Mutiara Medika: Jurnal Kedokteran dan Kesehatan

http://journal.umy.ac.id/index.php/mm

Vol xx No x Page xx-xx January/July 20..

Determinant of Complete Basic Immunization among

Aged 12-23 Months in Indonesia
Nur Najikhah, Nurjannah*, Mudatsir, Said Usman & Irwan Saputra
Magister Kesehatan Masyarakat, Fakultas Kedokteran, Universitas Syiah Kuala, Indonesia

DATA OF ARTICLE: Abstract: Complete basic immunization is an effort to prevent the spread of
Received: …. certain diseases by carry out basic complete immunization with a predetermined
Reviewed: …. schedule with certain doses, complete basic immunization coverage is one of the
Revised: …. five priority health issues in Indonesia, complete basic immunization coverage in
Accepted: … Indonesia in 2018 decreased of 57.9 % compared to the previous year, namely in
2013 obtained of 59.2%. Objective: The aim of this study was to identify the
*CORRESPONDENCE:
relationship of complete basic immunization coverage based on maternal age,
nurjannah_dr@unsyiah.ac.id
place of delivery, number of ANC, what order are the children in the family and
DOI: child's gender, parent's education, parent's occupation and place of residence.
………. Method: The method used was observational cross-sectional by total sampling
technique of 6849 respondents, statistical analysis used was chi-square test and
TYPE OF ARTICLE: logistic regression test use SPSS 24. Result: the chi-square test showed that was
Research a relationship between the palce of delivery, number of ANC, what order are the
children in the family, parent's education, parent's occupation and place of
residence with complete basic immunization (p≤0,05). There was no relationship
between maternal age and chils’s gender with complete basic immunization
(p>0,05). Based on logistic regression test, the number of ANC was obtained
with (p≤0.05). Conclusion: The most dominant factor affecting complete basic
immunization was number of ANC.

Keywords: Spatial; Determinant; Complete Basic Immunnization; Indonesia

Abstrak: Imunisasi dasar lengkap merupakan upaya pencegahan terjangkitnya

penyakit dengan melakukan imunisasi secara lengkap dengan jadwal yang telah
ditentukan dengan dosis tertentu, cakupan imunisasi dasar lengkap menjadi
salah satu dari lima isu prioritas kesehatan di Indonesia, cakupan imunisasi
dasar lengkap di Indonesia pada tahun 2018 mengalami penurunan sebanyak
57,9%, dibandingkan dengan tahun 2013 yang didapatkan sebanyak 59,2%.
Tujuan: penelitian ini bertujuan untuk mengidentifikasi hubungan imunisasi
dasar lengkap berdasarkan umur ibu, tempat persalinan, jumlah ANC, anak ke-,
jenis kelamin anak, pendidikan orang tua, pekerjaan orang tua dan tempat
tinggal. Metode Penelitian: Metode yang digunakan cross-sectional dengan
total sampling sebanyak 6849 responden. Analisis statistik yang digunakan
adalah uji chi square dan uji regresi logistik dilakukan menggunakan SPSS 24.
Hasil Penelitian: Hasil uji chi-square didapatkan bahwa ada hubungan tempat
persalinan, jumlah ANC, Anak Ke-, Pendidikan orang tua, Pekerjaan orang tua,
Tempat tinggal dengan imunisasi dasar lengkap (p≤0,05), tidak mempunyai
hubungan umur ibu dan jenis kelamin dengan imunisasi dasar lengkap (p≥0,05)
dan berdasarkan uji regresi logistik didapatkan jumlah ANC dengan (p≤0,05).
Kesimpulan: Faktor yang paling dominan berhubungan dengan imunisasi dasar
lengkap adalah jumlah ANC.

