Children and Youth Services Review 108 (2020) 104651

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Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Factors associated with complete immunizations coverage among T

Indonesian children aged 12–23 months
⁎
Ferry Efendia,f, , Dwida Rizki Pradiptasiwia, Ilya Krisnanab, Tiyas Kusumaningrumb,
Anna Kurniatic, Mahendra Tri Arif Sampurnad, Sarni Maniar Berlianae
a
Department of Community Health Nursing and Mental Health, Faculty of Nursing, Universitas Airlangga, Jl. Mulyorejo Kampus C Unair, Surabaya, Indonesia
b
Department of Maternity and Child Health Nursing, Faculty of Nursing, Universitas Airlangga, Jl. Mulyorejo Kampus C Unair, Surabaya, Indonesia
c
The Board for Development and Empowerment of Human Resources for Health of Ministry of Health of the Republic of Indonesia, Jalan Hang Jebat III Blok F3, Jakarta,
Indonesia
d
Department of Pediatrics, Faculty of Medicine Universitas Airlangga, Jl. Mayjen Prof. Dr. Moestopo 47, Surabaya, Indonesia
e
Politeknik Statistika STIS, BPS, Jalan Otto Iskandardinata No.64C 1 4, Jakarta, Indonesia
f
School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia

A R T I C LE I N FO A B S T R A C T

Keywords: Immunization is one of the most cost-effective health interventions to prevents illness, disability and death
Children associated with communicable disease. This study aimed to identify factors associated with completed re-
Complete coverage commended childhood immunizations in children aged 12–23 months in Indonesia. This study used data from
Immunization the Indonesia Demographic and Health Survey 2012 with a multistage cluster sampling procedures. A total data
Vaccine
from 3,231 mothers with children of 12–23 months of age were extracted from dataset. Mothers’ self-reported
data along with vaccination cards determined vaccine coverage. This study found the prevalence of complete
immunization status for their age cohort was 37.4%. The highest immunization coverage was BCG (86.9%) and
the lowest coverage was hepatitis B3 (46.2%). The multiple logistic regression showed that mothers with a first
born child are 2.84 times more likely to fully vaccinate their children compared to mothers with ≥6 children.
Mothers in the lowest economic level, delivered in non-health facilities, attended antenatal care less than four
were less likely to fully vaccinate these children. Meanwhile, mother who delivered by professional assistants
was significantly associated with complete immunization status of their children. Appropriate strategies should
be designed targeting high-risk group including culturally approached to address immunization completion and
improved accessibility in various provinces within the country.

1. Introduction The world health organization (WHO) developed an expanded

Immunization is the cornerstone of infectious disease prevention
that effectively reduces mortality and morbidity in children under five
years of age. It’s estimated that about 1.5 million deaths per year are
associated with vaccine-preventable diseases (VPD) among this popu-
lation (WHO, 2018). A previous study reported that high coverage of
vaccination could prevent about 1.6 death per years among children
under five years old (Ehreth, 2011; WHO, 2018). Appropriate im-
munization level can eliminate common childhood diseases such as
Tuberculosis, Diphtheria, Pertussis, Tetanus, Polio, Measles, Hepatitis B
(Duclos, Okwo-Bele, Gacic-Dobo, & Cherian, 2009; Kemenkes, 2017).
The under-five mortality rate remains a challenge for Indonesia to
improve the health status of the nation (Warrohmah, 2018).
programme on immunization (EPI) in 1974 to ensure accessibility of
basic immunization for all children internationally. Every children
should receive Bacillus Calmette Guerin (BCG), three doses of oral polio
vaccine (OPV) and Diphtheria Pertussis Tetanus (DPT), and measles
vaccines by 12 months of age (WHO, 2018). In Indonesia, EPI was
implemented in 1977 for every children 0 month to 11 years of age, it is
required they receive 1 dose of hepatitis B, 1 dose of BCG, 3 doses of
DPT, 4 doses of polio, and 1 dose of measles (Kemenkes, 2017). A child
in the 12–23 months of age group who has received a single dose of
BCG vaccine, three doses of DPT, hepatitis B, three doses of polio
vaccine (excluding the dose given shortly after birth) and first dose of
measles (Kemenkes, 2017). However, not all children in the world,
Indonesia in particular, have access to the routine and complete

