Sociocultural and geographical disparities in immunization among different geographical regions of Maharashtra

Background In Maharashtra, child immunization is an essential factor in maternal and child health services and effective in reduced child morbidity and mortality. The study focuses on the prevalence of child immunization in different geographical regions of Maharashtra. It also depicts the immunization status (no immunization, partial immunization, and full immunization) according to various socio-demographic characteristics and determinants of full Immunization and partial Immunization among children of age 12–23 months in Maharashtra The fourth round of the National Family Health Survey (NFHS-4) has been used for this study. The univariate analysis and simple chi-square test were conducted to test association. The Multinomial logistic regression model was conducted to determine the determinants of partial and full immunization.


Abstract Background
In Maharashtra, child immunization is an essential factor in maternal and child health services and effective in reduced child morbidity and mortality. The study focuses on the prevalence of child immunization in different geographical regions of Maharashtra. It also depicts the immunization status (no immunization, partial immunization, and full immunization) according to various socio-demographic characteristics and determinants of full Immunization and partial Immunization among children of age 12-23 months in Maharashtra Data source and Methodology: The fourth round of the National Family Health Survey (NFHS-4) has been used for this study. The univariate analysis and simple chi-square test were conducted to test association. The Multinomial logistic regression model was conducted to determine the determinants of partial and full immunization.

Result
In the wealth category, the middle and richest are more likely to receive full immunization than the poorest people statically signi cant effect. In religion, Muslims less likely to receive full Immunization, and Buddhists more likely to use full immunization compare to Hindu people. In the different geographical regions of Maharashtra, North-Maharashtra, West-Maharashtra, Konkan is less likely to have full immunization correspond to the Vidarbha region. Mothers who have any media exposure are more likely to have full immunization compare to no media exposure.

Conclusions
To conclude, the study shows a need to adopt a multi-pronged strategy while formulating an action plan for immunization by keeping in mind that vaccination is a right of every child. An appropriate proportion of childhood immunization is required to develop "Herd Immunity" to protects other unimmunized children. The most "e cient" and "equitable" way should be chosen to deliver vaccination services to identify the population's risk group. Who has remained unimmunized? As immunization in the different geographical regions in Maharashtra remained very far from the target set by Mission Indradhushya. Hence, there is a need to focus more on responsible socio-demographic factors while implementing immunization services.

