Fidelity of Measles Intervention Implementation on Measles
Elimination Phase in Primary Health Center City of Yogyakarta
Dina Arisonaningtyas
1a
, Mei Neni Sitaresmi
1
and Riris Andono Ahmad
2
1
Postgraduate Master Program, Faculty of Medicine Public Health and Nursing Gadjah Mada University,
Farmako Sekip Utara Sinduadi Mlati Sleman Yogyakarta, Indonesia
2
Faculty of Medicine Public Health and Nursing Gadjah Mada University, Farmako Sekip Utara Sinduadi Mlati Sleman
Yogyakarta, Indonesia
Keywords: Measles, CBMS, Measles Immunization, Implementation Fidelity, City of Yogyakarta.
Abstract: Introduction: Measles is an infectious viral diseases that can be prevented by vaccination. Indonesia has
recently entered the elimination phase, and has set the target to achieve the goal in 2020. Yogyakarta has
implemented Case Based Measles Surveillance (CBMS) since 1998. Fidelity of the program may contribute
to the outcome of these efforts regarding this issue. Methods: This research used a mixed method exploratory
sequential design conducted at 18 Primary Health Centres (PHCs) City of Yogyakarta from September to
November 2017. Qualitative approach by a cross sectional survey among 33 respondents. We used secondary
data to support the qualitative findings. Results: Health staff routinely adhered to the standard operating
procedures but experienced a lack of funding support for follow up and did not have adequate staff for data
analysis. Surveillance and immunization officers were not always making proper coordination during the
outbreak. Most of epidemiologic investigations were performed after the peak of the cases. Quality of delivery
of the CBMS program lacked in: timely delivery of measles report cases, coordination with private practice
in case detection, and feedback to patients about laboratory result. Quality of delivery of the measles
immunization program lacked in: timely delivery report, refreshing knowledge from District Health Office
(DHO) annually, and coverage of booster measles immunization , Surveillance officer’s knowledge showed
46,7% was good and for immunization officer’s knowledge showed only 5,6% was good. There were a
number of key aspects needing improvement. Conclusion: Coordination between surveillance and
immunization officers during outbreaks and performance of management duties are needed to address the
complexity of measles intervention program implementation.
1 INTRODUCTION
Measles is an infection disease caused by the
Paramyxoviridae family which belongs to the
morbillivirus genus and can be prevented by
vaccination. Routine measles immunization
accompanied by mass immunization programs can be
implemented in countries with low coverage of
measles immunization, which are expected to help
reduce global mortality from measles[1]. Measles
vaccine provides long-term immunity against the
measles virus[2]. After following the supplementary
immunization activities (SIAs) in 2008, 192 of 193
countries delivered an offer of 2 doses of measles
vaccine to make high immunity in at risk populations
a
https://orcid.org/0000-0003-4161-2137
to prevent the measles outbreak[3]. In 2015 global
control milestones and regional measles elimination
goals were not achieved and more effort is needed to
reach measles elimination by 2020[3]. The Indonesia
Ministry of Health in the Basic Health Research
(Riskesdas) in 2007 reported that measles was the
most common cause of death in children aged 29
days-4 years in Indonesia[4]. Success was seen in the
measles reduction efforts in 2015, and now Indonesia
is in the measles elimination phase, and committed to
the goals of ASEAN and SEARO that would achieve
the elimination target by
2020[3]. In addition, the
coverage of measles immunization should be at least
95% equally in all districts/cities according to World
Health Organization (WHO) recommendations[6].
174
Arisonaningtyas, D., Sitaresmi, M. and Ahmad, R.
Fidelity of Measles Intervention Implementation on Measles Elimination Phase in Primary Health Center City of Yogyakarta.
DOI: 10.5220/0011646900003608
In Proceedings of the 4th International Conference on Social Determinants of Health (ICSDH 2022), pages 174-179
ISBN: 978-989-758-621-7; ISSN: 2975-8297
Copyright
c
 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

Surveillance systems play an important in assessing
the effectiveness of the current measles control
strategies[5]. Yogyakarta has implemented the Case
Based Measles Surveillance (CBMS) since 2008 and
coverage of measles immunization was high in
Yogyakarta City based on the Indonesia health profile
of the Ministry of Health in 2014 and 2015 showing
measles immunization coverage had reached 96.93%
and 98.1%[7, 8], but in 2016 measles was still in the
top ten of the most common diseases in Yogyakarta
City[9].
