Assembly i n Mar 197d whtch called on all member States ta develop and maintain ... According to the Department of Health plan, during Repelita. IV : 1.
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Report s e ~ i e sno. 44
SOCIAL FACTORS AFFECTING THE USE OF CHILDHOOD
7
IMMUNIZATION IW YOGYAKARTA , JAVA , 4
/
Population Studles Center Gadjah Mada Univers i t y Yogyakarta,
Indonesia
June 1986
I
, Ji
I
Population Studies Center, Gadjah Mada University, Library Cataloguing in Publication Data
STREATFIELD, Kim and Masri SINGARIMBUN
Social Factors affecting the use of Childhood immunization in Yogyakarta, Java. Yogyakarta, Population Studies Center, Gadjah Mada University, 1986. (Report series no. 4 4 ) 1. Immunization
-
Yoqyakarta. I. Title, 11. (Series)
614.47
7 J
1 4
FIRST EDITION, June 1986. Population Studies Center, Gadjah Mada University.
@by
The ~ n v e s i i q a t o r s i n t h i s study ujsh fo express t h e i r gratitude fop a s s i s t a t t ~ ep r w i d c d by dr. Tuti Roastant8 and her s t a f f
a t the Fiangigulan WSKESHRS.
&I+o the heads of
hamlets and v i l l a g e s i n the research areas. O f great assistance i n the provision of otcmdarr data
concerning the Expanded Programme on I m n i z a t i o n was Pak R.M.
friharranto, SW, of the Yogyakarta provincial af+izc
of the Department of Heal t h . The study was supported by research funds from WFW
provided by Universi tr.
the
Popul a t i an Reorarch Center,
Badjah Hada
LIST OF CONTENTS
FOREWORD
LIST OF CONTENTS LIST OF TABLES SECTION 1 1.1 1.2
1.3 1.4 1.5 1.6
SECTION 2 2.1 2.2
2.3 2.4 2.5 2.6 SECTION 3
3.1 3.2 3.3 3.4 3.5
.
3.6 3.7 3.8
-
INTRODUCTION
M o r t a l i t y s i t u a t i o n i n Indonesia Background o f the € P I i n Indonesia Progress o f the EPI S i t u a t i o n i n Yogyakarta Implementation o f the €PI i n Yogyakarta Survey Methodology
-
KNOWLEDGE ABOUT
IlWWIZATION
Knowledge of smallpox inanunitation Knowledge of what diseases D f l , BC6, and A n t i - p o l i o can prevent Knowledge o f a p p r o p r i a t e age ranges and sources o f immun i z a t ion Sources o f knowledge on immunization Illness history Diseases considered dangerous
-
PReSCTICE OF I ~ ~ I Z A T I U U
P r a c t i c e according t o Knowledge o f diseases p r o t e c t e d a g a i n s t V i l l a g e of residence Age o f roungast c h i l d Age o f mother F e r t i l i t y : c h i l d r e n ever born and c h i l d r e n s t i l l 1i u i n g Education o f mother Work s t a t u s , and occupation o f mother Occupation of husband
iii 3 . 9 Household e c o n m l c score 3.10 M e m b e ~ s hI p of soc l a 1 groups 3 . 1 1 Use o f f a m ~ l rp l a n n ~ n g 3.12 Use of a a t e n a t a l care 3.13 Attendance at baby w s ~ g h t n g c l ~ n i c 3.14 Use o f c u r a t i v e health services 3.15 P l a c e and a t t e n d e r s of birth o f roungest c h ~ l d
31 32 33 34
35 37 38
SECTION 4
-
REASONS W H Y IMMUNIZATION I S INCOMPLETE
41
SECTION 5
-
EXPERIENCE OF CLINIC S E W I C E S
45
5.1 5.2
5.3
Information prouided a t clinic Reasons for provider refusing immunization Unpleasant experience at c l i n i c
-
SECTION 6
MI-TETANUS FOR WOMEN
45
46 d7
48
6.1
Knowledge and practice o f tetanus toxoid (TT>
48
6.2 6.3
immun i z a t i on Reasons for not receiving TT i m m u n i t a t i ~ n Frequency, timing, source of TT immunization
48
SECTION 7
REFERENCES
-
DISCUSSICIN
49
49
57
LIST OF TABLES Page
1.1
P r o p o r t i o n s (%I o f T a r g e t P o p u l a t i o n Immunized w i t h BCO, DPT, A n t i - P o l i o , and TT i n Yogyakarta
2.1
D i s t r i b u t i o n o f Be1 i e f s about F u n c t i o n o f %a1 l p o x V a c c i n a t i o n
2.2
D i s t r i b u t i o n o f B e l i e f s about F u n c t i o n s o f OPT, BCG, and P o l i o Immunizations
2.3
D i s t r i b u t i o n of Knowledge o f Age Range f a r I m u n i z a t i o n Courses
2.4
D i s t r i b u t i o n o f Respondents M e n t i o n i n g P d r t i c u l a r Sources o f I n f o r m a t i o n on Immun izat ion
2 . 5 . Percentage o f C h i l d r e n -Having Had I m u n i t a b l e
Diseases 2.5
D i s t r i b u t i o n o f Respondents M e n t i o n i n g S p e c i f i c Diseases as Dangerous t o t h e H e a l t h o f Their Children
3.:
Completeness (%) Vacc i n a t ions
3.2
D i s t r i b u t i o n o f Number o f Vaccine Doses Received by C h i l d r e n According t o Knowledge o f Mother about S p e c i f i c Diseases Prevented {%I
