eprintid: 507
rev_number: 10
eprint_status: archive
userid: 30
dir: disk0/00/00/05/07
datestamp: 2022-01-19 21:25:51
lastmod: 2022-01-19 21:25:51
status_changed: 2022-01-19 21:25:51
type: thesis
metadata_visibility: show
creators_name: George, Nithya Maria
corp_creators: Supervisor: Dr.  Catherine Rossiter
title: A Quantitative Study on Factors Associated with the Implementation and Uptake of Paediatric Vaccination in India and Ireland
ispublished: submitted
subjects: RS
divisions: MScPBT
full_text_status: public
abstract: Vaccinations are the simplest, safest and cost-effective  method to protect  population from infectious diseases by boosting a person’s immune system. It is important to enhance Paediatric immunogenicity as they are at high risk of getting serious infectious disease by harmful germs. Parents and healthcare professionals play an important role in the coverage rate of vaccination among  children. Despite the  success  of  Paediatric  vaccination,  the  coverage rate of  child immunization is very less in certain countries. It is essential to evaluate parental behaviour and knowledge  of  healthcare  professionals about child immunization and to  identify the factors associated  with the implementation  and  uptake of childhood vaccination to improve the practice of Paediatric vaccination.

Method:
A cross-sectional  quantitative  study was  undertaken on  parents and healthcare  professionals, who  live  in  Ireland and  India. A total of 133 participants; 69 parents and 64  healthcare professionals were involved in the study. Specifically developed questionnaire used to collect data from participants through email and mobile apps.
date: 2021
date_type: completed
institution: Innopharma
department: Innopharma Faculty Of Pharmaceutical Science
thesis_type: masters
referencetext: A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021 CANDIDATE DECLARATION

I hereby certify that this document, which is now submit for assessment on the program of the study leading to the award of the MSc In Pharmaceutical Business And Technology, is my own; based on my personal study and/or research, and that I have acknowledged all material and sources used in its preparation. I also certify that I have not copied in part or whole or otherwise plagiarized the work of anyone else, including other students.

SIGN: Nithya Maria George

REGISTER NUMBER: 3008811

DATE: 04/06/2021 A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021 ACKNOWLEDGMENT

First and foremost, praise and thanks to God, the almighty whom I awe my very existence and for all blessings showered upon me to successfully bring my thesis.

I considered this an opportunity to express my gratitude to the entire dignitaries who were directly or indirectly involved in the successful completion of this study.

I express my heartfelt gratitude and sincere thanks to my esteemed supervisor Dr. Catherine Rossiter, for her valuable suggestions, encouragement, guidance and cooperation during my thesis work. I will always be thankful for her guidance throughout my studies.

I am very grateful to my family for providing me moral support and blessings, without which this project work would not have been completed. I express my love and gratitude to my parents Mr. George Kunnel and Mrs. Shiby George, my sisters Nimmy George and Nimisha George and My brothers Dinu Abraham and Sajo Joy for their constant support, prayers and guidance.

It is the moment of great pleasure and immense satisfaction for me to express my deep gratitude and gratefulness towards Ms Ria Rose Roy, Sajo Joy and San Joy for their continuous encouragement, support and worthy suggestions during my research time.

I also express my deep sense of gratitude to all participants who involved in my study, without them this research would not have been completed.

I would like to thanks all my best friends and seniors for their valuable support and helping hand throughout my thesis work.

As a final word, thanks to all my teachers, friends and relatives whose name has not mentioned here, but have been a support to complete my dissertation successfully. NITHYA MARIA GEORGE A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021 TABLE OF CONTENTS

Table of Contents CHAPTER 1 .........................................................................................................................................9 INTRODUCTION .................................................................................................................................9 1.1 PAEDIATRIC VACCINATION AND ITS IMPORTANCE ...............................................................9 1.2 ROLE OF PARENTS AND HEALTHCARE PROFESSIONALS IN THE PRACTICE OF PAEDIATRIC VACCINATION ...................................................................................................................... 10 1.3 AIMS AND OBJECTIVE OF THE STUDY ................................................................................. 11 CHAPTER 2 ....................................................................................................................................... 12 LITERATURE REVIEW ........................................................................................................................ 12 2.1 OVERVIEW OF CHILDHOOD IMMUNIZATION IN IRELAND.................................................... 12 2.2 OVERVIEW OF PAEDIATRIC VACCINATION IN INDIA……………………………………………………………13

2.3 PARENTAL BEHAVIOUR TOWARDS PAEDIATRIC VACCINATION………………………………………..…15

2.4 ATTITUDE AND KNOWLEDGE OF HEALTHCARE PROFESSIONALS ABOUT PAEDIATRIC VACCINATION ...................................................................................................................... 19 2.5 OVERVIEW OF CHILDHOOD MORTALITY RATE IN INDIA ...................................................... 21 2.6 CONCLUSION..................................................................................................................... 22 CHAPTER 3 ....................................................................................................................................... 23 RESEARCH METHODOLOGY .............................................................................................................. 23 3.1 RESEARCH DESIGN............................................................................................................. 23 3.2 RESEARCH POPULATION AND SAMPLE SIZE ........................................................................ 24 3.2.1 INCLUSION CRITERIA ........................................................................................................ 24 3.2.2 EXCLUSION CRITERIA ........................................................................................................ 24 3.3 DATA COLLECTION AND ANALYSIS ..................................................................................... 25 3.4 QUESTIONNAIRE DEVELOPMENT ....................................................................................... 26 3.4.1 QUESTIONNAIRE FOR PARENTS ........................................................................................ 26 3.4.2 QUESTIONNAIRE FOR HEALTHCARE PROFESSIONALS ......................................................... 27 3.5 ETHICAL CONSIDERATION .................................................................................................. 27 CHAPTER 4 ....................................................................................................................................... 28 DATA ANALYSIS AND RESULTS .......................................................................................................... 28 4.1 ANALYSIS OF DATA OBTAINED FROM PARENTS ....................................................................... 28 4.1.1 DEMOGRAPHIC CHARACTERISTICS .................................................................................... 28 4.1.2 ATTITUDE OF PARENTS TOWARDS PAEDIATRIC VACCINATION ........................................... 30 4.1.3 FACTORS THAT INFLUENCE PARENTAL DECISION ............................................................... 37 A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

