Vaccine 31 (2013) 15161522

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Vaccine
journal homepage: www.elsevier.com/locate/vaccine

A qualitative study on knowledge, perceptions, and attitudes of mothers and

health care providers toward pneumococcal conjugate vaccine in Bandung, West
Java, Indonesia
Agnes Tri Harjaningrum a, , Cissy Kartasasmita b , Joanna Orne-Gliemann a,c , Marthe-Aline Jutand a ,
Nicolas Goujon a , Jean-Louis Koeck d
a

Univ. Bordeaux, ISPED, Centre Inserm U897 - Epidemiologie-Biostatistique, F-33000 Bordeaux, France
Faculty of Medicine, Padjadjaran University, Bandung, West Java, Indonesia
c
INSERM, ISPED, Centre Inserm U897 - Epidemiologie-Biostatistique, F-33000 Bordeaux, France
d
Clinical Biology and International Vaccinations Center Hpital Inter Armes Robert Picqu, Bordeaux, France
b

a r t i c l e

i n f o

Article history:
Received 13 September 2012
Received in revised form
12 December 2012
Accepted 1 January 2013
Available online 11 January 2013
Keywords:
Immunization
Parents
Health care providers
Pneumococcal vaccination
Pneumococcal vaccination in childhood
Pneumococcal conjugate vaccine

a b s t r a c t
Due to the high burden of pneumonia in Indonesia, the inclusion of pneumococcal conjugate vaccine (PCV)
into Indonesias National Immunization Program (NIP) is recommended by World Health Organization.
Prior to the introduction of new vaccines, it is imperative to assess the perceptions of the public and
medical community about the disease and the vaccine. The purpose of this qualitative study was to
explore the knowledge, perceptions, and attitudes of mothers and health care providers (HCPs) toward
PCV in Bandung, West Java, Indonesia.
Methodology: Fifty-ve respondents (26 mothers and 29 HCPs) were interviewed at public and private
health care facilities in Bandung using semi-structured interviews in MayJune 2011. Data were analyzed
manually according to pre-dened themes.
Results: Although most mothers had low knowledge about PCV, did not perceive themselves as susceptible
to the disease, perceived that cost was the main barrier to PCV access, and obtained little information on
PCV, they considered pneumonia as a severe disease and a priority health problem, perceived benets of
the vaccine, and were likely to adopt it. Similarly, knowledge about PCV among most HCPs was limited.
Despite perceiving cost as the main barrier, most HCPs perceived benets of the vaccine, susceptibility
and severity of the disease, regarded pneumonia as a priority health problem, and were likely to suggest
the new vaccination.
Discussion/Conclusions: Despite the poor knowledge of mothers and HCPs about PCV, they are aware of the
high burden of pneumonia and the need for a vaccine in the NIP. Perceived severity and benets among
mothers, and, additionally, perceived susceptibility among HCPs were manifested in the willingness
to accept PCV. The ndings would contribute to better understanding the factors, which could support
decision-making about vaccine introduction, and be utilized for developing suitable messages for mothers
and HCPs.
2013 Elsevier Ltd. All rights reserved.

1. Introduction
Pneumococcal disease is the leading cause of mortality and
morbidity in children under ve years of age, particularly in developing countries [1]. Pneumococcal disease caused by Streptococcus
pneumonia is responsible for 3050% of pneumonia cases in children followed by Haemophilus inuenza type B for 1030% of cases.

Corresponding author. Tel.: +6281910573343.

