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Year : 2020  |  Volume : 64  |  Issue : 1  |  Page : 44-49  

Quality of routine immunization service: Perception of clients

1 MHSc Candidate, School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
2 Associate Professor, UCMS and GTB Hospital, Delhi, India
3 Professor, Department of Community Medicine, UCMS and GTB Hospital, Delhi, India

Date of Submission25-Feb-2019
Date of Decision18-May-2019
Date of Acceptance04-Feb-2020
Date of Web Publication16-Mar-2020

Correspondence Address:
Reena Titoria
Hamilton Street, Vancouver, BC - V6B2R9
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_92_19

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Background: Immunization prevents over 2–3 million deaths each year worldwide. In India, even though vaccines are offered free of cost at public health facilities the coverage remains low. Limited scrutiny has been conducted at health service and client interface for routine immunization (RI) services, which may have been affecting the acceptance of vaccines. This emphasizes the importance of assessing the level of satisfaction and perceived quality of clients regarding RI services. Objectives: This study aimed to assess the perceived quality and level of overall general satisfaction with RI services of clients. In addition, determine the association of factors influencing clients perceived quality and overall general satisfaction with RI services. Methods: A community-based cross-sectional study was conducted in an urbanized village of Delhi from November 2015 to April 2017. A total of 279 RI visits were covered in the study, and the clients were interviewed at their residence using a pretested tool. Results: The dissatisfaction toward the domains of perceived quality of RI services was reported to be 3.2% for vaccine availability, 9.7% for vaccine information, 3.2% for staff behavior, 6.1% for doctor behavior, and 7.5% for infrastructure. Multivariable-regression analysis indicated that distance to health facility, literacy and age of the client, doctor behavior, staff behavior, and infrastructure had an effect on overall general satisfaction of client toward RI services. Conclusions: The client's perception is multidimensional; improvement in one domain is likely to strengthen the other. By understanding the client's perspective toward quality of RI service, the health-care mangers may improve the level of overall satisfaction.

Keywords: Client perception, client satisfaction, immunization coverage, routine immunization, service quality, vaccine

How to cite this article:
Titoria R, Upadhyay M, Chaturvedi S. Quality of routine immunization service: Perception of clients. Indian J Public Health 2020;64:44-9

How to cite this URL:
Titoria R, Upadhyay M, Chaturvedi S. Quality of routine immunization service: Perception of clients. Indian J Public Health [serial online] 2020 [cited 2023 Jan 27];64:44-9. Available from:

   Introduction Top

Childhood immunization remains one of the most cost-effective public health interventions to reduce the morbidity and mortality from several infectious diseases. Over 2–3 million deaths are delayed through immunization each year worldwide.[1] Despite this, vaccine-preventable diseases remain the most common cause of childhood mortality. In India, immunization services are offered free of cost at public health facilities, but still, the coverage remains low. According to the National Family Health Survey, only 62% of children aged 12–23 months are fully immunized, which is less than the desired goal.[2] Hence, it is important to look into the factors which are debarring us from reaching the goal of universal immunization.

Studies conducted to discern the factors responsible for nonattainment of universal immunization primarily focus on the deficiencies of beneficiaries. Limited exploration has been done to look into the factors at health service interface, which may hamper the acceptance of vaccines. To enhance the coverage of immunization, it is crucial that shortcomings in the routine immunization (RI) service quality perceived by the client (beneficiary) at the facility level are addressed and explored.[3] Client satisfaction reflects the extent to which their service standard expectations have been met and reflects personal preferences more than the rating of a specific aspect of service qualities. On the other hand, service quality perception records the rating for different aspects of the service. It has been considered as a sensitive indicator of health-care utilization as client's perception influences their compliance and also provides information not only on the positive aspects but also on the negative aspects of health-care delivery system, which needs to be focused on to improve the service quality.[4] Hence, the present study was conducted with the primary objective to assess perceived quality and level of overall general satisfaction with RI services of the clients. The secondary objective was to determine the associated factors that influence the client's perception and overall general satisfaction with RI services.