4.2 ANALYSIS OF DATA OBTAINED FROM HEALTHCARE PROFESSIONALS........................................ 43 4.2.1 DEMOGRAPHIC CHARACTERISTICS .................................................................................... 43 4.2.2 KNOWLEDGE OF HEALTHCARE PROFESSIONALS ................................................................ 44 4.2.2 BARRIERS TO THE IMPLEMENTATION AND UPTAKE OF PAEDIATRIC VACCINATION ............ 47 4.2.3 ENABLERS TO THE IMPLEMENTATION AND UPTAKE OF PAEDIATRIC VACCINATION ............ 54 4.3 DISCUSSION .............................................................................................................................. 55 4.3.1 ATTITUDE OF PARENTS TOWARD PAEDIATRIC VACCINATION ................................................ 58 4.3.2 FACTORS INFLUENCE ON PARENTAL DECISION ...................................................................... 59 4.3.3 KNOWLEDGE OF HEALTHCARE PROFESSIONALS .................................................................... 60 4.3.4 FACTORS ASSOCIATED WITH IMPLEMENTATION AN UPTAKE OF PAEDIATRIC VACCINATION .. 61 CHAPTER 5 ....................................................................................................................................... 63 CONCLUSION ................................................................................................................................... 63 5.1 PARENTAL ATTITUDE AND FACTORS INFLUENCES PARENTAL DECISION .................................... 63 5.2 KNOWLEDGE OF HEALTHCARE PROFESSIONALS ABOUT PAEDIATRIC VACCINATION ................. 64 5.3 BARRIERS AND ENABLERS OF PAEDIATRIC VACCINATION......................................................... 64 APPENDIX 1: QUESTIONNAIRE FOR HEALTHCARE PROFESSIONALS .................................................... 69 APPENDIX 2: QUESTIONNAIRE FOR PARENTS .................................................................................... 72 APPENDIX 3: PARTICIPANT COSENT FORM ........................................................................................ 74

LIST OF CHARTS

Chart 1: Flow chart of number articles which are included in the study..................................12

Chart 2: Percentage of age of parents from Ireland and India................................................29

Chart 3: Percentage of parents with number of children from Ireland and India...................29

Chart 4: Number of parents who participated from Ireland and India....................................30

Chart 5: Response of parents on affordability of vaccines for an average family in percentage............................................................................................................................38

Chart 6: Response to awareness about Paediatric vaccination in society...............................39

Chart 7: Parent's response on the safety of Paediatric vaccines.............................................39

Chart 8: Response on the influence of religious belief on Paediatric vaccination....................40

Chart 9: Response on the influence of ethnic culture on the uptake of Paediatric vaccination............................................................................................................................40 A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

Chart 10: Response on the attitude of healthcare professionals in Paediatric vaccination......41

Chart 11: Response on the effect of COVID-19 on Paediatric vaccination...............................42

Chart 12: Medical profession of healthcare professionals in percentage................................43

Chart 13: Response to Educational status of parents as a barrier...........................................47

Chart 14: Response on family income as a barrier..................................................................48

Chart 15: Response on religion of parents as a barrier...........................................................48

Chart 16: Response on place of residence (rural/urban) as a barrier......................................49

Chart 17: Response on anti-vaccination programs as a barrier...............................................50

Chart 18: Response on misinformation regarding Paediatric vaccination as a barrier...................50

Chart 19: Response on reluctance of parents towards Paediatric vaccination as a barrier.........51

Chart 20: Response on lack of healthcare professional's knowledge about Paediatric vaccination as a barrier............................................................................................................................52

Chart 21: Response on lack of communication between parents and healthcare workers as a barrier...................................................................................................................................52

Chart 22: Response on storage of vaccines as a barrier..........................................................53

Chart 23: Response on continuous training programs as an enabler.......................................54

Chart 24: Response on getting signed consent from parents as an enabler............................55

Chart 25: Response on improved availability of high quality data as an enabler.....................55

Chart 26: Response on close monitoring of infants by parents as an enabler.........................56

Chart 27: Response on improved vaccine storage facility as an enabler.................................56

Chart 28: Response on door to door visit and reminders as an enabler..................................57

LIST OF TABLES

Table 1: List of vaccines for infants with two months of age..................................................13

Table 2: Current uptake level of Paediatric vaccination in Ireland..........................................14

Table 3: Percentage of fully-vaccinated children in different state of India............................15

Table 4: Routine vaccination schedule for infants and children in India..................................16 A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

Table 5: The number and percentage of age and number of children.....................................28

Table 6: Trust in Paediatric vaccination run by Government..................................................31

Table 7: Level of recommendation of Paediatric vaccination by parents................................31

Table 8: Response to importance of vaccination against common childhood diseases...........32

Table 9: Parent's level of agreement whether vaccination boosts children's immunogenicity.....................................................................................................................33

Table 10: Expected value of Parent's level of agreement on vaccination boosts children's immunogenicity.....................................................................................................................33

Table 11: Parents response to harmful side effects of vaccination.........................................34

Table 12: Expected value of responses to harmful effects of vaccination...............................34

Table 13: Parents response to multiple injections in single visit.............................................35

Table 14: Expected value of responses to multiple injections in single visit............................35

Table 15: Parents response to allowing unvaccinated children to school................................35

Table 16: Expected value for sending unvaccinated children to schools.................................36

Table 17: Parents response to vaccination as waste of time and money................................36

Table 18: Expected value for response to vaccination as waste of time and money...............37

Table 19: Demographics of healthcare professionals who participated .................................43

Table 20: Response of healthcare professionals regarding Paediatric vaccination..................44

Table 21: Observed value and expected value of healthcare professional's response in the evaluation of their knowledge...............................................................................................46 A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021 ABSTRACT

Introduction

Vaccinations are the simplest, safest and cost-effective method to protect population from infectious diseases by boosting a person's immune system. It is important to enhance Paediatric immunogenicity as they are at high risk of getting serious infectious disease by harmful germs. Parents and healthcare professionals play an important role in the coverage rate of vaccination among children. Despite the success of Paediatric vaccination, the coverage rate of child immunization is very less in certain countries. It is essential to evaluate parental behaviour and knowledge of healthcare professionals about child immunization and to identify the factors associated with the implementation and uptake of childhood vaccination to improve the practice of Paediatric vaccination. Method

A cross-sectional quantitative study was undertaken on parents and healthcare professionals, who live in Ireland and India. A total of 133 participants; 69 parents and 64 healthcare professionals were involved in the study. Specifically developed questionnaire used to collect data from participants through email and mobile apps. Results