Kata Kunci: Spasial; Determinan; Imunisasi Dasar Lengkap; Indonesia

INTRODUCTION

Immunization is one of the global health efforts and also one of the best health investments to save
millions of lives every year, immunization can prevent 2-3 million deaths every year caused by diseases:
diphtheria, tetanus, pertussis, polio, and measles by carrying out basic immunizations, namely: HB-0, BCG,
DPT-HB, Polio, and Measles. However, despite these advances, there were still almost 20 million infants
each year who did not have adequate access to immunization1.
Based on data from the World Health Organization (WHO) in 2019, globally, 5.7 million infants in the
world did not get complete immunizations. Based on the type of basic immunization coverage according to
WHO data, the lowest immunization coverage was HB-0 immunization which was obtained of 43%, but the
polio immunization coverage obtained in the western region was the highest of 84% and the lowest was in
Africa of 6%, while globally the polio immunization coverage had a fairly good immunization coverage
reaching 82%. WHO also stated that of the 19.7 million children under one year old who did not get
complete basic immunization at all, 60% came from 10 middle or lower-middle economic countries, one of
which was Indonesia2.
Based on Riskesdas data in 2018, nationally, complete basic immunization coverage decreased by
57.9% compared to the previous year, which was 59.2% in 2013. Based on each type of basic immunization in
2013 the lowest proportion of DPT-HB immunization was 75.6%, then there was a slight difference followed
by polio immunization of 77%, HB-0 immunization of 79.1%, measles immunization of 82.1%, and the highest
coverage of BCG immunization of 87.6%. Meanwhile, in 2018 the lowest proportion was also found in DPT-
HB immunization, which was 61.3%, then there was a slight difference followed by polio immunization of
67.6%, measles immunization of 77.3%, HB-0 immunization of 83, 1% and the highest of BCG immunization
coverage was 86.9%3.
Efforts that have been made globally to increase complete basic immunization coverage were:
helping all countries to make immunization a priority, WHO set national targets and plans by allocating
adequate human and financial resources, supporting communities to understand that immunization is a
right and responsibility, develop plans to ensure every child gets immunized, strengthen the immunization
system, increase funding for immunization1.
Efforts made nationally to increase complete basic immunization coverage, namely through the
Healthy Indonesia Approach with Family Approach (PIS-PK) program, in this program efforts are made
through promotive and preventive measures by conducting home visits to complete immunization status
and providing information or counseling on parents, empowering the community through cadres at
Integrated Health Post and cross-sectoral involvement to provide outdoor services 4.
Based on the data and efforts that have been made to increase complete basic immunization
coverage, it can be concluded that although there were programs related to increasing complete basic
immunization coverage, the provision of complete basic immunization was still in the poor category as
evidenced by complete basic immunization coverage was one of the 5 priority health issues. In this case,
the researcher wanted to identify the problem of decreasing complete basic immunization coverage based
on the determinants of complete basic immunization, namely maternal determinants, child determinants,
and socio-economics.

METHOD

This study used an analytical research design with a cross-sectional observational approach as
observations. This study was conducted in 34 provinces in Indonesia using secondary data which is data
obtained from the Indonesian Data Management Laboratory related to Indonesian Basic Health Research in
2018 using the total sampling technique which is the number of samples equal to the total population of
6849 respondents. The data analysis used descriptive, Chi-Square test and logistic regression test.

RESULT AND DISCUSSION

The distribution results of the frequency of complete basic immunization

determinants among children aged 12-23 months in Indonesia are shown in Table 1.
 Table 1. The Frequency Distribution of Complete Basic
Immunization Determinants among Children Aged 12-23 Months
in Indonesia (n= 6849)
Variable f %
Maternal Age
≥ 40 years old 596 8.7
30-39 years old 3266 47.7
≤ 29 years old 2897 43.6
Total 6849 100
Number of ANC
0 times 546 8.0
1-3 times 1248 18.2
≥ 4 times 5055 73.8
Total 6849 100
Place of Delivery
Home/non-healthy facilities 1875 27.4
Healthy facility 4974 72.6
Total 6849 100
Childs’ Gender
Male 3543 51.7
Female 3306 48.3
Total 6849 100
Birth Order
5th born-onwards 1025 15.0
3rd-4th born 2831 41.3
1st-2nd born 2993 43.7
Total 6849 100
Parent’s Education
Primary education 2224 32.5
Secondary education 3705 54.1
Higher education 920 13.4
Total 6849 100
Parent's Occupation
Unemployed 158 2.3
Farmers/Fishermen/Labourers
3700 54.0
/Drivers/Housemaid
Private employee/Entrepreneur 2523 36.8
Civil Servant/ Indonesian National
Armed Forces/ Indonesian Police/
468 6.8
State-Owned Enterprise/ Regional-
Owned Enterprise
Total 6849 100
Residence
Rural 4137 60.4
Urban 2712 39.6
Total 6849 100
Complete Basic Immunization
Incomplete 5658 82.6
Complete 1191 17.4
Total 6849 100

