Prevalence and predictors of immunization in a health insurance plan in a developing country

Abstract

The aim of the present study was to describe rates and predictors of compliance with immunization schedule among children enrolled in the Health Insurance Plan of the American University of Beirut.
Charts were reviewed for 774 children, and 154 parents underwent a randomly selected sample survey of demographic characteristics, parental behavior and attitudes, and health-care system variables.
The overall compliance rate was 49.9%. By age 4 years, 54.6% of children had taken the required vaccines on time. A total of 86% of parents whose children were non-compliant had recall bias. Age of the child (older), incorrect parental perception of immunization status, mother's low education, and use of other health-care facility, were associated with non-compliance.
Health education about vaccines should be promoted, with an emphasis on high-risk groups. Recall systems and other tools to increase immunization coverage may have an effective role, but in developing countries, aspects such as wide availability of computers and addresses need to be secured before such implementation.

Full text

Pediatrics International (2009) doi: 10.1111/j.1442-200X.2008.02769.x
© 2009 Japan Pediatric Society
Vaccination is an important public health intervention to achieve
a high standard of community well-being.
1 – 3 Present vaccines
prevent morbidity and mortality for millions of individuals every
year. During the last decade the reported coverage of the three
doses of oral polio virus vaccine (OPV3) remained relatively
stable at approximately 80% globally, ranging from 53% in the
African Region to 93% in the Western Pacifi c Region. While
industrialized countries are shifting more and more to injectable
polio vaccine vaccination and poliomyelitis is progressively dis-
appearing in most regions, the most challenging question for the
eradication initiative is when and how to stop the polio virus
vaccine administration.
4
In developing countries, such challenges appear to be more
remote, and eradication lags behind. In this context the success
of routine childhood immunization is demonstrated by high
immunization rates or low rates of preventable illnesses, which
are the main contributing indicators of effective vaccination.
Improvement of the immunization rate, which, besides being a
reliable indicator of health-care quality and a good performance
measure for many managed care systems, is by itself an impor-
tant goal.
5
Reasons for under-immunization include: parents’ religious
or philosophical objections, parents’ failure to present children
for well care visits, parents’ and clinicians’ failure to recognize
that scheduled doses are due, real and inappropriately perceived
contraindications, fi nance obstacles, vaccine supply shortages,
and deferred dose visits.
6
Although adherence to vaccination was extensively studied,
there are factors peculiar to each country, especially developing
ones, which differ with sociodemographic and personal factors,
number of children, birth order, family size, mother’s education,
receiving health-care services, family environment, and the
mother’s history of prenatal care use.
2,7,8 In addition, the fi nancial
barriers are larger in developing countries, and these include low
income and lack of insurance, lack of routine source of health
care, and decreased availability of physician services.
9 – 11
In Lebanon, very few studies have been conducted to investi-
gate factors associated with immunization status of children.
In two rural areas, reasons for failure to immunize or to miss vac-
cination in the primary series of OPV and diphtheria pertussis
tetanus (DPT; decrease from 71.3% in 1994 to 61.7% in 1997)
were related to lack of awareness of parents about the impor-
tance of vaccination, mis-conceptions or contraindications and
fear of side-effects.
12 No studies, however, were done in well-
structured managed health-care system where access to health
care is readily available.
The need to identify variables that help in predicting compli-
ance with immunization is thus critical in view of the eradication
targets for polio and measles set by the World Health
Organization.
In addition, in developing countries, the decision of policy
makers to incorporate new vaccines in the national calendar will
Original Article
Prevalence and predictors of immunization in a health
insurance plan in a developing country
Durriyah D. Sinno , 1 Hikma A. Shoaib , 2 Umayyah M. Musharrafi eh 3 and Ghassan N. Hamadeh 3
1 Department of Pediatrics , 2 Faculty of Health Sciences and 3 Department of Family Medicine,
University Health Services, American University of Beirut, Beirut, Lebanon
Abstract Background : The aim of the present study was to describe rates and predictors of compliance with immunization
schedule among children enrolled in the Health Insurance Plan of the American University of Beirut.
