Download - Factors for Immunization,Refrence
FACTORS AFFECTING CHILDHOOD IMMUNIZATION IN NORTH
SUMATRA PROVINCE, INDONESIA
JULIANDI HARAHAP
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF MASTER OF ARTS (POPULATION AND REPRODUCTIVE HEALTH RESEARCH)
FACULTY OF GRADUATE STUDIES MAHIDOL UNIVERSITY
2000 ISBN 974-664-603-6
COPYRIGHT OF MAHIDOL UNIVERSITY
Fac. of Grad. Studies, Mahidol Univ. Thesis / iv
4238524 PRRH/M : MAJOR: POPULATION AND REPRODUCTIVE HEALTH
RESEARCH; M.A. (POPULATION AND REPRODUCTIVE HEALTH RESEARCH).
KEY WORDS : IMMUNIZATION STATUS/CHILDHOOD/NORTH SUMATRA
JULIANDI HARAHAP: FACTORS AFFECTING CHILDHOOD IMMUNIZATION IN NORTH SUMATRA PROVINCE, INDONESIA. THESIS ADVISORS: BUPPHA SIRIRASSAMEE, Ph.D., ALAN NOEL GRAY, Ph.D., 64 p. ISBN-974-664-603-6
Immunization is one of the major public health interventions to prevent
childhood morbidity and death. Without immunization, more than five million children would die every year due to vaccine preventable diseases. Immunization will become more effective if the children receive the full course of recommended immunization doses. However, due to various circumstances, many fail to complete the course of immunization. In North Sumatra province, the immunization coverage in 1997 was the lowest in Indonesia, of which only 36 per cent of children (12-23 months) were fully immunized. The objective of this study was to examine the factors affecting the status of childhood immunization in North Sumatra province, Indonesia.
In this study, secondary data from the Indonesia Demographic and Health
Survey 1997 was used. The subjects considered in this study were 599 children aged 12-59 months. To study the factors affecting the status of childhood immunization, thirteen variables under four broad categories, namely, characteristics of mothers, characteristics of fathers, characteristics of children, and characteristics of households were selected.
The findings showed that 41 per cent of the children received complete
immunization. Among thirteen variables, which were considered to influence immunization status of children, nine variables were found to have statistically significant relationship with the completeness of immunization. They are maternal education, maternal occupation, prenatal care, father’s education, father’s occupation, birth order, place of delivery, assistant at delivery, and household’s economic status. There is no relationship between immunization status and maternal age, age of child, sex of child, and place of residence.
It is therefore recommended that programs need to focus on special health
education programs for parents, particularly at the low socioeconomic level. Mothers also need to be given special education to encourage them to immunize their children and also to raise their awareness regarding the necessity for complete immunization.
TABLE OF CONTENTS
ACKNOWLEDGEMENT iii
ABSTRACT iv
TABLE OF CONTENTS v
LIST OF TABLES vii
LIST OF FIGURES viii
LIST OF ABBREVIATIONS ix
CHAPTER I : INTRODUCTION
1.1. Background and Rationale 1
1.2. Research Problem and Justification 3
1.3. Research Questions 5
1.4. Research Objectives 6
1.5. Scope and Limitations 6
CHAPTER II : LITERATURE REVIEW
2.1. Role of Immunization 7
2.2. Immunization Program in Indonesia 9
2.3. Socioeconomic and Demographic Factors Related to Immunization 12
2.3.1. Theoretical Concept of Socioeconomic-Demographic Status and Health 12
2.3.2. Findings from Previous Research 13
2.4. Conceptual Framework 19
2.5. Definition of Terms 21
2.6. Hypotheses 21
CONTENTS (Cont.)
CHAPTER III : RESEARCH METHODOLOGY
3.1. Source of Data 23
3.2. Sample Size 24
3.3. Operational Definitions 24
3.4. Data Analysis and Management 29
CHAPTER IV : RESULTS AND DISCUSSION
4.1. Selected Background Characteristics of the Sample 30
4.1.1. Characteristics of Mothers 30
4.1.2. Characteristics of Fathers 34
4.1.3. Characteristics of Children 35
4.1.4. Characteristics of Households 38
4.2. Status of Immunization 39
4.3. Results of Bivariate Analysis 42
CHAPTER V : SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1. Summary 54
5.2. Conclusion 55
5.3. Recommendations 56
5.3.1. Recommendations for Policy Implementation 56
5.3.2. Recommendations for Further Study 57
REFERENCES 59
BIOGRAPHY 64
LIST OF TABLES
Page Table 1 Recommended Immunization Programme in Indonesia 11
Table 2 Percentage distribution of selected characteristics of mothers
of children under five years 33
Table 3 Percentage distribution of selected characteristics of fathers
of children under five years 35
Table 4 Percentage distribution of selected characteristics of children
under five years 37
Table 5 Percentage distribution of selected characteristics of households 38
Table 6 Percentage distribution of status of immunization of children
under five years 40
Table 7 Percentage distribution of BCG, DPT, polio, and measles
immunizations of children under five years 41
Table 8 Percentage distribution of status of immunization by selected
characteristics of mothers 45
Table 9 Percentage distribution of status of immunization by selected
characteristics of fathers 47
Table 10 Percentage distribution of status of immunization by selected
characteristics of children 51
Table 11 Percentage distribution of status of immunization by selected characteristics of households 53
LIST OF FIGURES
Page Figure 1 Conceptual framework of selected socioeconomic and
demographic factors and status of immunization 20
LIST OF ABBREVIATIONS ASEAN = Association of South East Asian Nations
BCG = Bacillus Calmatte Guiren
DPT = Diphtheria, Pertussis, Tetanus
DT = Diphtheria Tetanus
EPI = Expanded Programme on Immunization
IDHS = Indonesia Demographic and Health Survey
Measles = Measles vaccine
OPV = Oral Polio Vaccine
Polio = Poliomyelitis vaccine
TBA = Traditional Birth Attendant
TT = Tetanus Toxoid
UNICEF = United Nation Children’s Fund
WHA = World Health Assembly
WHO = World Health Organization
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 1
CHAPTER I
INTRODUCTION
1.1. Background and Rationale
Children under five years of age constitute about 15 per cent of the population
of most developing countries. An estimated 12.2 million deaths occur in this age group
every year, and young children in these countries have higher probability of death.
Most of the deaths occur from infectious diseases; that is diarrheal diseases, acute
respiratory infections, measles, and malaria (WHO, 1995). Efforts have been made for
quite a long time to reduce childhood mortality and mortality through child survival
interventions. In 1974, the World Health Assembly established the Expanded
Programme on Immunization as one of the major public health interventions to
prevent childhood morbidity and mortality. The Expanded Programme on
Immunization (EPI) is a global effort of governments, the World Health Organization
(WHO), United Nations Children’s Fund (UNICEF), other United Nations agencies,
bilateral development agencies, and non-government organizations to immunize the
world’s children to prevent suffering, disability and death due to six vaccine-
preventable diseases. They are measles, diphtheria (whooping cough), tetanus,
tuberculosis and poliomyelitis. As of July 1988, the estimated number of cases
prevented by poliomyelitis immunization in developing countries increased to
217,000. The estimated number of measles deaths prevented by immunization in
Juliandi Harahap Introduction / 2
developing countries increased to 978,000; for tetanus up to 248,000; for pertussis up
to 356,000 (Gadomski and Black, 1990).
Studies have demonstrated that measles vaccination appears to reduce
mortality by a larger proportion than would be expected from a simple reduction in
measles deaths. For example, the risk of mortality in immunized children between 6
and 8 months of age was 3 per cent, compared to 40 per cent among non-immunized
children in Guinea-Bissau (Aaby et al., 1984). Immunization against measles and
pertussis protects the child from two major causes of acute respiratory infection
mortality. Measles immunization also reduces mortality from diarrhea or pneumonia
that are frequently associated with post-measles diarrhea. Feacham and Koblinsky
(1983) estimate that measles vaccination may decrease diarrhea incidence by 2.2 per
cent and associated mortality by 16 per cent.
Immunization is also one of the most cost-effective weapons that protect
children against diseases (World Bank, 1993). Without immunization, more than five
million children would die every year due to these diseases. Immunization will
become more effective if the child can receive the full course of recommended
immunization doses. However, due to various circumstances many fail to complete the
course of immunization, which will result in lowered effectiveness of the
immunization program in reducing childhood morbidity and mortality.
Fac. Of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 3
1.2. Research Problem and Justification
The Expanded Programme of Immunization (EPI) in Indonesia was launched
officially by the Indonesian Ministry of Health in 1977 with recommendation that all
children should receive immunization against six diseases: tuberculosis (TB),
diphtheria, pertussis (whooping cough), tetanus, poliomyelitis, and measles. The aim
of this program is to increase immunization coverage in Indonesia and simultaneously
reduce infant and child mortality.