   Materials and Methods Top

The study was a community based cross-sectional descriptive study, conducted in Ghazipur, an urbanized village of Delhi, from November 2015 to April 2017. In the geographical area, vaccines to under-five children are provided free of charge under the public health system at six Anganwadi centers and one primary health-care facility. The Department of Community Medicine of University College of Medical Sciences (UCMS) and Guru Teg Bahadur Hospital runs an Urban Health Training Centre (UHTC) in Block C, also provides immunization services on Wednesday of every week to under-five children with no charges to the beneficiaries. In this study, study participants were recruited from the UHTC. Due to nonavailability of many studies from India on client's perception on quality of RI services, the safest choice for anticipated proportion 50% was taken as the “P” for the computation of sample size. This gave minimal “n” for random sample as 271 (Epi info 7: a database and statistics program for public health professionals. CDC. Atlanta: CDC. 2011) at 90% confidence level and 5% precision (“e”).

The unit of sampling was RI visit of the under-five children visiting UHTC, Ghazipur, for immunization. The caregiver accompanying the under-five child was defined as a client and was the unity of inquiry. Around 30 children came to UHTC for immunization every week, who served as the sampling frame. Every week all the children visiting UHTC, Ghazipur, for the purpose of immunization were enumerated by the interviewer to form a sampling frame with unique child ID generated for each by the researcher and a visit number for each visit of each child. During the enumeration of the under-five and the accompanying client, the contact details and their residential address were recorded. Each week from the sampling frame nine children were selected randomly using MS Excel generated random numbers. If the number of children visiting, the UHTC for immunization was <10 then all the clients were included in the study. The study participants were then contacted at their respective house within 1-week time frame by the researcher. If after two subsequent visits to the resident of the selected client the researcher was unable to contact them, then the immediate next number from the sampling frame was selected to interview.

A 19-item validated questionnaire to measure patient perception of quality and level of general satisfaction developed by Rao et al., with Cronbach's α-value >0.7, was used in this study.[5] It was modified pertaining to immunization services and was then pretested by the investigator. Translation validity was done in two parts. Initially, the questionnaire was translated into Hindi (forward translation) by two experts. Subsequently, the back translation was done in English by another expert unaware of the source document. All discrepancies were resolved by investigators and translators to get the final version. The scale comprised of two sections, namely, client's perception of quality of RI service and general satisfaction with RI service. The first section consisted of 16 questions with five dimensions of perceived quality of immunization service-vaccine availability, immunization information, staff behavior, doctor behavior, and infrastructure of UHTC. The second section consisted of three questions on general satisfaction. The responses given by the clients were measured on a 5 point Likert Scale. A score of 1, 2, 3, 4, and 5 was used for strongly disagree, disagree, neutral, agree and strongly agree, respectively. Before beginning the interview, the interviewer first explained the scale to the clients and responses were obtained according to choices made by them.

The data collected was analyzed using Statistical Package for the Social Sciences software for Windows version 20.0 (Armonk, NY: IBM Corp). During exploratory analysis, it was found that the score for each domain of the perceived quality were highly skewed. Therefore, the observed median score was used to dichotomise the variables: (i) score ≤13 was “dissatisfactory” vaccine information score and >13 was “satisfactory” vaccine information, (ii) score ≤23 was “dissatisfactory” and >23 was “satisfactory” doctor behavior, and (iii) score ≤16 was “dissatisfactory” infrastructure and >16 was considered “satisfactory.” The median score for vaccine availability and staff behavior given by the informants was equivalent to the maximum score of each domain; therefore, these two domains could not be categorized. The association between these two domains with the level of general satisfaction was analyzed using Mann–Whitney test. For vaccine information, doctor behavior and infrastructure, Chi-square test was applied to find the association with level of overall general satisfaction. For variables with expected cell count in each cell <5, Fisher's exact test was used. Multivariable logistic regression was used to investigate factors influencing clients' perceived quality and overall general satisfaction with RI services.

The study was subjected to clearance from the Institutional Ethics Committee-Human Research of UCMS and GTB Hospital. Each subject was explained about the purpose of the study and a written informed consent was obtained from the participants prior to inclusion in the study. The privacy of participants and confidentiality of responses was maintained. The study does not include any method that goes beyond “less than minimal” risk to participants or their acquaintances.

