IJPHCS International Journal of Public Health and Clinical Sciences Open Access: E-Journal E-ISSN : 2289-7577

IJPHCS International Journal of Public Health and Clinical Sciences Open Access: e-Journal e-ISSN : 2289-7577. Vol. 4:No. 5 September/October 2017

PREDICTORS OF ADHERENCE TOWARD CHILDHOOD IMMUNIZATION OF UNDER FIVE CHILDREN

Zamzaireen Z.A.1,2, Muhamad Hanafiah Juni1*, Faisal I1

1Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia. 2Ministry of Health, Malaysia

*Corresponding author: Associate Professor Dr. Muhamad Hanafiah Juni Email: [email protected]

ABSTRACT

Introduction: Vaccine preventable diseases are occuring despite high immunization coverage. Hence, the predictors of adherence toward childhood immunization are important to be identified. A cross-sectional study conducted to determine the predictors of adherence toward different vaccines of childhood immunization among mothers of under five children.

Materials and Methods: Recruitment of 320 respondents into the study was via systematic random sampling technique. Validated self administered questionnaires and proforma were used as the study instruments. Descriptive and inferential statistics were analyzed using SPSS version 22. Multiple logistic regression conducted for the analysis of predictors.

Result: Response rate of 98.1% was obtained from 314 respondents. Adherence (completeness) towards childhood immunization and adherence (timeliness) towards different vaccines were 98.09% and 56.5% - 97.1% respectively. The predictor of adherence (completeness) was household income category of RM2000 to RM2999 (p=0.047). The predictors of adherence towards vaccine timeliness were; employed mothers towards BCG vaccine (p=0.011), third and onwards born children towards Hepatitis B dose one vaccine, (p=0.049), 25 year old and above mothers towards Hepatitis B dose two vaccine (p=0.038) and household income of RM5000 and more towards MMR dose one vaccine, (p=0.044).

Conclusion: High adherence (completeness) towards childhood immunization relatively differs with the lower adherence (timeliness) towards different vaccines and its doses. Household income was the predictor for adherence (completeness). Predictors of vaccine timeliness included; mother’s employment status for BCG vaccine, birth order for Hepatitis B dose one vaccine, maternal age for Hepatitis B dose two vaccine, and household income for MMR dose one vaccine.

Keywords: Predictor, adherence, childhood immunization, under five children

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1.0 Introduction

Immunization coverage is one of the nation’s important health indicator. The denominators are estimation of live births from the Department of Statistics, Malaysia and also the National Tuberculosis Information System Manual, TBIS (Ministry of Health Malaysia, 2015). Global immunization coverage in mid 2015 was; BCG 88%, Hep B 84%, DTP1 91%, DTP3 86%, HIB 64%, Polio 86%, MCV1 85% and MCV2 61% (World Health Organization, 2017). Immunization coverage for Malaysia in the same year was; BCG 98.53%, third dose Hep B 99.27%, third dose DPT-Hib 99.04%, third dose Polio 99.04% and MMR 93.07% (Ministry of Health Malaysia, 2016). However, there is still occurence of vaccine preventable diseases despite high immunization coverage (Ministry of Health Malaysia, 2012, 2013, 2014).

Adherence towards childhood immunization provides maintenance of herd immunity against vaccine preventable diseases and non-immunized susceptible individuals (Blumberg, Enanoria, Lloyd-smith, Lietman, & Porco, 2014). Adherence are measured by completeness and timeliness towards childhood immunization (Tauil, Sato, & Waldman, 2016; Yu Hu, Yaping Chen, Jing Guo, Xuewen Tang, & Lingzhi Shen, 2014). Completeness is obtaining the recommended vaccines from National Immunization Programme (Barreto & Rodrigues, 1992; Tauil et al., 2016). Timeliness is the accepted intervals between vaccine doses and also valid minimum ages to receive the vaccines (Luman et al., 2005; Tauil et al., 2016). Four days earlier (Centers for Disease Control and Prevention, 2011) and up to seven days (Daniel Ansong et al., 2014; Riise et al., 2015) after recommended age are considered as valid.