The study found that most of the parents have a positive attitude towards childhood vaccination and majority of healthcare professionals expressed good and average knowledge on Paediatric vaccination. Lack of communication between parents and healthcare professionals, concern about the safety of vaccines, misinformation, storage of vaccines and reluctance of parents were identified as barriers to the implementation and uptake of Paediatric vaccination. Getting consent letter from parents, close monitoring of children, high quality data about infant population, establishment of immunization programs and training for parents can facilitate the future practice of Paediatric vaccination. Conclusion

Despite the favourable attitude of parents and adequate knowledge of healthcare professionals, concern about the side effects of vaccines, multiple injections at a visit and lack of communication between parents and healthcare professionals have negative influence on the coverage of child immunization. Therefore, it is necessary to conduct vaccination programs and provide training for healthcare professionals and parents to update knowledge on child vaccination in society in order to reduce the child mortality rate across the world. A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021 CHAPTER 1 INTRODUCTION

1.1 PAEDIATRIC VACCINATION AND ITS IMPORTANCE According to World Health Organization (WHO), vaccinations are the simplest, safest and cost effective method to protect humans from infectious diseases by boosting a person's immune system. It is important to enhance Paediatric immunogenicity as they are at high risk of getting serious infectious disease by harmful germs. After the successful intervention of Paediatric vaccination, the overall rate of child mortality has been declined across the world(Whelan et al., 2020).

The success of variolation led to the discovery of vaccination by Edward Jenner in 1796. Advancement in chemistry technologies and molecular biology helps to establish more vaccines for children. The child death rate was 5.1 million in 1990 and it is decreased to 1.8 million by 2017 due to the coverage of vaccine preventable diseases(Vanderslott, Dadonaite and Roser, 2013). Childhood immunization provides protection to infants and children from severe disease, which is caused by certain pathogens like virus, bacteria and parasite. The introduction of Paediatric vaccination is one of the successful interventions in healthcare sector(Sankar, Rameh and Sunny, 2018). As a result of National Vaccine Programs, Paediatric vaccines prevented millions of death every year in the world. Vaccines contain inactivated cells of virus or pathogens that cause serious infectious diseases. They act by interacting with child's immune system, resulting in a rapid and specific immune response produced against antigen present in the vaccines (Pollard, Finn and Curtis, 2017).

As a result of smallpox eradication effort, WHO has established a new program in 1974, called Expanded Program on Immunization (EPI) with an aim to vaccinate all children in the world for a better public health. EPI has introduced new vaccines for infant against six infectious diseases included Diphtheria, pertussis, measles, poliomyelitis and tuberculosis. After the implementation of six vaccines, a considerable progress was obtained in the child mortality and morbidity rate. Apart from these six vaccines, a number of new vaccines such as Hepatitis B, A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

Men B and C, Pneumococcal conjugate vaccines (PCV) and Rotavirus oral vaccines were included in the list of routine vaccination for children(WHO, 2021).

Vaccination reduces the transmission of diseases by protecting everyone in the world. Since majority of virus are transmitted by the air, it is easy to spread among children. A completed dose of DTP provides 99% protection against Diphtheria, tetanus and pertussis. The proportion of vaccination coverage rate is indirectly connected to the spread of diseases. In other words, higher the uptake of vaccination among children, lesser will be the spread of diseases or childhood mortality rate(Vanderslott, Dadonaite and Roser, 2013).

According to a study of Anderson et al., (2018), establishment of child vaccination programs have resulted with a decreased number of childhood mortality rate and an increased rate of vaccination uptake among children under 5 years old across the world. The practice of rotavirus vaccines have been decreased approximately 94% of hospitalization rate of children with diarrheal diseases in 2012, according to National surveillance data. After the implementation of heptavalent Pneumococcal conjugate vaccine (PCV4), the rate of children with IPDInvasive pneumococcal disease have decreased in the USA in 2000 followed by 64 percent decrease in IPD cases after the entry of 13-valent PCV (PCV13) in 2010(Anderson et al., 2018).

1.2 ROLE OF PARENTS AND HEALTHCARE PROFESSIONALS IN THE PRACTICE OF PAEDIATRIC VACCINATION Parents and healthcare professionals play an important role in the coverage rate of vaccination among children. The rate of child immunization is mainly depends upon the parental attitude towards Paediatric vaccination. Parental decision making regarding the immunization for their children is influenced by many factors such as side effects of vaccines, misinformation and parent's knowledge regarding Paediatric vaccination. Misinformation about the side effects and inadequate knowledge about vaccination often leads to take a decision to avoid vaccination for children by parents. Good practice of child immunization by parents can minimize many immunization errors in the society. Thus, helps to reduce child mortality rate and provides 100% protection against infectious diseases(Qutaiba B Al-lela et al., 2014). A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

The knowledge of healthcare professionals and their willingness to recommend vaccination for children are another set of major factors, which plays an important role in the implementation and uptake level of Paediatric vaccination. Healthcare professionals such as doctors, nurses, pharmacist and other healthcare providers are considered as the primary source of information on child immunization(Herzog et al., 2013). Since healthcare professionals are the most trusted resource for parents, their level of confidence in childhood vaccination has a significant impact on parental attitude towards Paediatric vaccination. The healthcare professional's lack of knowledge and concerns regarding the adverse effects of vaccination would directly affect the child immunization rate(Huber et al., 2020).

As parents and healthcare professionals plays an important role in the vaccination coverage rate, it is essential to evaluate their attitude and knowledge regarding Paediatric vaccination. The study will explore healthcare professional's knowledge and parental behaviour towards childhood vaccination in Ireland and India. Despite the success of vaccination in child immunization, the practice of Paediatric vaccination is low in certain countries especially in developing countries such as India. The uptake level of Paediatric vaccination in Ireland is not beyond 92%, according to the report of UNICEF and WHO (2019). By identifying the primary facilitators and barriers to the implementation and uptake of childhood vaccination will help to resolve the pure coverage rate of vaccination among children.