Methods : Charts were reviewed for 774 children, and 154 parents underwent a randomly selected sample survey of
demographic characteristics, parental behavior and attitudes, and health-care system variables.
Results : The overall compliance rate was 49.9%. By age 4 years, 54.6% of children had taken the required vaccines on
time. A total of 86% of parents whose children were non-compliant had recall bias. Age of the child (older), incorrect
parental perception of immunization status, mother’s low education, and use of other health-care facility, were associated
with non-compliance.
Conclusions : Health education about vaccines should be promoted, with an emphasis on high-risk groups. Recall
systems and other tools to increase immunization coverage may have an effective role, but in developing countries,
aspects such as wide availability of computers and addresses need to be secured before such implementation.
Key words compliance , immunization rate , pediatrics , predictors of compliance , recall bias , tracking system .
Correspondence: Durriyah D. Sinno, MD, American University of
Beirut, PO Box 11-236, University Health Services, Riad El-Solh,
Beirut 1107 2020, Lebanon. Email: ds03@aub.edu.lb
Received 14 June 2007; revised 4 August 2008; accepted 12
September 2008.

2 DD Sinno et al.
© 2009 Japan Pediatric Society
always partly depend on fulfi lling the requirement of more urgent
and basic vaccines that target serious disease. The absence of
nation-wide studies, and tight budget allocations in third world
countries will cause diffi culty for policy makers when deciding
on newly introduced vaccines such as varicella and rotavirus.
Thus, lag in the basic vaccine immunization schedule is an
important issue, and it may slow down the adoption of newly
introduced vaccines, affecting future vaccine policies.
The aim of the present study was therefore to investigate the
rates of compliance with the immunization schedule for basic
vaccine among children aged 0 – 7 years in a managed care sys-
tem, and identify factors and predictors of non-compliance that
are peculiar to Lebanon.
Methods
Materials
The current retrospective study was conducted at the University
Health Services (UHS) of the American University of Beirut
(AUB). The AUB Medical Center is a 400-bed tertiary hospital
and an academic center affi liated with the AUB. It offers critical
care and operates a 24 h emergency service. UHS is a primary
health-care center located near the hospital and run by family
physicians and two pediatricians. It provides free services to the
employees of the university and their dependents. The UHS
functions from 07.30 hours to 16.00 hours on an appointment
and walk-in system. It serves both academic and non-academic
appointees from different Lebanese districts, socioeconomic
classes, and educational backgrounds. Well-baby care and vacci-
nation are services provided at the UHS.
Charts of all children born between 1994 and 2001 were
retrieved and reviewed for the year 2003 ( n ⫽ 1334). The
immunization schedule of each child as documented in the
charts was compared to that adopted in Lebanon by the Minis-
try of Public Health ( Appendix 1 ). A total of 774 children were
found to have received at least one vaccination shot at UHS.
Compliance with vaccination was classifi ed as A, B, C or D
( Table 1 ). Delay in vaccination was calculated according to
Appendix 2 .
The aim of the survey was to study the demographic charac-
teristics, parental attitudes and knowledge, and health-care sys-
tem variables.
To identify predictors of compliance with the immunization
schedule, a randomly selected subsample survey was conducted
whereby 200 questionnaires were sent to parents with regard to
the variables listed in Table 2 .
To determine factors that predict non-compliance with the
schedule for children aged 0 – 7 years at UHS, binary logistic
regression was performed using the forced entry method.
The Institutional Review Board (IRB) at AUB was consulted
and approval was obtained for the study.
Statistical analysis
Statistical analysis was done using SPSS for Windows version
11.5.0 (SPSS, Chicago, IL, USA ). In bivariate analysis the ␹ 2 test
was used for categorical variables, and Spearman and Kendall’s
tau correlation coeffi cients were used for associations between
variables. Logistic regression was carried out for variables that
were signifi cantly associated with the outcome to fi nd the predic-
tors of compliance.