E-mail address: bundaagnes@gmail.com (A.T. Harjaningrum).
0264-410X/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.vaccine.2013.01.007

According to the World Health Organization (WHO), 1.6 million

people die from the disease every year, 0.71 million of which
are children under the age of ve years [2]. In 2009, Indonesia
accounted for the sixth rank or 3% of the reported pneumococcal
cases worldwide [3].
Pneumococcal conjugate vaccine (PCV) that is used for childhood pneumococcal vaccination was rst recommended in the
United States in 2000 and was widely used in 26 countries. Since
2006, 18 out of these 26 countries have introduced the vaccine
including Australia, New Zealand, South Korea, and countries in
Europe, the Americas, and the Middle East [4]. After the vaccine
introduction in many of those countries, the regular use of this

A.T. Harjaningrum et al. / Vaccine 31 (2013) 15161522

vaccine has led to huge decline of invasive pneumococcal disease

(IPD) [5].
The Indonesian Pediatric Association (IDAI) has since 2006,
and for the private sector only, recommended the use of PCV
to be administered to infants at 2, 4, 6 months of age, and readministered once when the child is 1215 months of age [6]. The
total cost per child for a full 4-dose vaccine was estimated at 258,84
Euro (3,200,000 Indonesian Rupiah) which is 1.25 times higher than
the average monthly income of Indonesian in 2011, a cost that only
small number of people can afford [7,8].
In 2007, WHO emphasized that countries with high pneumonia and high under ve mortality rates, such as Indonesia, urgently
needed to introduce the PCV into their National Immunization Program (NIP) [2]. Since 2010, the global alliance for vaccines and
immunization (GAVI) has been providing nancial support to eligible countries for the introduction of PCV. Although GAVI has
tightened its budget early 2011, Indonesia remains part of the graduating countries, which will receive GAVI support until 2015 [9].
There are several issues to be considered before deciding to
introduce a new vaccine into a NIP and one of them is its public
health priority [10]. According to WHO vaccine introduction guidelines in 2005, the perception of the public and medical community
about the vaccine and the disease is a crucial factor to identify its introduction as a priority. The acceptance and uptake of a new vaccine is
likely to be higher if the public and medical communities perceive
the disease to be important and visible, and the vaccine to be safe
and effective. Qualitative data on the knowledge and perception
of key actors can help policy makers in dening the best approach
to introduce a new vaccine as shown by a multi-countries study
conducted on rotavirus vaccine [11].
The objective of the study was to document the knowledge, perceptions, and attitudes of mothers and health care providers (HCPs)
toward PCV in public and private health care facilities in Bandung,
West Java, Indonesia. This study is aimed at contributing to the
decision-making of Indonesian public health authorities as regards
the introduction of PCV into the NIP. This is the rst time such a
study on PCV is conducted in Indonesia.

1517

Table 1
Interview topic guide.
Background for mothers:
How old are you? How many children do you have? What is your
highest education? What is your spouse highest education? Do you have
a job? What is your job? Do your spouse have a job? What is your
spouses job? How much is your familys monthly Income? What is your
religion?
Background for HCPs:
Sex? How old are you? Where do you work (type of health facilities)
What is your job? What is your highest education? How long have you
been working?
Knowledge about pneumonia:
Have you heard about pneumonia? If no, change the term to lung infection
What the symptoms of the disease? What causes of the disease? Do you
think pneumonia can transmit to other people? How could pneumonia
transmit? Do you think pneumonia is curable? How to treat pneumonia?
Do you think pneumonia can be prevented? How pneumonia can be
prevented?
Knowledge about its vaccine:
For unvaccinated Mothers and HCPs: Have you heard about vaccine against
pneumonia? If yes, from where did you hear the rst time about the vaccine?
What do you know about the vaccine?
For vaccinated Mothers: From where did you hear the rst time about the
vaccine? What do you know about the vaccine?
Perceived susceptibility, severity, and priority health problem on pneumonia:
How at risk your child do you feel for catching pneumonia? How serious
is the disease? How serious a public health problem is pneumonia in this
country?
Perceived benet toward pneumonia:
What are possible benets of childhood pneumonia vaccination or PCV?
Perceived barriers toward pneumonia:
What possible barriers do you feel regarding PCV?
Source of information on PCV:
Have you received any information and recommendation about PCV?
From where do you want to get information about the vaccine and the
disease? Which or whom do you trust the most?
Attitudes about PCV:
Do you think PCV should be included into NIP? How do you rank your
likelihood to vaccinate PCV if it is included into NIP? (For vaccinated group:
to complete the schedules): (rank from 1 to 7: (1) absolutely yes, (2)
probably yes; (3) maybe yes; (4) neither yes or no; (5) maybe no; (6)
probably no; (7) absolutely no)
Additional question for mothers:
Do health care providers willing to talk and give explanation during a
vaccination process?