A. Maternal Age

Table 2. The Relationship between Maternal Age and Complete Basic Immunization among Children aged 12-23
Months in Indonesia (n= 6849).
Basic Immunization
Maternal
Incomplete (%) Complete (%) Total OR CI 95% P-Value
Age
≥ 40 years 481 115 596 0.434
-
old 80.7 19.3 100
30-39 years 2706 560 3266
0.86 0.69-1.08
old 82.9 17.1 100
≤ 29 years 2471 516 2987 0.87 0.70-1.10
old 82.7 17.3 100
 5658 1191 6849
Total -
82.6 17.4 100

In this study, it was found that there was no relationship between maternal age and
complete basic immunization and it was found that maternal aged 30-39 years old were
1.16 times more likely to not carry out complete basic immunizations and maternal aged
≤29 years old were 1.14 times more likely to not carry out complete basic immunization,
both age categories were compared with maternal aged ≥40 years old.
The results of this study were supported by research conducted by Mbengue in 2017
in Senegal, West Africa, it was found that maternal age had no relationship with complete
basic immunization5. Rakhmanindra stated that age could not affect actions, experiences,
and decision making, because age does not always support a person to do something,
including in efforts to prevent the occurrence of a disease such as immunization 6.
Maternal age is one of the determinants that cannot be modified, this is the same as
gender in children, but maternal age is also related to the child's birth order, assuming
that younger mothers will have 1st-2nd born of birth order category, but, according to the
OR value for maternal age, it was found that maternal aged 29 years old was less likely to
not carry out complete basic immunizations compared to maternal aged 30-39 years old,
because younger mothers still made their children the main focus and always prioritized
the best for their children, however, prayogo stated that younger mothers were less
psychologically prepared for child care, including immunization 7.
Holipah also stated that younger mothers were often unable to make decisions on
their own, they always wanted to discuss a decision with their family members and
younger mothers were also less likely to use health facilities 8.

B. Place of Delivery

Table 3. The Relationship between Place of Delivery and Complete Basic Immunization among Children
aged 12-23 Months in Indonesia (n= 6849).
Basic Immunization
Place of
Incomplete % Complete % Total OR CI 95% P-Value
Delivery
Home/ 1171 164 1875
Non Healthy -
91.3 8.7 100
Facility
Healthy 164 1027 4974 0.000
2.72 2.28 – 3.23
Facility 8.7 20.6 100
5658 1191 6849
Total -
82.6 17.4 100

This study showed that there was a relationship between place of delivery and
complete basic immunization and it was also found that mothers who gave birth in health
facilities were 2.72 times more likely to carry out complete basic immunizations compared
to mothers who gave birth at home/non-health facilities.
This study was in accordance with research conducted by Dharma in 2017, it was
found that there was a relationship between the place of delivery and complete basic
immunization9. Holipah also stated that mothers who gave birth in health facilities would
receive delivery assistance from professional health workers, with professional health
workers not only assisting in the delivery process, because in Indonesia before the
mother gave birth, the mother had received ANC services, to give birth, and continued
with perinatal care, advice regarding nutrition for growth and development and also
immunization services for children, also mothers who are more often exposed to health
facilities will be more aware of their children's health because they often receive
information related to children's health, one of which is about immunization 8.
C. Number of ANC

Table 4. The Relationship between the Number of ANC and Complete Basic Immunization among
Children Aged 12-23 Months in Indonesia (n= 6849).
Basic Immunization
Number of Incomplete
Complete % Total OR CI 95% P-Value
ANC %

530 16 546
0 times -
97.1 2.9 100
1120 128 1248
1-3 times 3.79 2.23-6.43
89.7 10.3 100
0.000
4008 1047 5055
≥ 4 times 8.65 5.29-14.3
79.3 20.7 100
5658 1191 6849 -
Total
82.6 17.4 100