⁎
Corresponding author.
E-mail addresses: ferry-e@fkp.unair.ac.id (F. Efendi), ilya-k@fkp.unair.ac.id (I. Krisnana), tiyas-k@fkp.unair.ac.id (T. Kusumaningrum),
mahendra.tri@fk.unair.ac.id (M.T.A. Sampurna), sarni@stis.ac.id (S.M. Berliana).

https://doi.org/10.1016/j.childyouth.2019.104651
Received 13 October 2019; Received in revised form 23 November 2019; Accepted 23 November 2019
Available online 30 November 2019
0190-7409/ © 2019 Elsevier Ltd. All rights reserved.
F. Efendi, et al.
immunizations. In 2014, about 19.5 million children did not have ac-
cess to the DPT vaccine, of these, 60% were lived in developing country
i.e., Brazil, India, Indonesia, Iraq, Nigeria, Pakistan (WHO, 2018).
According to Indonesian health profile data, complete coverage of
basic immunization among children-under five years increased in 2015
(86.54%) to 2016 (91.58%), indicating a successful Indonesian gov-
ernment program (Kemenkes, 2017). Indonesia is a large country and
not all children receive routine basic immunizations. Of the 33 province
in Indonesia, only 12 achieved the 2016 national targeted (Kemenkes,
2017). A previous study conducted in Ethiopian found that the im-
munization cover was higher among children living on urban area
compared to in rural areas (Lakew, Bekele, & Biadgilign, 2015). A study
conducted in one Indonesian province reported that quality and level of
education, socio-economic status, and the ability to access to the
healthcare facilities was significantly associated with higher im-
munization coverage (Maharani & Kuroda, 2018). However, there is a
paucity of information on factors associated with complete basic im-
munization status among children aged 12–23 month in Indonesia.
Thus, in this study we aimed to explore the prevalence of immunization
status and its associated factors in children age 12–23 months of age in
Indonesia.
2. Materials & methods
2.1. Study design
This study used a secondary data from the Indonesian Demographic
and Health Survey (IDHS) from 22 April to 5 May 2012. Briefly, IDHS is
a national health survey implemented to all province in Indonesia
provinces that collected data on fertility rates, family planning, and
contraception, maternal and child health (Statistics Indonesia, BKKBN,
& Kemenkes, 2013). Ethical permission was obtained from the National
Health Research and Development agency in Indonesia and from the
OCR Macro (number 45 CFR 46). All respondent identifiers were re-
moved from the data and permission for the use of data in this study
was obtained from ICF International, part of the DHS program (DHS,
2013).
2.2. Sample
The sample in this study were women with children aged
12–23 months of age in 33 Indonesian provinces in both rural and
urban areas. Multistage random sampling was applied to select parti-
cipants. There were N = 16, 954 women with children under five years
of age and of them 12–23 months of age (n = 3,231).
2.3. Measurement
The 2012 IDHS collected data including child’s sex, mother’s age
and education, father’s age and education, birth order, place of re-
sidence, delivery place, economic status, antenatal care, and skill birth
attendance. Information regarding the immunization status was col-
lected by interviewing mothers who had survived children from
12 months to 23 months of age, and extracted from children’s and
maternal medical records. Immunization status was categorized as
completed or uncompleted. Completed immunization was defined
based on the WHO definition, “ a child in the 12–23 months of age
group who has received a single dose of BCG vaccine, three doses of
DPT, hepatitis B, three doses of polio vaccine (excluding the dose given
shortly after birth) and one dose of measles.”
Studies have shown determinants that affect immunization cov-
erage, such as facility readiness, decision to vaccinate, child’s factors,
and mother’s factors (Phillips, Dieleman, Lim, & Shearer, 2017). Vari-
ables on this study was chosen based on previous research and the