The District Health Office (DHO) of
Yogyakarta City reported during the year of 2016,
there were 2,196 cases of suspected measles and
positive measles were found in 583 cases, of which
121 cases of measles were reported from Yogyakarta
City[10]. There were 2 cases of measles outbreak that
occurred in 2014, and there have been 7 cases of
measles outbreak from January to April 2017 [10,
11].
Due to the increasing number of measles
outbreaks in the city of Yogyakarta, the researcher
was interested to examine the implementation of
measles program interventions in the city of
Yogyakarta. In this study, researchers aimed to assess
the fidelity of both the detection of and response to
measles cases which occurred in Yogyakarta city in
order to achieve the target of measles elimination in
2020.
2 METHODS
We conducted a mixed method study with an
exploratory sequential design delivered throughout
18 Public Health Centers (PHC) in the City of
Yogyakarta from September to November 2017. This
study started with the collection and analysis of
qualitative data to measure health staff adherence
towards case-based CBMS and measles
immunization SOP/guidelines, in order to to see the
coordination between surveillance and the
immunization officers. This initial stage was followed
by the subsequent data collection and analysis of
quantitative data to measure the coverage, delivery
quality of CBMS-measles immunization program,
and health staff knowledge. We conducted informed
consent to all of respondents before data collection.
2.1 Samples
The qualitative method used purposeful sampling,
specifically criterion sampling, and for quantitative
method we used total population. We asked the
respondents who were the Disease Surveillance
Officers (DSO) to choose the PHC where we could
conduct our in-depth interviews. When the DSO
chose 3 PHC with measles outbreak and 3 PHC
without outbreaks in that year, we asked the
respondents whether they would be willing to
participate in an in-depth interview. From 12
respondents consisting of 6 surveillance officers and
6 immunization programmers, all of the respondents
fulfilled our inclusion criteria. The interviews started
from the PHCs which had outbreak, then continued to
the PHCs which had no outbreak. The total of sample
subjects in the beginning of the quantitative study was
36 health staff, but 3 respondents (surveillance
officers) were excluded in our study because they
fulfilled our exclusion criteria. The inclusion criteria
were: had been working in PHC at least 2 years; and
knowledgeable in program for CBMS service
delivery and measles immunization program. The
exclusion criteria were: surveillance staff and
immunization programmers who held the program
position less than twelve (12) months; and refused to
participate in data collection activities. We distributed
33 questionnaires among the selected health staff
consisting of 15 surveillance officers and 18
immunization programmers.
2.2 Measures
2.2.1 Adherence of Health Staff
The researchers conducted in depth interviews among
the selected respondents. We had standardized and
developed an interview guide beforehand. The
interviews for each respondent took about 30 minutes
to one hour, we recorded the interview with electronic
device and make the foot note. Then The researchers
encouraged the participants to talk in-depth,
prompting more details whenever possible without
leading the participants to specific answers. We did
the transcript from audio recorder to conducted data
analysis. The analysis used descriptive content
analysis.
2.2.2 Quality of Delivery
Our questionnaire consisted of respondents'
demographic data; assessment of quality delivery on
each program with ordinal scale of measurement; and
level of knowledge of each officer with an ordinal
measurement scale.
Scoring assessment on quality of delivery used a
Likert scale where: (1) = never; (2) = sometimes; (3)
= often; and (4) = always. We computed each
category of quality of delivery score as a percentage.
Fidelity of Measles Intervention Implementation on Measles Elimination Phase in Primary Health Center City of Yogyakarta
175

The scores on the health staff’s knowledge were
calculated as a percentage of the total answers which
were correctly answered. The level of knowledge of
the health staff was calculated as a percentage.
2.2.3 Coverage
Assessment of coverage in each program used
secondary data obtained from the district health office
of Yogyakarta city. We obtained the number of
samples examined by Ig M in cases of suspected
measles; and first and second dose measles
immunization coverage in 3 consecutive years (2014-
2016), in a numerical measurement scale with score
number per year (percentage).
