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Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 278-282  

Quality of routine childhood immunization and mothers' satisfaction toward it in Gangajalghati block of Bankura district of West Bengal, India

1 Department of Medicine, Bishnupur Super Speciality Hospital, Bankura, West Bengal, India
2 Department of Community Medicine, Medical College, Kolkata, West Bengal, India
3 Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
4 Department of Community Medicine, IPGMER, Kolkata, West Bengal, India

Date of Submission03-Mar-2020
Date of Decision07-Jul-2020
Date of Acceptance07-Jul-2020
Date of Web Publication12-Feb-2021

Correspondence Address:
Sanjay Kumar Saha
Sahapur Govt. Housing Estate, Flat No. G-4, Kolkata - 700 038, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_79_20

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Background: Auxiliary nurse midwife (ANM) provides immunization service at subcenter. This study aimed to assess the quality of care and client satisfaction toward immunization. Materials and Methods: A cross-sectional survey was conducted during January 2018 in three randomly selected subcenters of Gangajalghati block of Bankura district. Immunization services and client satisfaction were assessed by nonparticipant observation of immunization process in 86 “vaccination encounters” and exit interview of mothers of the same vaccinees selected randomly in equal number from each subcenter. Data were collected using checklist and questionnaire containing some questions with options on Likert scale. Clients' satisfaction was also explored through “focus group discussions” (FGDs) among randomly selected samples of eight mothers at each subcenter. Providers' perspective was grasped from an “FGD” conducted among a sample of accredited social health activists and in-depth interview of ANMs of selected subcenters. Verification of cold chain, logistics, and registers was done using checklist. Results: Coverage with appropriate vaccination was universal in each of the subcenters. The waiting time was 21.82 ± 15.37 (mean ± standard deviation) min. Postvaccination message was provided to 97.70% of mothers. Improper biomedical waste management was the rule. Cold chain was maintained properly. Only 45.30% of respondents knew the vaccine that was given in the session; however, 91.90% could utter the next date of vaccination. Sitting arrangement, cleanliness in clinic, attendance, timeliness of service, skill, and attitude of ANMs were labeled as “good” by 59.30%, 82.60%, 100%, 100%, 100%, and 98.80% of respondents, respectively, and overall, 94.00% was satisfied toward service. Conclusion: An overall good quality immunization service was found existing in the study area.

Keywords: Quality of care, routine child immunization, satisfaction

How to cite this article:
Lo S, Mondal T, Haldar D, Saha SK. Quality of routine childhood immunization and mothers' satisfaction toward it in Gangajalghati block of Bankura district of West Bengal, India. Med J DY Patil Vidyapeeth 2021;14:278-82

How to cite this URL:
Lo S, Mondal T, Haldar D, Saha SK. Quality of routine childhood immunization and mothers' satisfaction toward it in Gangajalghati block of Bankura district of West Bengal, India. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2022 Jun 25];14:278-82. Available from: https://www.mjdrdypv.org/text.asp?2021/14/3/278/309191

  Introduction Top

The quality of service in health means an inexpensive type of service with minimum side effects.[1] The American Medical Association has also duly recognized health status and patient satisfaction as key areas of patient care. Poor quality of service in terms of technical inputs, processes, interpersonal communications, and limited choice leads to unsatisfied clients with resulting suboptimal utilization of services.[2] Shortcomings in the delivery of primary health-care services have resulted in lesser utilization rates.[3] Quality of service is necessary for its acceptance and unsatisfied clients may result in underutilization of service.[3],[4] Patient satisfaction is one of the difficult to measure important goals of any health system.[5]

Subcenter is the first contact point in health facility between primary health-care system and the community.[6],[7] Auxiliary nurse midwife (ANM) is the key functionary of subcenter who provides comprehensive care in which immunization is the most important cost-effective public health intervention. About one-quarter of under-five mortality is due to vaccine-preventable diseases.[8] In spite of lots of efforts by government and other health agencies, approximately 10 million children and infants in India remain unimmunized which is the highest number of such children in the world.[9] It was also realized that merely providing vaccine just to achieve targets without giving adequate attention to quality of immunization services does not guarantee a reduction in disease morbidity and mortality.[10] Due to scarcity of reliable database regarding quality of immunization services rendered from the subcenters in the district Bankura of West Bengal, India, the present study was undertaken. The findings of this study may help the health managers to shape their strategy in improving immunization coverage by hunting its quality.


The objective of this study was to determine the quality of routine immunization service, to assess the clients' satisfaction toward it, and to find the factors influencing the quality of care and client satisfaction.

