Compliance Determinants of Mothers in Full Child Immunisation

in Bangkalan District

Djazuly Chalidyanto

, Diah Indriani

, Fahmi Ashar

and Nurhasmadiar Nandini

Faculty of Public Health, Universitas Airlangga, Mulyorejo, Surabaya, Indonesia

District Health Office of Bangkalan, Bangkalan, Indonesia

azul

km.unair.ac.id

Keywords: Compliance, Immunisation, Mother’s Characteristic, Health Service.

Abstract: Child immunisation is one of the cost-effective interventions in response to health problems and it provides

protection against a variety of health problems for children. Universal Child Immunisation (UCI)’s

achievement is a projection of the coverage of complete child immunisation. Child immunisation coverage

in Bangkalan in 2011 had a gap compared to the target. The study aims to analyse the factors that influence

mothers’ compliance with child immunisation based on maternal characteristics, community support, and

health workers in Bangkalan district. This research used a cross-sectional design and the populations were

all mothers of children aged 12-24 months. The analysis was then continued using Path Analysis. The data

was collected using a multi-stage sampling method. The samples included 360 respondents selected by the

snowball technique. The results reveal that 37.3% of infants had been fully immunised on schedule and this

indicates the mothers’ compliance with child immunisation. The Path Analysis Model is able to predict

immunisation compliance. The predictive factors are Community Support, Mother’s Characteristics, Health

worker, Service, and the Mother’s Factors. Result showed that mother’s characteristics and the health

service directly affected the mother’s compliance of child immunisation. Community support, health

manpower and the mother’s factors only have indirect effects.

1 INTRODUCTION

Child immunisation is one of the most effective

health interventions in terms of cost. Budiman

(2011) in Kompasiana (2012) said that in 1974,

since the launch of the Expanded Program on

Immunization (EPI) that included immunisation

against seven diseases, immunisation has saved

more than 20 million in two decades. UNICEF in the

Report Card on Immunisation (2005) stated that

vaccines have saved millions of children in the last

three decades. Immunisation has becomes one of the

programs for decreasing the child death rate in

MDGs and programs of health development in

Indonesia.

What Universal Child Immunisation (UCI) has

achieved is a projection of the coverage of complete

immunisation towards a group of infants. If UCI’s

coverage is put into a certain area, we can see the

level of people or infants’ immunity (herd

immunity) against disease contagions that can be

anticipated by immunisation (PD3I).

In the past few years, some mothers refused to

bring their children to health care services for

immunization even though it’s free and provided by

the government. The low mother’s compliance to

giving their children immunization caused by

several factors such as mother’s characteristics (age,

education, income, attitude, etc), family support,

poverty, lack of information about immunization,

and other socio-economic factors (Ramayani, 2007;

Falagas, 2008; Goofman & Frerichs, 2000;

Octaviani, 2015).

The UCI of Ministry of Health’s target was 80%

in 2008, and the UCI of East Java’s target pursuant

to the Minimum Standard of Service (SPM) up until

2015 was ≥ 95%, and the UCI of Bangkalan

District’s target amounted to 90% in 2011.

Table 1: Coverage of Immunisation in Bangkalan District

for the January - December 2011 period.

Immunization Target Coverage

Coverage

HB0 90% 69.5% 20.5%

360

Chalidyanto, D., Indriani, D., Ashar, F. and Nandini, N.

Compliance Determinants of Mothers in Full Child Immunisation in Bangkalan District.

In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 360-366

ISBN: 978-989-758-335-3

Immunization Target Coverage

Coverage

BCG 95% 76.2% 18.8%

POLIO 1 95% 77.3% 17.7%

POLIO 2 90% 76.0% 14.0%

POLIO 3 90% 74.3% 15.7%

POLIO 4 90% 72.9% 17.1%

DPT-HB1 95% 76.1% 18.9%

DPT-HB 2 90% 73.8% 16.2%

DPT-HB 3 90% 73.2% 16.8%

MEASLES 90% 73.2% 16.8%

Source : Report of PSE Division of Bangkalan District

Health Office 2011 (2012)

According to Table 1, there is a gap between

immunisation coverage in Bangkalan District and

the target. Therefore, there is a need to do a study

that analyses the mothers’ compliance determinants

in giving children immunisation based on the

mother’s characteristics, community support, and the

role of health workers in Bangkalan District.