   Results Top

Of the total 279 RI visits, 252 RI visits were first visit of the clients, 23 were second and four were third visit of the clients. The study showed that 246 (88.2%) clients were parents of the children, 21 (7.5%) were grandparents, 8 (2.9%) were relatives while 4 (1.4%) of the clients were neighbor. The mean age of the clients was 27.2 ± 8.1 years and median age was 25.0 years (interquartile range [IQR]: 23–29). Majority (93.4%) of the clients were female and 6.6% were male. Around three-fourth (75.9%) of them were literate. [Table 1] shows that most of the children (89.2%) were from Blocks C, D, and E which were situated near to the block of UHTC, Ghazipur.
Table 1: Socio-demographic characteristics of the family of index child (n=279)

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Around half of the children (54.1%) included in the study were ≤9 months of age, 69 (24.7%) aged 10–19 months and 59 (21.2%) aged ≥20 months. Of these 149 (53.4%) were male and 130 (46.6%) were female. Two-third (66.3%) of the children were completely immunized and one-third (33.7%) were partially immunized. On their last visit to UHTC 264 (94.6%) children received all the vaccines scheduled, 9 (3.2%) received some, but not all vaccines and a proportion of children (n = 6, 2.2%) did not receive any vaccine due to nonsupply of measles vaccine to the UHTC. Of the 273 children who received vaccine on their last visit, 175 (64.1%) developed minor adverse event following immunization (AEFI), of which most common were fever and swelling at the site of immunization; for these, the clients were counseled regarding the management and when to return to health facility. No serious or severe AEFI was reported during the study.

To assess the perceived quality and overall general satisfaction score more than the median was termed satisfactory, and a score less than or equal to median was termed dissatisfactory. The quality of RI services was perceived satisfactory by 98.2% (n = 274) clients (median: 70 and IQR: 65–76) and 93.2% (n = 260) of clients (median: 13 and IQR: 12–15) reported overall general satisfaction. Toward each domain of perceived quality dissatisfaction was reported to be 3.2% (n = 9) for vaccine availability, 9.7% (n = 27) for vaccine information, 3.2% (n = 9) for staff behavior, 6.1% (n = 17) for doctor behavior, and 7.5% (n = 21) for infrastructure [Table 2].
Table 2: Percentage distribution of dimensions of perceived quality and overall general satisfaction (n=279)

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On univariate analysis factors that showed statistically significant association with perceived quality were residential status (P = 0.049; odds ratio [OR] =0.446, confidence interval [CI] = 0.197–1.012), per capita income (P = 0.002; OR = 3.084, CI = 1.458–6.525), socioeconomic status (SES) (P = 0.003; OR = 0.486, CI = 0.301–0.784), client's age (P = 0.019; OR = 0.475, CI = 0.254–0.890), client's education (P ≤ 0.001; OR = 0.306, CI = 0.170–0.548), number of children (P = 0.013; OR = 0.406, CI = 0.176–0.939), age of child (P = 0.036, OR = 1.681, CI = 1.034–2.732), birth order (P = 0.018, OR = 0.530, CI = 0.313–0.899), and child having received all vaccines (P = 0.001; OR = 13.582, CI = 1.761–104.774). To find out the predictors of perceived quality of RI service at UHTC, multivariable logistic regression was applied on the above-mentioned variables. Hosmer and Lemeshow test was used for goodness of fit of the model (P = 0.699) and Naglkerle R2 explains 18.8% of the variation. As shown in [Table 3], odds of satisfactory perceived quality were more in client's who were tenant, older, and illiterate and also those who received all the vaccines scheduled for the child on their last visit to UHTC.
Table 3: Predictor variables of perceived quality of immunization service

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Overall general satisfaction on univariate analysis showed statistically significant association with residential status (P = 0.04; OR = 0.432, CI = 0.190–0.980), block of residence (P = 0.026; OR = 2.015, CI = 1.078–3.765), SES (P = 0.003; OR = 0.487, CI = 0.302–0.786), client's age (P = 0.041; OR = 1.639, CI = 1.019–2.636), client's education (P = 0.011; OR = 0.486, CI = 0.277–0.852), literacy status of mother (P = 0.044; OR = 0.551, CI = 0.307–0.987) and father (P = 0.026; OR = 0.552, CI = 0.330–0.922), place of delivery of index child (P = 0.038; OR = 1.915, CI = 1.030–3.559), and child having received all vaccines (P = 0.027; OR = 3.881, CI = 1.070–14.069). Vaccine information, vaccine availability, staff behavior, doctor behavior, and infrastructure also showed statistically significant association (P < 0.001) with general overall satisfaction. On regression analysis predictors of general overall satisfaction of RI services [Table 4] were found to be child residing in Block C, D, and E (near to UHTC), clients who were illiterate and older and also doctor's behavior, staff behavior, and infrastructure of UHTC.
Table 4: Predictor variables of general overall satisfaction of routine immunization services