  Materials and Methods Top

Design, setting, and duration

A cross-sectional survey through mixed method was carried out during January 2018 in Gangajalghati Community Development Block of Bankura district of West Bengal, which has Amarkanan Community Health Center (CHC) and a network of 30 subcenters to cater its entire population along with provision of routine immunization to children according to the “Universal Immunization Programme” of India.

Study population

  1. The ANMs and accredited social health activists (ASHAs) were included for assessing providers' perception and practice in relation to immunization processes
  2. The mothers of vaccinees were considered as respondents for assessing clients' perception in regard to various aspects of immunization service
  3. ”Vaccination encounter” pertaining to the children aged 2 years and below was considered to qualify the vaccination process.

Sample size and sampling design

Three out of 30 subcenters were selected by simple random sampling technique. The sample size for client respondents was calculated based on the following formula: n = Z1-α/22PQ/L2, where Z = 1.96 (two-tailed) at 95% confidence interval (CI), P = prevalence (p) of client satisfied to services, Q = complement of P = 100 – P, and L = acceptable error around the reported prevalence. Considering P = 71.58% as per the existing literature,[11] L = 10 (absolute), the sample size was estimated to be 78. Assuming 10% nonresponse, the revised sample size was 86.

All (2 × 3 = 6) ANMs of selected subcenters and two ASHAs from each of the selected subcenters (2 × 3 = 6) were chosen through simple random sampling. On an average, 16 vaccinees attended on each immunization session in the selected subcenters. The inclusion of 86 client respondents was done through three consecutive visits to each selected subcenter selecting 10, 10, and 9 mothers following simple random sampling on the 1st, 2nd, and 3rd visits, respectively.

Study variables

Study variables were gender and caste of children, sitting arrangement and cleanliness in clinic, immunization coverage, cold chain system, vaccines and related logistics, timeliness and regularity of vaccination services, child tracking and biomedical waste (BMW) management process. Awareness of mothers' about the vaccine given to their children on the day of survey and the vaccine(s) would be given in the next visit, delay in any dose of any vaccine along its cause and their perception regarding the attitude and skill of the care providers were also considered as variables.

Study tools

A questionnaire containing quite a few questions on three-point Likert scale, a checklist, and guides for focus group discussion (FGD) and in-depth interview were designed and validated by nine senior faculty members (the subject matter expert), Department of Community Medicine, BS Medical College (BSMC), Bankura. The reliability was tested only for questionnaire through test–retest method of reliability on a sample of mothers of subcenters other than the selected ones with a correlation value of r > 0.70.

Study technique

Nonparticipant observation of “vaccination encounter” was done using a checklist which was also utilized in collecting information via physical verification of cold chain, vaccines and related logistics, child tracking and BMW management. Clients' satisfaction and quality of care were assessed through exit interview as well as FGD involving respondent mothers using predesigned questionnaire and guide for FGD. Providers' perspective was assessed through in-depth interview of the ANMs and FGD among ASHAs using predesigned guides.

Method of data collection

As per plan, on the day of visits to each subcenter, “vaccination encounters” were observed through “nonparticipant observation” and the mothers of those vaccinees were subjected to exit interview. On one visit to each of the subcenters, chosen through lottery methods out of three visits, an FGD was held involving eight mothers selected through random sampling technique. Hence, altogether, totally 87 mother respondents were involved in exit interview and 24 in FGDs. Six ASHAs were called in one of the subcenters for participating in an FGD to assess their view regarding immunization services, and all six ANMs of selected subcenters were involved in in-depth interview to explore their opinion about different aspects of immunization service. To avoid interobserver variation, the same trained investigators were engaged in each type of activity, for example, nonparticipant observation of vaccination encounter, exit interview, FGDs of ASHAs, and in-depth interview of ANMs.

Statistical plan for data analysis

Data were described by mean, standard deviation (SD), and proportions. Data display was done using chart and table. For data analysis, the IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. 0 version, was utilized.

Ethical issues

The study was conducted with approval of the Institutional Ethics Committee, BSMC (Memo No. BSMC/Aca/90, dated January 2, 2018) and District Health and Family Welfare Society, Bankura, and prior informed verbal consent of the participants.