2 LITERATURE REVIEW

2.1 Immunisation

In accordance with the Verdict of the Minister of

Health of the Republic of Indonesia No.

1059/MENKES/SK/IX/2004 on Guidelines of

Immunisation Implementation, immunisation is one

of the preventive actions against diseases through

the administration of immunity to the body.

Administering immunity should be done regularly,

completely, and in compliance with the set standards

to provide health protection and to stop disease

contagions.

As one of the government’s policies,

immunisation is the most effective measure to

prevent infectious diseases. It is considered as an

investment since in the long run, immunisation is

able to decrease morbidity and the child death rate in

several countries. For the children, immunisation

aims to provide immunity for infants and toddlers

against diseases and against the deaths caused by the

infection of such illnesses.

Immunisation through certain vaccine provisions

will also protect children from particular diseases.

Despite the available facilities in the society, not all

infants have complete immunisation. The paper size

must be set to A4 (210x297 mm). The document

margins must be the following:

2.2 Compliance

Kyngas, et al. (2000) believed that the low level of

compliance will contribute to the decrease of

effectiveness and medication benefits as well as the

increase of treatment cost as a result of off-standard

implementation. Lack of compliance also influences

the health of the surrounding society; for example,

TBC patients who do not obey the treatment

conditions will contaminate others.

Kyngas (1999) found that motivation, health

services, normal feelings and adequate energy as

well as the willingness to reach the goals in the

context of the health services are the factors that

increase compliance. Motivation could be improved

by support and affirmation from parents, and it also

influences the individual energy and willingness to

reach the goal of the health services.

According to Haynes (1979) in Evangelista

(1999), compliance in the health sector is the

increase of someone’s behaviour (taking medicine,

going on a diet, or changing their lifestyle) in

implementing the health workers’ advice. The

definition was also stated by Flatcher (1989) in

Evangelista (1999) that compliance is how patients

do what the health professionals want them to do.

2.2.1 Compliance with Immunization

Ramayani, et al. (2007) conducted a study on several

factors related to the lateness of giving immunisation

in Health Centres in urban and suburban area. The

results show that late immunisation is related to

social-economic factors including poverty,

vaccination cost, and late first immunisation. A lack

of information about immunisation for parents and

health workers and also health practices in private

institutions where the schedule of the practice and

immunisation do not often meet which also

contributes to the lateness. Other factors include the

lack of reminder system for immunisation times and

difficulties in implementation in accordance with

standards.

Another study conducted by Falagas (2008)

stated the factors that influence incomplete

immunisation such as under-age mothers (under 20

years old) which most commonly leads to a lack of

knowledge. Goodman & Frerichs (2000) who did a

research study on compliance with immunisation in

Kern Country, California, found that the main

factors of immunisation disobedience are ill

condition, postponement, and a lack of access to

information and services. Several other factors

related to lack of compliance are demographic

Compliance Determinants of Mothers in Full Child Immunisation in Bangkalan District

361

characteristics such as the mother’s age, race,

income, education, and also the father’s education

level. Information on the purpose of immunisation

for parents from health workers is also considered to

be significant in increasing compliance with

immunisation.

An analysis study by Waluyanti (2009) in Depok

City that aimed to learn the causes and analysis

factors influencing the low coverage rate of

complete immunisation for infants that led to

vulnerability from PD3I diseases found that health

insurance and the response towards immunisation

has a meaningful relationship with compliance with

immunisation.