Results
Immunization rates for each vaccine
Of the 774 children, 386 (49.9%) were ‘compliant with immu-
nization schedule’ (group A). The immunization rates for each
vaccine were calculated as shown in Table 1 . The rates of com-
pliance with the vaccination schedule decreased from the pri-
mary to the secondary series to the booster doses. A total of
56.99% of the studied group completed the primary series of
OPV-DPT on time, 39.93% the secondary series and 20.50%
the tertiary series. The same was noted for Haemophilus infl u-
enzae type b (Hib) primary and secondary series, and for
both series of the measles, mumps and rubella vaccine (MMR1
and MMR2).
Factors that were signifi cantly associated with compliance
from the chart review were age of child, parent’s employment
and completion of the primary immunization series ( Table 3 ).
Table 1 Immunization rates for each vaccination series (chart review, n ⫽ 7 7 4 )
Vaccine Immunization groups Total no. children
eligible to take the
vaccination series
n (%)
All doses
taken on time (A)
n (%)
All doses taken
but delayed (B)
n (%)
Missed one or
more doses (C)
n (%)
Vaccination followed
up elsewhere (D)
n (%)
Hepatitis B 292 (39.25) 157 (21.10) 146 (19.62) 149 (20.02) 744
OPV-DPT Primary
(3 doses)
53 (56.99) 12 (12.90) 19 (20.43) 9 (9.68) 93
OPV-DPT Secondary
(4 doses)
109 (39.93) 51 (18.68) 93 (34.06) 20 (7.33) 273
OPV-DPT (Tertiary) 74 (20.50) 74 (20.50) 197 (54.57) 16 (4.43) 361
HIB Primary (3 doses) 44 (47.31) 13 (13.98) 23 (24.73) 13 (13.98) 93
HIB Secondary (4 doses) 271 (41.37) 81 (12.37) 155 (23.66) 148 (22.59) 655
Measles 406 (56.23) 57 (7.89) 259 (35.87) 722
MMR 1 dose 193 (62.26) 30 (9.68) 87 (28.06) 310
MMR 2 doses 26 (7.20) 19 (5.26) 214 (59.30) 102 (28.25) 361
DPT, diphtheria pertussis tetanus; HIB, Haemophilus infl uenzae type b; MMR, measles mumps rubella; OPV, oral polio virus vaccine.

Prevalence and predictors of immunization 3
© 2009 Japan Pediatric Society
Compliance decreased as the child aged and increased with
higher parental education as refl ected by employment position.
Completion of the primary immunization series on time was
associated with higher compliance with the schedule.
Predictors of compliance with vaccination schedule
Of the 200 questionnaires sent to parents of children who were
randomly selected, 154 responded (response rate: 78%).
Only eight variables were signifi cantly associated with the
outcome ( Table 4 ). Age of the child was found to be negatively
correlated with compliance. Child age <2 years, female gender,
parental high education, and non-smoking in the mother were
found to be signifi cantly associated with compliance. Perception
of the mother about her child’s vaccination status was positively
correlated with compliance and had the highest correlation coef-
fi cient. Of the structural variables, presence of a regular health-
care provider was associated with better compliance.
The variables that were highly signifi cant, namely, ‘mother’s
perception of her child’s compliance status’, ‘child age’, ‘educa-
tion of the mother’, ‘seeking of other health-care services’, and
‘presence of a regular provider’ were included in the logistic
regression model to identify predictors of compliance. The only
signifi cant predictor of compliance was ‘mother’s perception of
her child’s compliance status’ ( ␹ 2 ⫽ 104.6, P ⫽ 0.00; – 2log like-
lihood [2LL] ⫽ 206.234, R 2 L ⫽ 0.507). That is, the mother’s
incorrect perception of her child’s compliance status alone pre-
dicted 50.7% of the variance in the outcome. Exp ␤ of mother’s
perception was 69.1397 (95% confi dence interval: 24.5 – 195.5;
P ⫽ 0.000). The odds of the outcome occurring (non-compli-
ance status) are 69-fold higher when the mother’s perception of
her child’s compliance status is wrong.