3.3
Completeness (%I br V i l l a g e o f Residence
3..4
Completeness (%I by Age o f Youngest C h i l d
3.5
Completeness (%I by Age o f Mother
3.6
Completeness (%I by C h i l d r e n Ever Born
3.7
Completeness (%) by C h i l d r e n S t i l l L i u i n g
o f DPT, BCG, P o l i o
3.8
C m p l o t a n e r s (%I by Education of Mother
3.9
Completeness (%I by Occupation o f Working Mother
3.10 Completeness (%I by Occupation o f Father 3.11 Completeness (%I by E c o n m i c Score 3.12 Cdnpleteness (%I by Membership o f S o c i a l
Group 3.13 Completeness I%) by Family P l a n n i n g S t a t u s 3.14 Completeness (%)
by Number o f A n t e n a t a l V i s i t s
3.15 C m p l e t e n e s s ( X I by Attendance a t Baby Weighing C l i n i c 3.16 Completeness (%I by Source o f Treatment When Youngest Chi 1 d V e r y I 1 1
3.17 Completeness (%I by B i r t h p l a c e o f youngest Child 3.18 Completeness (%I by A t t e n d a n t a t B i r t h o f Youngest Ch i 1 d 4.1
Reasons f o r Incmnplete or No Immunization by Type ( % I
SECT1ON i
-
INTRODUCTION
T h i s r e p o r t i s p r i m a r i l y concerned w i t h s e v e r a l imrnuni z a b l e d i s e a s e s which take a c o n s i d e r a b l e t o 1 1 on c h i l d r e n According t o the under the age o f f i v e y e a r s i n I n d o n e s i a . 1980 P o p u l a t i a n Census, t h e i n f a n t m o r t a l ttr r a t e was 1 0 7 per 1,000 1 i u e b i r t h s f o r a l l I n d o n e s i a , r a n g i n g f r o m a r e l a t i v e l y low l e v e l o f $9 per 1,000 t n the p r o o l n c e o f YograKarta, t o 187 p e r f ,000 i n West Nusa Tenggaea (Soemantri,l983:187), a h i g h l e v e l by an? s t a n d a r d s .
i s 1 imi ted, the 1980 W h i l e d a t a on causes o f death Househol d Heal t h Survey p r o v i d e s an i n d i c a t i o n o f the m a j o r heal t h problems. For b o t h t h e i n f a n t s and t h e c h t l d r e n aged one t o f o u r r e a r s , around 70 p e r c e n t o f d e a t h s were due t o i n f e c t i o u s and p a r a s i t i c d i s e a s e s , a c a t e g o r y ~ n c l u d r n i ) diptheria, whooping cough (pertussis>, tetanus, These d i s e a s e s w e r e t u b e r c u l o s i s , p o l i o , and measles, spread u n e v e n l y through the f i r s t r e a r s o f l i f e w i t h most o f the t e t a n u s d e a t h s o c c u r r i n g i n the f ~ r s w t e e k , w h i l e the m a j o r i t y o f d i p t h e r i a and .measles cases tended t o o c c u r a f t e r the f i r s t r e a r ( B u d i a r s a , n.d.:100-1021. The 1980 H e a l t h Survey f o u n d t h a t neonatal tetanus deaths accounted f o r one i n f i v e i n f a n t d e a t h s i20._r/,> T h l s was c o n f i r m e d by o t h e r s u r v e y s whrch e s t i m a t e d t h a t the death r a t e due t o n e o n a t a l t e t a n u s was i n the range 13 -15 per 1,000 1 i v e b i r t h s (Gunawan,l984:82), The m o r t a l i t y due t o d i p t h e r ~ a i s a l s o d i f f i c u l t t c e s t i m a t e a s s e v e r a l sources i n d i c a t e m o r b i d i t y - p a t e s between 0.5 and 2.8 p e r 100,000 p o p u l a t i o n I i b t d ) a1 though t o WHO, t h e r a t e f o r young c h i l d r e n can be expected t o be around 140 per 100,000 w i t h a c a s e - f a t a l i t y r a t e o f about 10X. P o l i o 1 5 a s e r i o u s c r ~ p p l i n gdisease w ~ t ha r e l a t i u e l low c a s e - f a t a l i t r r a t e . Gunawan quotes an annual p r e v a l e n c e r a t e among c h i l d r e n o f school age of 37 cases per 100,000 c h i l d r e n . T h e - c a s e - f a t a l i t y r a t e from a h o s p ~t a ? s t u d y was e s t i m a t e d a t 2 p e r c e n t , b u t t h r s may be based
p r i m a r i l y on s e r i o u s cases, lower,
overall
the r a t e
i s probably
A prospective study by the Department o f Health's Research and Development U n i t estimated t h a t deaths r a t e s due t o p e r t u s s i s were o f the order o f 346.5 per 100,000 i n f a n t s , and 37.9 per 100,000 c h i l d r e n under age f i v e ( F o s t e r , 1983) a t though Gunawan argues t h a t due t o f r e q u e n t can4usIon of pertussis w i t h other r ~ s p i r a t o r r tract i n f e c t i o n s , the t r u e r n o ~ t a l i t yr a t e s may be 3 t o 4 timas h i g h e r IGunawan,1984:82).