1.3 AIMS AND OBJECTIVE OF THE STUDY  To evaluate parental attitude towards Paediatric vaccination in India and Ireland.  To identify the factors associated with the implementation of Paediatric vaccination in India and Ireland.  To evaluate the knowledge of healthcare professionals regarding Paediatric vaccination in India and Ireland.  To identify the barriers and enablers to the practice of Paediatric vaccination in India and Ireland. A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021 CHAPTER 2 LITERATURE REVIEW

It has been proven that an approximately 95% of the morbidity rate is decreased after the entry of the vaccines into the market. Therefore, children need to be vaccinated to improve their immunogenicity to handle an attack of harmful germs(Anderson et al., 2018). The literature review will provide an overall concept of Paediatric vaccination in India and Ireland with child immunization schedule and current uptake level of Paediatric vaccination. A literature research was undertaken in different database such as PubMed, Science Direct and Google Scholar to obtain data regarding the child immunogenicity. The data related to the current uptake level and immunization schedule was collected from the website of relevant healthcare departments of India and Ireland. This literature review included studies regarding the mortality rate, knowledge and attitude of parents and healthcare workers towards Paediatric vaccination from different countries. Chart 1: Flow chart of number articles which are included in the study

2.1 OVERVIEW OF CHILDHOOD IMMUNIZATION IN IRELAND Health Service Executive (HSE), public agency of Ireland provides Paediatric vaccination to children under 13 months free of charge. In the year 2016, HSE in Ireland, established a booklet named “Your Childhood Immunization”, to support and guide parents to improve the immunogenicity of Irish children. The booklet guides the parents on the importance of A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

Paediatric vaccination, which type of vaccines and when it should be received by children, mechanism of vaccines and after effects of vaccination. According to HSE, children under 13 months must visit their General Physician for five times to complete their childhood vaccination in order to achieve complete protection from infectious diseases. Ward et al. (2007) states that childhood immunization routine of Republic of Ireland is marginally different compared to other European countries. The department of health such as National Immunization Advisory Committee (NIAC) and Health Information and Quality Authority (HIQA) declared that there is no need to provide BCG or Tuberculosis vaccine to all new born babies in Ireland. Therefore, HSE is not conducting any programs on BCG/Tuberculosis vaccination after the announcement of health department in 2015. At the month of two, infants are recommended to take four types of vaccination, which are given below; Table 1: List of vaccines for infants with two months of age

HSE also provides detailed information about the expected side effects that could occur after vaccination and also guides about ways to prevent and solve them. HSE suggests to give 3 doses of liquid Paracetamol after every vaccination. When they are at 4 months, children are advised to take three different vaccines, which are similar to the vaccines that are recommended at the age of two months but with an exception of PCV. Most of the recommended vaccines are given in the form of an injection, except rotavirus vaccine as it is an oral vaccine. On their third visit, children are supposed to get three different vaccinations which are 6 in 1, PVC and Men C vaccine to fight Meningococcal C disease. HSE does not advise to provide Paracetamol after their third visit as Men B vaccine is not recommended at 6 months. The MMR (Measles, Mumps and Rubella) vaccine is suggested to be provided at 12 months or one year along with Men B A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

vaccine. Finally, two vaccines namely Hib/Men C and PCV vaccines are suggested to be given at the age of 13 months. A second dose of MMR and 4 IN 1 (Pertusis, Polio, Tetanus and Diphtheria) are recommended to be given between the age of 4 and 5 years. According to HSE, a few numbers of parents are worried when their children are vaccinated by more than one vaccine(HSE, 2016).

Based on the quarterly reports (2020) of Health Protection Surveillance Centre, the current uptake level of Paediatric vaccination in Ireland is given in the following table; At 12 months of age:

AGE BCG DT3 P3 Hib3 POLIO3 Hep3 MenB2 MenC1 PCV2 Rota2 (%) (%) (%) (%) (%) (%) (%) (%) (%)

12 0.02 89.33 89.33 89.33 89.33 89.33 92.33 89.33 89.33 89.66 months

At 24 months of age:

AGE 6in1 (%) MenB MMR1 MenB3 Rota2 PCV3 Hibb MenCb complete (%) (%) (%) (%) (%) 24 94.5 92 92 90.5 90 86 89.5 89.3 months (HPSC, 2020) Table 2: Current uptake level of Paediatric vaccination in Ireland

Doherty et al., (2014) conducted a study to evaluate socioeconomic inequalities in relation to child vaccination in Ireland. According to Doherty et al, factors such as socio economic background, household income, household structure and parental and doctors attitude have an important influence on the uptake rate of infant vaccination in Ireland. The influence of socioeconomic background is directly related to the intake of infant vaccination. Even though, child vaccination is free in Ireland, there is an inequality in the rate of childhood vaccination(Doherty, Walsh and Neill, 2014). According to Welcome Global Monitor Report 2018, 91% of Irish parents agreed that vaccines are safe and important for children to boost their immunogenicity. And, 39% and 55% of parents from Ireland have expressed high and medium trust in scientists' index respectively. Whelan et al recommended to use parental A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

attitude as a tool for Paediatrician to encourage uptake level of Paediatric vaccination in Ireland(Whelan et al., 2020).

2.2 OVERVIEW OF CHILDHOOD VACCINATION IN INDIA International Institute for Population Science (IIPS) established a collaborative project called National Family Health Survey (NFHS) to collect comprehensive data on population, family welfare and health, with a focus on children throughout India. The fifth series of NFHS, 2019-20 deals with the data collected from 22 states/union territory (UT) of India. According to NFHS-5 (2019-2020), the current uptake level of Paediatric vaccination is higher than the data collected from 2015-16(NFHS-4). The table, which is given below shows the percentage of fully vaccinated children between 12 and 24 months in different states of India based on NFHS-4 and NFHS-5. STATES OF INDIA NFHS-5 (%) NFHS-4 (%) (2019-20) (2015-16) ASSAM 66.4 47.1 ANDHRA PRADHESH 73.0 65.3 BIHAR 71.0 61.7 GOA 81.9 88.4 GUJARAT 76.3 50.4 HIMACHAL PRADHESH 89.3 69.5 JAMMU & KASHMIR 86.2 75.0 KERALA 77.8 82.1 Table 3: Percentage of fully-vaccinated children in different state of India

The current rate of fully vaccinated children in different parts of India is increased compared to data from NFHS-4 except certain states such as Kerala and Goa(National Family Health Survey, 2020). According to Gurunani's study in 2018, approximately 38% of children did not get their basic vaccination in 2016, due to lack of awareness and anti-vaccination messages. In 2014, Ministry of Health & Family Welfare, Government of India initiated Mission Indradhanush (MI) to A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

address all underserved and insecure population due to poor coverage rate of Paediatric vaccination. Between 2015 and 2017, MI vaccinated about 25.5 million children and 6.9 million pregnant mothers with an increased rate of 6.7% in total immunization rate. MI is modified to Intensified Mission Indradhanush (IMI) in 2017, with an aim to cover 90% immunization rate by 2020(Gurnani, 2018). The immunization Programme IMI mainly focused on children aged up to 5 years and all pregnant women in targeted 173 districts across 24 states of India. After the implementation of IMI, an approximate 5.95 million children were vaccinated and about 8,50,000 children received their vaccination for first time during the period between October,2017 and January 2018(Gurnani, 2018).