  Results Top

One of the mothers refused to complete the exit interview, and the analysis was done on the sample size of 86. The results of the study showed that slightly more than half (51.20%) of the participant children were male and 61.60% belonged to general caste [Table 1]. Routine immunization coverage for children enlisted in the Reproductive Child Health (RCH) registers of selected subcenters was universal (100%). Vaccine vial monitors (VVM) were checked, time of opening of reconstituted vials marked and noted in all immunization sessions. Prevaccination counseling was given in 88% of cases. Proper positioning of children and drawing of injectable vaccines were found to be always correct. A boiled cotton swab was used before intramuscular (IM)/subcutaneous (sc) vaccination, and the used swab was discarded properly in 100% of cases. During injection, the angle between the needle and skin surface was found also correct. Rubbing was not used on vaccination site in 100% of cases. Only 1.20% of children were observed for 30 min for adverse events following immunization. Key messages were given to mothers in 98% of cases. However, using hub cutter and disposing syringes were found inappropriate. No needle stick injury was observed, and a significant delay (more than 1 week) in immunization was noted for none of the selected children [Table 2].
Table 1: Distribution of children receiving immunization according to their sex and caste (n=86)

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Table 2: Distribution of findings of nonparticipant observation of “vaccination encounter” (n=86)

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Cold chain and tickler bag were maintained properly and checking of vaccine vials for beyond expiry date was done in all selected subcenters.

The average waiting time was 21.82 ± 15.37 (mean ± SD) min. Sitting arrangement and cleanliness in subcenters were labeled as good by 59.30% and 82.60%. All respondent mothers ranked attendance of health workers and timing of service as good, while skill and attitude of ANMs were opined to be good by 98.80% and 100% of mothers, respectively [Figure 1]. However, less than ½ (45.30%) of participants knew “what” vaccine was given on that particular day and 91.90% knew the next date of vaccination.
Figure 1: Distribution of different attributes of quality immunization ranked as “good” by respondents (n = 86)

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Overall, 94% of mothers were satisfied and opined that their purpose of visiting subcenters for immunization was fulfilled. Quality of the immunization service seemed to be good at the time of survey as reflected by expression of the clients as well as assessment done objectively.

All of the ANMs received recent training on adverse event following immunization. No one practices safe disposal of syringe and vial due to unavailability of red bag for BMW management. Vaccine supply was reported to be occasionally irregular.

According to ASHAs, panchayat members were not optimally motivated in advocacy for immunization.

  Discussion Top

A coverage level of 100% in respect of routine childhood immunization was achieved in the area under study as compared to 87.10% in West Bengal.[12] This might be due to adequate facilities available in subcenters, effective intersectoral coordination with the Integrated Child Development Services program, and supportive supervision and monitoring in health system of Amarkanan CHC. It was observed that respondents were satisfied with the basic amenities such as sitting arrangement and cleanliness. The average waiting time was estimated to be 21.82 ± 15.37 min which had concurrence with findings of 19.2 ± 25.9 min reported by Nath et al.[13] According to a study carried out in West Bengal, 95% of health workers had a friendly attitude.[14] All these factors are conducive to clients' participation in any health care for achieving its objective.

Clients' satisfaction is the central theme of any service including health care. Both hard and intangible soft skills such as attitude, ethics, and communication are complementary to each other in providing health care. Poor quality care costs more as it damages the health and trust of concerned clients on health system and creates negative repercussion among other clients inhibiting their care seeking. In this study, skill and attitude of ANMs were good as opined by 98% and 100% of participants, respectively. A cross-sectional study among 409 women with children <12 months was conducted in Varanasi district to study the utilization of and satisfaction toward services where 16.30% of the respondents were not satisfied with the services provided by government health facilities.[15] A study on client satisfaction with the services rendered by ANM in subcenters of Dakshina Kannada district of Karnataka found that 71.58% of clients were “satisfied” about RCH services.[11] In this study, 5.80% of participants were seemed to be unsatisfied. In a study, Rahman Hanan Abbas reported that 57.30% of participants ranked the immunization at primary health center as good and 40.60% as fair. However, overall, 95.20% of the study participants were satisfied toward the immunization service.[16] Hussen et al. showed a low level of clients' satisfaction in the range of 61.10%.[17] However, 95.90% of clients' satisfaction was observed by Nath et al. who also reported that 99.60% of the clients were satisfied toward the behavior of health workers.[13] From a study conducted in Jamnagar district of Gujarat, Makwana et al. reported that quality of immunization services was found to be good except BMW disposal and key messages after vaccination which was done correctly by 36.50% and 28.60% of health workers, respectively.[18] Compromised BMW disposal was also found in the present study. The observations of present study, for example, proper maintenance of cold chain universally, observing only 1.20% children for 30 minutes for adverse reaction, inappropriate use of hub cutter and improper disposal of syringes in all immunization sessions have concurrence with a study conducted by Chavda and Misra in a district of Central Gujarat.[19]

