FACTORS ASSOCIATED WITH THE NON-COMPLIANCE OF THE CHILD VACCINATION OF DIPHTHERIA, PERTUSSIS AND TETANUS IN PERU, 2019

Introduction: Pertussis tetanus and diphtheria, (DPT) are highly contagious diseases in children; worldwide vaccination schemes have been established for the prevention of these pathologies. However, diﬀerent factors can lead to non-compliance with them. Objective: To determine the factors associated with non-compliance with the vaccination schedule against diphtheria, pertussis and tetanus (DPT) in Peru in 2019. Methods: Analytical, retrospective study of secondary source based on data from 7 187 mothers between 15 and 49 years old regarding the vaccination schedule of their children older than six months of age obtained in the Demographic and Family Health Survey (ENDES) Peru 2019. The vaccination schedule of children over six months of age and the sociodemographic variables of the mothers were analyzed. A bivariate and multivariate analysis was performed using the chi square test for independence (p<0,050). Results: The sample included in the study was 7 187 mothers surveyed regarding the vaccination schedule for their children older than six months of age. The variables associated with the incomplete scheme by multivariate analysis were: low educational level (RPa: 1,19; 95% CI: 1,02-1,40), not having health insurance (RPa: 1,41; 95% CI: 1,23-1,60), wealth index poor (RPa:1,19; CI95%: 1,02-1,40), age of the mother under 20 years (PR:2,63; CI95%:2,06-3,35) and having two or more children (PRa:1,36; CI95%:1,19 -1,57). Conclusion: The index factors of wealth, mother's age, low educational level, not having health insurance and having more than two children are associated with non-compliance with the DPT vaccination schedule.

One of the pillars for the eradication and control of diseases is to ensure adequate vaccine coverage; Compliance with the DPT vaccination schedule must be (10,11) guaranteed at no less than 85% . Unfortunately, this c o m p l i a n c e i s h a m p e r e d b y d i ff e r e n t sociodemographic, economic, and environmental factors.
One of the pillars for eradicating and controlling diseases is to ensure adequate vaccine coverage, where compliance with the DPT vaccination schedule must be (10,11) guaranteed at no less than 85% .Unfortunately, compliance with the vaccination schedule is hampered by sociodemographic, economic, and environmental factors.
Likewise, diphtheria is an acute transmissible infectious disease caused by toxigenic strains of Corynebacterium diphtheriae.Although the incidence of diphtheria (4,5) cases/ has been decreasing year after year in October 2020, new cases of this disease were reported in Peru (6) after almost twenty years of absence .This regrowth also occurred in Paraguay, Venezuela, the Dominican (7) Republic, and Haiti .Currently, the prevention of these three pathologies occurs with global and national (8) vaccination schemes , contemplating three doses of the DPT vaccine at two, four, and six months of age in (9) children under one year of age .
Pertussis is a highly contagious acute respiratory disease; Every 3 to 5 years, there are outbreaks of this (1) disease .In the United States, 15,609 new cases were (2) reported in 2018 .Tetanus, a disease caused by the Clostridium tetani, is highly fatal; In 2016, it presented an incidence rate of 0.01 per 100,000 inhabitants in the (3,4) United States .
Increasingly non-compliance with vaccination schedules that include more than one dose is observed in countries such as the United States, Canada, the (12)(13)(14) Netherlands, and Mexico where it is described that the number of children who comply with the rst dose (12)(13)(14)(15) is between 80 to 89% , while for the following doses (12,13) compliance tends to decrease between 10 to 15% , in additional factors such as children born in rural areas, parents with a lower educational level or type of (13) economic condition that would make this goal of complying with the vaccination schedule difficult year after year.
In Peru, according to data from the Ministry of Health (MINSA), through a teleconference held on January 11, 2019, it was found that national coverage of DPT was 78.5% in 2014;in 2015, 87.6%;in 2016, 88.6%; in 2017, An observational, analytical, retrospective secondary source study based on the (ENDES ) of the year 2019, carried out by the National Institute of Statistics and Informatics of Peru (INEI).It is a balanced, strati ed, selfweighted, and independent two-stage complex probabilistic sampling population survey for the departmental level and by urban/rural area.The database is freely available (http://iinei.inei.gob.pe/micAbove, the objective of this research was to determine the factors associated with non-compliance with the DPT vaccination schedule in Peru in 2019.

METHODS
Information from the ENDES of 7,187 women between the ages of 15 and 49 who had children were used, including questions on demographic and social characteristics and the immunization status of their children.

Variables and instruments
Dependent or child variable The dependent variables were: rst, second, and third dose vaccine against (DPT); The responses that were in the survey were recorded as "vaccinated" as vaccinated with the date on the card, The factors that are associated with non-compliance with vaccination have been described in international studies, but very few have focused on determining whether the economic status and the implications of this at the social level are determining factors in complying with an adequate vaccination schedule.Therefore, it is necessary to carry out studies that allow knowing in greater detail the situation of compliance with the DPT vaccination scheme and the factors that are associated with it, as it is an immunization strategy that avoids the complications of three such relevant and (1,3,5) deadly diseases .