Data from the Indonesian Health Profile 1996 (Ministry of Health, 1997)
shows that immunization coverage tends to increase yearly. However, infant and child
mortality remains a severe health problem in many parts of the country. In 1993 the
under-five mortality rate in Indonesia was the highest among ASEAN (Association of
South East Asian Nations) countries, namely 81 deaths per 1,000 live births (Ministry
of Health, 1997). After the expansion of ASEAN, this rank decreased in comparison to
other countries. Based on the household health survey in 1992, among the main causes
of infant deaths were vaccine preventable diseases, such as respiratory disease,
neonatal tetanus, diphtheria, pertussis and measles (ibid). According to the Indonesian
Demographic and Health Survey 1997, the probability of death between birth and age
five in the North Sumatra province was 72 deaths per 1,000 live births (CBS et al.,
1998). This number was higher than for Indonesia as a whole, which was 70.6 deaths
per 1,000 live births.
Juliandi Harahap Introduction / 4
In 1994, the highest immunization coverage of children 12-23 months in
Indonesia was 76.7 per cent in Bali but the immunization coverage in North Sumatra
was 40.8 per cent (CBS et al., 1995). The immunization coverage decreased in 1997 to
as low as 36 per cent of children fully immunized in North Sumatra, while the highest
immunization coverage was 87 per cent in Yogyakarta (CBS et al., 1998). The
immunization coverage had unexpectedly decreased from 40.8 per cent in 1994 to 36
per cent within three years. Despite the efforts of the government to increase the
immunization coverage to acceptable levels to attain its goal of 80 per cent by the year
2000, it is evident that this figure is decreasing in North Sumatra. It may be mentioned
here that the immunization coverage in this province is currently the lowest in the
country (CBS et al., 1998).
Many studies have been conducted to explore the socioeconomic and
demographic factors related to immunization practice. Many factors have been
identified as the reasons, but these factors vary from one society to another. For
example, a study in Nepal by Ahluwalia et al. (1988) found that the educational status
of mothers was not a significant predictor of children’s vaccine coverage. Streatfield et
al. (1990) also revealed that the levels of immunization coverage did not follow a clear
linear pattern according to educational level. But in another study of many countries,
Hobcraft (1993) argued that the more educated women are the more likely to have
initiated immunization and even more likely to have their children fully vaccinated.
Therefore, based on the findings from many studies, it is evident that several different
factors might be responsible for the low immunization coverage in North Sumatra. It
certainly needs further investigation.
Fac. Of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 5
The present study will be undertaken to explore the selected socioeconomic
and demographic factors that affect the immunization status of children under five
years in North Sumatra province, Indonesia. This study will focus on children who
were aged between 12-59 months during the survey to determine whether or not
children had been fully immunized and what factors are related to the immunization
status of the children. To be fully immunized, a child should receive each of the
following vaccinations: Bacillus Calmatte Guiren (BCG), measles, and three doses of
diphtheria-pertussis-tetanus (DPT) and of polio. The ages between 12-59 months were
chosen to allow a three-month period of grace for children to receive measles
immunization, which is given at the age of nine months. Immunization should be
complete at twelve months of age.
1.3. Research questions
1.3.1. What is the immunization status of children under five years in North Sumatra
province, Indonesia?
1.3.2. What are the socioeconomic and demographic factors that affect the
immunization status of the children under five years in North Sumatra
province, Indonesia?
Juliandi Harahap Introduction / 6
1.4. Research Objectives
1.4.1. General Objective:
• To study the factors affecting the status of childhood immunization in North
Sumatra province, Indonesia.
1.4.2. Specific Objectives:
• To examine and evaluate the immunization status of children under five years
in North Sumatra province, Indonesia.
• To determine the association between the selected socioeconomic and
demographic factors and immunization status of children under five years in
North Sumatra province, Indonesia.
1.5. Scope and Limitations
This study is based on data from the Indonesia Demographic and Health
Survey 1997. Obviously, there are many factors affecting childhood immunization,
such as factors associated with maternal belief, attitude, and behaviour regarding
immunization, and also factors associated with health care provider for example,
number of contacts with target population, work commitment, knowledge and attitude
regarding each type of immunization (Limtragool et al., 1992). The limitation of this
study is related to the fact that some such information is not available and therefore
could not be included in this study. This study only focuses on some selected
socioeconomic and demographic factors related to childhood immunization.
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 7
CHAPTER II
LITERATURE REVIEW
This chapter reviews the literature concerning the role of immunization as one
of the major health interventions to prevent childhood morbidity and death. After that,
there is a brief presentation about immunization programmes in Indonesia, which
constitute the efforts of Indonesian government to increase immunization coverage.
Socioeconomic and demographic factors related to immunization and the findings
from previous studies will be described at the end.
2.1. Role of Immunization
There are many factors that contribute to infant and child morbidity and
mortality, and many of these deaths can be prevented and reduced through health
intervention programs, such as immunization, adequate nutrition, provision of safe
water and improved sanitation, family planning and education, and the availability of
health services. It is estimated that thirty five thousand children under five years in
developing countries die every day. Over 60 per cent of 12.9 million child deaths in
the world each year are caused by pneumonia, diarrheal diseases, or vaccine
preventable diseases (measles, diphtheria, whooping cough, poliomyelitis,
tuberculosis, and neonatal tetanus), or by some combination of the three. The
percentages of these three causes are 28 per cent, 23 per cent, and 16 per cent
respectively (UNICEF, 1993).
Juliandi Harahap Literature Review /
8
Immunization is one of the major public health interventions for reducing
morbidity and mortality of the children. In 1974, World Health Assembly (WHA)
created a program called the Expanded Programme on Immunization (EPI) to cover
immunization of all children in the world by 1990, and it was an essential element of
WHO’s strategy to attain health for all by the year 2000 (UNICEF, 1983). As a
member of the World Health Assembly, the Indonesian Ministry of Health has started
this program (EPI) since 1977.
In 1984, United Nations Children’s Fund (UNICEF) established the child
survival strategy, called “child survival revolution”, based on the GOBI-FFF strategy
in order to improve child survival and to reduce infant and child mortality, mainly in
developing countries. The GOBI-FFF is an acronym, where ‘G’ stands for growth
monitoring, ‘O’ for oral rehydration therapy, ‘B’ for breastfeeding, and ‘I’ for
immunization, plus the equally vital but more difficult and costly elements of the three
‘F’s as food supplements, family spacing and female education (Cash et al., 1987).
The vaccines employed in the immunization program are used to prevent the six major
communicable diseases. The Bacillus Calmatte Guirine (BCG) vaccine is for the
protection against tuberculosis in childhood, Diphtheria Pertussis Tetanus (DPT)
vaccine for the protection against three diseases -- diphtheria, pertussis (whooping
cough) and tetanus, Oral Polio Vaccine (OPV) for the protection against poliomyelitis
and measles vaccine for the protection against measles disease.
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 9
These efforts have increased the immunization coverage in developing
countries to approximately 80 per cent. As a result, three million deaths from vaccine
preventable disease are now being prevented each year, which consist of 1.6 million
deaths due to measles, 0.8 million deaths due to neonatal tetanus, 0.6 million deaths
due to pertussis, and 0.4 million deaths due to poliomyelitis (UNICEF, 1993).
2.2. Immunization Programme in Indonesia
The Expanded Programme on Immunization (EPI) aimed at reducing mortality
and morbidity from diphtheria, pertussis, tetanus (with special emphasis on neonatal
tetanus), measles, poliomyelitis and tuberculosis through the provision of
immunization against these diseases for every child by 1990. The Indonesian
immunization programme is part of a national effort to reduce infant and child
mortality rates as the target of the fourth five-year National Health Plan. In 1977 an
expanded programme on immunization was started in selected sub-districts offering a
series of vaccines including smallpox, BCG, DPT and TT (Tetanus Toxoid). The
importance of EPI as an essential component of maternal and child health and primary
health care was emphasized in WHA resolution number 31.53 adopted in May 1978
and in the Declaration of Alma Ata in September 1978. In 1980, following the
Declaration of global smallpox eradication, smallpox vaccination was discontinued.
And in 1981, due to the occurrence of poliomyelitis outbreaks, in some provinces oral
polio vaccine was introduced. Since 1982, recognizing that measles was a major
contributor to infant and child mortality, measles vaccine was also introduced. On the
basis of national and international evidence, BCG vaccination of school children was
Juliandi Harahap Literature Review /
10
terminated in favour of DT (Diphtheria Tetanus) and TT (Tetanus Toxoid) (Sutto et
al., 1986)
Although the coverage of immunization is still low, it tends to continually
increase. As early as in 1986, acceleration of the immunization programme in
Indonesia had been developed to increase immunization coverage significantly. Many
efforts have been made to intensify immunization coverage more rapidly than just the
implementation of the routine vaccination programme. This acceleration effort
included the commitment of the EPI manager from the central level to the regional
level; the attention and involvement of other sectors such as the private sectors and
community participation; and the provision of funds and moral support from donor
agencies (Sutto et al., 1986). In accordance with the goal of Global Eradication of
Poliomyelitis, which was formulated in the World Summit for the Children in
September 1990, the Indonesian Ministry of Health launched a program, called
National Immunization Week (Pekan Immunisasi Nasional). National Immunization
Week was executed in September and October of three consecutive years (1995, 1996,
and 1997) to immunize every child under five years of age, irrespective of its
immunization status (repeated administration of OPV is known to cause no side
effects) (Ministry of Health, 2000). In addition, the number of immunization sites has
increased from 5,656 health centers in 1990 to 7,105 health centers in 1995 in all
provinces (Ministry of Health, 1996).