availability of data in the 2012 Indonesia DHS. Independent variables
on this study namely children’s gender, parents’ age group, parents’
2
Children and Youth Services Review 108 (2020) 104651
education, birth order, number of antenatal care visits, economic status,
place of delivery, residence area, and delivery assistance.
We do not conduct statistical tests to determine whether a variable
is a confounder or not but instead inspect the data. We do not find
important or meaningful relationship between the variable and the risk
factor and between the variable and the outcome to be said that a
variable is a confounder. Furthermore, we apply multiple logistic re-
gression that control confounding variables. The regression result will
show the association between dependent and independent variables
controlling for the confounding variable.
2.4. Data analysis
We utilize bivariate analysis and binary logistic regression to iden-
tify factors associated with complete immunization status among chil-
dren aged 12–23 months. A p-value less than 0.05 was set up to de-
termine the significant factors. All data management procedures and
statistical analysis were completed using IBM SPSS version 22.0 for
Windows 10.
3. Results
Table 1 summarizes demographic comparison between children
who completed and uncompleted basic immunization in Indonesia
(n = 3,231). Overall, the majority of the sample were male (52%), first
birth order (48.1%), maternal age of was 25–29 years old (29.1%),
mother’s education background was secondary level (54.8%), and fa-
ther’s age was 30–34 years old (28.3%). There were a significant dif-
ference between children who completed and uncompleted basic im-
munization in maternal age and education level, father’s education,
birth order, antenatal care, socioeconomic status, delivery place, re-
sident, and labor helper.
Table 2 shows the results of logistic regression analysis to identify
factors associated with immunization status. The first child was more
likely to have complete vaccinated compared to the sixth child
(AOR = 2.842, 95% CI: 1.643–4.915). Children between 12 and
23 months of age whose mother attended fewer than four antenatal
visit (OR = 0.445, 95% CI = 0.338–0.586) in the lowest economic
status (AOR = 0.630, 95% CI: 0.465–0.854), and delivered at non-
health care facility (AOR = 0.667, 95%CI: 0.549–0.811) were less
likely to have child who complete immunization compared to mother
who had 4 or more antenatal visit, in higher economic status and de-
livered at healthcare facility. In addition, professional care during labor
was significantly associated with complete child immunization status
(AOR = 1.561, 95%CI: 1.189–2.049).
4. Discussion
This study found that mothers of a first born child aged 12 month to
23 months of age were more likely to have child with completed basic
immunization compared to mothers who had more than three children.
Previous studies conducted in Afghanistan, Techiman Municipality, and
Cameroon reported the prevalence of completed immunization among
first and second born children were higher compare children who were
three or four in birth order (Adokiya, Baguune, & Ndago, 2017; Farzad,
Reyer, Yamamoto, & Hamajima, 2017). Another study conducted in
Nigeria and Ethiopia emphasized that children up to 5th in birth order
were more likely to completed basic immunizations compared to those
who mine the sixth or more in birth order (Adedire et al., 2016; Lakew
et al., 2015). There is a general assumption that parents of a first born
tend to devote more attention to the child, including attention to the
completing the required immunizations.
Mothers who had attended antenatal care fewer than 4 times were
less likely to complete the basic immunization for their child compared
with mothers who had antenatal care more than 4 times. On the other
words, those who attended the minimum standard of visit received a
F. Efendi, et al. Children and Youth Services Review 108 (2020) 104651