2.2.4 Data Analysis
We described the results of the data obtained. In-
depth interview results were analyzed by content
analysis which illustrated the adherence of health
staff to SOP/guidelines, where adherence was
assessed starting from the routine service that had
been implemented and when the measles outbreak
occurred in each program. Quality of delivery and
coverage analysis were conducted with statistical
computation, with each category shown as a
percentage result.
3 RESULT
3.1 Demographic Characteristics of
Participants
The demographic characteristics of respondents in
PHC of Yogyakarta City are seen in Table 1.
Table 1: Characteristic of Respondents.
3.2 Adherence of Health Staff Towards
SOP/Guideline
Adherence of surveillance and immunization officers
at PHC of Yogyakarta City has been in accordance
with SOP/guidelines on routine service and during
measles outbreak. However, the management of
outbreaks was not yet compatible with SOPs since not
all surveillance officers coordinated with
immunization programmers during field
investigations; investigation of risk factors during the
outbreak occurrence was still lacking; evaluation of
measles immunization coverage in the last 3 years
had not been done; vitamin A was only focused on the
patients who suffers from measles, whereas in
susceptible populations (especially toddlers) who
were around the patients had not been given; and
vulnerable populations within the outbreak area were
not reported.
3.3 Quality of Delivery of CBMS and
Immunization Program
In measurement of the quality of delivery of CBMS
at primary health centers of Yogyakarta City, we
found delivery of measles report cases was on time
with only 26.7% who answered always, feedback to
patients about laboratory result was medium with
60% who answered always, and cooperation with
private practice for case finding was low with only
20% who answered always. The results are shown in
Table 2.
Table 2: Quality of Delivery CBMS Program.
In measurement of the quality of delivery measles
immunization at the PHC of Yogyakarta City, we
found the report delivery on time was only 27.8%
who answered always, knowledge refreshed annually
was 50% who answered always, and booster measles
immunization coverage met the target was only 5.6%
who answered always. The results are shown in the
Table 3.
Primary quantitative data was also supported by
secondary quantitative data from measles outbreak
reports which have been made by the district health
office of Yogyakarta City. The measles outbreak
reported, in 2017 from January to September there
N
o
Va
r
i
a
b
l
es
(n=33
)
% Mean Med
i
an S
t
. De
v
i
a
t
i
o
n M
i
n Max
1 Sex Ma
l
e 3 9.
0
9
Female 30 90.91
2 Qualification Midwife 18 54.55
Nu
r
se 15
4
5.
4
5
3 De
p
a
r
t
m
en
t
E
p
i
d S
t
aff 15
4
5.
4
5
Mother & child 18 54.55
4
Age
4
0
.
4
2 38 8.686 28 56
5 Length of work 15.42 14 8.846 2 31
6
L
eng
t
h
o
f h
o
l
d
the program 7.24 5 5.309 1 27
No Question Never Sometimes Often Always
n= 15
% % % %
1 Implementation according to SOP 0 0 33.3 66.7
2 Refreshing the knowledge annually 0 13.3 26.7 60
3 Supporting facilities is available 0 0 20 80
4 There are changes to the CBMS program 40 33.3 20 6.7
5 Flexibility of program implementation related
to change
53.3 13.3 13.3 20
6 Form C1 is filled completely 0 20 20 60
7 Validate data with SIMPUS 0 6.7 6.7 86.7
8 F
e
e
d
b
a
c
k
t
o
p
a
t
i
e
n
t
s
a
b
o
u
t
la
b
o
r
a
t
o
r
y
r
e
s
u
l
t
0 0 40 60
9 Feedback through mini workshop at PHC 6.7 20 26.7 46.7
10 Delivery of C1 reports on time 0 33.3 33.3 26.7
11 Feedback from DHO 0 0 0 100
12 Supervision from DHO 0 33.3 13.3 53.3
13 Coo
r
di
n
a
t
io
n
wi
t
h i
m
m
u
n
iza
t
io
n
o
f
f
i
c
e
r
s
when measles outbreak
6.7 13.3 6.7 73.3
14 Cooperation with private practice for case
finding
26.7 40 13.3 20
15 CBMS d
e
t
e
c
t
s
c
a
s
e
s
o
f
m
e
a
s
l
e
s
a
n
d o
u
t
b
r
e
a
k
s
0 6.7 13.3 80
16 CBMS a
n
al
y
s
e
s
t
h
e
i
n
c
id
e
n
c
e
o
f
m
e
a
s
l
e
s
f
r
o
m
year to year
0 0 26.7 73.3
ICSDH 2022 - The International Conference on Social Determinants of Health
176

were 7 cases with 4 cases of measles outbreak, 1 case
of clinical measles outbreak, and 2 cases of rubella-
measles outbreaks. To see the quality of the
surveillance system we also measured the response
time of intervention when the outbreak was
happening as seen in the Figure 1.