The regression was repeated in an attempt to explain the
49.3% unexplained variance in the outcome, with the mother’s
perception variable excluded. The model ␹ 2 was 21.621 ( P ⫽
0.0002). The original 2LL when only the constant was included
was 195.8385, hence the Hosmer – Lemeshow measure
RL
2 ⫽ 0.1104 (dividing ␹ 2 by – 2LL), that is, the model including
‘highly educated mother’, ‘having a regular health-care provider’
and ‘child age >2 years’ predicted only 11.04% of the variance in
the outcome ( Table 5 ).
Discussion
This is the fi rst study in Lebanon to investigate vaccination rates
in a well-structured health-care system, extending over a 7 year
period, and involving all vaccines simultaneously. The data
obtained shed light on the extent of the problem and provide a
reference for future studies.
The present fi ndings indicate a high overall compliance rate
of 49.9% with the vaccination schedule. Of signifi cance is the
relatively high compliance for the whole set of vaccines required
up to the age of 7 years. Previous studies have illustrated the cor-
relation between sociodemographic factors such as child age,
family size and birth order, and compliance with the vaccination
schedule. 2,7,8 The present study shows that child age is signifi -
cantly correlated with compliance. A total of 71% of children
<2 years of age were found to be compliant with the schedule
( P ⫽ 0.038); a result consistent with that of other studies.
2,7,8
Highly signifi cant compliance is also noted in academically
employed parents (56%; P ⫽ 0.015), and particularly in highly
educated mothers (69.8% of them followed the schedule). This is
in agreement with other reports that highlight the importance of
education, knowledge and awareness among parents.
2,7,8
In accordance with the literature, a mother’s perception of her
child’s immunization status is an important personal factor pre-
dicting vaccination compliance.
13 This was found in the present
study, whereby among parents of compliant children, 75 of 83
(90.4%) thought that their child was compliant with the sched-
ule. This can be attributed to maternal recall bias. Valadez and
Weld in 1992 showed that relying on maternal recall resulted in
underestimation of vaccination rates. As a consequence, immu-
nized children were revaccinated while those in need were left
unimmunized. 14 Another interesting fi nding of that study was
that maternal recall of the vaccination status of children younger
than 6 months was more accurate compared to their recall for
older children.
14 As children grow older, mothers are more likely
to err in recalling dates. Mothers may perceive vulnerability to
disease to lessen with older age in the already sensitized child
who completed the primary series. Thus mothers may feel safe if
the primary series was completed giving less importance to
booster shots.
Table 2 Variables involved in the sample survey
Sociodemographic Mother and father’s age, mother and father’s
education, mother’s age at marriage,
mother’s age at fi rst birth, gender of the
child, number of children in the family,
number of children younger than 6 years,
and birth order of the child.
Socioeconomic Professional status of the parent, income,
and presence of health insurance
Personal Mother’s perception of her child’s
compliance status, breast-feeding,
mother and father’s smoking, parental
worry about risks and delay of shots,
perceived severity of illness, perceived
susceptibility to disease, and perceived
benefi t to prevent disease.
Structural Availability of the physician, waiting time,
and seeking other health-care centers
Table 3 Factors associated with compliance with schedule (chart
review, n ⫽ 774 children)
Variables Compliant with schedule
n (%)
P
Age >4 years 155/351 (44.2) 0.004 **
Gender (Male) 198/404 (49.0) 0.755
Parent’s position at AUB 0.015 **
Non-academic 306/636 (48.1)
Academic 42/75 (56.0)
Managerial 24/36 (66.7)
Not completing the primary
immunization series on time
136/321 (42.4) 0.027 *
* P < 0.05 ; ** P < 0.01.

4 DD Sinno et al.
© 2009 Japan Pediatric Society
The present study also shows that as children receive their
primary, secondary then tertiary series of vaccines, the compli-
ance rate decreases. A possible explanation besides recall bias is
the fear of adverse effects. Although the vast majority of parents
know about the importance of vaccination, some have concerns
regarding vaccine safety.
15 The increasing number of childhood
vaccine shots on one hand, and the emerging reports regarding
long-term adverse reactions of some new vaccines on the other,
produces doubt and fear among caregivers. This was also illus-
trated in a local study in Lebanon.