The Universal Immunization program (UIP) of India is providing free Paediatric vaccinations for all infants especially to resist 6 types of diseases. According to Ministry of Health & Family Welfare, Government of India, national immunization schedule for infants and children is as follows; (National Immunization Schedule, 2020) Table 4: Routine vaccination schedule for infants and children in India

Shrivastwa et al., (2015) conducted a study in different part of India with the help of District Level Household and Facility Survey Data (DLHS3) conducted in 2008. The study focused on the prediction of Paediatric vaccination among Indian children aged between 12 and 36 months. This primary research study classified childhood vaccination into three categories namely; fully vaccinated, under vaccinated and non-vaccinated according to the intake rate of BCG, DPT3 and A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

MCV vaccines in children in accordance with WHO. According to Shrivastwa et al, predictors of vaccination belongs to four groups namely; childhood, maternal factor, sociocultural factors and household, all these predictors have an important influence on the child's immunization status. Apart from these predictors, religion, caste and birth place like urban or rural, have a huge effect on the children's vaccination status. According to the research data, 57% of children got their suggested dose of vaccinations; at the same time the percentage of children who comes in the category of under vaccinated and non-vaccinated were 31 percent and 12 percent respectively. Although the Universal Immunization Program (UIP) of India is supplying essential Paediatric vaccines to the new born babies for free of cost, India has the lowest immunization coverage rate due to the lack of unavailability of vaccines and inadequate knowledge regarding the benefits of Paediatric vaccination. Major parts of the total study population of children were listed in the category of under and nonvaccinated and the children from rural area were reported low immunization rate than the children from urban area. Multifaceted health programs are the essential factors required to support or improve the status of Paediatric vaccine coverage rate(Shrivastwa et al., 2015).

2.3 PARENTAL BEHAVIOUR TOWARDS PAEDIATRIC VACCINATION The role of parental decision and their knowledge regarding Paediatric vaccination is an important factor in the overall immunization rate. Adequate knowledge, attitude and practice of vaccines by parents are mandatory elements to improve child's immunization rate. Parental perception regarding adverse effects and misinformation of child's immunogenicity may have a detrimental impact on uptake level of childhood vaccination and often result in a range of health issues. Good practice of Paediatric vaccination by parents is closely related to source of information they receive from healthcare professionals. Therefore, communication between parents and health care providers is a significant determinant, which affects parental decision regarding children's immunization(Qutaiba B Al-lela et al., 2014). According to Richards and Sheridan, parental attitude and guidance from healthcare practitioners are the major predictors of Paediatric vaccination. Many parents did not provide up to date vaccination to their children as they considered that mild illness is a contraindication to vaccination(Richards and Sheridan, 1999). A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

As per Mills et al., (2005) parental concerns regarding the adverse effects of vaccination, discomfort from painful process, belief that vaccination is not required while the child has mild disease and inadequate communication between parents and healthcare providers are the major barriers to Paediatric vaccination. A number of parents are concerned about the short and long term effect of vaccination and some parents also reported several access issues that hampered vaccination(Mills et al., 2005). According to VACSATC project (Vaccination Safety, Attitude, Training and Communication Project), majority of parents in five European countries agreed to vaccinate their children after attending childhood vaccination programs. They also agreed that it is important to immunize their children for a better community. The research study of Miller et al (1994) and Prislin et al (1998) reported highly educated parents are less worried about vaccine safety, as a result, their children had greater immunization rate. Higher proportion of parents from England, considered that disease such as Meningitis, Poliomyelitis and tetanus are the most serious disease and measles, mumps, rubella and diphtheria are less serious(Stefanoff et al., 2010). In 2012, Chow et al., (2017) conducted an online survey to assess attitude of Australian parents toward Paediatric vaccination. 90% of parents were responded positively to questionnaire regarding childhood vaccination. Providing parents with clear and evidence based information would improve the average coverage rate of Paediatric vaccination and guide them to make an informed decision regarding their children's immunogenicity(Chow et al., 2017).

Chidiebere et al (2014) says that maternal sociodemographic factors such as mother's educational status, religion, wealth class, urban/rural residence and occupation status have a greater influence on child immunization uptake. In comparison to mothers within 15 to 18 and 19 to 34 years age category, mothers between 35 and 45 were more willing to have their children vaccinated. Likewise, parents from urban area with access to media and upper or middle class have been shown positive response to Paediatric vaccination(Chidiebere, Uchenna and Kenechi, 2014). According to a report by Gellin et al (2000), some parents were willing to provide vaccines for their children by considering school entry requirements as a primary reason. Despite the fact that the majority of parents accept Paediatric vaccination, many are concerned with their children being vaccinated with so many vaccines or several vaccines at A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

once(Gellin et al., 2000). In order to increase the immunogenicity rate of children, it is important to provide accurate information about childhood vaccination to parents. As a result, healthcare providers should conduct vaccination programmes with reliable and comprehensive information(Stefanoff et al., 2010).

2.4 ATTITUDE AND KNOWLEDGE OF HEALTHCARE PROFESSIONALS ABOUT PAEDIATRIC VACCINATION Globally, vaccines are approved as a tool to reduce the burden of infectious disease for better public health(Andre et al., 2008). WHO reports state that the practice of vaccines is safer more than the use of therapeutic medicines. Yaqub et al conducted a study on the attitude of healthcare professionals and public towards the implementation and practice of vaccination in Europe. In their study, it is stated that healthcare professionals are facing lots of challenges to make trustful bond with patient to convince them regarding the benefits of vaccines due to lack of information. According to Yaqub et al. (2014), the attitude of healthcare professionals and their information regarding vaccines and vaccination plays an important role in the coverage and uptake rate of vaccines across the world. The advice from doctors and other health care professionals is considered a major strength to encourage patients to be vaccinated, but in many studies like Gottvall et al., (2011) and Oscarsson et al., (2011) report says that doctors have no time to discuss or to advise their patients regarding vaccination. Doctors can recommend vaccines to their patients by giving information about the benefits of vaccination to their patients and this trustful bond between the physician and patient may improve the knowledge of society in relation to vaccination(Yaqub et al., 2014). The greatest factor, which has influenced the uptake level of Paediatric vaccination is the ability of healthcare professionals like Doctors, Nurses, Pharmacist and other healthcare providers to communicate with parents regarding the information related risk and benefit of vaccination(Taylor et al., 1997). A cross sectional study was conducted by Huber et al on parents (1040) and Paediatric healthcare professionals (198) in Hungary to evaluate the attitude and knowledge regarding the practice of varicella vaccination in children. Huber et al., (2020) found that healthcare professionals are the important sources that provide information of Paediatric vaccines to A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

