Vaccination is undoubtedly one of the greatest public health achievements in the history of mankind. Leading health economists of the world have ranked childhood immunization among the top 3 most cost-effective solutions to advance human welfare, offering long-term benefits to the community for economic growth and development [1]. Studies have estimated for every single rupee invested in vaccines, a nation can save approximately five times the amount in direct costs and about eleven times the amount in additional cost benefits [2]. In India, the vaccination journey begins with the introduction of BCG vaccine in 1962 [3]. The 27th World Health Assembly in 1974 led to the establishment of the Expanded Programme on Immunization (EPI), initially targeting six diseases [4]. Later on, India launched its Universal Immunization Program (UIP) in 1985, which is one of the largest immunization efforts globally, given the number of beneficiaries, sessions conducted, and geographical coverage. The main aim of UIP was to immunize a birth cohort of 2.7 crore children annually against the seven vaccine-preventable diseases which include diphtheria, whooping cough, Tetanus, polio, tuberculosis, measles, and hepatitis B [5]. In selected geographical locations additional vaccines such as Hemophilus influenzae type B (Hib) and Japanese Encephalitis (JE) are administered.

Despite the vaccination efforts in India, the results have remained suboptimal because full immunization coverage is received by 65% of children in the first year of life. It has been shown that 89 lakh children in India remained under-immunized each year which is the highest number globally [6]. Approximately 34 million children across the world are not fully immunized and of them, 98% are residing in developing countries [7]. UIP implementation saw significant success in the early years (1985–1995), achieving 70–85% vaccine coverage and drastically reducing the incidence of vaccine-preventable diseases. India was declared polio-free in 2012, smallpox eradicated by 1977 tetanus cases were reduced by 95% in 2015, and measles, diphtheria, and pertussis incidence fell by 80% in the year 2012 [5, 8]. India continues to face the arduous task of improving equitable vaccine coverage, especially as it accounts for nearly one-fifth of global under-five deaths [9]. Diarrhea and pneumonia are the leading causes resulting in the death of one child every two minutes [10]. In response, the government launched Mission Indradhanush to increase immunization rates, boosting full immunization coverage from 61% in 2009 [11]. India also achieved the highest positive change among 15 countries in the Global Action Plan for Pneumonia and Diarrhoea (GAPPD) report, with significant increases in coverage of Hib (+35%), MCV1 (+1%), DTP3 (+1%), and rotavirus vaccine (+4%) [12]. National surveys such as NFHS and DLHS continue to reveal gaps in vaccine delivery and urban-rural disparities [13]. NFHS-4 data from Warangal district indicated 67.3% full immunization [14], while DLHS-4 reported lower rates 45.8% in urban and 48.8% in rural areas [15]. Independent surveys, including those by UNICEF, have suggested that reported coverage may be overestimated by 15–40%. Given this scenario, the present study was conducted to compare beneficiary characteristics and immunization patterns among urban and rural health centers. The goal is to better understand the socio-demographic influences on immunization uptake and address the gaps in vaccine delivery systems essential steps toward achieving global child health targets and the Sustainable Development Goal 3 (SDG-3): ensuring healthy lives and promoting well-being for all at all ages.

This cross-sectional descriptive study was conducted in the urban health center as well as the Rural Primary Health Center Dharmasagar, of Mahatma Gandhi Hospital, attached to Kakatiya Medical College, Warangal, Telangana. Written consent was obtained from the parents/guardians of the children included in the study after explaining the nature of the study in vernacular language. The study population included infants and children under the age of 2 years brought by mothers or caretakers to the above centers.

Inclusion Criteria:

1. All children between 0 to 2yrs of age
2. weighing above 2 kg
3. willing to participate in the study.

Exclusion Criteria:

1. Children above 2 years of age
2. Mothers who are not willing to participate in the study.
3. All children who do not choose to come to the public sector for immunization.

Sample Size: by birth rate, by residence Urban 17.1 per 1000 population, Rural 17.2 per 1000 population, Total population in Dharmasagar PHC is 40,200 Total population in the urban health center is 40,000.

Estimation of target population = total population x birth rate of the state in urban x (1-infant mortality)/ 1000

40200 x 17.1   x (1-20)/1000=40000 x 17.1 x 0.980/1000=670

40000 x 17.2   x (1-38)/1000=40000 x 17.2 x 0.962/1000=661

Sampling fraction =670/250=37.3%

Study Procedure

Step 1: Questionnaire Design: A semi-structured questionnaire was developed based on the standard guidelines and recommendations provided by the World Health Organization (WHO), with reference to the specific objectives of the study. The tool aimed to assess beneficiary characteristics and immunization patterns among urban and rural health center attendees.