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 11
The long term objective of the expanded programme on immunization is to
make immunization against these diseases accessible to every child in Indonesia and to
ensure that at least 65 per cent of those aged 3-14 months are fully immunized by 1990
and 80 per cent by the year 2000. The recommended basic immunization schedule in
Indonesia is as follows: BCG from birth to 14 months; DPT and polio from 3 to 14
months, with at least 4 weeks interval between two immunizations; and measles from
9 to 14 months (Lwanga and Abiprojo, 1987). One of the obstacles of EPI is that many
parents bring their children for DPT1 and polio 1, but only a few continue to complete
the series of vaccination (Grant, 1984). Hence, if the children do not receive the series
of doses of DPT and of polio completely, the protective effect of immunization or
vaccination is reduced.
Table 1. Recommended Immunization Programme in Indonesia
Recommended schedule Eligible age group Vaccine
Number of doses Interval between doses Youngest Oldest
BCG One - At birth 14 months
DPT Three Minimal 4 weeks 3 months 14 months
OPV Three Minimal 4 weeks 3 months 14 months
Measles One - 9 months 14 months
DT* Two Minimal 4 weeks 6 years 7 years
TT** Two Minimal 4 weeks Early in
pregnancy
8 months
Note: * DT is child ‘booster’ immunization for diphtheria and tetanus. ** TT is also given to pre-marriage bride, primary school student class VI, and in certain
areas to all reproductive women.
Juliandi Harahap Literature Review /
12
2.3. Socioeconomic and Demographic Factors Related to Immunization
2.3.1. Theoretical Concept of Socioeconomic-Demographic Status and Health.
Many researchers have been trying to explain the relationship between
socioeconomic-demographic status and health by comparing the mortality and
morbidity experiences of different socioeconomic-demographic groups within
individual countries, contrasting health experiences across countries, documenting the
extent of inequalities and exploring possible explanations of differential health
outcomes (Feinstein, 1993).
Feinstein (1993) organizes these various explanations into two dimensions.
One dimension refers to the underlying characteristics of a person that may cause
differences in health status, and divides these characteristics into two distinct groups:
resource-dependent characteristics like wealth, home ownership, and automobile
ownership; and non-resource-dependent behavioral characteristics, including
psychological, genetic, and cultural factors. The second dimension refers to the stage
of life experience in which inequalities are generated, and can be divided into two
groups: inequalities arising from different experiences over the life span, such as
differences in occupation, education; and inequalities that arise from differences in
access to and utilization of formal health care services.
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 13
In accordance with differences of socioeconomic and demographic status,
researchers also try to explain some behaviors that may be related to health outcomes.
The health related behavior has been defined broadly to include any behavior that has
a significant effect on health or is generally believed to have such an effect. Health
related behavior could be subdivided into risky behavior, preventive behavior, and
treatment seeking or self-treatment (Waldron, 1988).
Childhood immunization is a preventive health behavior that is directed toward
the child by the parent. In this sense, childhood immunization behavior can be defined
as a preventive behavior related to child health, in which the parent gets the child
immunized for the purpose of preventing infectious diseases in the child (Burns, 1992
cited in Gore et al, 1999). According to these theoretical concepts, in the context of
childhood immunization, health related behavior of the parent and their socioeconomic
and demographic background may have influence on the completeness of
immunization of the child.
2.3.2. Findings from Previous Research
The immunization of children is an important factor that contributes to the
child’s chance of survival. The data obviously indicates that the immunization status
of children is one of the important factors in determining children’s survival rate.
Howlader and Bhuiyan (1999) in Bangladesh found that the chances of survival of
children who have been immunized are higher than those who are not. In another
Juliandi Harahap Literature Review /
14
study, Amin (1996) revealed that immunization coverage reduced infant and child
mortality by around 60 per cent in West Africa.
Various socioeconomic and demographic factors may influence immunization
coverage of children, such as, parent’s education and occupation, age of mother,
prenatal care, sex of child, age of child, birth order of child, place of delivery and
assistant at birth of child, household income/economic status, and residence. Many
factors have been identified as the reasons, which affect the acceptance of child
immunization, but these factors vary from one society to another. For example, a study
in rural Yogyakarta in Indonesia found that the community leader played an important
role in motivating or instructing parents to seek immunization for their children, so it
was possible that illiterate mothers might have been motivated to have their children
immunized (Streatfield and Singarimbun, 1988).
Education of Parents
The formal education of parents usually increases their children’s survival rate
because they know that by having immunization, it will reduce the probability of death
of their children. Education is also associated with knowledge and the functions of
specific types of immunization, or the benefit of childhood immunization, and with a
greater awareness of proper immunization schedules. Parent’s education plays an
important role in decision making to immunize their children. Many studies have been
conducted in order to find out the relationship between mother’s education and child
immunization. Maternal education has been recognized as an important factor, which
determines immunization of children. For instance, a study in Bangladesh by Rahman
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 15
et al. (1995), Islam and Islam (1996), and a study in Ghana by Matthews and Diamond
(1997) revealed that education of mothers has a significant and positive relationship
with childhood immunization coverage. But Rahman et al. (1995) argued that even in
the presence of maternal illiteracy, educating mothers about the vaccines and vaccine
preventable diseases may be highly effective in increasing immunization coverage. By
contrast, Ahluwalia et al. (1988) found that education of mother was not a significant
predictor of children’s immunization status in Nepal. As well, Streatfield et al. (1990)
revealed that the levels of immunization coverage did not follow a clear linear pattern
according to educational level, because of the role of community leader in motivating
the mothers to immunize their children in Central Java.
So far, only a few studies have been conducted to explore the role of fathers in
determining immunization of children. A study in Nepal by Ahluwalia et al. (1988)
found that children whose fathers had a high school or greater education were more
likely to be vaccinated or to be received the complete immunizations than those whose
fathers had less formal education. In the Eastern Region of Ghana, Brugha et al.
(1996) found that fathers also played an important role in decision making to send
their children for immunization.
These findings suggested that fathers who had a relatively high education did not only
play a significant role in immunization coverage, but were also involved in using
preventive health services in order to improve their children’s overall health status.
Juliandi Harahap Literature Review /
16
Maternal Age
Mother’s age can also influence the completeness of child immunization. A
study in Bangladesh by Bhuiya et al. (1995) found that children of younger mothers
had higher immunization coverage than those mothers aged 30 and older. In another
study a younger mother who had no other or just one older child tended to have her
child immunized than a higher birth order child born to an older mother (Kaplan and
Taylor, 1992). But Matthews and Diamond (1997) found that there was no significant
relationship between maternal age and immunization of children.
Occupation of Parent and Economic Status
Parents’ occupation has been found to be related to family income in many
counties. For example, Matthews and Diamond (1997) revealed that father’s
occupation was associated with completeness of immunization in Ghana. Bhuiya et al.
(1995) in Bangladesh also found that children from better socioeconomic backgrounds
had twice higher chance to receive immunization compared with children from lower
socioeconomic backgrounds. But in a developed country setting, a study in Pinellas
County, Florida revealed that there was no relationship between maternal employment
and child immunization status (Coreil et al., 1998)
Age of Child and Birth Order
The age of child is associated with immunization where a child should
complete his or her immunization by the age of one year. Study in Ghana found that
the age of child is a significant factor related to immunization (Matthews and
Diamond, 1997). But the survey results in Indonesia showed that a majority of
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 17
children were not immunized according to the recommended schedule (Lwanga and
Abiprojo, 1987). This finding suggested that many children were not fully immunized
by the age of one year. Kaplan and Taylor (1992) in England found that the
completeness of immunization of child with high birth order was lower than that with
low birth order. Schaffer and Szilagyi (1995) in United State found that the percentage
of secondborn children who were fully immunized significantly lower than the
percentage of fully immunized firstborn children.
Sex of Child
The Expanded Programme on Immunization emphasizes the importance of
protecting all children regardless of their sex. Studies in Bangladesh by Islam and
Islam (1996) and Bhuiya et al. (1995) found that the sex of the child was one of the
important determinants of childhood immunization where male children were more
likely to be immunized than female children. Male children were twice as likely to
have received immunization as female (Ahluwalia et al., 1988). The data from
developing countries showed that child mortality rate was higher among females than
males. The lack of immunization was one of the main causes of female mortality in
developing countries (Hill and Upchurch, 1994).
Health Care Services
An association between the use of modern health care services and
immunization has been found in a number of demographic surveys conducted in
developing countries. It is generally the case that mothers who deliver at hospitals or
clinics are more likely to immunize their children than mothers who deliver at home.
Juliandi Harahap Literature Review /
18
The completeness of immunization is also associated with the number of antenatal
visits, hospital or clinic birth and attendance by physician or nurse at the time of
childbirth (Singarimbun et al., 1986; Ahluwalia et al., 1988). These findings suggest
that most of the mothers who deliver at hospital receive some advice from health
personnel to have their children vaccinated.