parents. Recommendation of the intake of vaccines by healthcare professionals was identified as the key determinant in the case of acceptance of Paediatric vaccine by parents in their study. Huber et al included 189 healthcare professionals in their study, out of which, 46 participants did not support varicella vaccination with and/or without reasons. 25 out of 46 were given reasons for why they were not supporting; the reasons included cost of the vaccine, fear of its side effects, doubts or disbelief in vaccination, misinformation and insufficient knowledge regarding the Paediatric vaccination. The decision of parents on Paediatric vaccination is highly influenced by the recommendation or advice of healthcare workers, therefore it is mandatory to evaluate the knowledge of healthcare professionals and to clear their misinformation regarding the Paediatric vaccination(Huber et al., 2020). A research study of Petousis-Harries et al included family practice nurses to identify and evaluate nurses' view regarding the immunogenicity of children less than five years. Around 89% of nurses reported fear of vaccination by parents, as a major reason for the decreased coverage level of Paediatric vaccination in New Zealand and only 4% of them agreed with the lack of knowledge among healthcare workers as a barrier to achieving better immunization rate. They also identified the area of educational needs such as information about new vaccines, current issues related to Paediatric vaccination, side effects, knowledge of diseases and information regarding the advanced technology, by the participants(Petousis-Harris et al., 2005).

Systematic research conducted by Herzog et al (2013) reported that a few numbers of healthcare workers in developed countries are not ready to recommend vaccination due to lesser knowledge about vaccines and diseases, past belief and historical side effects of vaccination. Healthcare workers are the important source to provide information on vaccination and to encourage public to accept Paediatric vaccination for healthy generation; therefore it is crucial to improve the knowledge and attitude of healthcare workers about vaccination. As the importance of the healthcare worker's knowledge and belief about vaccines takes an account in the uptake level of Paediatric vaccination, the Summit of Independent European Vaccination Experts (SIEVE) in 2007 recommended conducting various healthcare programs or events to improve healthcare professional's understanding regarding the importance of both Paediatric and adult vaccination(Herzog et al., 2013). Schupfner et al, A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

(2002) conducted a cross sectional study in Germany and reported that some of the Paediatricians recommend providing combined vaccines rather than taking each vaccines separately. Furthermore, the study of Taylor et al, (2002) and Davis et al., (2003) reported that 25% of family Physicians and Paediatricians preferred to give more than one dose of Paediatric vaccines at one visit. At the same time, Salmon et al, (2008) expressed the concerns of Paediatricians about the side effects of vaccines in their study conducted in USA. According to Huber et al. (2020), the healthcare workers who did not support the Paediatric vaccination are concerned about various factors which included side effects of vaccination, actual need of vaccination and safety of vaccines. Healthcare worker's knowledge regarding Paediatric vaccination is an important factor as healthcare professionals with more education and knowledge are known to recommend vaccination to parent at a higher rate than healthcare workers with lesser knowledge. It is important to provide accurate information and to clear their potential concerns regarding the Paediatric vaccination in order to enhance their confidence level(Huber et al., 2020).

2.5 OVERVIEW OF CHILDHOOD MORTALITY RATE IN INDIA A review study of Rohini Gosh, (2012) says that, India, a south central Asian country has the second world wide largest population in terms of children. At the same time, India is failing to minimize the rate of childhood mortality as the country is holding number one highest position in the case of child mortality rate and Neonatal death rate. As per Rohini Gosh, India is contributing around one million of deaths to the total world's number of neonatal deaths(Ghosh, 2012). Pandey et al., 2000 reviewed NFHSNational Family Health Survey (1992 93) in the year 1998, in their study, the mortality rate and reasons behind the childhood mortality are determined in terms of four different categories namely; Neonatal, Post neonatal, infant and child mortality. Exposure to tetanus is the biggest reasons behind the increased neonatal mortality rate due to certain background attributes include rural and urban residence and unhygienic handling of umbilical cord. The enhanced rate of neonatal mortality can be prevented by the uptake of tetanus vaccination in new born babies(Pandey et al., 2000).

Establishment of child vaccination programs have resulted with a decreased number of childhood mortality rate and an increased rate of vaccination uptake among children under 5 A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

years old across the world(Anderson et al., 2018). Child mortality rate is highly influenced by the knowledge and preventive health care behaviour of parents. The lack of knowledge about the benefits of vaccination leads to increase in the mortality rate as well as kids are forced to suffer from serious conditions that should have been avoided(Esposito, Principi and Cornaglia, 2014). A number of studies include Basu, 1989; Muhuri and Preston, 1991 have reported that sex of child is an important factor in the childhood mortality level; discrimination and son preference are some of the factors that has caused a significant increase in the female child mortality rates. According to NFHS, the main cause of escalated child mortality includes insufficient realization regarding the Paediatric vaccination among parents due to socioeconomic background and demographic characteristics.

In fact, the fifth series of NFHS (2019-20) reported that there is a moderate decrease in the level of child and infant mortality rate compared to NFHS-4 based on data collected from 2015 2016. For example, the neonatal mortality rate (NNMR) has decreased from 23.6% to 19.9% in Andhra Pradesh, a state of India and rate of infant mortality and child mortality has reduced from 34.9% and 40.8% to 30.3% and 35.2% respectively(National Family Health Survey, 2020). The factors such as unavailability of health care and nutritional events, unawareness of child immunogenicity, various socioeconomic and cultural practice and discrimination mentality are highly influenced on the child mortality rate in India(Ghosh, 2012).

2.6 CONCLUSION The knowledge of healthcare professionals and parental behaviour towards Paediatric vaccination are the major factors that have influence on the overall child immunization rate(Richards and Sheridan, 1999). Communication between parents and healthcare workers is very important as good practice of Paediatric vaccination is closely connected to source of information(Qutaiba B Al-lela et al., 2014). Despite the healthcare departments of India and Ireland are providing free childhood vaccination to all infants, the uptake level of Paediatric vaccination is still remains low. It is necessary to conduct multifaceted health programs to clear potential concerns regarding the Paediatric vaccination to improve child immunization rate((Stefanoff et al., 2010);(Shrivastwa et al., 2015);(Huber et al., 2020)). A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021 CHAPTER 3 RESEARCH METHODOLOGY

This section will provide with a brief idea about the study design, sampling size and method of sampling size, data collection, data analysis and description of developed questionnaire with ethical considerations.