Table 1 Table 2
Characteristics comparison between children with completed and uncompleted Determinant of completed recommended childhood immunization status in
immunization status aged 12–23 months old in Indonesia. children 12 to 23 months of age in Indonesia.
Variable Immunization status X2 Variable Adjusted odds ratio 95% CI

Uncompleted Completed Lower Upper

n % n % Mother's age in years

15–19 0.423 0.139 1.288
Children’s gender 20–24 0.534 0.182 1.506
Male 1047 62.1 638 37.9 0.340 25–29 0.545 0.192 1.548
Female 976 63.1 570 36.9 30–34 0.607 0.214 1.719
Mother's age in years 35–39 0.755 0.267 2.139
15–19 100 69.4 44 30.6 13.115* 40–44 0.506 0.173 1.484
20–24 442 62.1 270 37.9 45–49 Ref
25–29 580 61.8 359 38.2 Mother’s education
30–34 460 61.0 294 39 Not at all 0.652 0.294 1.446
35–39 291 61.4 183 38.6 Primary 0.99 0.733 1.337
40–44 138 73.0 51 27 Secondary 1.068 0.832 1.37
45–49 12 63.2 7 36.8 Higher Ref
Mother’s education Father's education
Not at all 71 88.8 9 11.3 67.587*** Not at all 0.426 0.155 1.173
Primary 640 70.2 272 29.8 Primary 0.872 0.64 1.189
Secondary 1061 59.9 709 40.1 Secondary 0.903 0.698 1.169
Higher 251 53.5 218 46.5 Higher Ref
Father’s age Birth order
15–19 10 83.3 2 16.7 9.163 1 2.842*** 1.643 4.915
20–24 164 63.1 96 36.9 2–3 2.132** 1.272 3.573
25–29 469 61.8 290 38.2 4–5 1.52 0.892 2.592
30–34 557 60.9 357 39.1 ≥6 Ref
35–39 403 62.8 239 37.2 Antenatal care
40–44 263 62.6 157 37.4 ≥4 0.445*** 0.338 0.586
45–49 97 68.8 44 31.2 <4
≥50 60 72.3 23 27.7 Economic status
Father's education The lowest 0.630** 0.465 0.854
Not at all 660 69.9 284 30.1 63.395*** Lower middle 0.889 0.676 1.17
Primary 1088 60.3 717 39.7 Medium 0.875 0.67 1.144
Secondary 224 52.6 202 47.4 Upper middle 0.936 0.722 1.215
Higher 51 91.1 5 8.9 Highest Ref
Birth order Place of delivery
1 647 56.6 497 43.4 58.850*** Health facilities Ref
2–3 977 62.9 577 37.1 Non-health Facilities 0.667*** 0.549 0.811
4–5 283 71.6 112 28.4 Residence
≥6 116 84.1 22 15.9 Rural Ref
Antenatal visit Urban 0.785 0.659 0.936
<4 401 84.2 75 15.8 111.6*** Labor helper
≥4 1622 58.9 1133 41.1 Non-health professional Ref
Economic status Health professional 1.561** 1.189 2.049
The lowest 705 76.5 217 23.5 118.3***
Lower middle 433 60.8 279 39.2 Note: *p < 0.05; **p < 0.01; ***p < 0.001.
Medium 341 59.2 235 40.8
Upper middle 292 54.7 242 45.3
Highest 252 51.7 235 48.3
2017; Rumaseuw, Berliana, Nursalam, Efendi, Pradanie, Rachmawati,
Place of delivery & Aurizki, 2018). Although in Indonesia more than 80% of pregnant
Health facility 1012 74.1 353 25.9 134.2*** women had attended antenatal care more than four times (Efendi,
Non-health facilities 1011 54.2 855 45.8 Chen, Kurniati, & Berliana, 2017), issues associated with culture, re-
Residence
ligion, and political issues needs to be considered in national level.
Rural 851 58.4 606 41.6 20.04***
Urban 1172 66.1 602 33.9 This study found that parents with lower economic status was less
Labor helper likely to complete basic childhood immunizations compared to parents
Non-health professional 1516 58.0 1100 42.0 127.6*** in the highest economic status. In consistent with previous studies
Health professional 507 82.4 108 17.6 conducted in Indonesia and Ethiopia, this study found that the pre-
Total 2023 62.6 1208 37.4 valence of complete immunization uptake was higher in family with
higher economic status (Maharani & Kuroda, 2018; Mbengue et al.,
Note: *p < 0.05; **p < 0.01; ***p < 0.001. 2017). Family with the highest economic status probably have better
access to information about immunizations as well as ability to com-
positive benefit or completed the immunization services. These align plete recommended childhood immunizations. Although basic im-
with previous study in Ethiopia and Cameroon which suggested that munizations are provided at no cost for all children in Indonesia, access
attended antenatal care more than three times was significantly asso- to the public health services especially in rural area is limited. Ag-
ciated with completed child immunizations uptake (Russo et al., 2015; gressive campaign on mandated immunizations is needed for families
Travassos et al., 2015). Antenatal care programs generally provide in- with lower economic status and who live in a urban area.
formation about children care including the schedule and importance of Mothers who gave birth in a non-health care facility were less likely
immunizations for children. Active participation of the husband ac- to complete the mandated childhood immunization compared with
companying the mother for antenatal care is a substantial factors, in those who delivered in a health care facility. A study conducted in
which he is involved in decisions related to the familys’ health in- Senegal reported that place of delivery was significantly associated with
cluding immunization for children (Kurniati, Chen, Efendi, & Elizabeth, immunization level in children (Mbengue et al., 2017). Mothers whose