2. Methods
2.1. Study design and sample
A qualitative study was conducted in MayJune 2011 targeting two population groups: mothers and HCPs from several health
care facilities in Bandung, West Java, Indonesia. This study used a
semi-structured interview guide composed of a list of open-ended
questions and probes (Table 1). The mean duration of interview was
29 9 min ranging from 13 to 50 min.
Health care facilities were purposively selected from all levels
of the health pyramid to increase the richness the information of
the study results; wide representation of HCPs (physicians, nurses,
midwives, and doctor assistants), different patient of characteristic
in term of socio economic status between private and public health
care facilities. The study was conducted in one public hospital, one
primary health care (PHC), one private hospital, ve pediatric private clinics, three midwives private clinics, and the Division of
Immunization of the Bandung Health Department. The inclusion
criteria for the health care facilities were: to attend to more than
ve children patients below the age of 5 years per day.
Mothers were women whose children were registered in one
of the public or private health care facilities selected for the study.
Mothers inclusion criteria were: being older than 18 years, having at least one child age 05 years old, being Indonesian, living in
Bandung city, and providing written consent to participate to the
study.

In addition, mothers from private health care facilities, where

PCV vaccine is available, were recruited in two groups: those whose
children were immunized against pneumonia (called vaccinated)
or not (called unvaccinated). All mothers from public health care
facilities were considered as unvaccinated; if a mother from public
health care facility group reported that her children had been vaccinated for PCV, she was excluded from the study (immunization
would have been conducted in a private health care facility).
Inclusion criteria for HCPs were as follows: aged above 21 years
old (the common age for completing three years vocational degree
in Indonesia as nurse and midwife); employed in Bandung with at
least 1 year working experience; and providing written consent to
participate to the study. Except for the participants from the immunization division, and the doctor assistants, other HCPs screened
typically assist, administer or prescribe ve or more immunizations
each week.
2.2. Instrument and ethical aspects
Data was collected using a semi-structured interview guide
based on a list of open-ended questions, and organized in
seven sections: socio-demographic characteristics of participants;
knowledge of pneumonia and the vaccine; perceived susceptibility, severity, and a priority health problem toward pneumonia;
perceived benet toward PCV; perceived barriers toward PCV;
information on PCV; and attitudes toward PCV.

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A.T. Harjaningrum et al. / Vaccine 31 (2013) 15161522

Table 2
Socioeconomic and demographic characteristics of respondents in the mothers
group (n = 26).
Socioeconomic and demographic variable Public (n = 8)
n
Vaccination status
Vaccinated
Unvaccinated
Registration place
Hospital
Clinic
Primary health care
Education level
Junior high school
Senior high school
Vocational training
College graduates
Post graduates
Employment status
Employed
Unemployed
Spouses employment status
Employed
Unemployed
Religion
Islam
Christianity
Variable
Number of children
Mean
Range
Age (years)
Mean
Range
Average monthly income (EURa )
Mean
Range

Private (n = 18)
n

0
8

9
9

4
0
4

4
4
0

4
4
0
0
0

0
1
2
10
5

1
7

10
8

7
1

18
0

8
0

15
3

2
13

2
13

28.6
2138

32.2
2738

85.9
66.2206.9

Table 3
Demographic characteristics of respondents in the HCPs group (n = 29).
Demographic variable

Public (n = 15)
n

Sex
Male
Female
Job
Pediatrician
General practitioner
Nurse
Midwife
Doctor assistant
Immunization division staff
Highest education level
Senior high school
Vocational training
College graduated
Medical undergraduate
Pediatrician masters degree
Pediatrician consultant
Doctorates
Variable
Working experience (years)
Mean
Range
Age (years)
Mean
Range

Private (n = 14)
n

3
12

6
5

4
3
3
2
0
3

7
0
2
3
2
0

0
5
2
4
4
0
0

1
5
1
0
4
2
1

12
230

11
135

38
2352

39
2265

n: number of respondents.

