The Relationship between Maternal Knowledge, Attitude, and Action with Children’s Basic Immunization Status at Permata Depok Hospital

One of the common causes of infant death is infectious diseases which can be prevented by immunization also called PD3I (diseases that can be prevented by immunization). The three domains of behavior knowledge, attitude


Introduction
Children's health is one of the global health concerns in Indonesia (1).PD3I (diseases that can be prevented by immunization) was known to be one of the most common causes of infant death.
But if many children are vaccinated, and the immunization coverage is high, then children who are not yet vaccinated have a chance to still be protected, this is called herd immunity (2).Therefore, attempts to fulfill immunization coverage must be considered and prioritized.Currently in Indonesia, the fulfillment of immunization for children are regulated in the 2017 Indonesian Minister of Health Regulation with immunization programs provided by local health facilities as promotive and preventive efforts to achieve the highest level of public health (3).
It was recorded in the Depok City Population and Civil Registration Department that in 2020 the number of babies in Sawangan District was 814 babies, of which only 597 babies had complete basic immunization status (4).This means that immunization coverage in Sawangan District Depok City only reached 73.3% in 2020 according to Sawangan Community Health Center data, while immunization is considered successful according to the World Health Organization (WHO) if at least 80% of the total population of babies are vaccinated to develop adequate immunity or based on Universal Child Immunization (UCI) standards (5).This figure is considered to be one of the impacts that occurred in the health sector during the COVID-19 pandemic, one of which was a decrease in immunization services (6).This low coverage will increase the risk of the emergence of Extraordinary Events (KLB) such as outbreaks of measles, diphtheria, rubella, polio, and other infectious diseases (7).
According to the concept by H.L. Blum health status is influenced by behavioral factors, which consist of the domains of knowledge, attitudes, and actions (8).Therefore, after postpandemic recovery, an improvement in immunization services were expected from the mother's behavioral change on awareness and compliance towards the implementation of basic infant immunization.It is proven in the 2022 Depok City health profile data that Depok City's immunization coverage has increased to 98.41% from 79.37%.However, Sawangan District has not yet reached the UCI standard immunization coverage and so it is not yet possible to expect herd immunity among Sawangan District children (9).

Methods
This research is an analytical survey using a cross-sectional approach design with consecutive sampling techniques.The independent variable studied was the maternal knowledge, attitudes, and actions regarding basic immunization and the dependent variable studied was the child's basic immunization status.The sampling size was 52 participants who were mothers of toddler patients (aged 13-35 months) in Permata Depok Hospital and were willing to take part in the research.
Mothers who don't own the KIA book were excluded from the research.
Primary data was obtained from a 62-question questionnaire with 25 questions on the topics of knowledge, 19 questions on attitudes, and 18 questions on actions towards basic infant immunization programs.The Guttman scale with categories of good (≥ 80%), adequate, and poor (≤ 60%) was used to evaluate the results of the questionnaires (10).Secondary data regarding the completeness of children's basic immunization status was obtained from the KIA book brought by each participant.The assessment is complete if all basic immunizations are met within the first year (according to schedule) and it is incomplete if the basic immunizations within the first year were not yet fulfilled.Univariate analysis was carried out to determine the characteristics of the participants and each participant's level of knowledge, attitude, and action as well as the child's basic immunization status.Bivariate analysis is used to determine the relationship between the independent variable and the dependent variable using the Pearson Chi-square Test or using Mann-Whitney Test with a confidence level of 95% (α=5%).