3.1 RESEARCH DESIGN A cross-sectional descriptive survey will be conducted among parents and healthcare professionals in India and Ireland to evaluate the factors associated with the implementation and uptake of Paediatric vaccination during the month of May, 2021. In order to conduct a quantitative study, the researcher must select relevant research techniques like questionnaire because a quantitative research methodology is characterized as a standardized questionnaire to collect information(Choy, 2014). The research design for my study includes an online survey approach to collect quantitative data. According to overall child immunization coverage rate (2019) by UNICEF and WHO, it has been identified that the total coverage rate of childhood vaccination in India and Ireland is not beyond 92%. This study will evaluate the parental attitude and knowledge of healthcare professionals with the identification of barriers and enablers of the practice of Paediatric vaccination. Descriptive statistical analysis will be performed to describe and summarize the generated data response to maximize the practice of Paediatric vaccination as the research involved focus groups to identify the factors associated with the implementation and uptake of childhood vaccination. The study follows positivism as it is a general fact that parental behaviour and healthcare professional's knowledge have a great influence on the uptake of vaccination among children(Saunders, Lewis and Thornhill, 2009). Online questionnaire will be prepared with the help of online survey tools such as Google form and prepared questionnaire will be distributed to participants through Email and other social media apps (Facebook and Whatsapp) during the month of May, 2021. The importance and objectives of the study will be informed to all participants prior to answering the questionnaire. A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

3.2 RESEARCH POPULATION AND SAMPLE SIZE Depending upon the nature of the data to be collected, two cohorts of participants will be involved in this research study; parents and healthcare professionals like doctors, nurses and pharmacist. According to latest United Nation Data, the contribution of India and Ireland to the total worldwide population size is 17.70% and 0.06% respectively. India has the second highest position with a population size of 1.3 billion, whereas Ireland is in the 124 th position. A sample size of 69 parents and 64 healthcare professionals were selected for the survey depending on the proposed criteria, parameters, availability of resource and duration of the study. The sample size was calculated using Survey Monkey, an online survey tool by providing randomly selected population size of 1 million of parents and 1000 of healthcare professionals. All the participants will be contacted through the Email and other social media apps such as Whatsapp, Facebook and Linked In as these were the easiest way to connect.

3.2.1 INCLUSION CRITERIA  Parents who reside in India and Ireland.  Healthcare professionals like Doctors, Nurses and Pharmacists who are working in India and Ireland.  Healthcare professionals like Doctors, Nurses, Pharmacist and who are working in hospitals, private clinics, pharmacies and nursing homes.  Healthcare professionals who are working in private sector and public sector will be accepted to participate in this research.

3.2.2 EXCLUSION CRITERIA  All healthcare professionals who are working outside Ireland and India will be excluded from this research study.  Parents who do not live in India and Ireland.  The healthcare professionals such as doctor, nurses and pharmacists who do not have interest to participate in this research study and students or any other healthcare providers who have prior experience in healthcare profession will be excluded. A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

3.3 DATA COLLECTION AND ANALYSIS The data will be collected from the candidates via Email and Whatsapp by using online survey form; Google Forms during the month of May 2021. Specifically developed two separate questionnaires will be used to collect data from parents and healthcare workers. Prepared questionnaire will be distributed to all participants includes parents and healthcare workers who are working in India and Ireland. The purpose and objective of the study will be included as an introduction part to the questionnaire for understanding of the participants. A section that will collect participant informed consent will be introduced to the questionnaire to confirm the participation of the candidates to the survey as it is difficult to collect consent from candidates directly.

The obtained data will be analysed based on the factors influencing, knowledge of healthcare professionals and attitude of parents toward Paediatric vaccination. The researcher can estimate and evaluate the general knowledge and awareness of the healthcare professionals regarding the application and uptake rate of vaccination in children and parental behaviour through the analysis of collected data. The study will represent the collected data with the help of charts, graphs and contingency table. A deductive approach will be performed to test the hypotheses;

Null Hypotheses: The parental behaviour and knowledge of healthcare professionals regarding the Paediatric vaccination are not dependent upon the country; they live in.

Alternate Hypotheses: The parental behaviour and knowledge of healthcare professionals regarding the Paediatric vaccination are dependent upon the country; they live in.

The data analysis tools such as chi-square test will be used to check null and alternate hypotheses. Chi Square test is one of the simplest and easiest tests to check whether the two variables are related or not. The chi square test will be performed in Excel using contingency table and observed P value will be compared with alpha/critical value of 0.1 at confidence level of 90%. If the p value is greater than alpha value then the null hypotheses will be accepted (Rana, 2015). A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

3.4 QUESTIONNAIRE DEVELOPMENT As mentioned earlier, the survey will include two groups of candidates depending upon the nature of the research. A questionnaire is a quick fix and multi-method approach to collect data as it is structured by researcher in such a way that the responders can only answer the questions or select the answers from given choices. Questionnaire is the best way to get information with number of advantages such as easy to analyse, low cost in terms of time and price and anonymity of participants(Gillham, 2008).

3.4.1 QUESTIONNAIRE FOR PARENTS The questionnaire for parents will be divided into three sections to evaluate their attitude towards Paediatric vaccination and factors that have influence on parental decision about child immunogenicity. This questionnaire is developed with the help of previously published articles(Herzog et al., 2013);(Qutaiba B Al-lela et al., 2014);(Yaqub et al., 2014).

Section 1: Demographic characteristicsthis section will deal with the demographic details of parents such as age, residence and number of children they have to confirm inclusion criteria for the study.

Section 2: this section will contain questions to evaluate parental behaviour towards the implementation and uptake of childhood vaccination in India and Ireland. The Likert scale and closed ended questions will be used in this segment. Closed questions are commonly used in a quantitative type of study. It is preferred when the researcher has predetermined answers to their questions(Gillham, 2008). The attitude of parents towards Paediatric vaccination can be evaluated by using Yes or No questions followed by five point Likert scale. Likert scale or agree disagree scale will determine how strongly a respondent agree to a statement using five point scale (strongly agree, agree, neither agree nor disagree, disagree and strongly disagree). Likert scale provides overall attitudinal score with a standard deviation(Brace, 2004).