Residence
The type of place of residence is also an important factor, which determines the
survival of children. Kabir and Amin (1993) explained that urban-rural differences
might be attributed to different health care services, including access to health care
services and higher coverage of immunization. The children residing within one mile
of the health facility had a higher chance to be immunized than those residing more
than two miles away from the health facility (Bhuiya et al., 1995). A study in India
also revealed that the number of fully immunized children was higher in urban areas
than in rural areas (Dhadwal et al., 1997). Matthews and Diamond (1997) also found
that unimmunized children tended to come from rural families with illiterate mothers.
These finding suggested that children in rural areas tend to lack access to health
information and health facilities.
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 19
2.4. Conceptual Framework
The conceptual framework used in this study is based on the literature review,
the findings from previous research and in accordance with the objectives of this study
(Figure1). The figure shows the relationships among the variables used in this study.
The selected socioeconomic and demographic factors are considered as independent
variables, namely characteristics of mother, characteristics of father, characteristics of
child and characteristics of household. These characteristics are parents’ education and
parents’ occupation, maternal age, prenatal care, sex of child, age of child, birth order,
place of delivery and assistant at birth, household’s economic status and place of
residence, which all may have influence on the status of immunization of the child
according to research that has been cited in the literature review.
Juliandi Harahap Literature Review /
20
Figure 1: Conceptual framework of selected socioeconomic and demographic
factors and status of immunization
Independent Variables Dependent Variable
Characteristics of household: - Household’s economic
status - Residence
Characteristics of mother: - Maternal education - Maternal occupation - Maternal age - Prenatal care
Characteristics of father: - Father’s education - Father’s occupation
Characteristics of child: - Age of child - Sex of child - Birth order - Place of delivery - Assistant at delivery
Status of
Immunization
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 21
2.5. Definition of terms
Immunization: The process of introducing a substance pertaining to a particular
organism into the body to stimulate the defence mechanism of the body so that the
body increases its ability to prevent the manifestation of infection by the particular
organism (Lee, 1996).
Status of immunization: State of completeness of immunization of child (under
5 years of age) who received four vaccinations; one dose of BCG, three doses of DPT,
three doses of OPV and one dose of measles vaccine, following the recommendation
of age and criteria set by the Ministry of Health.
2.6. Hypotheses
Based on the theoretical concepts and the findings from previous research
presented above, in the context of childhood immunization, the hypotheses are as
follows:
1) Children of mothers who have better education tend to receive more complete
immunization than children of mothers who have less education.
2) Children of mothers who work in the formal sector tend to receive more complete
immunization than children of mothers who work in the non-formal sector.
3) Children of mothers who are younger in age tend to receive more complete
immunization than children of mothers who are older.
Juliandi Harahap Literature Review /
22
4) Children of mothers who have prenatal care during pregnancy tend to receive more
complete immunization than children of mothers who do not have prenatal care.
5) Children of fathers who have better education tend to receive more complete
immunization than children of fathers who have less education.
6) Children of fathers who work in the formal sector tend to receive more complete
immunization than children of fathers who work in the non-formal sector.
7) Children who were born with the assistance of professional health personnel tend
to receive more complete immunization than children who were born with
assistance of non-health personnel.
8) Children who were born in hospital tend to receive more complete immunization
than children who were born at home.
9) Male children tend to receive complete immunization than female children.
10) Children who are older tend to receive more complete immunization than children
who are younger.
11) Children of low birth order tend to receive more complete immunization than
children of high birth order.
12) Children who come from households with better economic status tend to receive
more complete immunization than children who come from households with lower
economic status.
13) Children who are from urban areas tend to receive more complete immunization
than children who are from rural areas.
Fac.of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 23
CHAPTER III
RESEARCH METHODOLOGY
3.1. Source of Data
This study used data from the Indonesia Demographic and Health Survey 1997
(IDHS) which was carried out from September to December 1997 in selected
enumeration areas in all of the 27 provinces in Indonesia. This survey was conducted
as part of the worldwide Demographic and Health Surveys (DHS) project. The 1997
Indonesia Demographic and Health Survey was designed as a collaborative effort of
four institutions, which are the Central Bureau of Statistics (CBS), the State Ministry
of Population/National Family Planning Coordinating Board (NFPCB), the Ministry of
Health, and Macro International Inc.
The main objective of the 1997 IDHS was to provide policymakers and
program managers in population and health with detailed information on fertility and
family planning, infant, child and maternal mortality, and maternal and child health.
The 1997 IDHS sample is stratified by province and by urban and rural domain
within each province. The sample was selected in three stages. In the first stages,
census enumeration areas (EAs) were selected systematically with probability
proportional to population size. In the second stage, segments of approximately 70
contiguous households with clear boundaries were formed in each EA, and only one
Juliandi Harahap Research Methodology / 24
segment was selected with a probability proportional to size. In the third stage, 25
households were selected from each segment using systematic sampling. A complete
listing of all households in the selected segments was carried out prior to the selection
of households. The 1997 IDHS covered 27 provinces and a total of 35,500 households.
In North Sumatra province, a total of 1,407 households were covered.
3.2. Sample Size
Because children aged less than twelve months are not expected to have
complete immunization, it is appropriate to restrict analysis to households with
children aged between 12 and 59 months. Within one household, the youngest child
was selected if his/her age was between 12-59 months. Then, if the youngest child was
below one year of age the second youngest child with aged 12-59 months was
selected. Finally, a total of 599 children from North Sumatra province aged 12-59
months were recruited as sample in this study.
3.3. Operational Definitions
3.3.1. Dependent Variable:
Status of immunization is categorized into two groups; complete immunization
and incomplete immunization.
Complete Immunization:
This refers to a child who received BCG vaccine, three doses of DPT vaccine,
three doses of polio vaccine (OPV), and measles vaccine.
Fac.of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 25
Incomplete Immunization:
This refers to a child who did not receive vaccination completely among BCG
vaccine, DPT vaccine, polio vaccine (OPV), and measles vaccine or did not receive
any vaccination at all.
3.3.2. Independent Variable:
Education of mother and husband:
Education of both mother and her husband refers to the highest educational
level. It is categorized into four groups:
- no education
- primary education (this refers to any level of primary education, from
Grade 1 to Grade 6)
- secondary education (this refers to any level of secondary education, from
grade 7 to Grade 12)
- higher education (this refers to any level of education higher than the
secondary level, i.e. collage or university)
Occupation of mother and husband:
This refers to the type of occupation of the mother and her husband. It is
categorized into three groups:
- unpaid labor (this means not performing any kind of work for pay)
- working in agricultural sector, and
- working in non-agricultural sector
Juliandi Harahap Research Methodology / 26
Age of mother:
This refers to the current age of mother at the time of interview. It is
categorized into three groups:
- 15 – 24 years
- 25 – 34 years, and
- 35 – 49 years.
Prenatal care:
This refers to number of prenatal care visits to health centers for check up
during pregnancy. It is categorized into three groups based on the number of visits:
- no visit
- 1-3 visits, and
- 4 visits and more
Place of delivery:
This refers to the place of delivery of child, such as government hospitals,
private clinics, health centers, and at home. These are categorized into two groups:
- at home
- health care facility (hospitals, private clinics and health centers).
Fac.of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 27
Assistance at birth:
This refers to the attendant at birth where the mother was assisted by a series of
birth attendants, the least qualified is shown. It is categorized into four groups:
- doctor
- nurse/midwife
- traditional birth attendant, and
- other or none
Age of child:
This refers to the current age of child at the time of interview. It is categorized
into four groups:
- 12 – 23 months
- 24 – 35 months
- 36 – 47 months, and
- 48 – 59 months.
Sex of child:
The sex of child is categorized into:
- male
- female
Juliandi Harahap Research Methodology / 28
Birth order:
This refers to the birth order of the child. It is categorized into three groups:
- first child
- 2nd – 3rd child, and
- 4th child and above.
Residence:
This refers to the place of residence of child. It is categorized into two groups:
- urban area
- rural area
Economic status of household:
This refers to the level of economic condition of the household. In this study,
this is measured by the presence of durable goods in the household, such as car,
motorcycle, refrigerator, television, bicycle, radio and electricity. By using a
composite measure based on the frequency of possession of these items, it is given
scoring from 1 to 7. The item with the lowest frequency was perceived to be the most
expensive and was given the maximum score of 7.In this particular study, the car was
the least owned by people. The items which were commonly owned by many people
as represented by the higher frequency, were perceived to be less expensive and were
assigned the corresponding scores. In this study, electricity had the highest frequency
and was given the minimum score of 1. The total score ranges from 0 to 28. For
example, if in the household each item is available, the score is the sum of adding the
Fac.of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 29
scores of 1, 2, 3, 4, 5, 6, and 7, which equals to 28. If the household does not possess
any of the items, it gets a score of 0. The score between 0-6 is classified as low
socioeconomic status, the score between 7-21 as medium socioeconomic status, and
the score between 22-28 as high socioeconomic status.