,
The deaths fram measles are d i f f i c u l t t o e s t i m a t e because by age one r e a r the v a s t m a j o r i t y o f t h i l d r e n appear t o have c o n t r a c t e d measles w i t h v a r y i n g degrees o f sever it^^ Several s t u d i e s have shown c a s e - f a t a l i t y r a t e s f o r those who c o n t r a c t e d the disease o f between 0.6% and 1.4% ( i b i d ) ,
1 .Z
aackaround oQ the Expanded P r o c t r m e an I m u n i z a t i a n i n Indonesia
i m u n i z a t * i o n 1 5 not f o r e i g n t o the The concept o f A v a c c i n a t i o n program was e s t a b l ished i n people o f Jaua. 1856 by the Dutch c o l o n i a l p e r i o d t o p r o t e c t the p o p u l a t i o n against smallpox, a s e r i o u s h e a l t h problem u n t i l a c e n t u r y The program d i v i d e d Java .into 200 v a c c i n a t i o n later. d i s t r i c t s , each served by a v a c c i n a t o r . This d i s t r i b u t i o n s t r u c t u r e s t i l l e x i s t s , t o some e x t e n t , tadar. Following subsequent expansion o f t h i s v a c c i n a t i o n s t r u c t u r e t o the o u t e r i s l a n d s , ma1 lpox was c a n p l e t e l y e l iminated Srom the c o u n t r y by 1937 the f i r s t c o u n t r y i n Southeast A s i a t o a c h i e v e t h i s goal CUWID, 1 9 7 9 : 6 ) . The d i s r u p t i o n s o f World War IJ and t h e r e a f t e r r e s u l t e d i n less c o n t r o l , and the disease r e t u r n e d t o the e x t e n t t h a t i n 19&8 i t was again a major heal t h problem. The i n t e n s i v e e r a d i c a t i o n campaign w h i c h c m e n c e d wor1dwide about t h a t time saw complete =allpox e r a d i c a t i o n from Indonesia by 1972 (Henderson, 1978:800!.
-
D u r i n g the p e r i o d f o l l a w ~ r ~ ;i?e.success of t h e smal l p o x canrpalgn, the Indonesian G o v e r n m e n t s h ~ f t e d v a c c i n a t ~ o n
emphasis t o a n a t i o n a l campaign a g a i n s t t u b e r c u l o s i s (TB), and a f i e l d t r i a l i n C e n t r a l Java a g a i n s t t e t a n u s . While many c h i l d r e n were v a c c i n a t e d w i t h BCG a g a i n s t TB, o n l y a low l e v e l o f e f f e c t i v e jmmunity r e s u l t e d . Second?v , + h e d e f e c t i v e d e s i g n o f the f i e l d t r i a l meant t h a t the impact on m o r t a l i tr of the v a c c i ' n a t i o n of 70 p e r c e n t o f the t a r g e t group o f pregnant m o t h e r s c o u l d n o t be e s t i m a t e d as the necessary d a t a on numbers o f deaths was n o t c o l l e c t e d . These two programs d i d , though, throw 1 i g h t on some of t h e t e c h n i c a l , and o t h e r weaknesses o f t h e v a c c i n a t i o n program. I n l i n e w i t h the resolution of the World H e a l t h Assembly i n Mar 197d whtch c a l l e d on a l l member S t a t e s t a develop and maintain immunization and su~ueillance programmes, I n d o n e s i a expanded i t s immunization program i n a s t a g e s approach, I n 1976-77, one p e r c e n t o f a1 1 k e c a m a t a ~ ( s u b d i s t r i c t s ) were covered f o r DPT ( D i p t h e r i a , Pertussis, and Tetanus), BCG ( a n t i -TBl, and TFT (Tetanus Formu: Toxo i d l BY 1977-78, same 17 p e r c e n t o f Recamatan 4cr.r: covered, and by 1982-03, the p r o p o r t i o n o f the n a t i o n a 1 p o p u l a t i o n cowered by t h e E P I was e s t i m a t e d a t 72 p e r c e n t , r a n g i n g from o n l y 26 p e r c e n t I n East Nusa Tenggara t o v i r t u a l l y everyone i n J a K a r t a ( H e a l t h , 1984:2).
.
The above f i g u r e s r e f l e c t the p r o p o r t i o n o f t h e papu l a t i o n w i t h access t o immunization r a t h e r than the p r o p o r t i o n immunized. If the €PI i s t o meet t h e Department o f H e a l t h t a r g e t o f immunizing 80 p e r c e n t o f a1 1 I n d o n e s i a n c h i l d r e n under the age o f f i f t e e n months br t h e year 2000, then i t w i l l need t o have c m p l e t e n a t i o n w i d e coverage o f inmuni t a t i o n ~ e r ivc e s long b e f o r e t h a t d a t e . Achievement o f a h i g h l e v e l o f immunization coverage would c o n t r i b u t e g r e a t 1 y t o a t t a i n m e n t o f the Government t a r g e t o f a r e d u c t i o n i n i n f a n t m o r t a l i t y r a t e t o 70 p e r 1,000 l i v e b i r t h s by the year 1990, the end o f t h e c u r r e n t f i v e - r e a r p i a n (Repel i t a XU). Indeed, t h e t a r g e t s o f reductions i n disease-speci+ic m o r t a l i t y are ambitious.
According to the Department of Health plan, during Repelita
IV : 1
.
