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BMJ Open. 2019 Sep 18;9(9):e028922. doi: 10.1136/bmjopen-2019-028922.

Determinants of timeliness in early childhood vaccination among mothers with vaccination cards in Sindh province, Pakistan: a secondary analysis of cross-sectional survey data.

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Department of Health Administration, Dankook University, Cheonan, Korea (the Republic of).
Global Health Unit, Department of Health Sciences, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
Jhpiego, Johns Hopkins University, Baltimore, Maryland, USA.
Department of Health Administration, Department of Information & Statistics, Yonsei University, Wonju, Korea (the Republic of).
College of Nursing, Sungshin Women's University, Seongbuk-gu, Korea (the Republic of).
National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, Maryland, USA.
Department of Humanities and Social Medicine, Catholic University of Korea College of Medicine, Seoul, Korea (the Republic of)
Obstetrics and Gynaecology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands.



Untimely vaccination refers to receiving the given dose before (early) or after (delayed) the recommended time window. The purpose of this study was to assess the extent of timeliness of childhood vaccinations and examine the determinants of vaccination timeliness in Sindh province, Pakistan.


Cross-sectional analysis of data from the 2013 and 2014 Maternal and Child Health Program Indicator Surveys.


Community-based maternal and child health surveys.


Among 10 200 respondents of Maternal and Child Health Program Indicator Surveys, 1143 women who had a live birth in the 2 years preceding the survey were included.


At the participants' home, an interviewer asked mothers to show their children's vaccination cards, which contained information regarding vaccinations. Children's vaccination status was categorised into timely or early/delayed compared with vaccination schedule. A logistic regression analysis using Firth's penalised likelihood was performed to identify factors associated with timeliness of vaccinations.


238 children (20.8% of children who received a full set of basic vaccinations) received all vaccinations on schedule among children who received a full set of basic vaccinations. The percentages of timely vaccinations ranged from 2.3% for second measles vaccination to 89.3% for bacillus Calmette-Guérin. Child's age and place of delivery were associated with timely vaccinations. Older child age and institutional delivery were associated with decreased timely vaccination rate.


Home-based vaccination record is a key tool to improve the timeliness of vaccinations. The redesigned vaccination cards, the new electronic registries for vaccination card information and the vaccination tracking system to remind the second/third vaccination visits may be helpful to improve timely vaccinations for children under 2 years old.


international health services; paediatric infectious disease & immunisation; public health

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