662.4
331.21655.9

Consenting mothers
in public health
care facilities

n: number of respondents.
a
1.0 EUR = 12,077.757 IDR; source: EUR in IDR Exchange Rates, available at
http://eur.exchangerates24.com/idr/?q=1 [Last access: 11.08.11].

Public Hospital

Primary Health
Care

N= 4

Formal ethical permission was obtained from the Ethical Committee of the Medical Faculty of Padjadjaran University Bandung
and research license was issued by Bandung Department of
Health and Bandung Interior Ministry (BPKPM) in Bandung, West
Java Indonesia. Verbal and written permission was systematically
obtained from all the respondents. The interviewees did not receive
any incentive to participate in the study.

N=4

Unvaccinated

Unvaccinated

(4 mothers)

(4 mothers)

Consenting mothers
in private health
care facilities

2.3. Data analysis

The interviews were audio-recorded and annotated by the primary investigator. All interviews were transcribed in Indonesian
language. Textual material was analyzed manually using a data
matrix for pre-dened topic as well as emerging themes and data
to be presented was translated into English.

Private Hospital

Private clinic

N=9

N=9

3. Results
We interviewed 26 mothers aged between 21 and 38 years, and
29 HCPs aged between 23 and 65 years (Tables 2 and 3). The mothers and HCPs grouping algorithm are depicted in Figs. 1 and 2,
respectively.
Our study results are structured along the six key areas of interest and stratied according to study group (mothers and HCPs).

Vaccinated
(5 mothers)

Unvaccinated
(4 mothers)

Vaccinated
(4 mothers)

Fig. 1. Schematic ow of mothers grouping.

Unvaccinated
(5 mothers)

A.T. Harjaningrum et al. / Vaccine 31 (2013) 15161522

Consenting health
care providers in
public health care
facilities

Public
hospital

4
pediatricians
and 1 nurse

Consenting health
care providers in
Bandung Ministry
of Health

Primary
Health Care

3 General
Practitioners

1519

3 staffs on
immunization
Division

2
nurses

2
midwives

Consenting health
care providers
in h
Consenting
healt
te health
privaprov
iders in
care
ties
care
te health
privafacili

Private clinic

3
midwives

5
pediatricians

Private hospital

2
nurses

2
doctor assistants

pediatricians

Fig. 2. Schematic ow of health care providers grouping.

3.1. Mothers and health care providers knowledge about

pneumonia and PCV
Almost all the mothers interviewed had low knowledge about
pneumonia. Most had never heard of the word pneumonia and we
thus opted for the more familiar term of lung infection during our
interviews. When asked about symptoms, the cause of the disease
and means of transmission, some mothers explained the following:
The cause of the disease is mostly cold weather, shower in
the night or swimming. Heredity and food can also cause the
disease. (Unvaccinated/NV5, public)
It must be contagious. [The way of transmission] I do not know.
(Vaccinated/V22, private).
All mothers in public health care facilities had never heard about
PCV and had no knowledge about the vaccine. Among mothers in
private health care facilities, some had heard of PCV or reported that
their child was immunized, but overall had very limited knowledge
of the vaccine:
The vaccine is to prevent pneumonia. It is 4 times, isnt it?
Another things about the vaccine, I forgot, no idea. (Vaccinated, V9, private)
Health care providers knowledge about pneumonia and PCV
We observed a high discrepancy in knowledge levels between
non-medical HCPs, who were little informed, and general practitioners (GPs) and pediatricians, who had good or even high
knowledge of pneumonia:

The cause (of pneumonia) depends on the age. For less than 2
months old usually is caused by E. coli and Streptococus pneumonia. For kids from 2 months until 1 year old it could be caused
by Streptococus pneumonia, Hib, Pneumococus, or Staphylococus.
More than 5 years old, usually caused by fungi, like Clamydia or
Mycoplasma. (HCP31, pediatricians, public)
It is caused by tuberculosis, (HCP50, nurse, public)
No difference in knowledge between private or public HCPs
was observed. Except for the physicians, the majority of HCPs also
responded inadequately to the questions about symptom, treatment and prevention.
Regarding the vaccine, half of the HCPs had never heard or had
no knowledge at all about PCV, and the others mostly pediatricians only described the vaccination schedule or the brand names
of the vaccine without knowing the types and its strains:
Here, we provide prevenar and synorix. I have read about it
but I forgot [the strain]. [The schedule is] started from 2 months
old, and then followed after 4 and 6 months. After 1 year old,
we only give one time. There must be a side effect, but mostly
is only fever. (HCP32, paediatrician, private)

3.2. Mothers perceived susceptibility, severity and priority health

problem on pneumonia
Most mothers in private and half of the mothers in public facilities stated that the risk of their children getting pneumonia was

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A.T. Harjaningrum et al. / Vaccine 31 (2013) 15161522

low. Several respondents even said that their children had no risk
of getting the disease at all.

The shot is so expensive, that is my main obstacle. (Unvaccinated, NV17, private).

The risk is not high if we have a healthy life style. I think I have
been giving enough healthy life for my kids: healthy food, milk,
clean clothes and house. (Unvaccinated, NV7, public)

Safety issues and side effects were reported as concerns particularly by mothers in public and unvaccinated group in private
facilities. Moreover, almost half of the mothers both did not feel as
comfortable with the new vaccine as with the basic immunization.
Other emerged barriers were the mismatch serotype of bacteria
in the vaccine and the local bacteria in Indonesia, the non-halal
status of the vaccine, anti vaccine movement, the age of children
more than one year means no need more vaccines as the system
immune is stronger, the lack of information provided by doctors,
the distance and the waiting time to access PCV.

However almost all of mothers agreed that pneumonia was a

life-threatening illness:
It should become a priority, because pneumonia can cause
death and meningitis that lead to permanent damage. (Vaccinated, V9, private)
3.3. Health care providers perceived susceptibility, severity, and
priority health problem on pneumonia
Most HCP participants both in public and private facilities stated
that the risk of getting pneumonia in children was high and
perceived pneumonia as a serious illness due to the complications:
meningitis, respiratory failure, septic shock, and death.
The risk is high since the mothers very often delay to bring
the children go to the health care. They have lack of knowledge.
So, when their children have common cold, they do not go to
the doctor. The second is economical reason; they do not have
money to bring the child to the doctor. (HCP49, public, nurse)
The majority of HCPs agreed that pneumonia was a health priority problem, due to its high mortality and morbidity, and the
complications that can cause death.
It is a high priority health problem since pneumonia is
among the ve most frequent infectious diseases in children
in Indonesia. The case is quite a lot and the mortality rate is also
high. (HCP29, private, paediatrician)
3.4. Mothers perceived benets of PCV
All unvaccinated group in public facilities and most vaccinated
group in private facilities perceived that PCV had benets, the major
one being its usefulness in preventing pneumonia.
I am sure it can prevent my child for getting pneumonia. I feel
safe that my son would not get the disease. (Vaccinated, V11,
private)