2.6
Diseases considered danaerous
U n d e r l y i n g t h i s study i s t h e assumption t h a t these i m u n i zabl e diseases are p o t e n t i a1 1 y dangerous t o c h i 1 dren who c o n t r a c t them. 1 t was, however, necessary t o e n q u i r e whether t h e respondents considered the diseases dangerous, meaning p o t e n t i a l l y f a t a l . The data i n the f o l l o w i n g t a b l e i n d i c a t e t h a t a t l e a s t sane o f the diseases are considered so by the respondents (Table 2.62. TABLE 2.6 DISTRIBUTION OF RESPONDENTS MENTI(3NING SPECIFIC DISEASES AS DANGEROUS TO THE HEALTH OF THEIR CHILDREN
Tetanus Tuberculosis Whoop i ng Cwgh Measles Diptheria Pol i o None o f above dangerous Do n o t Know i f any d a n ~ c o u s
*:
62.0 53.6 22.7 13.5 10 . a 7.1 3.1 l l .I3
Respondents could mention more than one d i sease
Whi l e many o f the r e s p o n d e n t s m e n t i o n e d more than one d i s e a s e as dangerous, t h e r e war; a c l e a r p a t t e r n o f t e t a n u s and t u b e r c u l o s i s b e i n g t h e m a j o r dangers, r e g a r d e d as v e r y s e r l o u s b y two t h i r d s and h a l f r e s p e c t i v e l y , of the resuondents. Whooping cough was m e n t i o n e d by one i n f i v e , and measles, d i p t h e r i a and p o l i a by one i n t e n or fewer o f the respondents. This ranking i s roughlr consistent w i t h the known case f a t a l i tr (CFj r a t e s due t o these d i s e a s e s where t e t a n u s , TB, and whooping cough h a v e CF r a t e s g r e a t e r t h a n 25/. w h i l e measles, d i p t h e r i a , and pol i o have r a t e s be1 ow 10% ( s e e Benenson , 1 9 8 5 ) As was seen above ( T a b l e 3.5>, measies was t h e rnost commonly e x p e r i e n c e d d i s e a s e y e t i t i s n o t c o n s i d e r e d as v e r r s e r i o u s by most of the m o t h e r s . The l i k e l i h o o d o f s u r v i v a l w i t h measles i s g r e a t l y a f f e c t e d b y the n u t r i t i o n a l s t a t u s o f the c h i l d (Benenson, 1 9 8 5 : 2 3 3 ) .
.
SECTION 3
-
PRACTICE OF IFIMWIZATIOFI
T h i s s e c t i o n discusses the three major types o f v a c c i n a t i o n s , DPT, BCG and A n t i - P o l i o , f o r young c h i l d r e n . A n t ! - t e t a n u s (Tetanus Toxoid) vaccine f o r a d u l t wmcn w i l l oe d t s c u s s e d i n S e c t i o n 6 . The a n a l y s i s u i l l u t i l i z e a number o+ s t a n d a r d s o c i a l and demographic uariables to test various hypotheses t o n c e m n l n g t h e p a t t e r n s , and l e v e l s o f use o f i m m u n i z a t i o n s e ~ ivc e s . These h y p o t h e s e s w i l l be p r e s e n t e d i n each s u b - s e c t i o n , and f o l l o w e d by r c s u l t s and d i s c u s s i o n .
A s the a n a l y s i s c o n c e r n s t h r e e t y p e s o f u a c c i n a t i o n , t h e r e are same 32 p e r m u t a t i o n s o f c m p l e t e n e s s (none, one, two, o r t h r e e p o s s i b l e v a c c i n a t i o n s f o r DPf and P o l i o , and none o r one f o r BCG? p o s s i b l e f o r any p a r t i c u l a r c h i l d . To simp1 i fr the a n a l y s i s a new u a r i a b l e c a l l e d "Completeness" has been d e r i v e d f r o m t h e combinat i o n o f the degree o f completeness o f t h e separate DPT and P o l i o v a c c i n a t i o n s , For much o f t h i s a n a l y s i s t h e l e v e l o f BCG coverage h a s been e x c l u d e d , f i r s t l y because t h e o v e r a l l l e v e l i s v e r r h i g h and will not add g r e a t l y to understanding o f usage differentials, and secandly the number of possible
permutations i s halved, so simp1 i f r i n g the a n a l y s i s w i t h o u t toss o f much important i n f o r m a t i o n , The h i g h e s t degree o f "Comp 1 e tenessn i s where the two vacc i nat ion courses have been completed, the lowest degree i s , of course, where no vaccinations have been given. I n the Indonesian i m u n i z a t i o n program, two doses of DPT are considered s u f f i c i e n t f o r f u l l p r o t e c t i o n , thus a c h i l d w i t h two or three doses w i l l be assumed t o have c m p l e t e d the DPT course. P o l i o r e q u i r e s three doses f o r f u l l cover,
TABLE 3.1 COMPLETENESS (%)
Number o f Vaccinatiou
OF DPT, BCG, POLIO WCCINATIONS
WT %
Cum %
%
BCG Cum %
Pol i o
% Cum%
The o v e r a l l . l e v e l s o f completeness f o r the three v a c c i n a t i o n types can be seen i n Table 3.1. C l e a r l y , the number o f vacc i n a t i o n s requ i r e d t o ach i eve p r o t a c t i o n from the r e s p e c t i v e v a c c i n a t i o n s i s an important f a c t o r . If3 f o r example, DPT o n l y r e q u i r e d a s i n g l e v a c c i n a t i o n , as does BCG, then DPT coverage would be 84.5/., the same as f o r BCG. For Pal i o , coverage would be a 1 i t t l e lower a t 69.7'/..