2.3 The Interaction Model of Client Health

Behaviour/IMCHB

The theories used to understand, predict, and

improve the level of compliance are among other’s

theory of Health belief model, the theory of Planned

Behaviour, and the Transtheoritical Model. Pender

(2004) stated that there is a model theory, namely

The Interaction Model of Client Health

Behaviour/IMCHB proposed by Cox (1984).

Health behaviour can be predicted more easily by

understanding the client’s social-economic status,

the influence of social or community values on the

patient’s health, as well as finance and health

accessibility. The background variables are

considered relatively static ones both in terms of

influence and influencing dynamic variables.

Dynamic variables tend to be more active than the

background variables that include intrinsic

motivation, cognitive assessment, and affectionate

response. The interaction between the client and

health workers involves four factors, namely

information, affectionate support, control of

decision, and skill.

3 METHOD

This is a cross-sectional design research. The

population were all mothers with children in the

susceptible age range of 12-24 months in Bangkalan

District, while the research subject were mothers

registered in UCI and non-UCI Health Centres.

The sampling technique used was Multi-stage

Sampling where Stage 1: Selecting Health Centres

(8 UCI Health Centres and 4 non-UCI Health

Centres); Stage 2: Categorising Health Centres into

3 village groups with 3 categories of UCI coverage

namely A (Good, 80-100%), B (Fair, 70-79.9%),

and C (Poor, <69.9%); and Stage 3: Selecting

villages through Stage 2 that resulted to 36 villages

from 12 Health Centres with 10 respondents each

Centre, which made it 360 respondents in total. The

respondents were determined by using the Snowball

technique and the data analysis used univariate,

bivariate, and multivariate analyses.

The influence of the various variables on the

mother’s compliance with complete child

immunisation was identified through Path Analysis,

which was executed after each variable was analysed

by using a computerised program.

4 RESULT AND DISCUSSION

The data results of all 360 respondents show that

351 of them (97.5%) take their child for

immunisation and 9 of them (2.5%) do not take their

child for immunisation. The coverage of Child

Immunisation based on the type of vaccine

implemented on schedule is: BCG at 53%, Hepatitis

B0 at 49.6%, Hepatitis B1 at 63.0%, Hepatitis B2 at

47.6%, and Hepatitis B3 amounts to 54.1%.

Meanwhile, coverage of DPT1 is at 49.3%, DPT2 at

58.1%, DPT3 at 47.0% and Measles amounts to

51.3%. Polio1’s coverage amounts to 66.4%, Polio2

at 47.3%, Polio3 at 63.0% and Polio4 is at 56.4%.

Approximately 37.3% of infants have been given

complete immunisation per vaccine type (antigen)

on schedule (compliant). The coverage of complete

immunisation given to infants off schedule or

incomplete immunisation amounts to 62.7%. The

result of immunisation completeness in accordance

with the schedule is basic for the mother’s

compliance level in taking their child for

immunisation.

4.1 Mother’s Characteristics

The mother’s individual aspects being studied in this

paper include motivation, knowledge on

immunisation, and response towards the

immunisation knowledge. The result shows that the

mother’s motivation to take their child for

immunisation is derived from the self-factor

(intrinsic) at 52% and non-self-factor (extrinsic) at

48%. Extrinsic factors included as the source of the

mother’s motivation are family, neighbour, health

worker, and health cadre. The mother’s self-

motivation becomes the determinant factor for them

to take their child for immunisation.

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The result of the mother’s characteristics is based

on aspects of knowledge and responses as shown in

Table 2.

