Figure 1. A school in Jimbaran, Bali, Indonesia, with the local health center, facilitates the students with Measles-Rubella (MR) and Cervical Cancer immunization, on 10 September 2020. Photo Credit Keyza Widiatmika/NurPhoto via Getty Images
The World Health Organization (WHO) initiated the Expanded Programme on Immunization (EPI) in 1974 with the goal of providing universal immunization for all children. With time, global immunization coverage has increased from 74% in 2000 to 86% in 2019. The global number of children dying from preventable and treatable causes decreased from 9.6 million in 2000 to 5.2 million in 2019. But immunization coverage has dropped from 86% in 2019 to 83% in 2020 globally. The COVID-19 pandemic has led to 3.7 million more children missing out on vaccination in 2020 than in 2019. This represents the highest number since 2009. Vaccine-preventable diseases are still responsible for 1.5 million child deaths each year.
The Indonesian Basic Health Survey (2018) reports 58% of children aged 12–23 months are fully immunized, much lower than the 93% national coverage target. Insights on the reasons are needed from caregivers, health workers, and community leaders, to inform strategic and tailored planning and help mitigate risks to immunization uptake.
To address under-vaccination, a clear understanding of the causes, tailor-made strategies for improving uptake, along with frequent monitoring and evaluation are required to determine the impact and sustainability of the vaccination interventions. WHO convened a working group to develop tools to measure the drivers of vaccination uptake in November 2018 named “Behavioural and Social Drivers of Vaccination” (BeSD). This is a workstream under the larger multi-partner Demand Hub developed in consultation with UNICEF, the US Centers for Disease Control (CDC), Gavi, the Vaccine Alliance, and the Bill and Melinda Gates Foundation. The BeSD supports programmes in boosting the availability, quality, and use of data to assess and address reasons for under-vaccination.
Against this background, the Department of Epidemiology, Faculty of Public Health, Universitas Indonesia supported by WHO, conducted a BeSD study from April to September 2020 in Bireuen District, Aceh Province and Padang City, West Sumatra. Both locations have low to moderate coverage of immunization.
The study aimed to identify behavioural and social drivers of vaccination in Indonesia. Specifically, it sought to identify beliefs, social norms, and practical barriers to vaccine uptake; identify local stakeholders in districts (urban and rural areas) in West Sumatera and Aceh Provinces; and provide technical assistance to local stakeholders to facilitate intervention implementation to increase vaccination uptake.
Socio-Demographic Characteristics of the study
A total of 540 samples, 240 in each location were selected using a cluster sampling approach. Most respondents were female (95.7%) in the 31-40 years age category (49.8%), followed by 21-30 years (35.9%). Most respondents were married or living with a partner (96.3%) and did not work for pay (80.9%). A majority had upper secondary education (50%), followed by higher education (23.3%), lower secondary (16.5%) and primary education (9.5%). Respondents mainly followed Islam (99.6%).
Key Results
A. Thinking and Feeling
(i) The majority felt that immunization is important; Bireuen district (88.2%), Padang city (93.9%).
(ii) The majority feel that all children should be immunized; Bireuen district (80.0%), in Padang city (91.1%).
(iii) Most respondents believe that immunization can protect children from diseases; 82.2% in Bireuen district and 93.7% in Padang city.
(iv) Participants were somewhat worried that immunization could cause a serious reaction; 59.3% in Bireuen District and 53.7% in Padang city.
(v) There is a sense of trust for health providers in both communities. A total of 94.9% in Bireuen district and 98.1% in Padang city trust their providers somewhat or very much for immunization.
Figure 2. The majority of respondents feel immunization is important
B. Social Processes
(i) Around half of the respondents (46.3% in Bireuen district, 64.8% in Padang city), said their religious beliefs supported immunization.
(ii) Respondents feel that their religious leaders support them in providing immunization (93.3% in Bireuen district and 81.1% in Padang city).
(iii) Decisions about taking the child for vaccination are taken by the family's head in around 66.7% of the households surveyed, impacting motivation to seek vaccines.
(iv) In both districts’ health providers were cited as the most trusted source of information on immunization (about 62% in both districts), followed by health cadres, family, friends or neighbours.
C. Practical issues
- Most respondents said they had easy access to immunization services (94.6% Bireuen district and 99.3% in Padang city).
- Most respondents said immunization costs are easy to afford (98.1% in Bireuen district and 96.3% in Padang city).
- Most respondents were satisfied with immunization services (98.0% in Bireuen district and 96.7% in Padang city).
- From respondents who were unsatisfied with immunization services, in Bireuen, the reasons cited were lack of time spent with healthcare staff and staff’s inability to answer all questions, whereas in Padang city, additional reasons cited were long waiting times and lack of respect from immunization staff.
D. Vaccination
- More than half the children had skipped or delayed vaccination (73.3% in Bireuen district and 51.5% in Padang city).
- Of all of children who had skipped or delayed immunization, less than half were visited by health providers; 34.8% in Bireuen District and 34.5% in Padang city.
E. Immunization Coverage
- Only 23% in Bireuen district and 32.2% in Padang city had received complete doses or were fully immunized.
- HB0 was the most common vaccine received by children, 80.7% in Bireuen district and 94.8% in Padang city.
- Posyandu or outreach facility was the most visited place to get immunization services for DTP-HB-Hib and Measles/MR antigen, (83.5% in Bireuen district and 65.4% in Padang city for DTP-HB-Hib and 86.4% in Bireuen district and 67.9% in Padang city for Measles/MR).
Recommendations
- BeSD core indicators could be useful to track changes over time. BeSD data should be looked at alongside other coverage, acceptance, and hesitancy studies in Indonesia for a complete picture.
- Communications and engagement strategies should reinforce the importance of vaccines for the individual and as well as the community (explaining the benefits of herd immunity) and aim to build strong social support and peer encouragement for immunization.
- There is generally very high community support for immunization in both districts, with great trust expressed in healthcare providers and health cadres as sources of immunization information. This must be capitalized and made more visible to showcase support for immunization as a social norm.
- In households where one parent does not have the autonomy to make decisions about immunization it is key to strengthen the household support for immunization, targeting fathers and other heads of household who have the final say on vaccination.
- It will be important to work with religious leaders, in combination with health workers and health cadres who are well-trusted sources, to reinforce religious support for immunization to parents and other community. Partnerships between health providers and religious groups, and leaders are encouraged to present united public support for immunization.
- Creating a discussion guide to support health workers address questions about immunization and religion is highly recommended, including how to have productive discussions that result in acceptance and uptake.
- Extending immunization service hours so working parents can immunize children after work or expanded school-based immunization activities to ensure these children do not miss out on life-saving vaccines.
For more information, please click here for the full report in English and here for full report in Bahasa.
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