Research Results
The total study population was 52 participants who met the inclusion criteria out of a total of 63 participants present on the day of the study.The research results are presented using univariate analysis to describe the characteristics (Table 1) and distribution of participants based on the three independent variables from the study (Table 2), then bivariate analysis to present data on the relationship between each independent variable and the dependent variable studied (Table 4,5,6).In both of these studies, we used the Mann-Whitney Test, because the data does not meet the requirements for the Pearson Chi-Square Test and it is determined that there is a significant relationship between maternal knowledge and the child's basic immunization status (p=0,010).We also found a significant relationship between the variable level of maternal attitude and the child's basic immunization status at Permata Depok Hospital in 2023 (p=0,006) The third category in Table 6 shows the results of the Pearson Chi-Square test on the variable level of maternal action and the child's basic immunization status.We found a significant relationship between the level of maternal action and the child's basic immunization status at Permata Depok Hospital in 2023 (p-value = 0.0001).From Table 5, the variable with the most influence on the completeness of children's basic immunization status is maternal action (OR=0,350), followed by maternal attitude (OR=0,379) as the confounding variable.Maternal knowledge was eliminated from multivariate analysis because the p-value obtained was <0.05 and after the confounding test was carried out, there was no change in the OR of more than 20%, so it can be defined that the maternal knowledge was not a confounding variable.

Discussion
This research showed that there is a significant relationship between the three independent variables studied, namely maternal knowledge, attitude, and action with their child's basic immunization status as the dependent variable studied with the most influence from the maternal Depok Hospital year 2023, therefore it was also determined that maternal action has the greatest influence on the completeness of a child's basic immunization status.This research yields a different conclusion from the study in Sampang District year 2014 with the maternal attitude as the most influential variable (OR=0,050) (18).Also the study in Sukolilo Village with knowledge and spouse's support following the maternal attitude variable (22).
An attitude is not automatically manifested in action, for an attitude to be realized in actions, supporting factors or enabling conditions are needed, such as local facilities, personal beliefs, and support from other parties in the neighborhood or family (19).One of the most dominant factors in maternal compliance is family support (22).Most participants in this research who had poor actions and did not complete their child's immunization stated that they were scared of the side effects of immunization and some of them missed their children's immunization schedule because of a lack of costs, time, and low of perception susceptibility so that mothers think their children are healthy even without immunizations.These results are comparable to the study in Cipicung Village year 2021 where it was determined that the participants who did not complete their children's basic immunization status mostly had a wrong perception of the vulnerability and severity of unimmunized children and a wrong perceived benefits of basic immunization for their children (20).Most participants in that study stated that they were lazy and refused to vaccinate their children because of time constraints from working hours, transportation cost for the distance they have to travel through, and their children was coincidentally sick on the scheduled immunization date.A study in Umban Sari Villlage year 2017 stated that issues about fake vaccines are another factor that has a significant relationship with the low immunization coverage in the area (21).
To conclude, our study showed good results for knowledge, good attitude, and favorable subject characteristics, but it still showed poor action and a low immunization coverage rate.It is comparable with the study in Sukolilo Village where participants who did not attend the scheduled immunization day mostly had a high level of education and were in the early adulthood age.This discrepancy is because even in formal education, someone does not necessarily receive or not everyone is exposed to information about immunization, likewise, age doesn't always affect someone's behavior dominantly.However, unlike the subjects in our study, their subjects have mostly poor knowledge and attitude.They also have poor reinforcing factors such as supports from the neighborhood, husbands, and exposure to information (22).Further research might be needed to provide more data explaining the discrepancy between action and immunization status such as data on participant's occupation, economic status, source of information, Posyandu distance from their home, availability of transportation, the quality of immunization and health services provided in the area at that time, and other family member's support.

Table 1
shows that the age distribution of the largest participants was in the early adulthood category (55.7%) and the educational level of the highest participants was in the higher education group category (53.8%).

Table 2 . Univariate Analysis of Participants Based on Level of Knowledge, Attitude, and Action
In Table2, most of the participant's maternal knowledge of basic immunization was in the good knowledge category (61.5%), the highest attitude level was in the good attitude category (78.8%), and most of the participant's action level was in the poor action category (44.2%).The participant's poor action levels are also reflected in the data from Table3, which found that although most of the participant's children have complete basic immunization status (59.6%) it has not yet achieved the UCI.