Parents’ hesitancy towards vaccination in Indonesia: A cross-sectional study in Indonesia
Introduction
The World Health Organization (WHO) reported that in 2017, an estimated 19.9 million infants worldwide did not receive routine vaccination services and approximately 60% of them live in 10 countries: Afghanistan, Angola, the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Iraq, Nigeria, Pakistan and South Africa [1]. In Southeast Asia alone, 4.2 million children under 1 year old have not received the third dose of diphtheria-tetanus-pertussis vaccine (DTP3) [2]. Despite improved vaccine coverage experienced by most countries in the region since year 2000, where seven countries in Southeast Asia have achieved ≥ 90% national coverage for DTP3 in 2016, DTP3 coverage has declined below 80% in Indonesia since 2014 [2]. Coverage of full vaccination for children aged 12–23 months in Indonesia was reported at 57.9% in 2018 [3], far below the global vaccination coverage of 85% [1]. Aceh was the province with the lowest vaccination coverage with only 20% of its children fully vaccinated [3]. West Sumatra was not far better, ranked the 5th province with lowest vaccine coverage with only 40% children aged 12–23 months fully vaccinated [3].
A number of studies have been conducted to investigate barriers to pediatric vaccination, and divided them into health system barriers, provider barriers, and parental barriers [4]. Health system barriers include cost for vaccination, difficulties in vaccine storage, problems in vaccine supply and distribution, and lack of information systems to collect and consolidate individuals’ vaccination status [4], [5]. For providers, barriers comprise poor knowledge of vaccination indications and contraindications, lack of access to children’s vaccination records, and poor communication with parents [4], [5], [6]. The barriers from the parents’ side include poor understanding of the real value of vaccines, fear of adverse effects, limited access to clinics, and economic problems [4], [5], [6]. Problems with health systems and providers can be addressed by improving services that reach the community, maintaining the vaccine supply, and training health workers. However, parental attitudes and knowledge issues are more difficult to address.
One growing concern related to vaccination is vaccine hesitancy [7], [8], which refers to the delay in acceptance or refusal of vaccination despite the availability of vaccination services [9]. Hesitant attitudes to vaccination are prevalent and increasing worldwide, with safety concerns as the most commonly cited reason [7], [8], [9], [10], [11]. Lack of knowledge and awareness, low perceived severity of illness, media influence, beliefs, and perceived crowding of the immunization schedule are other concerns and challenges raised by vaccine hesitant parents [10], [11], [12]. In contrast, advice from healthcare workers, knowledge and awareness of vaccine are some of the factors supporting positive attitudes towards vaccination [6], [10]. The WHO has listed vaccine hesitancy as one of the ten threats to global health in 2019 [13], but information from low- and middle-income countries is more limited [14], [15]. In addition, there is concern that vaccination programs in middle-income countries, like Indonesia, face particular challenges in that they receive less guidance and funding support from various international organizations [16]. As populations rapidly urbanize and become more educated in these middle income countries, determining if and how vaccine hesitancy has taken root is an important component of disease control programs. It is also possible that there is a complex interplay between acceptance of vaccines and the presence of severe disease in the community or an ongoing pandemic [17], [18]. Severity and susceptibility are often taken into consideration by parents in making decision regarding vaccination [19] and are also associated with willingness to pay for vaccination [20]. Parents are more likely to get their children vaccinated against a more severe, very contagious and easily transmitted diseases [19]. In this current study, we focus on Zika given its epidemic potential for Indonesia [18], [21].
The immunization program in Indonesia was first initiated in 1956, and through this program the country was declared free of smallpox in 1974 [22]. Since 1977, Indonesia has expended the program to cover vaccines for tuberculosis, diphtheria, pertussis, measles, polio, tetanus, hepatitis B, and pneumonia. Vaccines are provided for free at the community health centers (Puskesmas) and made compulsory for children under five, for elementary students in 1st-3rd grade, and women of reproductive age [22]. However, the coverage of vaccination in Indonesia has been decreasing for the past few years, even below global targets [1], [3]. On top of that, the country also experienced the re-emergence of diphtheria, a disease that has not been found for decades, due to low coverage of the compulsory diphtheria vaccine [3]. One possible reason why many children do not get vaccinated is that parents express various degrees of hesitancy towards vaccines. This study was conducted to investigate parents’ hesitancy towards vaccination in Indonesia.
Section snippets
Study design and study participants
A cross-sectional study was conducted in eleven regencies and municipalities in Aceh and West Sumatra provinces from February 1st until June 31st 2018. This study was part of the Indonesia Zika Vaccine Study [23], [24]. Participants in this study, recruited using convenient sampling, were parents who visited outpatient clinics of (Puskesmas) or hospitals in selected areas during the study period. Puskesmas and hospitals were chosen as the enrollment locations for two reasons. First, since 2014
Participants‘ characteristics
A total of 1102 parents were approached and interviewed in eleven regencies. However, 145 parents (13.2%) objected to take part or did not finish their interviews, leaving a total of 956 participants included in the final analysis. Demographic characteristics of the participants are presented in Table 1. The majority of the respondents (86.5%) were female and most were 20–39 years old (73.1%). Around 85% of the participants had finished senior high school and approximately half (50.7%) of the
Discussion
Although most respondents showed good attitude towards childhood vaccination, (with only 15.9% of them being hesitant), parents expressed several concerns about vaccines which highlight the importance of continued research of vaccine hesitancy in low- and middle-income countries. The overall proportion of those vaccine hesitant is similar to another study in Malaysia, in which hesitancy was only found in 11% of the parents [28]. In separate analyses for each subdomain, we found a majority of
Conclusions
In this study, 15.9% of the parents expressed hesitancy towards childhood vaccination and vaccine safety and efficacy issue is the main concern, in particular among young mothers and groups with lower education levels. Therefore, continuous dissemination of information by physicians on the safety and efficacy of vaccine is necessary to gain parents trust and increase vaccination coverage in Indonesia.
CRediT authorship contribution statement
Amanda Yufika: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing - original draft, Writing - review & editing, Project administration. Abram Luther Wagner: Conceptualization, Methodology, Validation, Formal analysis, Resources, Writing - original draft, Writing - review & editing. Yusuf Nawawi: Conceptualization, Methodology, Validation, Investigation, Data curation, Project administration. Nur Wahyuniati: Conceptualization, Methodology,
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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