In this study, it was found that there was a relationship between the number of ANC
with complete basic immunization and mother who performed ANC 1-3 times 3.79 were
more likely to carry out complete basic immunization for their children, also mothers who
performed ANC ≥4 times 8.65 times were more likely to complete basic immunization,
both categories were compared with mother who did not perform ANC at all.
This study was in line with research conducted by Mbegue in 2017 which found that
there was a relationship between ANC and complete basic immunization 5.
Mappadang in 2020 stated that mothers who performed ANC would be educated by
health service providers about the series of health services that must be obtained by
mothers and infants, such as after giving birth, mothers are directed to carry out
examinations so that the health of mothers and infants after childbirth can be monitored
with the aim that mother can carry out health care by preventing disease, one of which is
by immunizing infants10.
The number of ANC was related to the place of delivery, if the mother uses or
receives ANC services at a health facility, the mother will be directed by health workers to
give birth at a health facility and a mother who has performed ANC ≥4 times in
accordance with minimum service standards can show that the mother has good
behavior in the use of health services because mothers can realize that it is necessary to
access health services so that mother also wants and feels the need to provide care in
health services needed by their children11.

D. Birth Order

Table 5. The Relationship between the Birth Order and Complete Basic Immunization among
Children Aged 12-23 Months in Indonesia (n= 6849).
Basic Immunization
Incomplete Complete %
Birth Order Total OR CI 95% P-Value
%
5th born- 872 153 1025
-
onwards 85.1 14.9 100
2355 476 2831
3rd-4th born 1.15 0.95-1.40
83.2 16.8 100 0.011
2431 562 2992
1st-2nd born 1.32 1.08-1.60
81.2 18.8 100
5658 1191 6849
Total -
82.6 17.4 100
 This study showed that there was a relationship between birth order and complete
basic immunization and also found that birth order of the 3rd-4th born, 1.15 times more
likely to carry out complete basic immunization and children with birth order of the 1st-
2nd born obtained 1.32 times more likely to carry out complete basic immunization, the
two categories were compared with birth order of 5th born-onwards.This was in line with
research conducted by Fatiregun in 2012 which found that there was a relationship
between the birth order of children and basic immunization, 12 Prayogo stated that
children with the first birth order are always the main focus of attention for parents, so
preventive measures are more likely to be taken by mother, one of which is
immunization, because the more number of children in the family can lead to incomplete
basic immunization of children7.
Preventive actions that can be taken by parents to their children are also influenced
by parent’s education. Birth Order is also related to maternal age, which is assumed that
children with birth order of the 1st-2nd born have younger mothers. Mappadang stated
that mothers tended to pay more attention to their children, especially related to child
health, although age did not affect behavior, the increase in maternal age would also be
followed by an increase in the number of children and an increase in the busyness of a
mother. This will affect the time and motivation of mothers in providing health services
for their children10.

E. Child’s Gender

Table 6. The Relationship between Gender and Complete Basic Immunization among Children Aged
12-23 Months in Indonesia (n= 6849).
Basic Immunization
Child’s
Incomplete % Complete % Total OR CI 95% P-Value
Gender
2922 621 3543
Male -
82.5 17.5 100
2736 570 3306
Female 0.98 0.87 – 1.11 0.774
82.8 17.2 100
5658 1191 6849
Total -
82.6 17.4 100

In this study, it was shown that there was no relationship between gender and
complete basic immunization and that female child were 1.02 times more likely not to
have complete basic immunizations compared to male children.
This was in accordance with research conducted by Srhestha in Nepal in 2018 it was
found that the child’s gender had no relationship with immunization status, this
happened because there were no social differences between children with male and
female gender, which was accompanied by the presence of awareness and advocacy
related to gender equality between male and female 13, and also supported by Mbegue in
2017 which stated that females who were 1.01 times did not complete basic
immunizations compared to males5.