3
F. Efendi, et al.
delivered their baby in health facilities had higher percentage of com-
plete basic immunization compared to those who delivered in the home
(Adedire et al., 2016; Travassos et al., 2015). Children born at a health
care facility immediately received first dose of Hepatitis B within 12 h
after delivery, BCG and Polio vaccine when the baby is discharged.
Mothers who give birth at the hospital also receive information about
the schedule and the importance of completing recommended im-
munizations. However, some mother do not have sufficient knowledge
regarding the immunization schedule and the importance of booster
shoots (Kusnanto, Ulfiana, & Hadarani, 2017). For the reason, health
care professional must offer continue education appropriately to par-
ents regarding the recommended immunizations for all children re-
gardless birth order.
This study found that labor helper was significantly associated with
complete immunization among children aged 12–23 months. This is
consistent with a previous explained that mothers who gave birth as-
sisted by health professional were two time higher to complete im-
munization compared to the mother who gave birth with unskilled birth
attendance (Savitri, 2009). Health professional should advise parents to
complete immunizations for their children. Birth attendant had a very
important role in completing basic immunization because professional
birth attendants provides information comprehensively about postnatal
programs.
5. Conclusion
Our study found out that Indonesia need to deployed structured
policies in improving the required immunization services over the
country. It’s very important for policy maker to support public health
workers to increase the rate of completion of recommended im-
munization in children. This can be addressed by increasing antenatal
care for pregnant women, access to healthcare facilities and competent
health workforce. In addition, health workers need to provide educa-
tion and counselling to parents about the importance of complete im-
munization for children, along with the recommended immunization
schedules for children.
CRediT authorship contribution statement
Ferry Efendi: Conceptualization, Methodology, Writing - review &
editing. Dwida Rizki Pradiptasiwi: Conceptualization, Methodology,
Writing - review & editing. Ilya Krisnana: Conceptualization,
Methodology, Writing - review & editing. Tiyas Kusumaningrum:
Conceptualization, Methodology, Writing - review & editing. Anna
Kurniati: Writing - review & editing. Mahendra Tri Arif Sampurna:
Writing - review & editing. Sarni Maniar Berliana: Writing - review &
editing.
Declaration of Competing Interest
None.
Appendix A. Supplementary material
Supplementary data to this article can be found online at https://
Children and Youth Services Review 108 (2020) 104651
doi.org/10.1016/j.childyouth.2019.104651.
References
Adedire, E. B., Ajayi, I., Fawole, O. I., Ajumobi, O., Kasasa, S., Wasswa, P., & Nguku, P.
(2016). Immunisation coverage and its determinants among children aged 12–23
months in Atakumosa-west district, Osun State Nigeria: A cross-sectional study. BMC
Public Health, 16(1), 905.
Adokiya, M. N., Baguune, B., & Ndago, J. A. (2017). Evaluation of immunization coverage
and its associated factors among children 12–23 months of age in Techiman
Municipality, Ghana, 2016. Archives of Public Health, 75(1), 28.
DHS (2013). Protecting the Privacy of DHS Survey Respondents. Demographic and health
surveys. Calverton: Measure DHS.
Duclos, P., Okwo-Bele, J.-M., Gacic-Dobo, M., & Cherian, T. (2009). Global immunization:
Status, progress, challenges and future. BMC International Health and Human Rights,