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   Discussion Top

In the current study, perception of quality of immunization service was measured under five domains and it was found that majority of the clients (98.2%) perceived the quality of RI services as satisfactory. This was in agreement with Rao et al.[5] and Rasheed et al.,[6] however, studies conducted outside India have reported a wide range of satisfactory perceived quality 68%–83%.[7],[8],[9] The variation observed could be due to the difference in the health services studied by the researcher to measure the perception of service quality and also due to different tools employed to assess the same.

Tenants were found to be more satisfied with the RI services in our study, this could be due to the fact that a larger proportion of the population in Ghazipur were migrants and belonged to lower SES and because of monetary reasons, they might not have had access to other health facilities. It was also observed that literate clients were less satisfied with the perceived quality of services which was also reported by Das et al.,[10] it may be speculated that increasing levels of literacy would also increase the client's expectations as to the quality of care that they should be able to access. Similarly, younger clients were dissatisfied toward the services; the plausible explanation is that they may have been more aware and concerned about the quality of service. It was observed that those who received all the vaccines scheduled on their last visit to UHTC were more likely to be satisfied with perceived quality as it can be logically surmised that the availability of appropriate vaccines would have a positive effect on the perceived quality. Several studies have concluded that the reasons behind nonimmunization is usually lack of information but do not differentiate whether it was due to parental carelessness or resulted from lacunae on the provider side.[11],[12] However, in the present study, it was observed that among the domains of perceived quality maximal dissatisfaction by clients was toward vaccine information (9.7%) provided to them. This emphasizes the need for sensitizing the health workers to enable them to acknowledge the importance of providing vaccine information to the beneficiaries. Further qualitative studies can be conducted to explore the understanding of clients pertaining to the determinants of perception of service quality regarding RI to make the service more acceptable to them.

A higher proportion of clients' overall general satisfaction was observed in our study, this may be due to availability of other services at the facility along with RI on immunization day, like child growth monitoring, dietary advice given by a dietician, tracking of the missed cases of immunization by the multipurpose worker, health education activities and also outpatient department services. The results of overall general satisfaction corroborated with a study conducted by El Gammal HA[13] which reported 95.2% satisfaction for RI services at an urban primary health center in Egypt and also other studies which measured the level of satisfaction toward primary health-care services.[8],[14] The proximity of residence to the health facility is associated with satisfaction of clients[15] and similar results were observed in the present study. Although it has been observed that there is no consistent pattern of association between client's satisfaction and sociodemographic factors,[16],[17] but it was observed that overall general satisfaction is higher amongst illiterate clients. Among the domains of perceived quality doctor's behavior, staff's behavior, and infrastructure of health facility influenced the overall general satisfaction.[5],[7] Not many studies have commented on factors associated with overall satisfaction but it has been observed that client satisfaction is associated with the extent to which their rights are respected by health-care providers.[18] However, in India, this field has not been explored by researchers so far and the research in this context should be encouraged for the betterment of RI services.

Strengths and limitations

In this study, the data were collected at the premises of the participants by the investigator. Hence, the study participants felt comfortable and at ease in answering questions pertaining to quality of service, reducing response bias. However, few limitations could not be avoided. As the study was conducted in an urbanized village, which is in a transition phase between a village and an urban area, the results of the current study may not be representative or generalizable. Therefore, external validity in this study may be lacking.