F. Birth Order Parent’s Education

Table 7. The Relationship between Parent’s Education and Complete Basic Immunization among
Children Aged 12-23 Months in Indonesia (n= 6849).
Basic Immunization
Incomplete
Parent’s Educatio Complete % Total OR CI 95% P-Value
%
1916 308 2224 -
Primary Education 86.2 13.8 100 0.000
Secondary Education 3028 677 3705 1.39 1.20-1.61
 81.7 18.3 100
714 206 920
Higher Education 1.79 1.47-2.18
77.6 22.4 100
Total 5658 1191 6849 -
82.6 17.4 100
This study showed that there was a relationship between Parent’s Education and
complete basic immunization, it was found that secondary education was 1.39 times more
likely to carry out complete basic immunization for children, and parents with higher
education were 1.79 times more likely to carry out complete basic immunization in
children, both this category was compared with parents who had primary education.
This was supported by research conducted by Hikmayati which means that there
was a relationship between parent’s education and complete basic immunization,
education greatly influenced individual motivation to play a role in building health and
influenced in responding to something that came from external so that they were able to
absorb and understand related information received14.
Education plays an important role in determining the quality of human life, with
education, individuals will obtain and receive information well, the higher the individual's
education, the better the quality of his/her life, Makamban stated that higher education
had a positive effect in taking an action, in this study related to complete basic
immunization, it can be concluded that the action taken is a condition where you receive
preventive measures provided by health services such as complete basic immunization 15.
Hijani stated that parents who had higher education would be better at receiving
information obtained related to promotive actions provided by health services regarding
children's health, so that mothers can make good decisions for their children's health,
such as in immunization16.
Education had a relationship with the occupation which was associated with a person's
economic status, the assumption was that parents who were highly educated would have
a fairly good occupation so that this is a determinant that had a relationship with
complete basic immunization in this study, although complete basic immunization in
Indonesia did not cost money, however, Machsun stated that the family's economic
status could be an obstacle if it is not at a good level because access to health facilities for
immunization required economic needs17.

G. Parent's Occupation

Table 8. The Relationship between Parent’s Occupation and Complete Basic Immunization among
Children Aged 12-23 Months in Indonesia (n= 6849).
Basic Immunization
Parent's Incomplete
Complete % Total OR CI 95% P-Value
Occupation %
134 24 468 -
Unemployed
84.8 15.2 100
Farmers/
Fishermen/ 3112 588 2523
1.05 0.68-1.64
Laborers/ Drivers/ 84.1 15.9 100
Housemaid
2063 460 3700
Private employees 1.24 0.80-1.95 0.000
81.8 18.2 100
Civil
Servant/Indonesian
National Armed 349 119 158
1.9 1.18-3.08
Forces/Indonesian 74.6 25.4 100
Police/StateOwned
Enterprise/Regiona
 l-Owned Enterprise
5658 1191 6849
Total -
82.6 17.4 100

This study showed that there was a relationship between parent’s occupation and
complete basic immunization and found that parents who had an occupation as
farmers/fishermen/laborers/drivers/housemaid were 1.05 times more likely to carry out
complete basic immunizations for children, parents with occupation as private
employees/entrepreneurs were 1.24 times more likely to carry out complete basic
immunization for children, parents who work as Civil Servant/Indonesian National Armed
Forces/Indonesian Police/State-Owned Enterprise/Regional-Owned Enterprise were 1.90
times more likely to carry out complete basic immunization in children, these three
categories compared to parents which unemployed.
This was in line with research conducted by Fatiregun in 2012 which found that there
was a relationship between parent’s occupation and complete basic immunization. 12
Occupation is a need that should be carried out by everyone, based on the theory of
needs, there are five levels of basic human needs, five levels are physiological needs,
safety and protection needs, social needs, esteem needs and self-actualization needs.
Occupation is included in the need for self-actualization to meet the other four
needs, which involve motivation and education to make decisions in taking an action, to
achieve a good quality of life18.
Good quality of life was also influenced by good health level, thus this aspect of
health level is included in it related to infant mortality, reducing infant mortality can be
carried out by preventing a disease which is usually carried out by immunization, so with
this preventive action by immunization is also part of the needs that must be carried out
by every parent for their child.
Occupation related to education, so that parents who had good occupation were in line
with parents who had a good education so that in receiving and obtaining the
information it could be well received, as well as related actions to complete basic
immunizations carried out on their children based on the information and absorbed as
well as the awareness to immunize their children.