The curve diagram above explains the horizontal
axis showing the case of measles outbreak, and
vertical axis showing the week. The response time
taken when giving intervention to the outbreak
occurred before, during peak of case or after the case
but most of the intervention came after the peak of the
case. This finding suggests that the response to
intervention is still lacking, although the DHO and
PHC already delivered rapid response in 24 hours
since the outbreak was confirmed. This finding was
used to support the result of the assessment of the
delivery quality of the CBMS program.
Table 3: Quality of Delivery Immunization Program.
Figure 1: Response Time in 7
th
Cases of Measles Outbreak.
3.4 Coverage of CBMS and Measles
Immunization
For CBMS program coverage we only collected
sample data with measles suspects examined for Ig M
in 2015-2016 as shown in Table 4.
The unclear results were obtained from patients
who were sent directly from PHC to the health
laboratory center (HLC) but the patients data were not
in the HLC or it could be the patients did not reach
the HLC to provide specimen. For immunization
program data we collected first and booster measles
immunization coverage from 2014-2016 as seen in
Figure 2. As it is shown in the Background section
that Yogyakarta has set coverage targets as WHO
recommendation, for first and second routine dose of
measles vaccine should be at least 95%.
Table 4: Number Cases of Measles Suspects at PHC of
Yogyakarta City 2015-2016.
3.5 Knowledge of Health Staff
In the last category we measured the health staff
knowledge related to CBMS for surveillance officers
and measles vaccination with correlation to measles
elimination goal. We categorized the result of
knowledge into three levels: good if score or value
reached 76-100%; moderate when the score or value
reached 56-75%; and low when score or value
reached <56%[12]. The level of knowledge of
surveillance officers related to CBMS program
showed good knowledge as many as 7 people
(46.7%), moderate knowledge as many as 8 people
(53.3%), and low knowledge as much 0 people (0%).
The immunization staff knowledge about measles
immunization program related to measles elimination
program showed good knowledge as much as 1
person (5.6%), moderate knowledge as much as 6
people (33.3%), and low knowledge as much as 11
people (61.1%).
4 DISCUSSION
WHO recommendations to countries with elimination
phase goals include: case-based measles surveillance
should be conducted and every case should be
reported and investigated immediately, also
laboratory specimens should be collected from every
sporadic suspected case[3]. Effective measles and
rubella surveillance systems are capable of providing
essential information to plan, implement and evaluate
measles immunization strategies and monitor
progress toward measles elimination[2].