9(1), S2.
Efendi, F., Chen, C. M., Kurniati, A., & Berliana, S. M. (2017). Determinants of utilization
of antenatal care services among adolescent girls and young women in Indonesia.
Women Health, 57(5), 614–629. https://doi.org/10.1080/03630242.2016.1181136.
Ehreth, J. (2011). The global value of vaccination. Vaccine, 21(7–8), 596–600.
Farzad, F., Reyer, J. A., Yamamoto, E., & Hamajima, N. (2017). Socio-economic and
demographic determinants of full immunization among children of 12–23 months in
Afghanistan. Nagoya Journal of Medical Science, 79(2), 179.
Kemenkes. (2017). Profil Kesehatan Indonesia 2016. Kementerian Kesehatan Indonesia.
Retrieved from https://www.depkes.go.id/resources/download/pusdatin/profil-
kesehatan-indonesia/Profil-Kesehatan-Indonesia-2016.pdf.
Kurniati, A., Chen, C. M., Efendi, F., Elizabeth Ku, L. J., & Berliana, S. M. (2017). Suami
SIAGA: Male engagement in maternal health in Indonesia. Health Policy Plan, 32(8)
(pp. 1203–1211). doi:10.1093/heapol/czx073.
Kusnanto, K., Ulfiana, E., & Hadarani, M. (2017). Behavior of Family in Practice Hepatitis
B Immunization at Baby 0–7 Days Old. Jurnal Ners, 3(2), 151–156.
Lakew, Y., Bekele, A., & Biadgilign, S. (2015). Factors influencing full immunization
coverage among 12–23 months of age children in Ethiopia: Evidence from the na-
tional demographic and health survey in 2011. BMC public health, 15(1), 728.
Maharani, A., & Kuroda, Y. (2018). Determinants of immunization status among 12-to 23-
month-old children in Indonesia (2008–2013): A multilevel analysis. BMC Public
Health, 18(1), 288.
Mbengue, M. A. S., Sarr, M., Faye, A., Badiane, O., Camara, F. B. N., Mboup, S., & Dieye,
T. N. (2017). Determinants of complete immunization among senegalese children
aged 12–23 months: Evidence from the demographic and health survey. BMC Public
Health, 17(1), 630.
Phillips, D. E., Dieleman, J. L., Lim, S. S., & Shearer, J. (2017). Determinants of effective
vaccine coverage in low and middle-income countries: A systematic review and in-
terpretive synthesis. BMC Health Services Research, 17(1), 681.
Rumaseuw, R., Berliana, S. M., Nursalam, N., Efendi, F., Pradanie, R., Rachmawati, P. D.,
& Aurizki, G. E. Factors affecting husband participation in antenatal care attendance
and delivery. doi:10.1088/1755-1315/116/1/012012.
Russo, G., Miglietta, A., Pezzotti, P., Biguioh, R. M., Mayaka, G. B., Sobze, M. S., ... Rezza,
G. (2015). Vaccine coverage and determinants of incomplete vaccination in children
aged 12–23 months in Dschang, West Region, Cameroon: A cross-sectional survey
during a polio outbreak. BMC Public Health, 15(1), 630.
Savitri, I. (2009). Faktor yang berhubungan dengan status imunisasi dasar lengkap tepat
waktu pada anak usia 12 bulan di 16 kabupaaten profinsi NTT. In: Skripsi FKM UI.
Statistics Indonesia, BKKBN, & Kemenkes (2013). Indonesia demographic and health survey
2012. Jakarta, Indonesia: BPS, BKKBN, Kemenkes, and ICF International.
Travassos, M. A., Beyene, B., Adam, Z., Campbell, J. D., Mulholland, N., Diarra, S. S., ...
Reymann, M. (2015). Strategies for coordination of a serosurvey in parallel with an
immunization coverage survey. The American Journal Tropical Medicine and Hygiene,
93(2), 416–424.
Warrohmah, Berliana, S. M., Nursalam, N., Efendi, F., Haryanto, J., Has, E. M. M., . . .
Wahyuni, S. D. (2018). Analysis of the Survival of Children Under Five in Indonesia
and Associated Factors. Paper presented at the IOP Conference Series: Earth and
Environmental Science.
WHO (2018). Immunization Coverage. Retrieved from http://www.who.int/en/news-
room/fact-sheets/detail/immunization-coverage.