Background
The distributive approach in health and health inequality is becoming in uential global health agenda (Lauridsen et al. 2011). Millennium development goal (MDG) has emphasized formulating the targets to measure the country-level achievements; childhood immunization is a crucial part of maternal and child health services and one of the essential health indicators among them. 'Sustainable immunization' coverage was one of the major concerns during the 65th world health assembly held in 2012. Collective efforts by the global public health community led to a call for "Decade of Vaccine," which proposed the full bene ts of immunization to all people, regardless of where they are born, who they are, or where they live. WHO, UNICEF in 2002, introduced the concept of 'reaching every district' now times has come to recast it as a 'Reaching Every Community and need of recognition immunization as a core component of the human right to health (Vashistha, National Population policy has been insisted on universal immunization coverage in India. It is the rst country that adapts to the WHO's Expanded Immunization Programme, and remarkable progress has been registered in reducing disease burden since its inception, but it remained unacceptably high compared to other developing countries (Purohit et al.;. The stalled and uneven progress of childhood vaccination in India could result from a complex set of factors associated with the demand for and supply of the vaccines (Prusty et al.,2014). Drop out to different doses of full immunization remains the major challenge in child health; in India, only 62% of the children aged 12-23 months are fully vaccinated by the fourth round of the National Family Health Survey (NFHS-4). The previous study observed the trend and pattern of inequality in child immunization across the region. It led to the argument that the theory of the "inverse equity hypothesis" persisted in India. The theory itself argues that "absolute health inequalities would increase in the short term and would only decline as the intervention gradually reaches the most deprived sectors of the population." Rural and girl children received bene ts in those regions, which observed an increase in average full immunization coverage during 1992-2006(Singh (2013; Khan et al., 2018).
In the Indian states, there is lagging of appropriateness among vaccination timing. The county is a signi cant shareholder in unimmunized children globally; therefore, it is crucial to understand the immunization pattern across different geographies in India (Panda, 2020). One of the most noticeable ndings in the National Family Health Survey over the years has been a decline in the number of fully immunized children's that is the gures have come down from 78.4 % in NFHS-2 to 58.8% in NFHS-3 and the present 56.3% in NFHS-4 (Natu et al., 2020). As per the fourth round of the District Level Household Survey (DLHS-4), only 65.3% of children in Maharashtra were fully immunized (Gawade et al., 2021). For the dismal UPI achievement in India, managerial, administrative, and government-related inadequacies are responsible rather than technical or nancial inadequacies, and the state is responsible for the implementation of immunization, so it is essential to investigate the regional variation of immunization coverage across the state (Vashistha, 2012). Kumar (2011) recorded that spatial pattern in immunization coverage in India is quite puzzling, demographically backward states like Uttar Pradesh, Bihar, and Orissa exhibiting an increase in immunization coverage while decline can be seen economically progressive states like Gujarat and Maharashtra. In the Coverage Evaluation Survey conducted by the Ministry of Health and Family Welfare, over 80% of the complete vaccination records up to 12 months and a meager non-vaccination rate of only 2%. Maharashtra is the participating state in the global post-marketing surveillance network to report AEFI (Adverse Events Following Immunization) associated with the new vaccine (Vashistha, 2012).
To Assess the Level of Child immunization in Different Geographical Regions of Maharashtra. Maharashtra is divided into ve geographical regions: Vidarbha, Marathwada, North-Maharashtra, West-Maharashtra, and Konkan. Vidarbha region contains 11 districts, Marathwada has eight districts, North-Maharashtra consists of ve districts, and the West-Maharashtra has only ve districts. Konkan part of Maharashtra is essential because it contains the capital of the state (Mumbai), consist of seven districts. Maharashtra has 36 districts, but at the time of the NFHS-4 survey, it has only 35 districts.
The economy in Maharashtra has become metropolises highly. Though there is a high economic development, Maharashtra suffers from acute regional inequality. About half of the total income for the state accounted only by the Konkan region; western Maharashtra is the next highest developed region and if followed by Vidarbha and Marathwada (Shaban, 2006). Weak immunization performance in such an undeveloped geographical region may also indicate system failure in reaching the underprivileged population; also, immunization services themselves may be inadequate or ineffective in such areas (Pande et al., 2002). There is a need to check whether the slow-down in immunization coverage is because of supply-side constraints or a change in the program's priority. It is a worrying factor that the decline in immunization among the poor in a progressive state like Maharashtra (Mohanty & Pathak, 2009). As there is a lack of data on various determinants of partial immunization coverage in Maharashtra, which is deemed a better progressive state (Natu et al., 2020), this study will investigate the immunization level and determine various associated factors Maharashtra. Hence, the present study plan to determine the immunization status and the determinants of partial and full immunization among children aged 12-23 months in Maharashtra.

Data Source And Methodology
The fourth round of the National Family Health Survey 2015-16 has been used in this study to investigate the effect of selected background characteristics on immunization coverage. The dataset provides information about the vaccination status of children born in ve years preceding the survey. The line of other Demographic Health Surveys (DHS) comprises a wide range of topics like Fertility, Mortality, family planning, immunization coverage, and nutritional status among children. The data recorded based on a vaccination card (interviewer note down each vaccination against the disease and date of it) or mothers' recall about vaccination except the date of vaccination (if vaccination card is not available). The measure of a child's immunization is a binary outcome, and it was calculated on whether a child aged 12-23 months (age group considers according to WHO schedule of immunization) has been administered all the six vaccinations or not. But in this paper, we have calculated three outcome variables of immunization as following 1) No immunization, 2) Partial immunization 3) Full immunization.
Full immunization: children in the age group of 12-23 months who have received one vaccination of BCG, Measles, and three doses each of DPT and Polio (exclude polio 0) are considered fully immunizations NFHS-4.
No Immunization: children in the age group of 12-23 months who have not received any vaccination are considered non-immunized as per NFHS-4.
Partial Immunization: Children in the age group of 12-23 who received at least one vaccination but not all the vaccination are considered partially immunized as per NFHS-4.
We have shown differentials of immunization according to the following socio-economic characteristics-age of the mothers, childbirth order, place of residence, education of mother, religion, caste/tribe, wealth index, region of Maharashtra.
As the meaningful prevalence of vaccination is available, we have used Relative Risk's computation over the Odds Ratio in this study (Schmidt et al., 2008). also checking association between the following characteristics on immunization outcomes-mothers exposure to mass media, Children Ever Born, Body Mass Index, ANC visits, Sex of child, Children's age, and Morbidity status of children.

Chi-square test
The Chi-square test uses to test the independence of two attributes of a population; it compares two variables in the contingency table to see they are related or not.
The Chi-square statistic is as following Relative Risk Ratio A Relative Risk Ratio is a ratio of two probabilities. (The relative risk is also called the risk ratio).