   Conclusions Top

The modifiable factors such as availability of vaccine, staff behavior, doctor behavior, and infrastructure of the health facility need to be addressed to improve the perceived quality of clients with RI services and their overall general satisfaction. It is recommended that periodic training of immunization service providers should be undertaken which must include attitudinal orientation toward serving the clients with respect and dignity and regular evaluation of the services. Moving beyond the soft skills of the providers, it is also essential to maintain a continuous supply of the vaccines at health facility for the clients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

World Health Organization. Global Vaccination Targets “Off-Track” Warns WHO. Geneva: World Health Organization; 2015. Available from: [Last accessed on 2016 Dec 22].  Back to cited text no. 1
Indian Institute for Population Sciences. National Family Health Survey 4 (NFHS-4): State Fact Sheet. Delhi: Indian Institute for Population Sciences; 2015. Available from: [Last accessed on 2016 Dec 15].  Back to cited text no. 2
Streefland PH, Chowdhury AM, Ramos-Jimenez P. Quality of vaccination services and social demand for vaccinations in Africa and Asia. Bull World Health Organ 1999;77:722-30.  Back to cited text no. 3
Ware JE Jr., Hays RD. Methods for measuring patient satisfaction with specific medical encounters. Med Care 1988;26:393-402.  Back to cited text no. 4
Rao KD, Peters DH, Bandeen-Roche K. Towards patient-centered health services in India – A scale to measure patient perceptions of quality. Int J Qual Health Care 2006;18:414-21.  Back to cited text no. 5
Rasheed N, Aray S, Acharya A, Khandekar J. Client satisfaction and perceptions about quality of health care at a primary health care center of Delhi, India. Indian J Community Health 2012;24:18-24.  Back to cited text no. 6
Hussien A, Haidar DJ. Assessment of Maternal Satisfaction towards Childhood Immunization and Its Associated Factors in MCH Clinic, At Kombolcha, in Amhara Regional State, Northern Ethiopia [Dissertation]. Addis Ababa University College of Health Sciences School of Public Health; 2015.  Back to cited text no. 7
Aziz KF. Client's satisfaction in primary health care centers toward immunization services in Erbil -IRAQ. Med J Babylon 2015;12:502-8.  Back to cited text no. 8
Benjamin Chukwudi N, Christina CP. Caregivers' perception of the quality of child health care services in a general hospital in Lagos state. J Public Health Epidemiol 2014;7:29-33.  Back to cited text no. 9
Das P, Basu M, Tikadar T, Biswas G, Mridha P, Pal R. Client satisfaction on maternal and child health services in rural Bengal. Indian J Community Med 2010;35:478-81.  Back to cited text no. 10
[PUBMED]  [Full text]  
Salmaso S, Rota MC, Ciofi Degli Atti ML, Tozzi AE, Kreidl P. Infant immunization coverage in Italy: Estimates by simultaneous EPI cluster surveys of regions. ICONA Study Group. Bull World Health Organ 1999;77:843-51.  Back to cited text no. 11
Yadav RJ, Singh P. Immunization status of children and mothers in the state of Madhya Pradesh. Indian J Community Med 2004;29:147-8.  Back to cited text no. 12
  [Full text]  
El Gammal HA. Maternal satisfaction about childhood immunization in primary health care center, Egypt. Pan Afr Med J 2014;18:157.  Back to cited text no. 13
Uzochukwu BS, Onwujekwe OE, Akpala CO. Community satisfaction with the quality of maternal and child. East Afr Med J 2004;81:293-9.  Back to cited text no. 14
Fatiregun A, Ossai E. Clients satisfaction with immunisation services in the urban and rural primary health centers of a South-Eastern state in Nigeria. Niger J Paed 2014;41:375-82.  Back to cited text no. 15
Schempf AH, Minkovitz CS, Strobino DM, Guyer B. Parental satisfaction with early pediatric care and immunization of young children: The mediating role of age-appropriate well-child care utilization. Arch Pediatr Adolesc Med 2007;161:50-6.  Back to cited text no. 16
Weiss GL. Patient satisfaction with primary medical care: An evaluation of socio-demographic and predisposition factors. Med Care 1998;26:383-92.  Back to cited text no. 17
Udonwa NE, Gyuse AN, Etokidem AJ, Ogaji DS. Client views, perception and satisfaction with immunisation services at primary health care facilities in Calabar, South-South Nigeria. Asian Pac J Trop Med 2010;3:298-301.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3], [Table 4]

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