothers of Underfive Children. International Journal of Innovative Research & Development
2013; 2: 620-7.
20. Papazoglou A, Giamaiou K, Poulopoulou S, Pavlopoulou I, Tsoumakas K. The National
Vaccination Programme in Greece: Factors affecting Parents’ Knowledge. Global Journal of
Medical Research Interdisciplinary 2013; 13.

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5. 3rd Year Student, Department of

AUTHORS:
Community Medicine, Travancore
1. Ahmad Nadeem Aslami
Medical College, Kollam, Kerala.
2. Athira T. K.
6. 3rd Year Student, Department of
3. Ankitha K. Salim
Community Medicine, Travancore
4. Athira V. Pillai
Medical College, Kollam, Kerala.
5. Asha T. J.
7. 3rd Year Student, Department of
6. Bency S.
Community Medicine, Travancore
7. Anas S.
Medical College, Kollam, Kerala.
8. Ahemmed A.
8. 3rd Year Student, Department of
Community Medicine, Travancore
PARTICULARS OF CONTRIBUTORS: Medical College, Kollam, Kerala.
1. Assistant Professor, Department of
NAME ADDRESS EMAIL ID OF THE
Community Medicine, Travancore
CORRESPONDING AUTHOR:
Medical College, Kollam, Kerala.
Dr. Ahmed Nadeem Aslami,
2. 3rd Year Student, Department of
Assistant Professor,
Community Medicine, Travancore
Department of Community Medicine,
Medical College, Kollam, Kerala.
Travancore Medical College,
3. 3rd Year Student, Department of
Kollam-691589, Kerala, India.
Community Medicine, Travancore
E-mail: ahmednadeemaslami@gmail.com
Medical College, Kollam, Kerala.
4. 3rd Year Student, Department of
Date of Submission: 06/07/2015.
Community Medicine, Travancore
Date of Peer Review: 07/07/2015.
Medical College, Kollam, Kerala.
Date of Acceptance: 11/07/2015.
Date of Publishing: 17/07/2015.

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