3.5. Data Analysis and Management
The data was analyzed with help of the SPSS software package. Descriptive
statistics and frequency distributions were used for describing the distribution of
background characteristics of dependent variable and independent variables. To
examine the bivariate relationship between dependent and independent variables cross
tabulation and chi-square test were applied. Cramer’s V was used to measure the
strength of the relationship between the dependent and independent variables.
Juliandi Harahap Results and Discussion / 30
CHAPTER IV
RESULTS AND DISCUSSION
This chapter presents the findings of the study followed by discussion on the
findings. The first section comprises the selected background characteristics of the
sample population. The second section deals with the status of immunization of
children under five years. The third section deals with the results of bivariate and chi-
square analysis to determine the relationship between independent and dependent
variables.
4.1. Selected Background Characteristics of the Sample
This section presents a description of the selected background characteristics of
the sample population. The selected variables are classified under four broad
categories, namely characteristics of mother, characteristics of father, characteristic of
child, and characteristics of household.
4.1.1. Characteristics of mothers
Table 2 presents the distribution of selected characteristics of mothers such as
maternal education, maternal occupation, maternal age and number of prenatal care
visits. As seen in the table, regarding the educational level of the mother, about ninety
five per cent of mothers had some education. It can be noted that almost half of them
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 31
attained primary school (47.1 per cent) and decreasing numbers had secondary and
higher education, at 42.9 and 3.7 per cent respectively. The proportion of mothers with
no education is only 6.3 per cent. This proportion is quite similar compared to the
percentage of the inhabitants in North Sumatra who had no education, which is 8.35
per cent in rural areas and 5.7 in urban areas (LGNSP, 1998).
Looking at the occupational status of mothers, Table 2 also shows that more
than half of the proportion of mothers is reported as working (59.3 percent). This
comprises 32.1 per cent of mothers who work in the agricultural sector and 27.2 per
cent who work in the non-agricultural sector. In accordance with this result, other
statistics also show that among working people, the majority work in the agricultural
sector (52 per cent), followed by trading sector, service sector, industrial sector, and
other sectors; 17.5, 13.4, 6.6, and 10.7 per cent respectively (LGNSP, 1998). The
percentage of mothers who do unpaid labor is 40.7 per cent. They are mainly
housewives.
More than half of the mothers belong to age group 25-34 (56.9 per cent),
followed by 26.9 per cent of mothers aged 35 and above and 16.2 per cent of mothers
aged 15-24. It can be noted here that among mothers in age group 15-24, there are
only five mothers who are in age group 15-19 (not shown in Table). In Indonesia it is
recommended that the minimum age at marriage for women is 20 years old, when the
women are considered mature in their reproductive physiology and ready to take care
of their children.
Juliandi Harahap Results and Discussion / 32
Regarding the prenatal visit during pregnancy, it is found that more than half of
pregnant mothers had at least 4 prenatal visits (57.6 per cent), while 30.7 per cent of
mothers had one to three visits, and 11.7 per cent of mothers had no prenatal visit. The
Indonesian maternal health program recommends that a pregnant woman should have
at least four prenatal care visits during pregnancy, according to the following
schedule: one visit in the first trimester, one visit in the second trimester, and two
visits in the third trimester.
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 33
Table 2. Percentage distribution of selected characteristics of mothers of children
under five years
Characteristics Per cent Number
Maternal education No education Primary education Secondary education Higher education
Total Maternal occupation
Unpaid labor Working in agriculture sector Working in non agricultural sector
Total Maternal age
15-24 years 25-34 years 35 years and above
Total Prenatal Care
No visit 1-3 visits 4 visits and over
Total
6.3 47.1 42.9 3.7 100.0
40.7 32.1 27.2 100.0
16.2 56.9 26.9 100.0
11.7 30.7 57.6 100.0
38 282 257 22 599
244 192 163 599
97 341 161 599
70 184 345 599
Juliandi Harahap Results and Discussion / 34
4.1.2 Characteristics of fathers
Table 3 presents the distribution of selected characteristics of fathers. For the
educational level of the fathers, the percentage who had no education is only 2.5 per
cent. This percentage is lower compared to the percentage of mothers who had no
education (6.3 per cent). Almost half of the fathers attained secondary school (49.9 per
cent), followed by 42.4 per cent fathers who attained primary school and 5.2 per cent
of fathers who attained higher education. The comparison between mother’s education
and father’s education indicates that slightly more fathers achieve education than
mothers.
Regarding the occupation of fathers, five people are reported without
information and classified as system missing. From the remaining 594 respondents,
most of them work in the non-agricultural sector rather than in the agricultural sector
(54.9 against 45.1 per cent). In general, the level of education of fathers is better
compared to mothers, so that more work in the non-agricultural sectors such as
government offices, private companies or are self-employed.
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 35
Table 3. Percentage distribution of selected characteristics of fathers of children
under five years
Characteristic Per cent Number
Father's education
No education Primary education Secondary education Higher education
Total Father's occupation
Working in agricultural sector Working in non-agricultural sector
Total
2.5 42.4 49.9 5.2
100.0
45.1 54.9 100.0
15 254 299 31 599
268 326
594*
* 5 cases are classified as system missing
4.1.3 Characteristics of children
Table 4 presents the distribution of selected characteristics of children. More
than half of the children are male (53.6 per cent). As seen in the table most of the
children are in the age group 12-23 months (36.7 per cent), followed by 27 per cent in
the age group 24-35 months, 21 per cent in the age group 36-47 months, and 15.2 per
cent in the age group 48-59 months. A child should complete the course of
immunization by the age of nine months. However, there are some factors causing
children to receive delayed immunization according to the recommended schedule.
For example if they were sick or if their mothers forgot to bring them to the health
center or the mothers did not know that although their children have exceeded age one
year, it was still possible to bring them for vaccination.
Juliandi Harahap Results and Discussion / 36
Children with birth order four or above are 40.9 per cent out of total 599,
which is almost twice the number of the children who are at the first birth order (21.9
per cent). The proportion of children in the second to third birth order is 37.2 per cent.
As for the place of delivery of children, 77 per cent were born at home, which is more
than three times higher than those born in a health care facility (23 per cent). Mothers
mainly in rural areas choose to give birth at home because it is cheaper than giving
birth in hospital. About seventy per cent children were born with the assistance of
professional health personnel (doctor, nurse/midwife), of which the majority were
assisted by nurses/midwives (62.9 per cent) and doctors assisted only 9.3 per cent. As
seen in Table 4, deliveries assisted by traditional birth attendants (TBA) are still quite
large (21 per cent). Seven per cent of the deliveries are assisted by other persons or
none at all. Other birth attendants could be husbands, parents or other relatives.
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 37
Table 4. Percentage distribution of selected characteristics of children under five
years
Characteristics Per cent Number
Sex of child Male Female
Total Age of child (months)
12-23 24-35 36-47 48-59
Total Birth order
1 2-3 4 and above
Total Place of delivery of child
At home Health care facility
Total Assistant at delivery
Doctor Nurse/Midwife TBA Other or none
Total
53.6 46.4 100.0
36.7 27.0 21.0 15.2 100.0
21.9 37.2 40.9 100.0
77.0 23.0 100.0
9.3 62.9 20.7 7.0 100.0
321 278 599
220 162 126 91 599
131 223 245 599
461 138 599
56 377 124 42 599
Juliandi Harahap Results and Discussion / 38
4.1.4 Characteristics of households
Table 5 presents the distribution of selected characteristic of households. The
majority of children come from households with low socioeconomic status (63.6 per
cent). Only 1.5 per cent of children comes from high socioeconomic status
households. About one third of the total children come from medium socioeconomic
status households (34.9 per cent).
About 72 per cent of the children live in the rural areas, and only 28 per cent of
the children live in urban areas. Other data show that in North Sumatra province,
61.93 per cent of people live in rural areas (Department of Health, 1996).
Table 5. Percentage distribution of selected characteristics of households
Characteristics Per cent Number
Household's economic status
Low Medium High
Total Residence
Rural Urban
Total
63.6 34.9 1.5 100.0
72.1 27.9 100.0
381 209 9 599
432 167 599
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 39
4.2 Status of Immunization
Table 6 presents the status of immunization of children under five years. As
seen in the table, more than half of children did not receive complete immunization.
Out of 599 children only 41.4 per cent received complete immunization or were fully
immunized. This percentage is low if compared to each type of vaccination that the
children had received (Table 7). The highest percentage of vaccination is 87.8 for
polio 1, while the lowest percentage is 60.4 for measles vaccine.
From Table 7 we can see that the percentage receiving DPT and polio vaccines is
decreasing. The coverage of DPT 1 is higher than DPT 2 and the coverage of DPT 2 is
higher than DPT 3. Similarly, although the coverage of polio vaccine is relatively
higher than other vaccine, the percentage receiving each polio vaccination is also
decreasing, that is 87.8 per cent, 82.1 per cent and 65.4 per cent for polio 1, polio 2,
and polio 3 respectively.