Clients, especially belonging to lower socioeconomic status, may be benefitted by health message provided by health worker in one-to-one situation to have their awareness increased sufficiently to guide future behavior and percolation to community. Interestingly, four key messages were given to almost all mothers (98%), as revealed in the present study in contrast to the study of Chavda and Misra where “not all mothers” were provided with it.[19] Having concordance with the observations of the present study, Assija et al. reported from their study conducted at rural Chandigarh that health workers at all the subcenters checked the vaccine vial marker (VVM) and expiry date before reconstituting or injecting the vaccine. All the ANMs had a clear idea about the right time to discard the reconstituted vaccines.[20]

This study is not without limitation. There were so many other correlates of quantity and quality of immunization service, but only a few of them could be explored. Other inherent limitations of a cross-sectional study with techniques such as interview within the health facility and nonparticipant observation might also affect the study results.

  Conclusion Top

Smooth and effective intersectoral coordination, regularity in logistics, and supply, for example, vaccines and color-coded bins/bags for BMW disposal, are essential prerequisites for effective immunization coverage. The present study results indicated an overall good quality immunization service existing in the study area at the time survey with occasional pitfalls required to be addressed by the health managers at concerned levels of health-care system.


The authors are thankful to the faculties of the Department of Community Medicine, BSMC, for their immense help in shaping the study design, study tools, etc., The authors also express their gratitude toward the ANMs and ASHAs of the selected subcenters as well as the participants without the cooperation of whom this study could not be possible.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Chandwani HR, Jivarajani PJ, Jivarajani HP. Community perception & client satisfaction about the primary health care services in a tribal setting of Gujarat. Internet J Health 2009;9:10-4. Available from: http://www.ispub.com/journal.html?journal_slug+the_internet_journal_of_health&comm. [Last accessed on 2017 Dec 20].  Back to cited text no. 4
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Bajpai N, Sachs JD, Dholakia RH. Improving Access, Service Delivery and Efficiency of the Public Health System in Rural India: Mid-term Evaluation of the National Rural Health Mission. CGSD Working Paper; 2009. p. 37. Available from: http://www.mohfw.nic.in/NRHM/Documents/NRHM_Evaluation_Report.pdf. [Last accessed on 2018 Jan 20].  Back to cited text no. 6
Manas PR, Mohan U, Singh SK, Singh VK, Shrivastava AK. Sub centre support, need of the hour: A comparative study from Lucknow. Peoples J Sci Res 2014;7:33-7.  Back to cited text no. 7
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Leena KC, Shakuntala BS. Assessment of client satisfaction with the services rendered by female health workers (auxillary nurse midwife) in sub-centers of selected primary health centers, Dakshina Kannaada District, Karnataka state, India. Muller J Med Sci Res 2014;5:19-22.  Back to cited text no. 11
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Programme Evaluation Organisation, Planning Commission. Evaluation Study of National Rural Health Mission (NRHM) In 7 States. New Delhi: Government of India; 2011. p. 1-147. Available from: http://planningcommission.nic.in/reports/peoreport/peoevalu/peo_2807.pdf. [Last accessed on 2018 Feb 05].  Back to cited text no. 14
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Rahman Hanan Abbas AA El Gammal. Maternal satisfaction about childhood Immunization In primary health care center, Egypt (internet). Pan African Medical Journal 2014;18:157. doi:10.11604/pamj.2014.18.157.1773. Available online at: http://www.panafrican-med-journal.com/content/article/18/157/full/ [Last accessed on 30 Jul 2020].  Back to cited text no. 16
Hussen A, Bogale AL, Ali JH. Parental satisfaction and barriers affecting immunization services in rural communities: Evidence from North Ethiopia. Sci J Public Health 2016;4:408-14. Availed from: http://www.sciencepublishinggroup.com/j/sjph. [Last accessed on 2018 Feb 09].  Back to cited text no. 17
Makwana NR, Shah VR, Yadav S. An evaluation of skill and knowledge in delivery of reproductive and child health services by female health workers in Jamnagar District and corporation area, Gujarat state, India. Int J Health Allied Sci 2012;1:79-84.  Back to cited text no. 18
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  [Figure 1], [Figure 1]

  [Table 1], [Table 2], [Table 1], [Table 2]


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