Treatment a b
Control c d From this table, the probability of an event in the treatment group is a/(a+b)=R1; similarly probability of an event in the control group is c/(c+d) = R2. So the Relative Risk Ratio (RRR) or Risk Ratio will be the ratio of these two probabilities that is R1/R2 In this study, the Event will be Immunization status for partial and full immunization. We have computed the Relative Risk Ratio of immunization coverage for various socio-economic characteristics.
If RRR=1, Association of socioeconomic characteristics with immunization is in question or No association; If RRR is greater than 1, this is evidence of positive association and may be causal; If RRR is less than 1, this is evidence of negative association, indicating a protective effect.
Statistical analyses have done using Stata (version13) software.
Result Figure 1 shows the status of child immunization in different geographical regions of Maharashtra. The full immunization is highest in the Vidarbha region with 57.4 percent and lowest in North Maharashtra with 41.9 percent, followed by Maharashtra, West-Maharashtra, Marathwada, and Konkan, respectively. Marathwada has the highest utilization of partial immunization with 44.7 percent and lowest with 37.1 percent Vidarbha in a geographical region. Konkan has the highest no immunization with 14.3 percent and lowest in Vidarbha, 5.5 percent, followed by North-Maharashtra, West-Maharashtra, and Marathwada. highest rate is 51.08% of partial immunization recorded among women marked as other relation. Mothers from the OBC category with the lowest percentage of no immunization and partial immunization also possess the highest rate of full immunization compared to the rest of the category.
Fifty-three percent of a mother who belongs to the OBC category receives full immunization while only 42.07 percent ST women receive full immunization. As the wealth quintile increases, the level of full immunization also increases. Still, in the case of no immunization, the poorest and richer mothers are almost the same. The percentage of no immunization is high among the richest compared to the rest of the wealth quintile. Only 41.21 percent of the poorest women receive full immunization compared to the richest women receiving 53.33 percent full vaccination. The association is found between the region and the type of immunization. In different geographical regions of Maharashtra, 57.42 percent of women received full Immunization in the Vidarbha region, followed by West-Maharashtra, Marathwada, Konkan, and North-Maharashtra, with the lowest 41.89 percent of women receive the full vaccination. Vidarbha region has the lowest percentage of no immunization and partial immunization coverage and the highest percentage of full immunization coverage.  When it comes to mass media exposure, the mothers exposed to any media are signi cantly more likely to go for partial (RRR=1.35, CI 1.073-1.699) and full immunization (RRR=1.501, CI 1.189-1.895) as compared to mothers with no media exposure. In terms of education, mothers who completed primary and secondary education are signi cantly more likely to go for a child's full immunization that is 1.62 times and 1.66 times, respectively, than illiterate mothers. Mothers having three children birth (RRR=0.711, CI 0.532-0.951) and above four childbirth (RRR=0.55, CI 0.377-0.802) are signi cantly less likely to have full immunization than mothers having one child. In terms of Body Mass Index, Overweight mothers are 37% signi cantly less likely to go for children's partial Immunization (RRR=0.63, CI 0.469-0.845) and 24% signi cantly less likely to go for full Immunization (RRR=0.759 CI 0.567-1.017) as compared to Underweight mother. Sex of child didn't nd signi cantly associated with partial and full immunization in our analysis. A similar result has been found in terms of morbidity of a child whose morbidity status of children doesn't found signi cantly associated with partial and full immunization coverage.