The required number of doses of DPT and of polio vaccine is three doses, usually each
vaccine is given to the child at the same time. The best time is when the child is aged 3
months, 4 months and 5 months for DPT 1 and polio 1, DPT 2 and polio 2, and DPT 3
and polio 3 respectively.
If we assume that the child received DPT and polio vaccines at the same time, then the
coverage of these vaccinations should be the same or similar. However, the results
show the differences in the percentage of coverage of each vaccine for DPT and polio.
As we can see in the table, 70.1 per cent for DPT 1 compared with 87.8 per cent for
Polio 1, 59.8 per cent for DPT 2 compared with 82.1 per cent for Polio 2, and 50.8 per
cent for DPT 3 compared with 65.9 per cent for Polio 3.
Juliandi Harahap Results and Discussion / 40
Two reasons are possibly responsible for this difference. First, the Indonesian Ministry
of Health launched one program in 1995, called Pekan Immunisasi Nasional (National
Immunization Week) which focuses on Polio Eradication. This program was carried
out in 1995, 1996, and 1997, and covered children under five years of age regardless
of their status of polio immunization. Second, the DPT vaccine has a common side
effect which is fever, and this vaccine is administered by giving an injection which
turns parents’ opinion against this type of vaccination, particularly if their older
children had fever after DPT vaccination. There is no side effect of polio vaccine and
it is taken orally. These factors may influence parents not to bring their children again
for DPT immunization.
Table 6. Percentage distribution of status of immunization of children under five
years
Status of Immunization Per cent Number
Complete Immunization
Not complete Immunization
Total
41.4
58.6
100.0
248
351
599
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 41
Table 7. Percentage distribution of BCG, DPT, polio, and measles immunizations
of children under five years
Immunizations Per cent Number
BCG Vaccine Yes No
Total DPT 1 Vaccine
Yes No
Total DPT 2 Vaccine
Yes No
Total DPT 3 Vaccine
Yes No
Total Polio1 Vaccine
Yes No
Total Polio 2 Vaccine
Yes No
Total Polio 3 Vaccine
Yes No
Total Measles Vaccine
Yes No
Total
71.3 28.7 100.0
70.1 29.9 100.0
59.8 40.2 100.0
50.8 49.2 100.0
87.8 12.2 100.0
82.1 17.7 100.0
65.9 33.9 100.0
60.4 39.6 100.0
427 172 599
420 179 599
358 241 599
295 304 599
526 73 599
492 106 599
395 203 599
362 237 599
Juliandi Harahap Results and Discussion / 42
4.3 Results of Bivariate Analysis
In order to determine the relationship between status of immunization and
characteristics of mothers, characteristics of fathers, characteristics of children and
characteristics of households, cross-tabulations and chi square tests were carried out in
this analysis. To measure the strength of the relationship between the dependent and
independent variable, Cramer’s V was applied. Cramer’s V ranges in value from 0, for
a very weak relationship or statistical independence, to 1 for a very strong relationship
of statistical dependence.
Table 8 presents the cross-tabulations between status of immunization of
children under five years and the selected characteristics of their mother. Only four
children or 10.5 per cent children of mothers who have no education received
complete immunization. The proportions of children with complete immunization and
whose mothers had primary education, secondary education, and higher education is
increasing, were 35.1, 51.0, and 63.6 per cent, respectively. In other words, children of
mothers who have better education are more likely to receive complete immunization
compared to children whose mothers have less education. The relationship between
immunization status of children and the level of education of their mothers is
statistically significant (p<0.001) and the Cramer’s V value of 0.273 shows a moderate
relationship. Maternal education is one of the most important and powerful factors for
improving health status of their children. By having better education, mothers tend to
have more knowledge about how to take care of their children properly, including the
ways to prevent diseases.
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 43
Looking at maternal occupation, more than half of the children whose mothers
are not working receive incomplete immunization (61.1 per cent). Mothers who are
unpaid labor are mainly housewives, therefore they are likely to receive little
information about vaccine preventable diseases and the proper immunization schedule.
Children of mothers who work in the non-agricultural sector have higher chance to
receive immunization completely than those of mothers who work in the agriculture
sector (55.2 against 32.8 per cent). Mothers who work in the non-agricultural sector
are likely to have access to many sources of information from which they can gain
more knowledge about immunization. The chi-square value of 19.270 indicates that
the relationship between immunization status of children and maternal occupation is
statistically significant (p<0.001). Nevertheless Cramer’s V shows that this
relationship is weak (0.179).
Regarding maternal age and immunization status, it is found that there is no
relationship between maternal age and immunization status of their children (chi-
square = 1.574 and p>0.05). It shows that age of mother is not associated with the
completeness of child immunization.
The number of prenatal care visits was found to be statistically significant
toward immunization status of children (chi-square = 26.727 and p < 0.001). The
highest proportion of incomplete immunization was among children whose mothers
had no prenatal care visit (75.7 per cent), while only about one fourth of children
whose mothers had no prenatal visit received complete immunization.
Juliandi Harahap Results and Discussion / 44
Children with mothers who attended prenatal care four times and more had twice as
high chance to receive immunization completely compared with children whose
mothers had no prenatal care visit (50.1 compared with 24.3 per cent).
Under maternal and child health program, mothers who come to health centers for
prenatal checkups are also given information about immunization and its benefits for
their children. Nevertheless, the Cramer’s V value shows a fairly weak relationship
(0.211).
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 45
Table 8. Percentage distribution of status of immunization by selected
characteristics of mothers.
Status of immunization Characteristics of mother
Not Complete Complete
Total (%)
Number
Maternal education No education Primary education Secondary education Higher education
Total Chi-square 33.725 df 3 P value < 0.001 Cramer’s V 0.273 Maternal occupation
Unpaid labor Working in agriculture sector Working in non agricultural sector
Total Chi-square 19.270 df 2 P value < 0.001 Cramer’s V 0.179 Maternal age
15-24 25-34 35 and above
Total Chi-square 1.574 df 2 P value 0.455 Cramer’s V 0.051 Prenatal Care
No visit 1-3 4 and over
Total Chi-square 26.727 df 2 P value < 0.001 Cramer’s V 0.211
89.5 64.9 49.0 36.4 58.6
61.1 67.2
44.8
58.6
57.7 56.9 62.7 58.6
75.7 68.5 49.9 58.6
10.5 35.1 51.0 63.6 41.4
38.9 32.8
55.2
41.4
42.3 43.1 37.3 41.4
24.3 31.5 50.1 41.4
100.0 100.0 100.0 100.0 100.0
100.0 100.0
100.0
100.0
100.0 100.0 100.0 100.0
100.0 100.0 100.0 100.0
38 282 257 22 599
244 192
163
599
97 341 161 599
70 184 345 599
Juliandi Harahap Results and Discussion / 46
Table 9 presents the cross-tabulation between status of immunization of
children under five years and the selected characteristics of their father. As seen in the
table, the majority of children whose fathers have no education receive incomplete
immunization (93.3 per cent). Children of fathers who have higher education are more
likely to receive complete immunization than children of fathers who have secondary
and primary education; 64.5, 48.8 and 31.9 per cent respectively. The more educated
the fathers the higher the percentage of the children who are fully immunized. The
result of chi-square shows p<0.001 indicating that the relationship between father’s
education and status of immunization is statistically significant. However, this
relationship is fairly weak (Cramer’s V is 0.237). The role of education for father is
similar to the role of education of mother, except that the role of the father as
household head includes more responsibility to make decisions for the health of their
children.
Status of immunization of children is also to have a statistically significant
relationship with father’s occupation (p<0.001). Children whose fathers are
agricultural workers are more likely to receive incomplete immunization (69.4 per
cent). The proportion of children who receive complete immunization is higher among
children whose fathers work in the non-agricultural sector than whose fathers work in
the agricultural sector (50.3 per cent compared with 30.6 per cent). The Cramer’s V
value of 0.199 indicates a weak relationship.
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 47
Table 9. Percentage distribution of status of immunization by selected
characteristics of fathers
Status of immunization Characteristics Not complete Complete
Total (%)
Number
Father's education
No education Primary education Secondary education Higher education
Total Chi-square 30.559 df 3 P value < 0.001 Cramer’s V 0.237 Father's occupation
Working in agricultural sector Working in non agricultural sector
Total Chi-square 23.550 df 1 P value < 0.001 Cramer’s V 0.199
93.3 68.1 51.2 35.5 58.6
69.4
49.7
58.6
6.7 31.9 48.8 64.5 41.4
30.6
50.3
41.4
100.0 100.0 100.0 100.0 100.0
100.0
100.0
100.0
15 254 299 31 599
268
326
594*
* 5 cases are classified as system missing
Juliandi Harahap Results and Discussion / 48
Table 10 presents the cross-tabulation between status of immunization and
characteristics of children. As seen in Table 10, between age groups 12-23 and 36-47
months, the percentage of children who received immunization completely increases
from 35.9 per cent to 50.0 per cent. This may be because some children receive
complete immunization late or it may reflect decreasing completeness of
immunization in North Sumatra, as discussed in chapter one. However, the chi-square
result shows that there is no significant difference between age of child and
completeness of immunization. (Chi-square = 6.691 with p value = 0.082). The lack of
significance is possibly attributable to small sample size.
