Vaccination Coverage and Factors Associated with Routine Childhood Vaccination Uptake in India: Findings from a National Survey and Household Surveys in Vellore, Southern India

Mark Francis

Research output: Book/ReportDoctoral thesisCollection of Articles


The Indian Universal Immunization Program (UIP) was established in 1985 and is tasked with vaccinating nearly 27 million children every year. Its most recent achievements include India being certified polio-free in 2014 and the subsequent elimination of neonatal tetanus in 2015. Despite these successes, reports of persistently suboptimal full vaccination coverage (children aged 12-23 months who receive three doses of DPT and OPV and one dose of BCG and measles vaccination) in many Indian districts led to the launching of the Mission Indradhanush (MI) campaign in 2014. This campaign aimed to increase full immunization coverage in the poorest performing districts to 90% by 2020, mainly through special immunization sessions and enhancing community engagement and mobilization of beneficiaries. While early administrative reports suggested improved immunization coverage in the MI districts after the first two phases of the campaign, these improvements were considered insufficient to achieve the MI coverage goal. Concurrent research assessing demand-side disparities (including individual and household characteristics such as children’s age and gender, parental education and occupation, socio-economic status, religious affiliation, and health- seeking behavior) in routine childhood vaccination uptake can bolster these governmental efforts to increase vaccination coverage uniformly. Therefore, the overall aim of this dissertation was to assess vaccination coverage and the factors associated with routine vaccination uptake among children aged 12-23 months, both nationally and subnationally, in the Vellore district of Tamil Nadu, southern India.

The first objective of this dissertation was to investigate the factors associated with routine vaccination uptake and describe the reasons for non-vaccination among Indian children aged 12-23 months nationally during 1998 and 2008 using the publicly available district-level household and health facility survey (DLHS) datasets (Study I). The study estimated that 53%, 32%, and 15% of children were fully vaccinated, partially vaccinated, and unvaccinated. Multivariate analysis revealed that children’s vaccination status was inversely associated with female gender, Muslim religion, lower caste, urban residence, lower maternal education, fewer antenatal visits, and non-receipt of maternal tetanus vaccination. Furthermore, a qualitative analysis of the mothers’ reasons for not vaccinating their children revealed gaps in awareness (of the need for vaccines), acceptance (including fears of side effects), and affordability (mainly due to indirect costs) as the main reasons for non-vaccination.

The second objective of this dissertation was to estimate vaccination coverage and investigate the factors associated with routine vaccination uptake among children from rural (Study II) and disadvantaged communities (Study III) in Vellore, southern India, during 2017 and 2018. Vellore and 600 other Indian districts were selected for intensified routine immunization through the MI campaign in 2015. Cross-sectional household surveys and focus group discussions were conducted among parents of children aged 12-23 months from rural and disadvantaged (Nomadic, tribal, and migrant) communities in Vellore. The proportions of fully vaccinated children were 96% and 65% based on information from vaccination cards or parental recall for children from rural and disadvantaged communities. While no socio-demographic characteristics were associated with childhood vaccination uptake, parental familiarity with the vaccination schedule and receiving information on vaccinations during antenatal visits were positively associated with children’s vaccination status in rural Vellore. However, maternal employment was negatively associated with children’s vaccination status in the survey among the known disadvantaged communities in Vellore. Focus group discussions with parents in these communities identified difficulties accessing routine immunization when travelling for work, knowledge gaps regarding the benefits and risks of vaccination, and fears due to common side effects following childhood vaccination.

In summary, the studies in this thesis reveal differences in vaccination coverage and the demand-side factors associated with routine childhood vaccination uptake nationally and subnationally in the Vellore district. The persisting disparities in childhood vaccination uptake by maternal and household characteristics nationally call for targeted interventions and additional research on the causal pathways through which maternal characteristics influence decision-making for childhood vaccinations in India. In addition, the household surveys in Vellore provide preliminary evidence that the MI campaign may have increased full vaccination coverage in some but not all communities or regions within the targeted districts.

Finally, the identified knowledge gaps regarding the need for vaccinations and fears due to vaccination in general or vaccine side effects highlight the potential for utilizing ongoing information, education, and communication interventions to simultaneously improve parental awareness and build trust in childhood vaccines. Collectively, the quantitative and qualitative findings of these studies provide valuable demand-side perspectives toward routine childhood vaccines and actionable evidence to inform targeted interventions to sustain or increase childhood vaccination uptake in Indian settings.
Original languageEnglish
Place of PublicationTampere
ISBN (Electronic)978-952-03-2437-7
Publication statusPublished - 2022
Publication typeG5 Doctoral dissertation (articles)

Publication series

NameTampere University Dissertations - Tampereen yliopiston väitöskirjat
ISSN (Print)2489-9860
ISSN (Electronic)2490-0028


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