Step 2: Validation of the Instrument: The preliminary questionnaire was reviewed, modified, and validated through expert consultation with senior faculty members and the research guide to ensure content validity and contextual relevance.

Step 3: Ethical and Administrative Approvals: Necessary permissions were obtained from relevant authorities including the District Immunisation Officer (DIO), the Medical Officer in charge of the Urban Health Centre (MGM Hospital), and the Rural Primary Health Centre at Dharmasagar. Prior coordination was also established with the Auxiliary Nurse Midwives (ANMs) at the respective sub-centers.

Step 4: Data Collection: Participants were recruited prospectively through convenient sampling. Children accompanied by mothers or caregivers attending the immunization clinics at the selected centers were enrolled according to predefined inclusion criteria. Data collection was conducted using the validated semi-structured interview schedule. Participants were also counseled on the benefits, cost-effectiveness, and necessity of complete immunization.

Statistical Analysis:

All collected data were compiled into a master database using Microsoft Excel. Subsequent analysis was performed using SPSS version 22 software. Descriptive statistics, including means, proportions, and percentages, were calculated. The Chi-square test was applied to evaluate associations between categorical variables. The p-value of (<0.05) was considered statistically significant.

A total of N=500 cases and n=250 children from Rural PHC Dharmasagar and 250 children from Urban Health Centre MGM Hospital, Warangal were included. Table 1 shows the demographic Characteristics by Residence. A critical analysis of the table shows that the age distribution was comparable (32.4% vs 33.2% <1 year; 67.6% vs 66.8% 1-2 years, p=0.924). Gender distribution showed near-equal proportions (50.4% vs 51.6% males, p=0.858). Birth order differed significantly - 64% of urban children were first-born vs 46.8% of rural (p<0.001), reflecting urban family planning trends. Rural areas had higher proportions of second/third births (43.6% vs 25.2%). These demographic similarities validate group comparability for immunization pattern analysis while highlighting key sociocultural differences in family structures between settings.

                                             *Significant

 Table 2 shows the socioeconomic factors by area of residence in the study. There were significant disparities existed in caste/religion distributions (p<0.001). Rural areas had higher SC/ST representation (38% vs 20%), while urban centers had dominant BC populations (76% vs 56.4%). Religiously, urban areas showed greater diversity (32.8% Muslim vs 0.8% rural), reflecting migration patterns. These factors influence healthcare access - marginalized groups (SC/ST) in rural areas and Muslim minorities in urban settings may face unique barriers to immunization. The Hindu majority was more pronounced in rural areas (98.8% vs 66.4%), suggesting potential cultural/behavioral differences in health-seeking behaviors between the populations.

                                                       *Significant

 Table 3 depicts the Immunization Coverage of Basic Vaccines from both centers, they achieved >90% coverage for core vaccines, though rural areas showed marginally better Penta3 completion (94.8% vs 91.2%, p<0.001). Dropout rates were low but higher in rural areas (Penta2: 1.6% vs 0%, p=0.046), possibly due to accessibility challenges. OPV2 coverage was identical (97.2%), but urban centers had more catch-up vaccinations (2% vs 0.4%). The statistically significant differences in dropout patterns (p=0.032-0.046) suggest urban systems may be more effective at tracking defaulters, while rural areas maintain slightly better initial series completion through community health worker engagement.

                                                    *Significant

Table 4 shows the 16 – 24-month-old children with booster dose coverage. Booster dose coverage was suboptimal in both settings (MR2: 64.4% rural vs 62.8% urban, p=0.746), with no significant differences. Nearly 40% of children missed age-appropriate boosters, indicating systemic gaps in reminder systems and parental awareness. DPTB1 and JE2 showed similar patterns (57-61% coverage), with urban areas performing marginally better (non-significant). The high proportion of "pending" vaccinations (33-39%) suggests many children were still within the allowable window, emphasizing the need for improved tracking of delayed vaccinations rather than classifying them as dropouts prematurely.