In relation to the sex of child, the total cases of children are 321 and 278 for
male and female, respectively. Among them 58.9 per cent of male children and 58.3
per cent of female children did not receive complete immunization. The Chi-square
statistic shows that there is no significant difference in immunization status between
male children and female children (p>0.05). Although, the patrilineal system in North
Sumatra has a strong influence on the lives of the majority of the inhabitants, for
example in the Batak ethnic group, it seems there is no difference in the way they take
care of their children whether male or female (Tahir and Pattiasina, 1998).
In terms of birth order, Table 10 shows that the prevalence of complete
immunization is higher among children who are at first birth order rather than children
with birth order four and above (48.9 against 31.4 per cent). The relationship between
birth order of child and status of immunization is statistically significant (chi-square =
17.024; p<0.001). In other words it can be said that the higher the birth order, the
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 49
lower the completeness of immunization. A possible reason is that mothers pay more
attention to their first child rather than the next child. Another possible reason is that
women having their first children are young and inexperienced and willing to accept
advice. They care more about the health condition of their first child and how to
prevent them from contacting diseases. Nevertheless, the Cramer’s V indicates that it
is a weak relationship (Cramer’s V = 0.169).
Regarding place of delivery of children, as shown in Table 10, the highest
prevalence of complete immunization is among the children who were born in health
care facilities (61.6 per cent). The reason may be that it is the policy of government
hospitals, private clinics, and health centers to provide adequate information about
immunization and to give BCG vaccination to the newborn baby after delivery. On the
other hand, the prevalence of incomplete immunization among the children who were
born at home is 64.6 per cent. The relationship between immunization status and place
of delivery is statistically significant (chi square = 30.134; p<0.001) but this
relationship is fairly weak (Cramer’s V = 0.224).
Looking at the assistant at delivery, there is a decreasing percentage of
complete immunization according to the level of training of the birth attendant. The
highest percentage of children who had complete immunization is 66.1 per cent, for
those assisted by doctors, followed by nurse/midwife 46.9 per cent, traditional birth
attendant (TBA) 23.4 per cent and other or none 11.9 per cent. It can be said that the
more professional the health personnel attending the birth delivery the higher is the
chance for children to receive complete immunization. The reason may be that
Juliandi Harahap Results and Discussion / 50
professional personnel advise mothers to bring their children for vaccination. The chi
square statistic shows the significant relationship between immunization status and
assistant at delivery of the children (chi square = 50.480 and p<0.001) and Cramer’s V
value of 0.290 shows a moderate relationship between immunization status and
assistant at delivery.
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 51
Table 10. Percentage distribution of status of immunization and selected
characteristics of children
Status of immunization Characteristics Not complete Complete
Total (%)
Number
Age of child (months) 12-23 24-35 36-47 48-59
Total Chi-square 6.691 df 3 P value 0.082 Cramer’s V 0.106 Sex of child
Male Female
Total Chi-square 0.022 df 1 P value 0.881 Cramer’s V 0.006 Birth order
1 2-3 4 and above
Total Chi-square 17.024 df 2 P value < 0.001 Cramer’s V 0.169 Place of delivery of child
At home Health care facility
Total Chi-square 30.134 df 1 P value < 0.001 Cramer’s V 0.224 Assistant at delivery
Doctor Nurse/Midwife TBA Other or none
Total Chi-square 50.480 df 3
64.1 57.4 50.0 59.3 58.6
58.9 58.3 58.6
51.1 52.0 68.6 58.6
64.6 38.4 58.6
33.9 53.1 76.6 88.1 58.6
35.9 42.6 50.0 40.7 41.4
41.1 41.7 41.4
48.9 48.0 31.4 41.4
35.4 61.6 41.4
66.1 46.9 23.4 11.9 41.4
100.0 100.0 100.0 100.0 100.0
100.0 100.0 100.0
100.0 100.0 100.0 100.0
100.0 100.0 100.0
100.0 100.0 100.0 100.0 100.0
220 162 126 91 599
321 278 599
131 223 245 599
461 138 599
56 377 124 42 599
Juliandi Harahap Results and Discussion / 52
P value < 0.001 Cramer’s V 0.290
Table 11 presents the relationship between status of immunization and selected
characteristic of households. As seen in the table, the majority of children come from
low socioeconomic condition (381 children). Statistical tests show that the
household’s economic status has a significant effect on the immunization status of the
children (Chi-square = 11.518, p<0.01). It shows that the lower the level of
socioeconomic status the lower is the percentage of completeness of immunization. It
suggests that it is important to increase the socioeconomic condition for most of the
families who are in low socioeconomic status. However, the relationship between
these two variables is very weak (Cramer’s V = 0.139).
It can be also seen from Table 11 that although most of the children live in
rural areas (72.1 per cent), their immunization status is similar to children who live in
urban areas. It is found that there is no significant difference in immunization status
between children who live in rural areas and urban areas (p>0.05), indicating that the
government program to set up many health centers to provide services for rural people
has achieved beneficial effects. In North Sumatra, it can be noted that in 1996, there
were 385 units of health centers (Puskesmas) with each unit covering 28,000 people.
Each health center has four or five health posts or satellite health centers (Department
of Health, 1996).
Fac. of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 53
Table 11. Percentage distribution of status of immunization by selected
characteristic of households
Status of immunization Characteristics Not complete Complete
Total (%)
Number
Household's economic status
Low Medium High
Total Chi-square 11.518 df 2 P value 0.003 Cramer’s V 0.139 Residence
Rural Urban
Total Chi-square 0.808 df 1 P value 0.369 Cramer’s V 0.037
63.5 50.7 33.3 58.6
59.7 55.7 58.6
36.5 49.3 66.7 41.4
40.3 44.3 41.4
100.0 100.0 100.0 100.0
100.0 100.0 100.0
381 209 9 599
432 167 599
Juliandi Harahap Summary, Conclusion and Recommendation / 54
CHAPTER V
SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1. Summary
Immunization is the process of stimulating the body’s immunity against certain
infectious diseases by administering vaccines. Immunization is one of the main health
interventions to prevent childhood morbidity and mortality. Immunization will become
more effective if the child receive the full course of recommended immunization
doses. Therefore, it is very important to study the status of immunization of children,
particularly in North Sumatra province where the immunization coverage is the lowest
in Indonesia.
This study explores the status of immunization of children under five years in
North Sumatra province. It examines factors affecting childhood immunization,
including selected socioeconomic and demographic factors, namely characteristics of
mothers, characteristics of fathers, characteristics of children and characteristics of
households. Based on secondary data from the 1997 Indonesia Demographic and
Health Survey, a total of 599 children age 12-59 months in North Sumatra province
were selected as unit of analysis in this study. Findings of this study can be
summarized as follows:
Fac.of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 55
Immunization status of children under five years refers to whether or not a child
receives complete immunization (one dose of BCG, three doses of DPT, three doses of
polio and one doses of measles). The study found that the majority of the children did
not receive complete immunization (58.6 per cent). The completeness of immunization
is very important in order to ensure the effectiveness of the vaccine and to ensure that
the child is fully protected from morbidity and mortality caused by tuberculosis,
diphtheria, pertussis (whooping cough), tetanus, poliomyelitis, and measles.
Among thirteen independent variables, which may influence the completeness
of immunization, it is found that nine independent variables are statistically significant
in their relationship to completeness of immunization. They are maternal education,
maternal occupation, prenatal care, father’s education, father’s occupation, birth order,
place of delivery, assistant at delivery, and household’s economic status. There is no
statistically significant relationship between immunization status and maternal age,
age of child, sex of child and place of residence.
5.2. Conclusion
According to the above results, most of the proposed hypotheses are supported
because this relationship is found to be significant. This analysis establishes that the
children who are more likely to receive more complete immunization are:
- Children whose parents are educated.
- Children of parents who work in the non-agricultural sector.
- Children of mothers who had prenatal care more than three times.
Juliandi Harahap Summary, Conclusion and Recommendation / 56
- Children with low birth order.
- Children who were born in health care facilities (government hospitals,
private clinics, health centers).
- Children who were born with the help of health personnel (doctor, nurse or
midwife)
- Children who come from the better economic status households.
5.3. Recommendations
5.3.1. Recommendation for Policy Implementation
In order to increase immunization coverage and to ensure the completeness of
immunization, based on the findings in this study it is recommended:
For children whose parents have low education, it is recommended that all
health center and health personnel should pay more special attention to encourage and
educate the parents about the values and benefits of the vaccination and vaccine
preventable diseases and its consequences to children’s health.
For those whose parents work in the agricultural sector where parents usually
do not receive adequate information, it is necessary to provide the parents with some
health information by distributing printed matter such as brochures, pamphlets and
leaflets.
Fac.of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 57
For children whose mothers have little access to health services including
access to prenatal care service, place of delivery, and assistant at delivery, it is
important to encourage mother to use health facilities. Health personnel assigned in
the area of these mothers should conduct home visits and inform the mothers of the
services available in the health facilities. They should also inform the mothers about
the benefits of having the children immunized.