12 Although no studies are
available on the extent of the spread of lay theories of immunity
in the public in Lebanon, the general impression is that some still
believe that multiple vaccines may overload the immune system.
For the older Lebanese generation, the belief that children should
acquire certain diseases as a natural rite of passage still holds.
16
Previous reports have suggested that of mothers who did not
comply for MMR vaccination, 43% strongly agreed that it was
better to ‘get immunity naturally’, compared with only 7% of
those who complied.
17 Furthermore, some parents may consider
that the primary series are the mainstay in protection and that
boosters offer only an add-on safety and thus can be missed.
Acosta-Ramirez et al. have stated that ‘children with a regular
health-care provider had greater odds of vaccination use than for
those who did not have one’. It was evident in their study as well
as the present one that having a regular primary care provider is
an important factor predicting compliance;
18 60.8% of children
compliant with the vaccination schedule have a primary care
provider at UHS ( P ⫽ 0.015) and present regularly for health
maintenance visits during which vaccination records are
reviewed. In the present study this was examined along with
seeking of other health-care facilities to assess the effect on
immunization delay. The present fi ndings support earlier studies
whereby the absence of a regular provider was found to be a sig-
nifi cant factor associated with vaccination delay.
9 – 11,18 Further-
more, absence of a regular provider may lead to seeking of other
facilities and hence result in underestimation of vaccination
rates.
Because vaccines are not offered for free at UHS, it is unlikely
that those seeking health-care at other places are doing so at pri-
vate clinics. Other options, however, such as vaccinating at poly-
clinics and dispensaries in Lebanon, are likely, because vaccines
are offered for free. But such places offer casual care and do not
guarantee the provision of education and health awareness.
One important conclusion from the present study is that newly
introduced vaccines may have better chances of being success-
fully implemented if the schedule of the vaccine series is con-
densed in the fi rst year, as is the case for hepatitis B vaccine.
Vaccines given beyond the fi rst and second year of life may have
lesser chances of successful implementation because parents
may perceive that the earlier the vaccine is given, the more seri-
ous the disease is.
A major limitation in the present study, besides its retrospec-
tive nature, was that the results cannot be generalized to the
whole Lebanese population. Families followed up at UHS have
the advantage of easy access to medical care and more exposure
to medical information, and a very high standard of education.
We recommend that physicians spend more time on educat-
ing mothers regardless of their academic and educational levels,
and on emphasizing the importance of the primary as well as the
booster vaccination during well-baby visits. In an era of increas-
ing complexity of immunization schedules, and more newly
emerging vaccines, parents need to be more reassured and their
worries should be alleviated.
Table 4 Variables signifi cantly associated with vaccination
compliance
Variables Children compliant with
vaccination schedule
n (%)
P
Child age ( n ⫽ 154) 0.038 *
£ 2 years 27/38 (71.1)
>2 years 58/116 (50)
Child gender ( n ⫽ 154) 0.017 *
Male 38/83 (45.8)
Female 47/71 (66.2)
Mother’s education ( n ⫽ 148) 0.026 *
Elementary, intermediate,
and technical
26/58 (44.8)
Secondary 19/37(51.4)
University and higher 37/53 (69.8)
Father’s education ( n ⫽ 143) 0.027 *
Elementary, intermediate,
and technical
18/46 (39.1)
Secondary 32/52 (61.5)
University and higher 29/45 (64.4)
Smoking mother ( n ⫽ 149) 0.053 *
Yes 12/31 (38.7)
No 71/118 (60.2)
Seeking other health
provider ( n ⫽ 149)
0.005 **
Yes 16/44 (36.4)
No 66/105 (62.9)
Presence of a regular
health-care provider
( n ⫽ 150)
0.015 *
Yes 76/125 (60.8)
No 8/25 (32.0)
Mother’s perception of her
child’s compliance status
( n ⫽ 150)
0.000 **
Wrong 8/67 (11.9)
Right 75/83 (90.4)
* P < 0.05 ; ** P < 0.01.