Adherence (completeness) with vaccine timeliness toward childhood immunization is an important effort towards reducing vaccine preventable diseases (Dummer, Cui, Strang, & Parker, 2012). Non-timeliness (non-adherence) towards immunization subsequently lead to unprotected children (Fadnes et al., 2011), being exposed to vaccine preventable diseases (Blumberg et al., 2014). Nationally, in 2016, there was an eight-year-old death in Langkawi, Kedah, due to Diphtheria and history of incomplete immunization (Director General of Health, Malaysia, statement release in January 5th, 2016). There were other 28 cases of Diphtheria and five deaths leading to a stern advice on the importance of immunization completion to prevent vaccine preventable diseases (Director General of Health, Malaysia in August 26th, 2016). Seroconversion is age-dependent hence infants should acquire protection early (Ministry of Health Malaysia, 2004). Non-adherence towards immunization may give a rise on the susceptibility period among children (Yu Hu et al., 2014).

Associating factors influencing adherence (both completeness and timeliness) are socio- demographic characteristics, child factors, healthcare services and logistics. Socio- demographic characteristics consist of; maternal age (Kusuma, Kumari, Pandav, & Gupta, 2010), religion (Jani et al., 2008), education level (Calhoun et al., 2014), employment status (Vasudevan et al., 2014), marital status (Babirye et al., 2012), number of children (Mbengue et al., 2017) and household income (Kawakatsu & Honda, 2012). Child factors include; birth order (Rejali, Mohammadbeigi, Mokhtari, Zahraei, & Eshrati, 2015) and caregiver that is not fully the child’s mother (Fiks et al., 2006). Healthcare services are the usage of government and private healthcare services (Dummer et al., 2012). Logistics factor consist of; distance (Jani et al., 2008) and accessibility to health facility (Odutola et al., 2015). Based on these factors, this current study aimed to determine the predictors of adherence toward childhood immunization among mothers of under five children attending Klinik Kesihatan Seremban.

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2.0 Materials and Methods

Study location was in Klinik Kesihatan Seremban, Seremban district, Negeri Sembilan. Cross-sectional study was the design conducted. Study population was mothers with under- five children attending the child health clinic. List of attendances of mothers with under five children attending immunization in the child health clinic was the sampling frame. Final sample size was 320. Systematic random sampling with fixed interval of five was implemented for selection of respondents. All mothers with under-five children attending child health clinic for childhood immunization purpose were included. Non-citizen mothers and also younger child (of mothers with multiple under-five children) excluded.

Validated self-administered questionnaires and proforma used for data collection. Data analyzed using the Statistical Analysis of Social Sciences System (SPSS) version 22.0. Frequencies, percentages, mean and median illustrated in figures or tables for descriptive analysis. All independent variables with p value less than 0.25 obtained from bivariate analysis included for multivariate analysis to determine the predictors. Confident interval was 95% and significance level for the said analyses was 0.05.

Approval had been obtained from Medical Research and Ethics Committee, Universiti Putra Malaysia Ethics Committee for Human Research, JKEUPM (UPM/FPSK/JKK-GS46530- 2016/2017), Negeri Sembilan State Health Department and Seremban Health District Office. Written informed consents from respondents were attained prior to collection of data.

3.0 Result

3.1 Response Rate

Out of 320 questionnaires distributed to eligible respondents, 314 consented and completed the questionnaire, giving a response rate of 98.1%. The remaining did not provide consents.

3.2 Descriptive Analysis

3.2.1 Socio-demographic Characteristics of Respondents

In Table 1, the majority of respondents were 25 years old and more (85.0%), Malay ethnicity (38.2%), Muslim (39.5%), attained secondary school as the highest level of education (43.0%), employed (60.2%), married (99.7%) and having total household income of RM5000 and more (37.3%). Other ethnicities of respondents include Orang Asli, Dusun, Rungus, Kadazan, Iban and Punjabi. Other religions’ include having no religion, Sikh and Bahai.