 Table 5 shows the immunization status based on the age groups. Age-stratified analysis revealed critical gaps: 60% of rural and urban infants achieved full immunization by age 1, but 35-39% were only partially vaccinated. By age 2, complete vaccination surged to 82-87%, though full immunization dropped sharply (13.6% rural, 7.2% urban), reflecting missed boosters. The dramatic age-based differences (p<0.001) highlight two key issues: 1) delayed vaccination is common, with most completing schedules by age 2, and 2) "full immunization" rates are misleading without age stratification, as they overlook time-sensitive antigen administration critical for disease protection.

                              *Significant

 Our multivariate analysis revealed significant predictors of incomplete immunization that differed substantially between rural and urban settings (Table 6). The most striking finding was that maternal illiteracy increased the odds of incomplete immunization by 3.2 times in rural areas (95% CI: 1.4-7.1) and 4.1 times in urban areas (95% CI: 1.8-9.3) compared to graduate mothers. Urban Muslim children had 2.1× higher dropout odds than Hindus (p<0.05), possibly due to cultural factors or healthcare access barriers. These findings emphasize the need for targeted interventions: urban programs should focus on religious minorities and less-educated families, while rural efforts should address geographical access limitations despite better overall equity.

                                      *Significant

The current study was done to compare the overview of immunization patterns and beneficiary characteristics between an urban health center (MGM Hospital, Warangal) and a rural primary health center (Dharmasagar). The vaccination rates were excellent across both communities yet certain population characteristics together with socioeconomic factors shaped vaccination patterns. Age and gender distribution did not show significant differences which indicates that both urban and rural populations were comparable. However, we found significant differences in birth order, with higher proportions of first-born children in urban areas (64% vs 46.8%, p<0.001).  These observations were consistent with the existing literature which has found that urban families often adopt a smaller family size and prioritize timely healthcare for their first-borns [16]. Studies have shown that higher birth order has been associated with a reduced rate of immunization coverage due to resource constraints and lower health prioritization [17-19]. Our study found socioeconomic, religious, and cultural differences were evident. Rural areas had a greater proportion of the population of SC/ST while the urban centers had a higher representation of Backward class and religious minorities, especially Muslims. This appears to be important because it has been found that marginalized communities whether due to caste or religion often face structural and perceptual barriers to immunization [20]. Our data shows that Muslim children in urban areas have 2.1 times higher odds of incomplete immunization. Similar findings have been reported by Singh PK et al. [16] where they found lower immunization rates among minority communities due to distrust in public health programs or logistical challenges.

This study found that the core vaccine coverage (Penta2, Penta3, OPV2) was above 90% in both groups. This shows a strong implementation of the Universal Immunisation Programme (UIP) in both areas. It was also found that rural areas have slightly higher Penta3 completion (94.8% vs 91.2%, p<0.001), which could be due to robust community outreach by frontline health workers like ASHAs and ANMs [21]. However, in urban centers, we recorded lower dropout rates and higher frequency of catch-up immunization. We found that booster coverage in the 16–24-month age group, remained suboptimal in both urban and rural areas. The results of this study also showed that there were one-third of children who had pending vaccinations, with no significant urban-rural differences. Booster vaccines such as MR2, DPTB1, and JE2 are often delayed due to poor recall systems and waning parental urgency after the completion of the primary series [22]. This shows that there is a need for automated reminders and digital tracking systems for age-appropriate booster administration. Age-stratified analysis in this study showed that complete immunization improved by the age of 2 (82–87%). The proportion of children fully immunized on time dropped sharply (13.6% rural and 7.2% urban). This has some important epidemiological implications since delayed immunization compromises timely protection and increases susceptibility to vaccine-preventable diseases during early infancy [23]. It also questions the credibility of complete immunization" as a performance metric without age adjustment. The results of this study found that multivariate analysis of maternal education is a strong predictor of immunization status. Illiterate mothers are 3–4 times more likely to have incompletely immunized children. These findings are consistent with previous studies showing maternal education as a key determinant of health-seeking behavior (Desai S, Alva S, 1998). In addition, higher birth order and Muslim minority status were associated with increased odds of dropout, highlighting the need for more targeted strategies addressing social determinants.

This study highlights that while immunization coverage for basic vaccines is high in both urban and rural health settings, there are important gaps persist in timely vaccination, booster coverage, and equitable access. Rural areas benefit from better initial vaccine outreach, while urban centers perform better in defaulter tracking. Socioeconomic and religious differences influence immunization outcomes, with maternal education emerging as a critical factor across both settings. Public health strategies should prioritize education-focused awareness campaigns, improved tracking systems for booster doses, and culturally sensitive outreach, particularly for Muslim minorities and high birth order children.

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