3.7. Health care providers perceived barriers to PCV

The HCPs in private facilities reported that they did not perceive
any obstacle to PCV at all except the cost. One respondent even said
that sometimes they changed the schedule of vaccination in order
to decrease the overload cost of vaccination in the rst 6 months
age of the children, or waited until the children were older than
one year to be able to give one shot only:
Our only barrier is cost. We offered the vaccine after 6 months
since before 6 months they already have many other vaccines
schedule, and there is a gap of vaccine schedule between 6 and
9 months old. (HCP32, pediatrician, private)
Most HCPs in public facilities agreed that, if the vaccine was
included into NIP, the main obstacle would be the socialization,
to gain trust and to inform people that the vaccine is important
and safe. One HCP illustrated it:
Even for the previous vaccines, not all people did it yet. So we
really need an effort in socializing this new vaccine. (HCP38,
GP, public)
Some HCPs in public and immunization division also concerned
with its side effects and the fact that the vaccine was new, not
yet included into basic immunization which is known as Expanded
Immunization Program (EPI).
3.8. Mothers source of information on PCV

All HCPs perceived that PCV had benets for children, and
specically could prevent pneumonia, decrease complications and
pneumonia cases in a community. One participant described the
benet of PCV in this way:

All unvaccinated group stated that they never obtained any

recommendation for PCV from their doctors or any other HCPs.
However, half of the unvaccinated group in private facilities had
received information from sources other than HCPs such as TV
advertisements, posters in doctors ofces, brochures, Internet,
seminars, or books.
All mothers from public facilities wished that doctors, as experts,
would be the expected and trusted information source of PCV. More
than half of the mothers from the private facilities preferred being
informed by their pediatricians, rather than from GPs or other HCPs.

Streptococcus pneumonia causes several diseases not only lung

infection, but also ear infection and meningitis. So, the vaccine
can prevent all of those diseases. (HCP31, paediatrician, private)

I prefer to get some information from the doctor because they

are the expert. [If it is from a television] I am afraid that the information had been over exaggerated just like an infotainment.
(Unvaccinated, NV5, public)

3.5. Health care providers perceived benets of PCV

When asked about possible benets if PCV was available in the

NIP, most public HCPs agreed that PCV would prevent morbidity
and mortality related to pneumonia and this reduce their workload.
3.6. Mothers perceived barriers to PCV
The most common barriers toward PCV perceived was the cost
of the vaccine, which is reported by all mothers in public and more
than half of the mothers in private facilities:

3.9. Health care providers source of information on PCV

Among the HCPs, only the pediatricians, one nurse in public and two private doctor assistants had received information
about PCV. All of the pediatricians obtained the information through
IDAIs symposiums and few of them updated themselves through
other sources such as WHO documents, monthly health magazines,
and some scientic journals. Only two GPs, one nurse, one midwife in PHC, and two HCPs from health department had obtained