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Table 1: Socio-demographic characteristics of respondents (N=314) Characteristics Mean ± SD Median ± IQR n (%) Maternal age (years) 30.27 ± 4.91 < 25 years old 47 (15.0%) ≥ 25 years old 267 (85.0%) Ethnicity Malay 120 (38.2%) Chinese 90 (28.6%) Indian 95 (30.3%) Others 9 (2.9%) Religion Islam 124 (39.5%) Christian 29 (9.2%) Hindu 80 (25.5%) Buddha 76 (24.2%) Others 5 (1.6%) Education level Primary school 13 (4.1%) Secondary school 135 (43.0%) STPM/Matriculation/Diploma 91 (29.0%) Degree 65 (20.7%) Masters 10 (3.2%) Maternal employment status Employed 189 (60.2%) Non-employed 125 (39.8%) Marital status Married 313 (99.7%) Single 1 (0.3%) Number of children 2.00 ± 2 Total household income < RM1000 5 (1.6%) RM1000 – RM1999 41 (13.1%) RM2000 – RM2999 61 (19.4%) RM3000 – RM3999 57 (18.1%) RM4000 – RM4999 33 (10.5%) ≥ RM5000 117 (37.3%)

3.2.2 Adherence (Completeness) towards Childhood Immunization

Majority (98.09%) of respondents adhered (completeness) towards childhood immunization schedule as shown in Table 2.

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Table 2: Adherence (Completeness) towards Childhood Immunization among Respondents (N=314) Adherence (Completeness) n (%) Complete 308 (98.09 %) Not complete 6 (1.91 %)

3.2.3 Adherence (Timeliness) toward Different Vaccines of Childhood Immunization

There was various adherences toward different vaccines and its doses as shown in Table 3.

Table 3: Adherence (timeliness) towards Childhood Immunization Schedule among Respondents (at Different Ages) Age Adherence Non-adherence Vaccine types (months) (timeliness) n (%) (timeliness) n (%) 0 BCG vaccine 304 (96.8 %) 10 (3.2%) 0 Hepatitis B Dose 1 305 (97.1%) (2.9%) 1 Hepatitis B Dose 2 278 (88.5%) (11.5%) 2 DTaP-IPV/Hib Dose 1 213 (76.3%) (23.7%)a 3 DTaP-IPV/Hib Dose 2 159 (66.3%) (34.1%)b 5 DTaP-IPV/Hib Dose 3 115 (58.1%) (41.9%)c 6 Hepatitis B Dose 3 87 (56.5%) (43.5%)d 9 MMR Dose 1 72 (64.9%) (35.1%)e 12 MMR Dose 2 54 (76.1%) (23.9%)f 18 DTaP-IPV/Hib Dose 4 25 (67.6%) (32.4%)g a35 children was not due for DTaP-IPV/Hib Dose 1 during the data collection b74 children was not due for DTaP-IPV/Hib Dose 2 during the data collection c116 children was not due for DTaP-IPV/Hib Dose 3 during the data collection d160 children was not due for Hepatitis B Dose 3 during the data collection e203 children was not due for MMR Dose 1 during the data collection f243 children was not due for MMR Dose 2 during the data collection g277 children was not due for DTaP-IPV/Hib Dose 4 during the data collection

3.2.4 Child Factors, Healthcare Services and Logistics Factors of Adherence

Child factors, usage of healthcare services and logistics among respondents are shown in Table 4.

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Table 4: Child factors, healthcare services and logistics factors of respondents (N=314) Child Factors n (%) Child’s Place of Birth Hospital/clinic 314 (100 %) Home 0 (0 %) Birth Order Second and below 217 (69.1%) Third and onwards 97 (30.9%) Child’s Caregiver not Fully the Mother Yes 232 (73.9%) No 82 (26.1%) Usage of Healthcare Services n (%) Government Clinic Yes 311 (99.0%) No 3 (1.0%) Government Hospital Yes 287 (91.4%) No 27 (8.6%) Private Clinic Yes 25 (8.0%) No 289 (92.0%) Private Hospital Yes 25 (8.0%) No 289 (92.0%) Logistics n (%) Distance to Health Facility (km) ≤ 5 km 118 (37.6%) > 5 km 196 (62.4%) Types of Transportation Public transportation 9 (2.9%) Own transportation 305 (97.1%)

3.3 Multivariate Analysis of Adherence towards Childhood Immunization

Dependent variable was categorical data with binary characteristic. The predictors of adherence (both completeness and timeliness) toward childhood immunization was determined by multiple logistic regression. All independent variables with p values of less than 0.25 (hence including the independent variables that was statistically significant too) were chosen from bivariate analysis, placed into preliminary models and subsequently analyzed using multiple logistic regression. Analysis of multicollinearity amongst the variables were also performed. Two variables namely ethnicity and religion were excluded based on tolerance value of 0.048 for each ones (less than 0.1). The analysis of regression applied three methods namely Enter, Forward LR and Backward LR.