Section 3: this section is designed to determine factors that have influence on parent's decision making skills on childhood immunization using Yes or No questions. A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

3.4.2 QUESTIONNAIRE FOR HEALTHCARE PROFESSIONALS The questionnaire for healthcare professionals will be divided into four sections to assess their understanding regarding the Paediatric vaccination and to identify barriers and enablers to its implementation and uptake.

Section 1: Demographic Details This section will deals with the demographic characteristics of healthcare workers to confirm sampling specification for inclusion.  Profession of the participant  Country you are work in;

Section 2: to evaluate healthcare professional's knowledge Using Yes or No questions and five point Likert scale, the awareness section was developed to assess healthcare worker's knowledge of Paediatric vaccination.

Section 3&4: This section is designed to identify factors those have influence on the implementation and practice of Paediatric vaccination in children according to healthcare professional's opinion. It will help to discuss the significant barriers and enablers of the practice of Paediatric vaccination in India and Ireland.

3.5 ETHICAL CONSIDERATION The proposed study will follow the terms and conditions provided in the Research Ethics Committee, Griffith College, Ireland. Participant information sheet, ethical approval form and participant consent will be submitted to the Research Ethic Committee. Before collecting data, all the participants will be informed regarding the purpose and aim of the study. In order to obtain Participants consent, a section will be included in the online survey. The dignity of each participant will be protected and the collected data will be used only for the research purpose. Researcher can only access the data and the data will be protected by a real time antivirus protection with daily virus definition updates. A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021 CHAPTER 4 DATA ANALYSIS AND RESULTS

4.1 ANALYSIS OF DATA OBTAINED FROM PARENTS A total of 80 parents participated in this survey from India and Ireland in the month of May, 2021. The online survey was distributed through email and mobile apps (Facebook and Whatsapp). Out of 80 responders, 11 were rejected because of the late submission and calculated sample size as the study required 69 parents. Finally, responses from 69 parents; were included in this study for the analysis of data to evaluate the attitude of parents towards Paediatric vaccination.

4.1.1 DEMOGRAPHIC CHARACTERISTICS 4.1.1.1 AGE AND NUMBER OF CHILDREN The table given below demonstrates the demographic details of parents. Majority of parents (54%) falls under the age group of 25-34 followed by 35-44 years (25%), 18-24 years (10%), 45 54 years (7%) and only 4% of parents with above 55 years have responded to this survey. 52% of parents reported have one child, where as 48% of parents have two or more than two children. AGE INDIA, IRELAND, n (%) n (%) 18-24 4 (11%) 3 (9%) 25-34 21 (60%) 16 (47%) 35-44 7 (20%) 10 (29%) 45-54 2 (6%) 3 (9%) Above 55 1 (3%) 2 (6%) NUMBER OF CHILDREN One 20 (57%) 16 (47%) Two or More two 15 (43%) 18 (53%) Table 5: The number and percentage of age and number of children. A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021 Age Group of Parents Age Group Of Parents From India (%) From Irelad (%) 6% 3% 11% 18-24 6% 9% 18-24 9% 20% 25-34 25-34 35-44 35-44 45-54 29% 45-54 47% 60% Above 55 Above 55 Chart 2: Percentage of age of parents from Ireland and India.

Percentage of Parents Percentage Of Parents with with Number Of Children Number of Children (IRELAND) (INDIA) 47% One 43% One 53% Two or More 57% Two or More

Chart 3: The percentage of parents with number of children from Ireland and India. A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

4.1.1.2 COUNTRY OF RESIDENCE The chart given below represents the number of participated parents from India and Ireland. A total of 69 parents included in this study, in which participants shared almost equal proportion of participation from each country. 35 parents from India and 34 parents from Ireland responded to the survey. Chart 4: Number of parents who participated from Ireland and India.

4.1.2 ATTITUDE OF PARENTS TOWARD PAEDIATRIC VACCINATION To evaluate attitude of parents towards the practice of Paediatric vaccination, the parents from India and Ireland were asked several questions using Yes or No questions and five point Likert scale. The data collected from the responders were analysed using Chi Square test in order to prove the hypotheses.

4.1.2.1 PARENT'S TRUST IN PAEDIATRIC VACCINATION PROGRAMS RUN BY GOVERNMENT The table 6 shows the number and percentage of parents who responded positively and negatively to the question regarding their confidence level in Government-Run Paediatric vaccination programs. A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021 CONFIDENCE LEVEL OF PARENTS IN PAEDIATRIC VACCINATION RUN BY GOVERNMENT OBSERVED VALUE EXPECTED VALUE COUNTRY YES (%) NO (%) TOTAL YES NO IRELAND 32 94% 2 6% 34 31.5 2.5 INDIA 32 91% 3 9% 35 32.5 2.5 TOTAL 64 93% 5 7% 69 64 5 Table 6: Trust in Paediatric vaccination run by Government.

According to table 6, 94% Irish parents and 91% Indian parents have shown trust in Paediatric vaccination run by respective Governments. By considering the P value (p=0.66) from the statistical analysis, it was clear that the confidence level (Attitude) of parents in Paediatric vaccination not dependent on the country they live in.

4.1.2.2 RECOMMENDATION LEVEL OF PAEDIATRIC VACCINATION BY PARENTS The table 7 evaluates the parental behaviour towards Paediatric vaccination by analysing data regarding the rate of recommendation of Paediatric vaccination by parents. RECOMMENDATION OF PAEDIATRIC VACCINATION BY PARENTS OBSERVED VALUE EXPECTED VALUE COUNTRY YES (%) NO (%) YES NO TOTAL IRELAND 31 91% 3 9% 30.1 3.9 34 INDIA 30 86% 5 14% 30.9 4.1 35 TOTAL 61 88% 8 12% 61 8 69 Table 7: Level of recommendation of Paediatric vaccination by parents.

91% of parents' livings in Ireland were willing to recommend vaccination for infants and children and the same was 86% for Indian parents who responded to the survey. For the data in this table, the calculated P value was 0.47, which is greater than 0.1 (Alpha value). Therefore, it is clear that the recommendation level of Paediatric vaccination by parents is not dependent on the country they live in. A quantitative study on factors associated with the implementation and uptake of Paediatric vaccination in India and Ireland-2021

4.1.2.3 IMPORTANCE OF PAEDIATRIC VACCINATION
citation:   George, Nithya Maria  (2021) A Quantitative Study on Factors Associated with the Implementation and Uptake of Paediatric Vaccination in India and Ireland.  Masters thesis, Innopharma.   
document_url: http://go.griffith.ie/507/1/10341_Nithya_Maria_George_DISSERTATION-2021_148435_1855904846.pdf