A.T. Harjaningrum et al. / Vaccine 31 (2013) 15161522

information about pneumonia through the Integrated Management

of Childhood Illnesses (IMCI) training.
All of the pediatricians mentioned IDAI and few others added
WHO as their preferred references. All HCPs from public facilities
cited training from the Health Department as their trusted source.
3.10. Mothers attitudes about PCV
Almost all mothers agreed that the government should include
PCV into its NIP. Since none of vaccinated group in private facilities
completely vaccinated their children 4 times as the recommended
schedule, we asked their likelihood to vaccinate completely if PCV
was integrated in the NIP. Most of the mothers said probably yes.
Mothers were also questioned about providers attitude, and
most of them stated that the majority of HCPs were reluctant to
give explanation and not easy to talk either about vaccination or
treatments.
They only said, Now it is time to have a hepatitis or polio vaccination, that is all. They never give information more than
that, neither about the advantages or possible side effects.
(Unvaccinated, NV3, public)
3.11. Health care providers attitudes about PCV
Almost all HCPs reported that the government should include
PCV into the NIP, if there is an adequate budget, due to the high
levels of pneumonia morbidity and mortality in Indonesia.
I think it would be good if the vaccine could be included into
NIP because then the price would decrease. (HCP43, doctor
assistant, private)
When asked about likelihood to vaccinate or to recommend
children if PCV integrated the NIP, all were in favor.
4. Discussion
The most important result of our study is that mothers and HCPs
(except physicians) in Bandung have poor knowledge of pneumonia. This nding is of concern because the Indonesian government
has been implementing its Acute Respiratory Infections (ARI) control program since 1984 and IMCI control program since1999 which
also encompasses pneumonia [12,13]. The availability of the vaccine which is only limited in the private sector and its expensive
cost probably explain this information gap. A possible reason for
mothers low knowledge levels may be related to the discrepancy between their expectations in terms of GPs and pediatricians
providing information of PCV and HCPs reluctance to discuss vaccination. In addition, although most pediatricians had been informed
and trained about PCV, their knowledge remained poor. The same
conclusion is also found for HCPs (except physicians) on pneumonia. This raises questions about the effectiveness of IDAI symposium
and IMCI training program.
Perceived susceptibility to pneumonia was low among mothers
and high among HCPs, however all respondents perceived pneumonia as a serious illnesses and a priority health problem, and also
perceived certain benets to PCV. Further, both groups also had
positive attitudes in terms of likelihood to vaccinate their children
with PCV, particularly if it was included into the NIP.
The fact that mothers both from private and public facilities
had little knowledge of PCV and did not perceive their children
to be susceptible to pneumonia, and yet were willing to accept the
vaccine, conrms that it is not always knowledge levels but often
peoples expectations and access to care that guide their action
[1416]. This may explain why mothers in the private sector had
their children vaccinated: not so much because they understand

1521

the severity of the disease or what the vaccine is but rather because
the PCV was available and they trusted the health care system in
providing them the appropriate services to improve the care and
health of their children.
The cost, safety and side effects, and the fact that the vaccine
was new were the main barriers for mothers to accept PCV. These
obstacles have frequently been mentioned as parental concerns in
previous studies [1719]. These barrier issues should be addressed
through specic information campaigns. The only barrier to PCV for
pediatricians was its cost, and this to a large extent explained their
reluctance to recommend the vaccine and their practice of changing
the vaccination schedule. However this practice may impact on the
effectiveness of the vaccine [10,20,21].
The poor quality of information on a vaccine can decrease
the acceptance and coverage of immunization. Communication
has been shown to be important in reaching coverage goals [22].
Prior to introduction of the new vaccine into NIP, communication
messaging needs to be clearly dened and directed. An effective communication strategy in Indonesian context on PCV would
emphasize issues on the fatal complication of pneumonia, the cost,
safety and side effects, and the fact that the vaccine was new.
Our study has certain limitations. Because we included people in a hospital setting, who have been in contact with HCPs, our
results may overestimate the knowledge and acceptability of PCV as
compared to the general Indonesian population. It would be interesting to conduct a complementary quantitative survey within the
same population, to be able to describe for example the prole of
women who accept the vaccine, information which could be used
by national authorities to further guide their promotion messages.
Overall however, this qualitative design has provided an
exploratory data on the knowledge, perception and attitudes about
PCV of two key stakeholder groups in Bandung, namely mothers of
children who were vaccinated or not and various types of HCPs
who provide the information and vaccinate the children. Another
strength of this research was that it allowed for the comparison of
private and public health care facilities.
In conclusion, the ndings of the current study suggest that
prior to the introduction of the new vaccine, the Indonesian public
health authorities should improve the existing information, education, and communication (IEC) programs such as the ARI control
program for mothers as well as strengthen the existing educational
programs (e.g. IMCI training program) for all HCPs.
If Indonesian public health authorities prefer to delay the introduction of PCV in an NIP due budget constraints, in the meantime
they would need to strongly promote prevention programs particularly on providing an environment where children are at low risk of
pneumonia including: exclusive breastfeeding for six months, adequate nutrition, prevention of low birth weight, reducing indoor air
pollution, and hand washing.
Acknowledgments
For their generous support on this study, the authors would like
to thank Yodi Mahendradata M.D., Ph.D.; Astri Ferdiana M.D., M.PH.;
Iis Sinsin Nuryasini M.PH.; Wendy Freely Nugraha M.D.; and Teti
Hendriani Agustin M.D.
References
[1] World Health Organization. Acute respiratory infection [online].; 2009
[cited 20.11.11]. Available from: HYPERLINK http://www.who.int/vaccine
research/diseases/ari/en/index3.html
[2] World Health Organization. Pneumococcal conjugate vaccine for childhood
immunization WHO position paper. WER 2007;82(12): 93104.
[3] OBrien KL, Wolfson LJ, Watt JP, Henkle E, Deloria-Knoll M, McCall N, et al.
Burden of disease caused by Streptococcus pneumoniae in children younger than
5 years: global estimates. Lancet 2009;374(12):893902.