Government should introduce free of charge of immunization services,
including registration fee, for the low economic group. Though the registration fee is
very little amount, but for the poor parents, it seems to be burden for them. So the poor
parent feel reluctant to immunized their children.
In terms of birth order, a mother would like to treat her children equally. So it
important to encourage mothers to provide equal treatment in order to take care of her
children.
Regarding household’s economic status, health provider should pay more
attention on the poor or low economic groups to meet their special needs. It is also
important to continue programs to improve the economic condition for most of the
families who are in low economic status. Income generating activities such as home
industries like handicraft making, home gardening, and animal raising should be
encouraged to improve the economic condition of these households. They should be
given financial support, if necessary, by government until such time that they are able
to stand on their own.
Juliandi Harahap Summary, Conclusion and Recommendation / 58
5.3.2. Recommendation for Further Study
Many concepts beyond the conceptual framework in this study could not be
examined. Therefore, it is recommended that for further study it would be desirable to
include some additional variables such as factors associated with maternal belief,
attitude and behavior regarding immunization, and factors associated with health care
providers, in order to capture the whole aspect that may influence immunization status
of children.
It is also important to study the effectiveness of immunization by comparing
the morbidity and mortality status of children under five years old between immunized
and non-immunized to provide information about the benefit of immunization.
In-depth interview or focus group discussions should be carried out particularly
among the low economic status groups to understand their situation, attitude, and their
perception about immunization for their children and to examine why this group had
low immunization rate. Studies should also be carried out to determine the most
appropriate methods to increase immunization coverage in this group.
Fac.of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 59
REFERENCES
Aaby, P., Bukh J, and Lisse I.M., 1984. Measles Vaccination and Education in Child
Mortality: A Community Study from Guinea-Bissau. Journal of Infectious
Disease, 8: 13-21.
Ahluwalia, I.B., Helgerson, S.D., and Bia, F.J., 1988. Immunization Coverage of
Children in a Semi-Urban Village Panchayat in Nepal, 1985. Social Science
and Medicine, 26 (2): 265-268.
Amin, Ruhul, 1996. Immunization Coverage and Child Mortality in Two Rural
Districts of Sierra Leone. Social Science and Medicine, 42 (11): 1599-1604.
Bhuiya, A., Bhuiya I., and Chowdhury M., 1995. Factors Affecting Acceptance of
Immunization among Children in Rural Bangladesh. Health Policy and
Planning, Sep; 10 (3): 304-11.
Brugha, R. F., Kevany J. P., Swan A. V., 1996. An Investigation of the Role of Fathers
in Immunization Uptake. International Journal of Epidemiology, 25 (4);
840-5.
Burns, A.C., 1992. The Expanded Health Belief Model as a Basis for Enlightened
Preventive Health Care Practice and Research. Journal of Health Care
Marketing 12 (3), 32-45.
Cash, Richard, Gerald T. Keusch and Joel Lamstein, 1987. Child Health and
Survival: The UNICEF GOBI-FFF Program, Croom Helm, London.
Juliandi Harahap References / 60
Central Bureau of Statistics (CBS)[Indonesia] and State Ministry of
Population/National Family Planning Coordinating Board (NFPCB) and
Ministry of Health (MOH) and Macro International Inc. (MI). 1995. Indonesia
Demographic and Health Survey 1994.Calverton, Maryland: CBS and MI.
---------, 1998. Indonesia Demographic and Health Survey 1997. Calverton,
Maryland: CBS and MI.
Coreil, J., Wilson F., Wood D., and Liller, K., 1998. Maternal Employment and
Preventive Child Health Practices. Preventive Medicine, 27 (3): 488-492.
Department of Health, 1996. North Sumatra Health Profile 1996. Department of
Health of North Sumatra Province.
Dhadwal, D., Sood, R., Gupta, AK., Ahluwalia, SK., Vatsayan, A., and Sharma, R.,
1997. Immunization Coverage among Urban and Rural Children in the Shimla
Hills. Journal of Communicable Disease, 29 (2); 127-30.
Feacham, R.G. and Koblinsky, M.A., 1983. Intervention for the Control of Diarrhea
Diseases among Young Children: Measles Immunization. Bulletin of the
World Health Organization, 61(4): 641-52.
Feinstein, J.S., 1993. The Relationship between Socioeconomic Status and Health: A
Review of the Literature. The Milbank Quarterly, 71 (2); 279-322.
Gadomski, A and Black, R., 1990. Impact of Direct Intervention. Child Survival
Programs: Issues for the 1990s, 85-128.
Gore, P., Madhavan, S., Curry, D., McClung, G., Castiglia, M., Rosenbluth, S.A., and,
Smego, R.A, 1999.’Predictors of Childhood Immunization Completion in a
Rural Population’, Social Science and Medicine 48: 1011-1027.
Grant, J., 1984. The State of the World’s Children 1985. Oxford University Press.
Fac.of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 61
Hill, K and Upchurch, D.M., 1995. Gender Differences in Child Health: Evidence
from the Demographic and Health Surveys. Population and Development
Review, 21 (1); 127-51.
Hobcraft, J., 1993. Women’s Education, Child Welfare and Child Survival: A Review
of the Evidence. Health Transition Review, 3 (2);159-175.
Howlader, A.A. and Bhuiyan, M.V., 1999. Mother’s Health Seeking Behaviour and
Infant and Child Mortality in Bangladesh. Asia Pacific Population Journal,
14(1): 59-75
Islam, S. M. and Islam M. M., 1996. Influences of Selected Socioeconomic and
Demographic Factors on Child Immunization in a Rural Area of Bangladesh.
Demography India, Jul-Dec; 25 (2): 275-83.
Kabir, M and Amin, R., 1993. Factors Influencing Child Mortality in Bangladesh and
Their Implications for the National Health Program. Asia Pacific Population
Journal, 8 (3): 31-46.
Kaplan, BA, Taylor M. CG., 1992. Mother’s Age, Birth Order and Health Status in a
British National Sample. Medical Anthropology, Jan; 13(4): 353-67
Lee, Kwok, 1996. Immunization Schedule. Infomedical.
(http://home.ipoline.com/~guoli/home/imune.htm).
Local Government of North Sumatra Province (LGNSP), 1998. Neraca Kwalitas
Lingkungan Hidup Daerah Tahun 1998, Badan Pengendalian Dampak
Lingkungan Daerah.
Lwanga, S. K. and Abiprojo, N., 1987. Immunization Coverage Surveys:
Methodological Studies in Indonesia. Bulletin of the World Health
Organization, 65(6): 874-53.
Juliandi Harahap References / 62
Matthews, Z. and Diamond I., 1997. Child Immunization in Ghana: The Effects of
Family, Location and Disparity. Journal of Biosocial Science, Jul; 29 (3):
327-34.
Ministry of Health, 1997. Indonesia Health Profile 1996. Central Data of Health,
Jakarta.
--------, 2000. National Immunization Week, Public Information
(http://www.depkes.go.id/ENGLISH/public.htm).
Rahman MM, Islam M.A., Mahalanabis D., 1995. Mother’s Knowledge about Vaccine
Preventable Diseases and Immunization Coverage of a Population with High
Rate of Illiteracy. Journal of Tropical Pediatrics, Dec; 41(6): 376-8.
Schaffer, S.J., and Szilagyi, P.G., 1995. Immunization and Birth Order. Archives of
Pediatrics and Adolescent Medicine, 149 (7): 792-797.
Singarimbun, M, Steatfield K, Singarimbun, A., 1986. Factors Affecting the Use of
Childhood Immunization in Indonesia. Population Council, Regional
Research Papers. Bangkok, Thailand.
Streatfield, K and Singarimbun, M., 1988. Social Factors Affecting Use of
Immunization In Indonesia. Social Science and Medicine, 27(11): 1237-45.
-----------, Singarimbun, M., and Diamond, I., 1990. Maternal Education And Child
Immunization. Demography, 27 (3), 447-455.
Sutto, Gunowiseso and Gunawan, S., 1986. Immunization Programme in Indonesia.
Nasution et al. (eds.) Vaccine Production and Immunization Programme in
South East Asia Its Present Status and Prospects, South East Asian Medical
Information Center.
Fac.of Grad. Studies, Mahidol Univ. M.A. (Pop & Repro H Res) / 63
Tahir, Syarifah and Pattiasina, Johannan, 1998. A Community Approach to
Enhancing Reproductive Health Status in Rural Sumatra: The Bina
Insani Experience. International Council on Management of Population
Programmes.
United Nations Children’s Fund, 1983. The Expanded Programme on Immunization:
A Child Survival and Development Revolution, Assignment Children, 61/62:
119-122.
--------, 1993. The State of the World’s Children 1993, Oxford University Press.
Waldon, Ingrid, 1988. ‘Gender and Health Related Behavior’, in Gochman, David S.
(ed.), Health Behavior: Emerging Research Perspectives, Plenuum Press,
New York.
World Bank, 1993. World Development Report: Investing in Health Oxford
University Press, New York.
World Health Organization, 1995. Integrated Management of the Sick Child. Bulletin
of the World Health Organization, 73(6): 735-40.