3.3.1 Predictors of Adherence (Completeness) towards Childhood Immunization

Based on bivariate analysis, types of transportation were statistically significant, p=0.041 (p<0.05). Maternal age and household income p values were 0.222 and 0.071 respectively (p<0.25). These independent variables were included in the preliminary models for adherence (completeness). The most number of significant variable obtained was from Enter method and

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household income was the predictor of adherence completeness toward childhood immunization as shown in Table 5.

Table 5: Predictors of Adherence (Completeness) towards Childhood Immunization Schedule 95% C.I. β S.E. Wald p value aOR Lower Upper Household Income (RM) < 1000 4.727 0.450 1 1000-1999 2.575 1.557 2.736 0.098 13.134 0.621 277.795 2000-2999 3.336 1.678 3.951 0.047* 28.114 1.048 754.513 3000-3999 20.255 5034.722 0.000 0.997 626060101 0.000 4000-4999 2.424 1.584 2.341 0.126 11.293 0.506 252.053

≥ 5000 2.455 1.381 3.160 0.075 11.641 0.777 174.298 Constant -1.924 1.896 1.030 0.310 61.161 Significant at p<0.05, aOR: Adjusted Odds Ratio

Mothers with household income category of RM2000 to RM2999 was 28 times more likely to adhere (completeness) toward childhood immunization as compared to mothers with household income category of less than RM1000 (aOR 28.114, 95%CI 1.048-754.513). Full model showed the predictor had the ability to distinguish the adherence completenesess and non-completeness in a statistically significant manner (2=9.493 df=7, p=0.219). It fit into the goodness of fit test; Hosmer and Lemeshow (2=1.811 df=5, p=0.875), variance of adherence completeness between 3.0% (Cox and Snell R Square) and 17.3% (Nagelkerke R squared), and also correctly classified at about 98.1%.

3.3.2 Predictors of Adherence (Timeliness) toward Different Vaccines of Childhood Immunization

In this research, employment status was statistically significant for BCG, Hepatitis B dose one and Hepatitis B dose two vaccines; p=0.008, p=0.018 and p=0.040 (p<0.05) respectively. Maternal age and usage of governement clinic were also significant statistically; p=0.030 and p=0.017 respectively for MMR dose one vaccine. The other independent variables with p less than 0.25 were; education level (p=0.141) and birth order (p=0.146) for BCG vaccine, education level (p=0.234), number of children (p=0.100) and birth order (p=0.193) for Hepatitis B dose one vaccine, maternal age (p=0.073), education level (p=0.074), household income (p=0.050), usage of government hospital (p=0.229) and usage of private hospital (p=0.163) for Hepatitis B dose two vaccine, and lastly, education level (p=0.237) and household income (p=0.139) for MMR dose one vaccine. All of the mentioned independent variables were included into the preliminary models for BCG, Hepatitis B dose one, Hepatitis B dose two and MMR dose one vaccines as appropriately and the most number of significant variables were produced from Backward LR, Enter, Backward LR and Enter methods respectively. Employment status, birth order, maternal age and household income were the predictors of adherence towards BCG, Hepatitis dose one, Hepatitis dose two and MMR dose one respectively, as shown in Table 6.