Table 2: Distribution of the Mother’s Characteristics

Based on Knowledge and Response Category

Mother’s

Characteristics

Cate

Total

Poor

Inade-

uate

Fair Good

(%) (%) (%) (%) (%)

Mother’s

Knowled

7.9 65.2 21.0 5.9 100

Mother’s

Res

onse

23.2 33.3 25.0 18.5 100

The mother’s knowledge on immunisation and its

schedule, as the result shows, shows that 65% of

mothers are in the inadequate category. The

mother’s insight on immunisation is needed to

develop their willingness to take their child for

immunisation on time. Inadequate knowledge on the

importance of on time immunisation will have an

impact on the mother’s obedience in relation to

taking their child for full immunisation. Octaviani

(2015) and Falagas (2008) stated that mother’s

knowledge have significant influence on mother’s

compliance to take their children for immunization.

The mother’s responses towards their insights

determine how much they comply with the

obligation to give full immunisation to their child.

Good response is when mothers take their child for

immunisation in accordance with the schedule. The

study result shows that among the mothers taking

their child for immunisation, 33% of them shows

negative response. These negative responses cause

the off-schedule implementation of immunisation.

4.2 Community Support

The role of the community in successfully

implementing immunisation is in their support of

mothers taking their children for immunisation on

time. Elements of community that supports the

mother’s compliance includes public figure,

neighbours, health cadre, as well as local religious

figures as the connector or due to the affirmation of

information on the importance of immunisation.

Community support based on the mother’s

compliance result shows that most mothers (49%) do

not have sufficient community support.

Approximately 4.3% of mothers receive good

community support, 41% of them gain fair support,

and the other 5.75% have poor support. Inadequate

support from the community will encourage the

mother’s to not taking their child for full and on

schedule immunisation. Research showed that

support especially from family affected in mother’s

compliance to take their children for immunization

(Octaviani, 2015).

4.3 Health Workers Support

The health worker factor in this study includes

affectionate support of health workers, information

on health, control of decision, and the health

worker’s skill. The distribution of the health

worker’s support based on the category of support is

shown in Table 3.

Table 3: Distribution of Health Workers Support Based on Category of Support

Health Workers Support

Category of Support

Poor Inadequate Fair Good Total

(%) (%) (%) (%) (%)

Affectionate Support of Health

Worker

5.8 22.2 16.8 55.2 100

Information on Health

25.2 34.7 24.5 15.6 100

Control of Decision

38.0 33.9 7.9 20.2 100

Health Workers’ Skill

5.6 15.9 36.7 41.8 100

The result shows that 55.2% of health workers

have been given affectionate support for mothers to

take their child for immunisation properly. Support

from health workers is able to give comfort to

mothers in taking their child for immunisation. The

support could be in a form of care and suggestions

that boosts the mother’s trust in the health workers.

Effective support can also convince mothers that

immunisation for their child is important.

Inadequate information about health becomes the

most determining factor (34.7%) of the mother’s

compliance with child immunisation. This result

consistent with research by Goodman & Frerichs

(2000) which stated that lack of access to

Compliance Determinants of Mothers in Full Child Immunisation in Bangkalan District

363

information affected the mother’s compliance of

immunization. The availability of health information

is significant in giving more insights and reinforcing

the mother’s adherence to full child immunisation.

Health workers who actively share information to

mothers could be working as a reminder for mothers

on the importance of on time and full immunisation.

Poor control of decision from the health workers

(at 38%) indicates that the lack of health worker’s

role in persuading mothers to take proper action and

reducing their anxiety about child immunisation.

Health workers could have control over the mothers’

decision to have child immunisation. The mother’s

decision in taking immunisation for their child

determines their adherence to full and on time

immunisation.

The standard of competence for health workers is

closely related to their skill in their service and

practices. Health workers with good skill can give

mothers a secure feeling and trust in taking their

child for immunisation, particularly related to after-

immunisation effects. The study result shows that

the health workers’ skill is categorised as good at

approximately 41.8%.

4.4 Health Services

The health service facility has a significant role in

child immunisation implementation. Various kinds

of health service available in the residential area are

options for having immunisation arranged. The

choice of immunisation venue is also related to

stronger community support. Table 4 shows the

choices of health service venue available based on

community support.