H. Residence

Table 9. The Relationship between Residence and Complete Basic Immunization among
Children Aged 12-23 Months in Indonesia (n= 6849).
Basic Immunization
Residenc Incomplete Complete
Total OR CI 95% P-Value
e % %
3476 661 3543
Rural -
84.0 16.0 100
2182 530 3306
Urban 1.27 1.13 – 1.45 0.000
80.5 19.5 100
5658 1191 6849
Total -
82.6 17.4 100

This study showed that there was a relationship between residence and complete
basic immunization, it was also found that parents and children who lived in urban areas
were 1.27 times more likely to have children with complete basic immunizations
compared to parents and children who lived in rural areas.
This was in line with research conducted by Etana in 2012 in Ethiopia, where it was
found that parents and children who lived in urban areas were 1.5 times more likely to
carry out complete basic immunizations than rural areas, 19 Lim in 2017 stated that children
who lived in rural areas were less likely to have complete basic immunization due to
differences in parents' religious understanding and attitudes that affected acceptance
and uptake of medical practices, such as immunization. The residence was also related to
the ease of access to health services for immunization, 20 according to Hafid in 2016 it was
found that having easy access to health services tended to carry out complete basic
immunizations21.

I. Dominant Factor

Table 10. Multivariate Logistic Regression Model among Maternal Determinants, Child
Determinants, Socio-Economic and Complete Basic Immunization among Children Aged
12-23 Months in Indonesia.
Variable OR CI 95% P-Value
Number of ANC
1-3 times 2.84 1.66 – 4.86 0.000
≥ 4 times 5.63 3.37 – 9.42 0.000
Place of Delivery
Health Facility 2.00 1.66 – 2.42 0.000
Parents' Occupation
Farmers/Fishermen/Labourers 1.14 0.72 – 1.79 0.585
/Drivers/ Housemaid
Private Employees/Entrepreneurs 1.02 0.64 – 1.61 0.943
Civil Servant/Indonesian National 1.46 0.88 – 2.40 0.139
Armed Forces/
Indonesian Police/State-Owned
Enterprise/
Regional-Owned Enterprise
Parent’s Education
Secondary Education 1.13 0.96 – 1.33 0.131
Higher Education 1.20 0.95 – 1.52 0.123
Birth Order
3rd-4th born 0.99 0.81 – 1.21 0.957
1st-2nd born 1.11 0.91 – 1.36 0.290
Residence
Urban 0.93 0.81 – 1.07 0.318

The most dominant factor in this study was the number of ANC in the category ≥4
times with an OR value of 8.65, which means that parents who did ANC ≥4 times 8.65
times tended to carry out complete basic immunization for their children compared to
the parents who did not perform ANC at all.
The use of ANC is to monitor the health and pregnancy of the mother, to ensure
fetal growth and development, to detect early abnormalities that occur or complications
that may occur during pregnancy, to prepare the mother for childbirth, to undergo the
postpartum period, and to prepare for the role of mother.22
If during pregnancy the mother performs ANC ≥4 times, then it becomes an opportunity
for health workers to provide education related to services that must be received and
carried out by mothers for themselves and their children, as well as the behavior of
mothers who perform ANC ≥4 times have shown that the mother's behavior in using
health facilities are good, so it can be assumed that they are aware of the need for access
to health services that their children need, and also if the mother has continuity use of
health services, the mother will get the MCH (The Maternal and Child Health) handbook,
which includes maternal and child health records, including complete basic
immunizations23.

CONCLUSION

Based on the results of this study, it can be concluded that the place of delivery
determinant, Number of ANC, Birth Order, parent’s education, parent's occupation, and
maternal age were the determinants that had a relationship with complete basic
immunization among children aged 12-23 months in Indonesia. Furthermore, there was no
relationship between maternal age and a child’s gender with complete basic
immunization among children aged 12-23 months in Indonesia. The most dominant factor
affecting complete basic immunization was the number of ANC.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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