Discussion
In the present study, it was found that the Vidarbha region in Maharashtra has the highest full immunization level and lowest partial and no immunization compared to the rest of the region in Maharashtra. The observation that any of the geographical regions don't ful ll the national target (90%) of full immunization coverage set by Mission Indradhanushya and this much level is needed to disrupt disease transmission also this will protect unimmunized children due to "Herd Immunity" (Malkar et al.,2013). all geographical regions in Maharashtra are not even close to this target.
While comparing with the Vidarbha region, Northern Maharashtra, west Maharashtra, and Konkan are signi cantly less likely to have partial immunization. Other determinants like Mass media exposure, mother age, and BMI status of mothers are also signi cantly associated with Partial immunization coverage in Maharashtra. Many studies on full immunization levels conducted in various districts of different geographical regions in Maharashtra show inconsistent ndings with our research showing a signi cantly higher vaccination rate, studies like Malkar et al.,2013 (78.57%); Khargekar et al.,2015 (71.1%).
Mass media exposure and mother's education were found signi cantly associated with full immunization in our study (Gupta et al., 2013) proclaims the reason for un immunization was rumor and ignorance, which could be changed with proper health education. Similar line results observed in the study (Gatchell et al.,2008), exposure to television was the most vital determinant of childhood immunization in Bihar.
Our study shows a slightly higher rate of full immunization in urban areas than in rural areas (Khan et al.,2020), probably because of the better accessibility and success of the "supply-side" factors. Signi cant inequality based on economic status has been observed even in a better progressive state like Maharashtra (Mathew et al.,2012) similar type of association of wealth index with immunization has been highlighted in our study.
Sex of the children and morbidity status of children doesn't found associated with types of immunization in our analysis akin results have been depicted in the study (Kar et al.,2001), morbidity status of children found the third leading reason for partial immunization in the survey of Wagh et al.,2013. as our study reveals, Muslim mothers are less likely to go for child immunization similar type of signi cant in uence of religion on immunization status also documented in the study (Malkar et al.,2013). Various socioeconomic, cultural, behavioral, and other factors related to religion could be responsible for this. Children with birth orders greater than two are less likely to go for full immunization than rst-order birth. And this found consonant with literature; one possible reason for this could be, till the second and above children mothers started to believe that immunization is risky or unnecessary due to the misleading facts like rstborn child experienced some adverse reaction to immunization or other children in the community, despite being immunized they did not contract the disease.
A slight association between caste status with immunization has been found in our study similar type of ndings illustrated in the study of (Gatchell et al. 2008) Validate the association of caste status with complete childhood immunization in Maharashtra. While the research Sharma (2007) documented that there are no substantial differences in immunization coverage among the children of scheduled caste, scheduled tribes, and other backward classes. However, the range is marginally low among scheduled tribes. However, coverage among the children of different caste groups is much higher.
The present study illustrates that the mothers who had availed full ANC are more likely to have full children Immunization; however, similar ndings also observed in partial immunization. In line with this, the study (De et al.,2002) put forward the same type of observation. One possible reason behind this is interaction at ANC enhancing mothers' knowledge about the bene ts of avail MCH services. Various studies proposed that partial immunization were visited the native place or other sibling are not well and inconvenient time of Immunization (Khargekar et al.,2015). Still, due limitation of data, we couldn't consider that during analysis. To put forward advice for maximizing the full immunization stated as to sustain the contact with a parent for the time between different doses of vaccination and hold the parent's attention during the non-immunization period. It will be adequate to provide some health care packages under maternal and child health (Sharma et al., 2009).

Conclusion
The coordinated effort and effective action plan are base on the multi-pronged strategy required to achieve universal immunization coverage in India (Jatti et al., 2017). Wealth status nds signi cantly associated with immunization status in our study; vaccination is a fundamental right of every child. In 1946, the government's appointed 'Bhore Committee also stated that health care is a fundamental right, not a commodity. The immunization program will run so that the system should pay incentives as it involves other costs like travel costs to reach the site, opportunity cost, and a day spent there instead of work (Pande et al.,2003). Khan et al., 2020 reported that among schedule tribe children, immunization coverage had been found lowest. The possible reason could be poverty and illiteracy, as most of them belong to the low wealth quintile. The rst constraint of these studies is that we couldn't establish causal inference from the observed relationship due to the cross-sectional design of these studies. The second limitation is there may be a chance of recall bias as responses regarding immunization were based on vaccination cards or mother recall-for mothers living in rural areas are where literacy rate among them still not satisfactory. The third limitation could be in NFHS, and there is an increased likelihood of misreporting of children's age that could exhibit selection and information bias in large-scale surveys. Strengthening the ICDS, emphasize health worker participation in implementing the immunization, organizing immunization camps regularly, and providing incentives have shown improvement in the immunization rate (Singh,2013) There is almost non-existence of the VPD (Vaccines-Preventable Disease) surveillance system in India due to which bottleneck in monitoring.
The impact of vaccination is essential to include induction of innovative methods, proper tracking of the program, improving operational e ciency, 'reaching every community,' and integrated health interventions and immunization to attain full immunization.
A massive public campaign like Pulse Polio is required for the remaining vaccine to reduce partial immunization. To bring accuracy in immunization recording purposes, Health Card should be compulsory irrespective of delivery place. Vashistha 2012 also suggests an urgent need to revamp the immunization system by re-de ning and re-designing roles, responsibilities, and coordination among at three-level; the center, state, and district. There is a need to strengthen program management skills at lower and mid-level managers (Sharma, 2007).
The Policymakers must formulate an action plan by considering "e ciency," which is a euphemism for performance, and "equity," which described the distribution of vaccination across the different groups because average value doesn't always re ect an accurate picture or provide information (Mathew et al.,2012). Identifying the high-risk groups to remained unvaccinated and setting up a proper action plan could also be "Equity." The developments had taken place till now in that region of vaccination are strengthening and expanding the cold chain system, also establishing a network of outreach immunization sites to alternatively vaccine delivery model, capacity building of health functionaries, drafting national vaccine policy, and tracking bene ciaries through maternal and child tracking system, etc. (Taneja et al., 2013).