Design
82.3% and for the year 2018 this was reduced to 81.2% (16) (8) with an expected coverage goal of 85.5% ; while in samples carried out in micro-networks of Lima, as is the case of the district of San Martin de Porres, it is observed (17) that the coverage was 58.6% .

Population and sample size
Socially, compliance with this health strategy impacts children since they will have better development and growth.However, the most important impact is observed in reducing the infant mortality rate, one of the priorities established by the United Nations (UN) for (10) 2030 .

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The independent variables were: age of the mother, distributed in ranges of ve years, then, for the inferential analysis, it was dichotomized with a cut-off of 20 years based on published bibliography; mother's highest educational level: no education, primary, secondary, higher; wealth index: richest, richest, average, poorest, poorest, for the analysis it was grouped into two categories: "poor and very poor" and "middle and rich"; health insurance; type of place of residence: urban, rural.
3. REC43: contains information regarding the immunization of the children of the mothers surveyed, this module codes each child with respect to his mother; All children born alive over 6 months of age were included.

Variables related to the mother
1. RECHo: contains information from the Household Questionnaire, where the variables related to the type of place of residence were taken.
Several modules from the ENDES database were used, corresponding to different parts of the survey, such as: 2. REC0111: contains information on basic data on women aged 15 to 49, from the women's questionnaire.From there, the variables related to the mother's age, level of education, wealth index and health insurance were taken; in addition, it presents the weighting factor.Any woman who was the mother of one or more children was included.
vaccinated without date on the card, vaccinated reported by the mother.The "unvaccinated" were obtained from the response with the same name.Any answer that used "I don't know" was invalidated.The estimate of coverage was accepted according to information obtained from the vaccination card or the maternal report.

Procedures
The respective modules were uni ed in the SPSS program to obtain results.The variables analyzed were the vaccination of children over 6 months of age, as well as the sociodemographic characteristics of the mothers surveyed.

Statistical analysis
Categorical variables were estimated in relative frequencies and percentages.Likewise, compliance with the DPT vaccine schedule ( rst, second and third booster doses) was estimated at the national level and according to sociodemographic characteristics.
The data collected was organized in a database (SPSS)

Ethical aspects
The ENDES databases are publicly accessible, and the con dentiality of the participants is respected.This according to each variable considered.In the descriptive analysis, the qualitative variables were expressed using absolute frequencies and percentages.
The bivariate and multivariate analysis was performed between the sociodemographic characteristics of the mothers and the compliance with the vaccination schedule of their children, with a p<0.05 as statistically signi cant.The Chi square test of independence was used.As a measure for evaluating the prevalence factors, the prevalence ratio (PR) with a 95% con dence interval was used.The CSPLAN analysis was elaborated in SPSS version 26 for complex samples according to the sample design.In addition, the weighting factor values that were added in the REC111 module were used.This was carried out by creating a new variable where this factor was divided by one million and subsequently applied to the database.

RESULTS
The population was 7187 mothers with children older than six months of age.Each mother of these children provided relevant sociodemographic information and reported the children's vaccination status.Table 1 shows the general characteristics of the study population.It can be seen that, of a total of 7,187 women surveyed, 83.9% (6 029) were between 20 and 39 years old.
In relation to their education, women "without education" or with "only primary" were 19.7% (1 416).73.7% (5 299) lived in an urban area and 26.3% (1 888) in a rural area.In addition, 49.7% (3 571) belonged to the poor and poorer economy range.The majority of women had health insurance, represented by a percentage of 76.2% (5 477).However, 23.8% (1 710) did not have insurance.29.9% (2 150) had only one child, while 71.1% (5 037) had two or more children.Table 2 shows the vaccination status for each dose of the applied vaccine in greater detail; it was found that 94.1% (6760) of the mothers had their children vaccinated with the rst dose, as con rmed in the vaccination record, while the "unvaccinated" is 5.9% (427).
Regarding the DPT vaccination status of the children of the women surveyed, there were 21% (1508) of children whose vaccination record was incomplete.In Figure 1, it When analyzing with the variable of "having health insurance" and incomplete vaccination, it was found that 15% (1081) have insurance, while 5.9% (426) do not have insurance; this relationship had a PR= 1.35 with a p<0.01.Regarding the variable "wealth index" and the incomplete vaccination status, the results obtained show that a PR was found: 1.27, 95% CI: 1.14-1.43,p < 0.01 with respect to families "very poor" and "poor." Age was signi cant with a PR: 1.72, 95% CI: 1.50-2.00,p<0.001.
primary school, the group that had secondary education or higher, is 16.3% (1171), with a PR= 1.22 and p=0.04.
Source: self made.
us that 4.7% (337) have no education or only attended The unvaried analysis is shown in Table 3, in relation to an incomplete DPT vaccination of the children and the variable "number of children" reported by the mother (1 507), it was observed that 5.6% (405) had a single child and 15.3% (1 102) had two or more children, resulting signi cant with a PR=1.16,p=0.04.The analysis of the variable "type of residence" analysis found that those who reside in a rural area and have incomplete vaccination are 5.8% (419).In contrast, mothers living in urban areas cover 15 1% (1 088); in this analysis, the PR= 1.10 was insigni cant, with p=0.12.The analysis with "type of education" and incomplete vaccination shows