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Table 6: Predictors of Adherence (Timeliness) toward Different Vaccines of Childhood Immunization Variable β SE Wald p value aOR (95% CI) Upper Lower BCG Employment Non employed 1 Employed 2.049 0.805 6.480 0.011* 7.761 1.602 37.594 Constant 4.010 1.012 15.698 < 0.001 55.151

Hepatitis B Dose 1 Birth order 2nd and below 1 3rd and onwards 2.142 1.088 3.877 0.049* 8.514 1.010 71.786 Constant 3.962 1.155 11.703 0.001 52.028

Hepatitis B Dose 2 Maternal age < 25 1 ≥ 25 0.994 0.480 4.296 0.038* 2.702 1.056 6.917 Constant 1.335 1.241 1.157 0.282 3.799

MMR Dose 1 Household income 1000-1999 1 2000-2999 0.393 0.662 0.353 0.552 1.482 0.405 5.427 3000-3999 1.371 0.756 3.290 0.070 3.938 0.895 17.315 4000-4999 0.663 0.853 0.605 0.437 1.941 0.365 10.330 ≥ 5000 1.536 0.764 4.042 0.044* 4.644 1.039 20.747 Constant - 23.444 22879.123 < 0.001 0.999 <0.001 Significant at p<0.05, aOR: Adjusted Odds Ratio

Employed mothers were the predictor for adherence towards BCG vaccine. Employed mothers were 7.8 times more adhered towards BCG vaccine as compared to non-employed mothers, with statistically significant evidence of aOR 7.761, 95%CI 1.602-37.594. Full model for BCG vaccine (2=11.020, df=2, p=0.004) comprised of all predictors that was able to distinguish between adherence (timelines) and non-timeliness. This model fit into the goodness of fit test, shown by Hosmer and Lemeshow (2=0.132, df=2, p=0.936), with variance of adherence (timeliness) between 3.4% (Cox and Snell R Square) and 14.0% (Nagelkerke R squared), and correctly classified at about 96.8 %. Third and onwards born children was the predictor for dose one Hepatitis B vaccine. These children were 8.5 times more adhered towards Hepatitis B first dose vaccine as compared to first and second born children (aOR=8.514, 95%CI 1.010-71.786). The statistical evidence for the full model of this vaccine were 2= 14.904, df=5 and p=0.011. The full model for this

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vaccine contained predictors that depicted the ability of the model to distinguish between adherence (timelines) and non-timeliness. This model was able to fit into the goodness of fit test namely; Hosmer and Lemeshow (2=4.881, df=6, p=0.559), variance of adherence (timeliness) of 4.6% (Cox and Snell R Square) and 20.2% (Nagelkerke R squared) and suitably classified at about 97.1%.

Mothers’ age of 25 years old and above was the predictor for second dose of Hepatitis B vaccine. Older mothers were 2.7 times more adhered to Hepatitis B dose two in contrary with mothers aged lesser than 25 years old (aOR 2.702, 95%CI 1.056-6.917). The full model for this vaccine was statistically significant (2=22.256, df=7, p=0.002) and included predictors that portrayed the ability of the model to show adherence (timelines) and non-timeliness. This model fit into the goodness of fit test, analyzed by Hosmer and Lemeshow (2=2.641, df=7, p=0.916), variance of adherence (timeliness) between 6.8% (Cox and Snell R Square) and 13.4% (Nagelkerke R squared) and also was rightly classified at about 88.5%.

Lastly, for dose one MMR vaccine, household income of RM5000 and more was the predictor for this vaccine. Mothers with this household income was 4.6 times more adhered towards this vaccine, aOR=4.644, 95%CI 1.039-20.747. Full model for this vaccine was statistically significant (2=18.237, df =7, p=0.011), and comprised of predictors that indicated the model’s ability to distinguish between adherence (timelines) and non-timeliness. Moreover, this model was able to fit into the goodness of fit test, described by Hosmer and Lemeshow (2=6.460, df=6, p=0.374), with variance of adherence (timeliness) between 15.2% (Cox and Snell R Square) and 20.9% (Nagelkerke R squared) and also properly correctly classified at about 70.3%.

4.0 Discussion

High response rate obtained from this study namely 98.1%. This is in comparison with a study in the Philippines (Bondy, Thind, Koval, & Speechley, 2009) and higher in contrast with a local study (Ahmad, Jahis, Kuay, Jamaluddin, & Aris, 2017). Most likely it was due to effective acquisition of information from immunization records brought by mothers.