3.1
Knowledae of Diseases P r o t e c t e d h a i n s t
Before corwnenc i n g the study o f the p a t t e r n s o f complcteness o f immunization by the s o c i a l and demographic v a r i a b l e s , t h i s s e c t i o n on practice w i l l be l i n k e d t o the
previous sect i o n (2) by examining the level o f imnunization a c c o r d i n g to t h e respondent's Knowledge o f what diseases the vaccines p r e v e n t .
TABLE
3.3
DISTRIBUTION OF NCRlBER OF VACCINE DOSES RECEIVED BY CHILDREN ACCORDING TO KNOWLEDGE OF MOTHER ABOUT SPECIFIC DISEASES PREVENTED i % 1
Typo of Vaccine:
Number of
Doses:
DP? : 212 or more 1 0
Correct
Knwlediae of Functron Incorrect No Knowleda?
36.4\ 34.5J70.9 9.1 20.0 100%
32.4\ 35.2/67.4 22.9 9.5 100%
29. 29.2l58.7 24.8 16.4 100%
- - - - - - -( 5-5 )- - - - -C105) - - - - - - (-3 5-9 )- - -
N
I or more 0
92.3 7.7 100%
87.4 12.6
100%
83.5 16.3 100%
. . . . . . . (52) . . . . . . .(103) . . . . . . (363) ....
N
Anti-Pal i o : 3
42.6
2 1 0
19.3 18.4 19.7 100%
Note:
28.6 20 .O 40 .O 11.4
100%
22.6 16.5 19.2 41.8 100%
As t h e D e p t . o f H e a l t h considers 2 doses o f OW s u f f i c i e n t , t h e levels o f 2 and 3 doses are presented here.
As these vaccines are s p a c l f i c t o p a r t i c u l a r diseases, it is inappropriate to use r combined concept o f canpleteness'. Thus f o r t h i s f i r s t v a r i a b l e , knowledga, the vaccines w i l l be examtned s e p a r a t e l y . The p a t t e r n o f f u l l coverage of the s p e c i f i c i m u n i z a t i o n s i s c o n s ~ s t e n t f o r each type ( T a b l e 3.2). As the l e v e l o f Knowledge about which diseases are prevented increases s t e a d i l r from 'no know1edge' through ' i n c o r r e c t knowledge" to 'correr t Knowledge', the p r o p o r t ion o f c h i l d r e n havlng f u l l cover increases, In the case of DPT, i t increases from 58.TL t o 70,SYA f o r 2 o r more doses (29.5/1 t o 36.4% f o r 3 doses), f o r BCG, from 83.Z.A t o 9 2 . Z ( 1 o r more doses), and f a r A n t i - p o l l o , frm 22,& 2 0 42.4% 13 doses)
.
The converse pat tern of p r o p o r t ion o f c h i Tdren :lot having r e c e i v e d any v a c c i n a t i o n s g e n e r a l l r decreases i s knowledge increases, The exception i s DPT where among c h i l d r e n whose mothers have c o r r e c t knowledge the proporti30 w i t h no cover i s s l i g h t l r greater, (20.0%) than .far those whose mothers have no Knowledge ( 1 6 . 4 % > . Far BCF the p a t t e r n i s very c l e a r w i t h 16.5/! o+ the c h i l d r e n o f m e t h e r s w i t h no Knowledge having no immunization compared t o o n l y 7.7% o f c h i l d r e n o f mothers w i t h the c o ~ r c c tKnwledge t h a t BCG immunization p r e v e n t s t u b e r ~ u l a ~ i s . The p a t t e r n f a r Anti-polio i s s i m i l a r l y clear,
3.2
Villaae of
Rrridrncc
The h y p o t h e s i s s t a t e s t h a t those who l i v o i n the e c a n u n i c a l l r b e t t e r o f f v i l l a g e are more l i k e l y t o have had t h e i r children imunized. T h c ~ e i s a t r e n d t o h i g h e r l e u c l s o f i m u n i z a t i a n among those couples who 1 i v c i n the w e a l t h i e r village of W i j irnulya. W i t h i n Ui j imulyo v i 1 lagc there arc gedukuhan (hamlets) w i t h l e v e l s b e l w some o f the hamlets i n Tanjunghardjo v i l l a g e , and v i c e versa, The general p a t t e r n is n o t one o f the g r e a t e r the d i s t a n c e between the pedukuhan and the H e a l t h C l i n i c the lawer the average l e v e l o f
immunization. There i s no c l e a r geographic p a t t e r n b u t r a t h e r the l e v e l s appear t o be r e l a t e d more t o t h e l e v e l of m o t i v a t i o n by t h e i n d i v i d u a l hamlet heads, who i n c l u d e a p a r t i c u l a r 1 Y en t h u s i a s t i c hcadkioman
.
TABLE 3 . 3 COMPLETENESS (%I BY VILLAGE OF RESIDENCE
Cunpletr Incompl-high Incmpl-law None
36.7
(11-52)
23.0
44.5 14.3 2.3
(16-68) (0-42) (0-9)
48.4 23.4
1 ow
5.1 100%
(5-42) (35-661 (7-45) (0-91
The a n a l y s i s w i l l t u r n now t o examine immunization pf 3 r t : c e u s l n g t h e i n d i c a t o r 'completeness' a c c o r d i n g t o t h e ;&rious demographic, economic and s o c i a l v a r i a b l e s s t u d i e d .
