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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, fathers education, fathers occupation, birth order, place of delivery, assistant at delivery, and households 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 ABSTRACT TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES LIST OF ABBREVIATIONS

iii iv v vii viii ix

CHAPTER I : INTRODUCTION 1.1. 1.2. 1.3. 1.4. 1.5. Background and Rationale Research Problem and Justification Research Questions Research Objectives Scope and Limitations 1 3 5 6 6

CHAPTER II : LITERATURE REVIEW 2.1. Role of Immunization 2.2. 2.3. Immunization Program in Indonesia Socioeconomic and Demographic Factors Related to Immunization 7 9 12 12 13 19 21 21

2.3.1. Theoretical Concept of Socioeconomic-Demographic Status and Health 2.3.2. Findings from Previous Research 2.4. 2.5. Conceptual Framework Definition of Terms

2.6. Hypotheses

CONTENTS (Cont.)

CHAPTER III : RESEARCH METHODOLOGY 3.1. 3.2. 3.3. 3.4. Source of Data Sample Size Operational Definitions Data Analysis and Management 23 24 24 29

CHAPTER IV : RESULTS AND DISCUSSION 4.1. Selected Background Characteristics of the Sample 30 30 34 35 38 39 42

4.1.1. Characteristics of Mothers 4.1.2. Characteristics of Fathers 4.1.3. Characteristics of Children 4.1.4. Characteristics of Households 4.2. Status of Immunization 4.3. Results of Bivariate Analysis

CHAPTER V : SUMMARY, CONCLUSION AND RECOMMENDATIONS 5.1. Summary 5.2. 5.3. Conclusion Recommendations 54 55 56 56 57 59 64

5.3.1. Recommendations for Policy Implementation 5.3.2. Recommendations for Further Study REFERENCES BIOGRAPHY

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 DPT DT EPI = Bacillus Calmatte Guiren = Diphtheria, Pertussis, Tetanus = Diphtheria Tetanus = Expanded Programme on Immunization

IDHS = Indonesia Demographic and Health Survey Measles = Measles vaccine OPV Polio TBA TT = Oral Polio Vaccine = Poliomyelitis vaccine = Traditional Birth Attendant = Tetanus Toxoid

UNICEF = United Nation Childrens Fund WHA = World Health Assembly WHO = World Health Organization

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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 Childrens Fund (UNICEF), other United Nations agencies, bilateral development agencies, and non-government organizations to immunize the worlds children to prevent suffering, disability and death due to six vaccinepreventable 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

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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.

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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.

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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 childrens 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.

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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?

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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.

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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).

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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 WHOs 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 Childrens 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 Fs 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.

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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

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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).

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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 Vaccine Recommended schedule Number of doses BCG DPT OPV Measles DT* TT** One Three Three One Two Two Interval between doses Minimal 4 weeks Minimal 4 weeks Minimal 4 weeks Minimal 4 weeks Eligible age group Youngest At birth 3 months 3 months 9 months 6 years Early in pregnancy
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.

Oldest 14 months 14 months 14 months 14 months 7 years 8 months

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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.

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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 childs chance of survival. The data obviously indicates that the immunization status of children is one of the important factors in determining childrens 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

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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, parents 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 childrens 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. Parents 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 mothers 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

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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 childrens 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 childrens overall health status.

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Maternal Age Mothers 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 fathers 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

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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.

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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.

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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, households 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.

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Figure 1: Conceptual framework of selected socioeconomic and demographic factors and status of immunization

Independent Variables

Dependent Variable

Characteristics of mother: - Maternal education - Maternal occupation - Maternal age - Prenatal care

Characteristics of father: - Fathers education - Fathers occupation Status of Immunization Characteristics of child: - Age of child - Sex of child - Birth order - Place of delivery - Assistant at delivery

Characteristics of household: - Households economic status - Residence

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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.

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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.

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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

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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.

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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

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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).

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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

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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

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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. Cramers V was used to measure the strength of the relationship between the dependent and independent variables.

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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 chisquare 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

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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.

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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.

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Table 2. Percentage distribution of selected characteristics of mothers of children under five years

Characteristics 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

Per cent

Number

6.3 47.1 42.9 3.7 100.0

38 282 257 22 599

40.7 32.1 27.2 100.0

244 192 163 599

16.2 56.9 26.9 100.0

97 341 161 599

11.7 30.7 57.6 100.0

70 184 345 599

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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 mothers education and fathers 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.

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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 * 5 cases are classified as system missing

2.5 42.4 49.9 5.2 100.0

15 254 299 31 599

45.1 54.9 100.0

268 326 594*

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.

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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.

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Table 4. Percentage distribution of selected characteristics of children under five years

Characteristics 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

Per cent

Number

53.6 46.4 100.0

321 278 599

36.7 27.0 21.0 15.2 100.0

220 162 126 91 599

21.9 37.2 40.9 100.0

131 223 245 599

77.0 23.0 100.0

461 138 599

9.3 62.9 20.7 7.0 100.0

56 377 124 42 599

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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

381 209 9 599

72.1 27.9 100.0

432 167 599

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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.