Majority of respondents (98.09%) in this study adhered (completeness) towards childhood immunization, in comparison with previous studies in Canada and China (Dummer et al., 2012; Tang et al., 2017; Yu Hu et al., 2014). High adherence completeness is also in comparison with the nation’s immunization coverage, namely more than 95% as indicated by the country (Ministry of Health Malaysia, 2012, 2013, 2014). One of the crucial maternal child health indicator is immunization coverage hence understandably, numerous efforts towards its succession is stressed upon, resulting in high adherence. However, adherence in term of timeliness towards different vaccine of childhood immunization is more challenging (Shah et al., 2012). It varies between vaccines’ types and also its doses. Employed mother is found to be the predictor for adherence towards BCG vaccine. This is in comparison with articles in Bangladesh (Subhani, Anwar, Khan, & Jeelani, 2015; Vasudevan et al., 2014) but in contrast with a previous study in India (Barman & Dutta, 2013). Employed mothers more likely to mingle in the society, intensifying their awareness on immunization. It is arguable that employed mothers could be too engaged in their career hence not prioritizing

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immunization for their children, but in the country they are entitled for maternity leave (International Labour Organization, 1955) therefore, post delivery BCG vaccine has high possibility of having high adherence. Furthermore, BCG vaccine is routinely administered post delivery at health facilities in the country hence higher likelihood of adherence.

Third and onwards born children was observed to be the predictor of adherence towards Hepatitis B dose one. It is comparable with a study in Vietnam discussing on higher likelihood of timeliness among a non first-born child (An et al., 2016). The justification maybe due to mothers having obtained previous experience with their former children in terms of adhering towards chilhood immunization and its importance. Furthermore, in the country, Hepatitis B dose one vaccine is administered routinely after delivery further increasing the adherence towards this vaccine.

Mother aged 25 years old and above is the predictor of adherence towards Hepatitis B dose two vaccine. This is comparable with a previous study in India (Kusuma et al., 2010). Older mothers are relatively more mature with more experience-sharing from other older mothers (Kusuma et al., 2010). In the country, a postnatal one-month check up is provided for mothers. This gives an opportunity for administration of hepatitis B dose two vaccine for their infants during this check up hence, higher adherence towards this vaccine.

Higher household income category namely; RM2000 to RM2999 towards adherence (completeness) and category of RM5000 towards adherence to MMR dose one vaccine in comparison with lower income category was found in this study. A relatively superior socio- economic status may provide an increment for health seeking behaviour among mothers. Moreover, these mothers may have lesser struggles to attain childhood immunization due to a more positive social determinant.

5.0 Conclusion and recommendation

High adherence (completeness) towards childhood immunization among mothers but various adherence (timeliness) for different types of vaccines and its doses. Various predictors includes; higher household income towards adherence (completeness), employed mothers and adherence (timeliness) towards BCG vaccine, third and onwards born child and adherence (timeliness) towards Hepatitis B dose one, maternal age of 25 years and more and adherence (timeliness) towards Hepatitis B dose two, and higher household income with adherence (timeliness) towards MMR dose one. This research is amongst the minimally available local area of interest therefore serves as a useful baseline for intervention purposes. High response rate obtained in this research represented the population that was targeted. Validity and reliability were taken into consideration for the questionnaires and proforma validation and test-retest. Due to a cross-sectional study design that was conducted, a causal relationship could not be measure at the point of time. Further study is advisable to be conducted on children of the same age at 18 months of age or more because higher chances of immunization to have completed hence analysis would be less hassling. Future studies shall be assisted from the usage of questionnaires and proforma that had been validated and pre- tested in this study.

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Acknowledgement

Our heartfelt thankfulness to the Director General of Health Malaysia for permission of paper publication and conduct of study that involves health facility. Our deepest gratefulness to the Director of Negeri Sembilan State Health Department, Dr Zainudin bin Mohd Ali and Seremban District Health Office for permissions of study location usage. Our warm love to our spouses, parents, parents in law and children for their prayers and sacrifices. Lastly, we would like to acknowledge those assisted both directly and indirectly in this study.

Declaration

Authors declare that this manuscript has never been published in any other journal.

Authors contribution

Author 1: information gathering, preparation and editing of manuscript Author 2: final review of manuscript and final editing Author 3: editing of manuscript

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