The p a t t e r n
of cmpleteness
o f coverage a c c o r d i n g
to
the c u r r e n t age o f the youngest c h i l d i s an i n v e r t e d - U shape. Among i n f a n t s aged s i x months t o one year coverage 1s r a t h e r i n c o m p l e t e , # h i l e t h r e e - q u a r t e r s o f t h e c h i l d r e n have s t a r t e d the twa immunization t y p e s I ' l n c o m p l e t e - h i g h J > v e r y f e w have completed b o t h t y p e s ('Complete'), Coverage f o r c h i l d r e n ' a g e d between one and t h r e e y e a r s i s q u i t e h i g h w i t h about h a l f h a v i n g 'completeJ immunization. The p r o p o r t i o n w i t h 'complete' immunization drops away t o about one f i f t h (19.S'X) o f t h r e e year o l d s , and 5%o f f o u r year olds. T h i s i n v e r t e d - U p a t t e r n i s c o n s i s t e n t w i t h a program which has o n l y r e a l l y been promoted h e a v i l y i n the l a s t t h r e e y e a r s or so. The age p a t t e r n suggests t h a t many o f t h e c h i l d r e n already o l d e r than t h e recommended s t a r t i n g age
range though s t i l l under f i v e r e a r s , were n o t i n c l u d e d i n t h e irnmun i z a t i o n campaign.
TABLE 3 . 4 COMPLETENESS I%) BY AGE OF YOWGEST CHILD
0-5
Complete Incompl-High Incompl-Low None
Aae (Months)
&-I1 12-17 18-23 24-29 30-35 3d-47 48-5? --------
0.0 1 46.4 5 3 . 7 55.4 50.0 I . 5.3 77.8 74.2 50.0 37.0 35.7 4 4 . 4 35.4 1 5 . 8 0 6.5 5.4 3.742.1 63.2 3.6 9.3 11.0 3.2 0.0 0.0 3.6 1.9 3 . 0 15.8 100% 100% 100% 100% loo;< 100% 100% 100%
Conversely, the p a t t e r n of no immunization i s r o u g h l r U-shaped dropping t o zero f o r one r e a r o l d c h i l d r e n and up t o about one s i x t h (15.8%> o f f o u r r e a r o l d s ,
3.4
Aoe o f Mother
The p a t t e r n o f coverage according t o age o f mother shows a decl ine o f 'complete' o r 'incomplete-high' f r o m over 90% f o r c h i l d r e n o f mothers aged l e s s than 25 r e a r s t o t h r e e - q u a r t e r s o f those aged 25 t o 34 r e a r s , down t o t w o - t h i r d s where mothers age i s over 35 r e a r s . The p r o p o r t i o n o f c h i l d r e n w i t h 'complete' coverage i s s i m i l a r f o r c h i l d r e n o f mothers aged l e s s than 25 years, 30-34 r e a r s and 35 r e a r s and ouer, b u t the p r o p o r t i o n w i t h 'none' or 'incomplete-low' coverage i s much h i g h e r f o r the c h i l d r e n o f o l d e r mothers (35.SL a g a i n s t o n l y 8.42 f o r those aged less than 25 y e a r s ) . A p o s s i b l e i n t e r p r e t a t i o n of t h i s p a t t e r n i s t h a t younger mothers arc mare c o n s c i e n t i o u s than o l d e r mothers i n i n i t i a t i n g v a c c i n a t i o n s f o r t h e i r c h i l d r e n , b u t
n o t more c o n s c i e n t i o u s i n c o m p l e t i n g the course. There i s a l s o an age e f f e c t i n v o l v e d here as the younger mothers w i l l tend t o have younger c h i l d r e n who have had less time t o complete t h e i r immunization course. TABLE 3.5
COMPLETENESS (%)
BY AGE OF MOTHER
- 25-29 { 25
Ccwnpl e t e Incomplete-high I n c m p l ete-!ow None
29.6 62.0 5.6 2.8 100%
3.5
Fertility:
Age (Years) 30-34 3%
34.8 41.6 19.9
26.2 49.2
3.7
0.8 100%
100%
23.8
28.2 36.3 28.2
7.3 100%
A l l Apes 30.1 46.4
19.8
3.7 100%
C h i l d r e n Ever Barn, C h i l d r e n S t i l l L i v i n q
The p a t t e r n o f completeness o f v a c c i n a t i o n i s clearly l l n k e d t o the f e r t i 1 i t y o f the mother, whether measured b y the number o f c h i l d r e n every born (Table 3 - 6 1 or c h i l d r e n s t i l l l i v i n g (Table 3 . 7 ) . Far those mothers w i t h o n l y one or two c h i l d r e n , the l e v e l o f Z c m p ? e t e ' or " incomplete-highc c o v e r a g e is h i g h e r t h a n f o r those mothers w i t h more than two c h i l d r e n . The mast complete coverage i s among two c h i l d r e n (ever born or s t i l l 1 ivingP f a m i l i e s . The r e l a t i o n s h i p i s n o t 1 inear as 'complete' or " i n c a n p l e t e - h i g h ' coverage i s h i g h e r f o r c h i l d r e n of mothers w i t h f i v s or more c h i l d r e n than i t i s f o r c h i l d r e n of mothers w i t h o n l y three o r f o u r c h i t d r e n .
TABLE 3.6 COMPLETENESS ranged from c h i 1 d (8) the H e a l t h Worker n o t a r r i u i n g when promised, n o t knowing the c o r r e c t day f o r weighing, f e e l i n g w e i g h i n g was n o t important, the c h i l d b e i n g s i c k on the day, and . f i n a l l r , the c h i 1 d was heal t h y and heal t h y c h i l d r c n are n o t g i v e n food supplements, so t h e r e i s no p o i n t i n g o i n g t o the c l i n i c .