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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

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Table 7. Percentage distribution of BCG, DPT, polio, and measles immunizations of children under five years

Immunizations 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

Per cent 71.3 28.7 100.0

Number 427 172 599

70.1 29.9 100.0

420 179 599

59.8 40.2 100.0

358 241 599

50.8 49.2 100.0

295 304 599

87.8 12.2 100.0

526 73 599

82.1 17.7 100.0

492 106 599

65.9 33.9 100.0

395 203 599

60.4 39.6 100.0

362 237 599

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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, Cramers V was applied. Cramers 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 Cramers 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.

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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 Cramers 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 (chisquare = 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.

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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 Cramers V value shows a fairly weak relationship (0.211).

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Table 8. Percentage distribution of status of immunization by selected characteristics of mothers.

Characteristics of mother Maternal education No education Primary education Secondary education Higher education Total Chi-square 33.725 df 3 P value < 0.001 Cramers 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 Cramers V 0.179 Maternal age 15-24 25-34 35 and above Total Chi-square 1.574 df 2 P value 0.455 Cramers V 0.051 Prenatal Care No visit 1-3 4 and over Total Chi-square 26.727 df 2 P value < 0.001 Cramers V 0.211

Status of immunization Not Complete 89.5 64.9 49.0 36.4 58.6 Complete 10.5 35.1 51.0 63.6 41.4

Total (%) 100.0 100.0 100.0 100.0 100.0

Number

38 282 257 22 599

61.1 67.2 44.8 58.6

38.9 32.8 55.2 41.4

100.0 100.0 100.0 100.0

244 192 163 599

57.7 56.9 62.7 58.6

42.3 43.1 37.3 41.4

100.0 100.0 100.0 100.0

97 341 161 599

75.7 68.5 49.9 58.6

24.3 31.5 50.1 41.4

100.0 100.0 100.0 100.0

70 184 345 599

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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 fathers education and status of immunization is statistically significant. However, this relationship is fairly weak (Cramers 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 fathers 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 Cramers V value of 0.199 indicates a weak relationship.

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Table 9. Percentage distribution of status of immunization by selected characteristics of fathers

Characteristics

Status of immunization 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 Cramers 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 Cramers V 0.199

93.3 68.1 51.2 35.5 58.6

6.7 31.9 48.8 64.5 41.4

100.0 100.0 100.0 100.0 100.0

15 254 299 31 599

69.4 49.7 58.6

30.6 50.3 41.4

100.0 100.0 100.0

268 326 594*

* 5 cases are classified as system missing

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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

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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 Cramers V indicates that it is a weak relationship (Cramers 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 (Cramers 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

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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 Cramers V value of 0.290 shows a moderate relationship between immunization status and assistant at delivery.

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Table 10. Percentage distribution of status of immunization and selected characteristics of children Characteristics Age of child (months) 12-23 24-35 36-47 48-59 Total Chi-square 6.691 df 3 P value 0.082 Cramers V 0.106 Sex of child Male Female Total Chi-square 0.022 df 1 P value 0.881 Cramers V 0.006 Birth order 1 2-3 4 and above Total Chi-square 17.024 df 2 P value < 0.001 Cramers V 0.169 Place of delivery of child At home Health care facility Total Chi-square 30.134 df 1 P value < 0.001 Cramers V 0.224 Assistant at delivery Doctor Nurse/Midwife TBA Other or none Total Chi-square 50.480 df 3 Status of immunization Not complete Complete 64.1 57.4 50.0 59.3 58.6 35.9 42.6 50.0 40.7 41.4 Total (%) 100.0 100.0 100.0 100.0 100.0 Number

220 162 126 91 599

58.9 58.3 58.6

41.1 41.7 41.4

100.0 100.0 100.0

321 278 599

51.1 52.0 68.6 58.6

48.9 48.0 31.4 41.4

100.0 100.0 100.0 100.0

131 223 245 599

64.6 38.4 58.6

35.4 61.6 41.4

100.0 100.0 100.0

461 138 599

33.9 53.1 76.6 88.1 58.6

66.1 46.9 23.4 11.9 41.4

100.0 100.0 100.0 100.0 100.0

56 377 124 42 599

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P value < 0.001 Cramers 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 households 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 (Cramers 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).

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Table 11. Percentage distribution of status of immunization by selected characteristic of households

Characteristics

Status of immunization Not complete Complete

Total (%)

Number

Household's economic status Low Medium High Total Chi-square 11.518 df 2 P value 0.003 Cramers V 0.139 Residence Rural Urban Total Chi-square 0.808 df 1 P value 0.369 Cramers V 0.037

63.5 50.7 33.3 58.6

36.5 49.3 66.7 41.4

100.0 100.0 100.0 100.0

381 209 9 599

59.7 55.7 58.6

40.3 44.3 41.4

100.0 100.0 100.0

432 167 599

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CHAPTER V SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.1. Summary

Immunization is the process of stimulating the bodys 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:

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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, fathers education, fathers occupation, birth order, place of delivery, assistant at delivery, and households 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.

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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 childrens 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.

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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 households 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.

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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.

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