In our study,
we found that the surveillance system in Yogyakarta
city could not do that, because the officers have not
been able to perform data analysis for the purposes of
making policy by the chairman of PHCs, and the data
collected in epidemiological investigations in case of
measles outbreaks did not include coverage of
measles immunization in the last 3 years. In addition
to having an adequate surveillance system,
No
Q
uestion
N
e
v
e
r
So
m
e
t
i
m
e
s
O
f
t
e
n
Alwa
y
s
n = 18
% % % %
1 The implementation according to SOP 0 0 11.1 88.9
2 knowledge refresh annually 0 22.2 27.8 50
3
Supporting facilities is available
0 0 11.1 88.9
4 There are any changes related to the
measles immunization implementation
5.6 77.8 16.7 0
5 flexibility of implementation related the
changes
22.2 66.7 5.6 5.6
6
r
e
p
o
r
t
i
s
f
ill
e
d
c
o
m
p
l
e
t
e
l
y
0 0 33.3 67.3
7 coordination with surveillance when
measles outbreaks
5.6 11.1 5.6 77.8
8 campaign/socialization of measles
immunization
0 16.7 16.7 66.7
9
f
e
e
d
b
a
c
k
t
h
r
o
u
g
h
m
i
n
i wo
r
k
s
ho
p
i
n
PHC 0 22.2 38.9 38.9
10 feedback from DHO 0 11.1 22.2 66.7
11
s
u
p
e
r
vi
s
io
n
f
r
o
m
DHO 0 16.7 44.4 38.9
12 report delivery on time 0 27.8 44.4 27.8
13 measles vaccine access easily 0 0 11.1 88.9
14 cooperation with private practice 11.1 16.7 5.6 66.7
15 routine measles immunization coverage
meets the target
0 5.6 0 94.4
16 coverage of measles immunization of
booster meet the target
27.8 55.6 11.1 5.6
Legen
d
In
d
ex Case Fi
r
st Case Peak Case Res
p
onse Time
Year
Total
of
suspect
case
sample Result
Taken
(n) (%)
Domicile
from
City
Meas
l
es
(+)
Ru
b
e
l
l
a
(+)
Nega
t
i
v
e Unc
l
ea
r
2015 604 526 87 424 58 174 292 0
2016 670 626 93 487 207 77 289 41
Fidelity of Measles Intervention Implementation on Measles Elimination Phase in Primary Health Center City of Yogyakarta
177

maintaining high immunization coverage is an
important step in controlling cases of measles[3]. It
means that CBMS and measles immunization should
work together to reach the elimination target. In our
study we found the coverage of first-dose
immunization measured in three years was 95%,
which exceeds the UCI target, but the average of
measles booster coverage in the last three years was
60%, which is inadequate. Another research showed
that although the coverage of single-dose measles
immunization was high enough, still it was not
sufficient to give population protection to prevent the
outbreak of measles[2].
This epidemiologic
description is similar to the situation in Yogyakarta,
where the first dose immunization coverage
surpassed target coverage and was exceptionally
high, but measurable incidents were still prevalent in
the region.
Quality health services should reflect 6
dimensions based on WHO guidelines, which include
effective, efficient, accessible, acceptable, equitable,
and safe services[13].
In this study we found the main
dimensions of effective, efficient and accessible
services were present in the study sites. The quality
delivery of CBMS was still inadequate in response
time when the outbreak was happening, while the
timeliness of monthly report delivered, and
cooperation with private practice such as doctors or
midwives to find the cases were also lacking. While
the quality of measles immunization program
services was inadequate or ineffective in timeliness of
monthly report delivered, refresh knowledge from
DHO annually, and coverage of immunization of
measles booster were also lacking. In order to
improve the overall quality of health services, all
aspects should be considered holistically covering the
organization, team, and health staff individually[13].
They already have a good fidelity by adhere the SOPs
in routine and outbreak cases, but they still need to
improve the performance of response time to have
good quality delivery of CBMS.
The key for the success of surveillance systems
involves not only being integrated with measles
immunization programs[2], but also it should be
integrated with training human resources, improving
the data analysis, monitoring the impact of
intervention, informing health policy design,
planning and program management, and
strengthening laboratory capacity, with emphasis on
community participation in detection and appropriate
response to public health problems[14].
5 CONCLUSIONS
Case based measles surveillance was implemented to
detect, prevent and control the measles disease.
District health offices of Yogyakarta already have
made an alert to detect the outbreak, and conducted
rapid response to give an intervention. However, a
number of gaps still remain. These include inadequate
human resources to perform data analysis, and a lack
of coordination to meet the challenges. Although the
coverage of first dose immunization can be seen as
high but the second dose immunization did not meet
the target and there were still many outbreaks in
Yogyakarta. To properly respond to the outbreaks, the
level of knowledge of immunization officers
associated with the measles elimination program
should be enhanced, as well as synchronization of
programs between CBMS and measles immunization,
so that the goal of elimination of measles in 2020 can
be achieved.
One of the limitations of this study, is that the
assessment is only seen from the perspective of health
workers. The results would be strengthened if this
research included observations and the points of view
of the patients.
ACKNOWLEDGEMENTS
Thank you to the Provincial Health Office and
District Health Office of Yogyakarta City, which has
given me permission to carried out our study at
Primary Health Center of Yogyakarta City. I would
like to thank Kihariadi for his guidance and assistance
in data collection and analysis for our study.
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