Second dose of DPT vaccine (n=7187)
Third dose of DPT vaccine (n=7187)

Has health
Wealth index

Age
Pág. 293 The results of the multivariate analysis, in

DISCUSSION
The creation of the WHO/PAHO Immunization Program .
In this study, it was found that the rst dose of the DPT vaccine schedule reached 94.1%.In comparison, the percentage of mothers whose infants did not receive this dose was 5.9%, an appropriate gure according to (14,15) the UN , since the organization quali es values above 85% as an expected percentage of vaccination.In the following doses, the proportion of mothers who had their children without vaccination increased, with 11.8% and 21.0%, for the second and third doses, respectively.It is alarming to see that, when analyzing in a general way, the percentage of complete DPT vaccination in infants is only 79%, a gure below the parameters suggested by the relevant health entities.
( type of education of the people , whose consequence is that vaccination coverage continues to be low and this represents a major problem with respect to community health. The level of education of the mother is a primary factor for compliance and understanding of the importance of a vaccination scheme such as DPT; in this study, the number of mothers "without education or only primary education" represents 19.7%, a similar gure is seen in (25) the study by Kurosky et al. , where they describe women with a "basic, but not higher" education, at 18.7%.In the bivariate analysis, our study found an association between women with no education or who only had primary education and incomplete DPT vaccination (PR=1.22;95% CI: 1.06-1.40;p=0.04). .al. with a population of 301 people surveyed found that parents who "do not know how to read or write" their children had an incomplete vaccination schedule in 45% (OR=7.4,p=0.01) suggests that poor educational level is a factor for "non-vaccination".
Within the sociodemographic characteristics of the mother, the place of rural residence and incomplete DPT vaccination was 5.8% (419), the analysis for this association was not signi cant (PR= 1.1; 95% CI: 0 .97-dollars; In studies in our country, the author Chuquin analyzed the association between the wealth index and vaccination in children under ve years of age, nding a signi cant association (p<(0.01)between these (28) variables, while Vásquez et al. did substantial signi cant results regarding this association (RPa:0.9,CI95%: 0.64-1.25,p=0.21);Faced with these results, we can see that in similar realities the association is presented in certain studies, and it is also suggested that in countries with greater economic scope this association is visualized in greater detail.
Added to the wealth index, the fact of having or not having health insurance must be analyzed, so when analyzing our data we obtained that the number of mothers without health insurance and who do not have a complete DPT vaccination schedule is 5 .9%(476), in the bivariate analysis, a PR= 1.35, p <0.001, was found.The antecedents support this value since in the work was approved by the Biomedical Sciences Research Institute (INICIB) and the ethics committee of the Faculty of Human Medicine of the Ricardo Palma University, Committee Code: PG-35-2020.

Figure 1 .
Figure 1.Map of Peru and incomplete DPT vaccination, with respect to each department Source: self-made.Adapted from ENDES 2019 has been one of the most valued public health strategies and one that contributes to equity.One of the pillars of the success of the programs is to achieve high vaccination coverage.The main indirect indicator of program development is the third dose of DPT vaccine . also analyzes in their study the level of education of parents in relation to non-vaccination in infants, obtaining an OR=1.99,CI95%: 1.02-3.91,p=0.000, in countries such as Ethiopia where Yismaw et(26) (29) investigations of Khan et al. found a signi cant association (p=0.03) in the relation between not having health insurance and incomplete vaccination status of

Table 1 .
Descriptive analysis of the mothers surveyed and the DPT vaccination status of their children according to ENDES 2019.that departments such as Puno, Loreto, Madre de Dios, Amazonas, and Lambayeque have the highest incomplete DPT vaccination schedule.

Table 2 .
Vaccination status of the children of the mothers surveyed against diphtheria, pertussis and tetanusforeach dose, according to ENDES 2019

Table 3 .
Bivariate analysis for sociodemographic characteristics and proportion of vaccination against DPT, in children older than six months of women enrolled according to ENDES 2019 95% CI: con dence interval.PR: Prevalence ratio.Source: self made.

Table 4 .
Multivariate analysis of the sociodemographic characteristics and the proportion of incomplete DPT vaccination in children older than 6 months of age of women enrolled in the ENDES 2019 asScheepers et al. and Gilbert et al. foundan association with respect to the family wealth index and non-compliance with the vaccination schedule with OR=2.14, 95% CI: 1.10-4.14,p<0.05, but the description of the "low income" per family differs a lot from the Peruvian reality, since they highlight that these incomes are less than 5,000 dollars per month, while the de nition of poverty in Peru shows a monthly income of approximately 500 soles, which is equivalent to 135 US such