.
I
3.14
Use o f C u r a t i v e H e a l t h S e r v i c e %
I
Several hypothet i r a l quest i o n s were about what k i n d of treatment they would youngest c h i l d was s c r i ousl y i 1 1 , and (b) or a member o f t h e i r f a m i l y was s u f f e r i n g
asked o f mothersseek i f ( a ) theiri f they themselves from a h i g h f e v e r .
The h y p o t h e s i s s t a t e s t h a t mothers who take thdir c h i l d r e n when v e r y i l l t o s m e source o f modern c u r a t i v e care are more 1 i k e l y t o use a modern p r e v e n t i v e heal th s c r v i ce such as i m u n i z a t i o n .
I
I
I
, I
The respondents were asked i f t h e i r youngest c h i 1d had ever been s e r i o u s 1 y i 11 and i f so, where d i d they seek medical h e l p , Almost ha1 f o f the respondan t s C44.941 r e p l i e d t h a t t h e i r c h i l d had indeed been i l l and the d a t a i n Table 3.20 i n d i c a t e t h a t the sources o f a s s i s t a n c e were almost i n v a r i a b l y af the modern v a r i e t y .
The p a t t e r n i s one o f i n c r e a s i n g p r o p o r t i o n s w i t h 'complete' coverage as the source o f c a r e passes f r a n the l e s s p r o f e s s i o n a l l e v e l s ( s e l f treatment or t r a d i t i o n a l h e a l e r ) (28.6%) through t a more p r o f e s s i o h a l l e v e l s such a s h e a l t h c l i n i c (33.3%) t o d o c t o r o r h o s p i t a l (50.0%). The ' h e a l t h worker' i n t h i s case can i n c l u d e the p r i v a t e , p r a c t i c e o f the c l i n i c nurse t o whm people c m e a f t e r
c l i n i c h o u r s i n o r d e r t o a v o i d w a i t i n g i n a queue, or i t may be a r e t i r e d b u t r e s p e c t e d nurse o r o t h e r h e a l t h worker. The lower l e u e l s o f 'complete' coverage (23.3%) and h i g h e r p r o p o r t i o n w i t h no coverage ( 6 . 7 % ) among those who would t u r n t o the p r i v a t e h e a l t h worker are p r o b a b l y due t o the f a c t t h a t the p r i v a t e h e a l t h worker would n o t n o r m a l l y have f a c i l i t i e s f o r immunization as p a r t o f h i s o r her p r i v a t e practice.
TABLE 3.16
COMPLETENESS . The r e s u l t s here do n o t i n d i c a t e t h a t concern over the c h i l d ' s d i s c o m f o r t was a major f a c t o r
determining f a c t o r course.
in
noncunpletion
of
the
immunization
The major reason f o r nonure or incomplete use o f DPT and Ant i - p o l i o was t h a t the v i 1 1 age o r hamlet h a a d a n had not i n s t r u c t r d the mother t o take the c h i l d f o r inmunization. T h i s r e f l e c t s the v e r y important r o l e o f the headman i n the implementation a t v i l l a g e l e v e l o f government programs of a l l k i n d s . I t has been argued t h a t one of the reasons f o r the success o f the F a m i l y Planning Program i n the province o f B a l i was t h a t the Program a d m i n i s t r a t o r s took account o f the importance o f t h headmen ~ and organized canpet i t i o n s between b a n j a r and v i 11ages w i t h a war i e t~ of rewards f o r the more successful heads (see S t r e a t f i e l d , 1985b). I t may be u s e f u l f o r the Department of Health t o consider a rsimilar approach t o opening channels f o r the dissemination of i n f o r m a t i o n about inmunization. I n the area o f t h i s study there were no i n f o r m a t i o n a l m a t e r i a l s a v a i l a b l e a t the YANDU posts. As mentioned i n Section 4, the response t h a t the c h i l d was not y e t o l d enough t o be immunized i s q u i t e l e g i t i m a t e . T h i s response, however, f r e q u e n t l y r e f e r r e d t o the c h i l d b e i n g s t i l l w i t h i n the p e r i o d of 40 days of b i r t h d u r i n g which the c h i l d may not be taken out o f the house. This religious r e s t r i c t i o n has i m p l i c a t i o n s f o r the attempt t o I t may be vaccinate w i t h BCG immediately a f t e r b i r t h . successful f o r a baby born i n h o s p i t a l but the vast m a j o r i t y ape s t i l l born i n the mother's home (see Section 3.13) and would n o t n o r m a l l y be taken t o a h e a l t h c l i n i c u n t i l f o r t y days o l d . The c u r r e n t Department o f Health p o l i c y i s based on the idea t h a t the immunization schedule i s simpler i f DPT I, A n t i - p o l i o I, and BCG a r e a l l given together a t three months of age. Before 1978 the p o l i c y was more f l e x i b l e The r isK w i t h BCG o f t e n given immediately a f t e r b i r t h . w i t h the new p o l i c y i s t h a t some c h r l d r e n may c o n t r a c t 70 b e f o r e BCG immunization a t t h r e e months. There were several important categor i en o f which were amenable t o education. These ranged a lack of knowledge o f a1 1 aspects of irnmunizat ion, s p e c i f i c aspects such as the a p p r o p r i a t e age range
response complete throuqh f o r the
child, to i n c w r e c t knwlrrdge such as t h i n k i n g that A n t i - p o l i o r e q u i r e s o n l y one dose f o r f u l l cover. Other be1 i e f that fundamental mirconcept ions included the irtnnunization was r c u r a t i v e process. I f the c h i l d was h e a l t h y then i t d i d n o t r e q u i r e immunization a g a i n s t any di sease
.