Table 4: Distribution of Health Service Venue

Venue of Health Service

Total

n %

Regional Hospital 16 4.5

Health Center 88 25.0

Village Health Clinic/Branch

Health Center

(

Polindes/ Pustu

)

25 7.1

Integrated Health Service

(

Pos

andu

)

17 4.8

Private Hospital 26 7.4

Health Clinic 23 6.5

Private Doctor Practice 20 5.6

Private Midwife Practice 136 38.7

Total 351 100

The most utilised health service facility is the

private midwife practice at approximately 38.7%.

The choice of venue for immunisation arrangements

was most likely related to the location of childbirth.

The more flexible open hours of the midwife

practice might probably be the reason of mothers’

choice for immunisation venue.

4.5 Analysis

The various factors of the mother’s compliance with

full and on time child immunisation has been further

analysed to learn the influence of each factor. The

analysis was conducted by using Path Analysis to

learn the cause-effect relationship or the

direct/indirect effects of the factors. Factors of the

mother’s characteristics, community support, and

health workers are analysed with the mother’s

compliance, mother’s factors or the health service

factor. The analysis result of each factor is shown in

Figure 1.

Figure 1: Result of Path Analysis

Community support, the mother’s characteristics,

and health workers are independent variables while

services, compliance, and mother factor are the

dependent variables. The calculation of the

relationship between the factors uses computerised

calculations. The red numbers show that the

variables do not have a correlation or relationship.

On the analysis of community support on

compliance and the mother factor, the assessment

result shows that the aforementioned does not

influence the mother factor (motivation, knowledge,

and response) as it is shown by the low number

(1.44) while community support does influence the

compliance variable (7.60). The mother factor shows

a low score (0.01) in the services factor, thus the

mother factor does not correlate with services.

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Factors that have a relationship or that correlate to

each other include: community support with service

and compliance, health worker with compliance and

the mother factor, as well as the services factor with

compliance.

In light of the relationship between the

independent and dependent variables, further

analysis is needed to learn if there is effect and

whether it is direct or indirect, which can be seen in

Figure 2.

Figure 2: Direct and Indirect Effect

The total of effect influencing the dependent

variables is determined by adding up the direct and

indirect effect. Direct effect is a variable that directly

influences the variable of compliance. Indirect effect

is a variable that indirectly influences the

compliance variable.

Variable of community support influences

variable of compliance with immunisation with a

total of 0.09 effect composed only by direct effect.

Variable of mother’s characteristics has a total of

0.72 effect (0.28 of indirect effect and 0.44 of direct

effect).

Variable of health worker has an influence on the

variable of compliance in a total of 0.20 (0,006 of

indirect effect and 0.2 of indirect effect). The

services variable influences compliance at a total of

0.52 entirely from direct effect. The mother factor

variable has a total of 0.03 effect on compliance, all

coming from direct effect.

In accordance with the scores of the 5 indicators

of Good Fit Index (P-value Chi Square, P-value

RMSEA, RMSEA, GFI, NFI), 4 out of 5 indicators

(except P-Value Chi Square), it shows that the effect

assessment result using Path Analysis has met the

requirements, thus this model can be used in

predicting compliance with immunisation.

5 CONCLUSIONS

Approximately 37.3% of infants have received

complete and on schedule immunisation. The

mother’s compliance with child immunisation is

identified through the use of a Path Analysis model

from various variables that include community

support, the mother’s characteristics, health workers,

health services, and the mother factor. There is no

relationship between the community support

variable and mother factor variable as well as

between the mother factor variable and health

services.

According to the assessment result, it can be

concluded that the variables which have greatest

influence on compliance with immunisation is the

mother’s characteristics variable (0.72) and services

variable (0.52). The high score of compliance

suggests that the variable of the mother’s

characteristics and health services directly influences

the mother’s compliance with full child

immunisation. Meanwhile, the variables of

community support, health workers, and mother

factor have an indirect influence on the mother’s

compliance with full child immunisation.

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