Table 5 Logistic regression analysis of predictors of
non-compliance
Variables Exp ␤ standardized
coeffi cient
P
Mother’s perception of her
child’s immunization status
69.14 ** 0000
Mother’s education 0.26 ** 0.0027
Seeking other health-care
services
3.50 ** 0.0030
Age of the child
(cut-off: 2years)
2.68 * 0.0251
* P < 0.05 ; ** P < 0.01.

Prevalence and predictors of immunization 5
© 2009 Japan Pediatric Society
Although integration of a patient reminder and recall system
improves compliance with immunization rates in primary care
facilities, 19 studies of recall systems were mostly done in devel-
oped countries and may not apply to developing ones.
20 This
may be due to factors such as variation in primary care organi-
zation, lack of resources, political instability, and the poor han-
dling of health issues during destructive natural phenomena and
hazards. Countries such as Lebanon may need to look at cost-
effective strategies in implementing recall networks, because
this may depend on characteristics of current computer systems,
perceived accuracy of patient telephone numbers or addresses,
availability of computer programmers, staff, and estimated
patient responsiveness to different types of reminders. Of spe-
cifi c importance is the political instability, which forces people
to move and change their residence, hence loss of addresses and
contact with parents .These all generate a burden that needs to
be considered. Other ways to increase immunization coverage
include school-based programs that require either update and
revision of immunization status at each level of education, or
school-based vaccine campaigns conducted with the coordina-
tion of the Ministry of Health and other governmental organiza-
tions. Such campaigns have been tried in the USA and were
found to be effective in providing vaccination for 41% of
enrolled students.
21 We also encourage a yearly fi xed day for
immunization, to be designated by the Ministry of Health as a
national day for vaccine campaigns, similar to that in Chad and
Iran. 22,23
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6 DD Sinno et al.
© 2009 Japan Pediatric Society
Appendix 1 Vaccination schedule provided by the Lebanese
Ministry of Public Health
Age Type of vaccination
Birth HEP1
1 month HEP2
2 months (OPV1 – DPT1) – HIB1
4 months (OPV2 – DPT2) – HIB2
6 months (OPV3 – DPT3) – HIB3 – HEP3
9 – 10 months MEASLES
1 year PPD1
15 months (1 year 3 months) MMR1
1 year 6 months (OPV4 – DPT4) – HIB 4
2 years PPD2
4 – 6 years (OPV 5 – DPT5) – MMR 2
DPT, diphtheria pertussis tetanus; HEP, hepatitis B; HIB, Haemo-
philus infl uenzae type b; MMR, measles mumps rubella; OPV, oral
polio virus vaccine; PPD, purifi ed protein derivative.
Appendix 2 Vaccination dose timing
Vaccine Dose Required age for the fi rst dose
(months)
Minimum period allowed
to take the dose (months)
Maximum period allowed
to take the dose (months)
Hepatitis B HEP1 Birth +2 weeks
HEP2 1 month HEP1 age + 1 month HEP1 age + 3 months
HEP3 6 months HEP1 age + 4 months HEP1 age + 12 months
Haemophilus infl uenzae type b HIB1 2 months +2 weeks
HIB2 4 months HIB1 + 1 month HIB1 + 2.5 months
HIB3 6 months HIB1 + 2 months HIB2 + 2.5 months
HIB4 18 months HIB1 + 15 months HIB3 + 13 months
Oral polio virus – diphtheria
pertussis tetanus
OPV-DPT1 2 months +2 weeks
OPV-DPT2 4 months OPV-DPT1 + 1 month OPV-DPT1 + 2.5 months
OPV-DPT3 6 months OPV-DPT1 + 2 months OPV-DPT2 + 2.5 months
OPV-DPT4 18 months OPV-DPT1 + 15 months OPV-DPT3 + 13 months
OPV-DPT5 48 – 72 months 48 months 73 months
Measles mumps rubella MMR1 15 months
MMR2 48 – 72 months 48 months 73 months
Measles MEASLES 9 – 10 months 9 months 10.5 months