Inadequacy o f s e r v i c e was r a r e l y mentioned as a f a c t o r f o r n o t c a n p l e t i n g a course o f immunization, although i f the mother has never t r i e d t o o b t a i n the s e r v i c e she would be u n l i k e l y t o have c a m p l a i n t s about i t . A small p r o p o r t i o n d i d s t a t e t h a t they c o u l d n o t a f f o r d the w a i t i n g t i m ~a t the c l i n i c , and a l s o a s u b s t a n t i a l number s a i d t h a t they were T h i s implies unable t o a t t e n d due t o work commitments, t h a t d i f f e r e n t c l i n i c times, o r e a s i e r access through m o b i l e teams, o r outceach programs might b r i n g i n more c l i e n t s . T h i s was the experience i n a N i g e r i a n c l i n i c when immunixat i o n s e r v i c e s were p r o v i d e d separate1 y from general c u r a t i v e s e r v i c e s i n the c l i n i c . W a i t ~ n g times f o r immmunization were reduced w i t h an increase i n acceptance of coverage (Eltunwe, 1984). 'The EPI i n Indonesia s t i l l experiences constraints due to 1 i m i ted numbers of paramedical s t a f f and a l a w p r o p o r t i o n o f YWDU p o s t s b e i n g a b l e t o o f f e r the : m p l e t e range o f s e r v i c e s (Pos Yandu Par i puma)
.
I n the above d i s c u s s i o n i n c o r r e c t knowledge o f the r e q u i r e d number o f doses was mentioned as one f a c t o r i n non-cunpl e t ion o f immun i t a t ion. The survey a1 so i n q u i r e d about whether or not the respondents received any i n f o r m a t ~ o na t the c l i n i c , and i f so, what war the" c o n t e n t . About three rn f i v e mothers r e c a l l e d h a v ~ n gr o c e r v e d some i n f o r m a t ~ o n a t the time t h e i r c h i l d was immunized. The a d v ~ c ewas g e n e r a l l y a warning t h a t the c h i l d was l i k e l y t o experience some f e v e r l a t e r i n the evening, and about h a l f o f them were advised t o use some m e d i c ~ n e such as paracetamol t o reduce the f e v e r . Such a d v ~ c e 1 5 reasonable In the case o f DPT, and i t should n o r m a l l y have been o f f e r e d t o a l l the mothers.
I t was h y ~ o t h e s i z e d t h a t i f the mothers fbund the experience of a t t e n d i n g the c l i n i c t o be unpleasant, then t h e y may choose not t o r e t u r n t o complete the s e r ~ e s o f i n j e c t i o n s or drops. H w e v e r there w e r e v e r y f e w cases o f unp Ieasan t exper i e n c e s a t the c 1 ~ nI c r e p o r t e d , and those t h a t d i d occur M e r e o f a general n a t u r e , such as c l i n i c There were v e r y s t a f f a r r ~ u i n gvery l a t e or n o t a t a l l . few complaints about aspects s p e c ~ f i c a l l r r e l a t e d t o immunization, such as the u a c c i n a t o r r e f u s ~ n g t o open the v i a l o f v a c c i r l e due t o an i n s u f f i c i e n t number o f c h i l d r e n be i ng present , As ment ianed i n Sect i o n 4, however, the l o c a l u a c c ~ n a t o rf o r the study area d i d n o t r e g a r d t h i s as a val ~d reason f o r r e f u s a l . I n other d i s t r i c t s the p o l i c y may have been d i f f e r e n t .
T h i s most important and e f f e c t i v e v a c c i n a t i o n had apparent1 y been accepted b y three-quar t e r s o f the women. T h i s i s a remarkably h i g h p r o p o r t i o n c o n s i d e r i n g the l e v e l s imp1 l e d by t h o p r o p o r t i o n s o f newborn babies be1 ieved t o be dying i n Indonesia from neonatal tetanus (Indonesian Household H e a l t h Survey, BPS,1980). Among those who d i d n o t o b t a i n t h i s vaccine, their reasons w e r e s i m i l a r t o the usual reasons f o r the nonuse o f the c h i l d h o o d immunizations (DPT, BCG, and AP). The mothers be1 ieved t h a t the vaccine was a c u r a t i v e agent n o t needed i f the i n d i v i d u a l was c u r r e n t 1 y heal thy. The o t h e r major reason f o r nonuse was t h a t the w m a n had n o t come i n t o c o n t a c t w i t h any modern a n t e n a t a l care f a c i l i t y d u r i n g her pregnancy, and the t r a d i t i o n a l antenatal care s u p p l i e r s , the dukun b a r i , d i d n o t entourage them t o seek o u t the uaccinatian.
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.
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HEALTH, INQtNESIAN DEPCIRTMENT OF I981 'The Indonesian N a t i o n a l Household Health Survey 1980, Jakarta, October. HEPJPERSU4, D.A. 1978 'Smallpox 6eoar anh i c
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HEN2ERSON, R.H. 3P84b
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gESEHATCYa, GEPARTaJM REPUBLIC INDONESIA 'Rencana Pmbangunan Lima Tahun Ketmpat B i dang 1984 Kesehatan 1984185-SPW89,
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