1522

A.T. Harjaningrum et al. / Vaccine 31 (2013) 15161522

[4] Centers for Disease Control and Prevention. Progress in introduction

of pneumococcal conjugate vaccine worldwide, 20002008 [online];
2008 [cited 01.02.12]. Available from: HYPERLINK http://www.cdc.gov/
mmwr/preview/mmwrhtml/mm5742a2.htm
[5] Kellner JD. Update on the success of the pneumococcal conjugate vaccine. Can
Paediatr Soc 2011;16(April (4)):23340.
[6] Ranuh IGN, Suyitno H, Hadinegoro SRS, Kartasasmita CB, Ismoedijanto, Soedjatmiko. Immunization guideline in Indonesia. 3rd ed. Jakarta: Indonesian
Pediatric Society (IDAI); 2008.
[7] Dwinanda R. Bebas Pneumonia tanpa vaksin mahal (free from pneumonia without expensive vaccine) [online]; 2011 [cited 03.03.11]. Available
from: HYPERLINK http://www.republika.co.id/berita/gaya-hidup/info-sehat/
11/01/08/157286-bebas-pneumonia-tanpa-vaksin-mahal-mau[8] Wibowo AT, Pratomo H. Per capita income increased 13.8%, good
news? [online]; 2012 [cited 02.12.12]. Available from: HYPERLINK
http://us.fokus.news.viva.co.id/news/read/286054-kelas-menengah-danpendapatan-per-kapita
[9] Usher AD. GAVI takes steps to address funding woes. Lancet 2011;377(February
(9764)):453.
[10] World Health Organization. Vaccine introduction guidelines: adding a vaccine
to a National Immunization Programme: decision and implementation. Geneva
(Switzerland): Department of Immunization, Vaccines and Biologicals; 2005.
[11] Simpson E, Wittet S, Bonilla J, Gamazyna K, Cooley LL, Winkler J. Use
of formative research in developing a knowledge translation approach to
rotavirus vaccine introduction in developing countries. BMC Public Health
2007;7(October):281.
[12] Purawidjaja S. The relationship between acute respiratory infection (ARI) handle practices by mother in the family level with incidence of pneumonia in

[13]
[14]

[15]
[16]
[17]
[18]
[19]
[20]
[21]

[22]

children under ve of ages in public health services Bandung district in year

2000. Jakarta: Faculty of Public Health University of Indonesia; 2001.
Indonesian Ministry of Health. Guideline for acute respiratory control, Jakarta:
Indonesian Ministry of Health; 2009.
Gordon JC. Beyond knowledge: guidelines for effective health promotion messages. J Extention 2002;40(December (6)) [cited 25.11.12]. Available from:
http://www.joe.org/joe/2002december/a7.php
Kimmel S, Burns T, Wolfe R, Zimmerman R. Addressing immunization barriers,
benets, and risks. J Fam Pract 2007;56(February (2)):S619.
Carpenter C. A meta-analysis of the effectiveness of health belief model variables in predicting behavior. Health Commun 2010;25(December (8)):6619.
Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM. Parental safety concern
in 2009. Pediatrics 2009;125(4):6549.
Chatterjee A, OKeefe C. Current controversies in the USA regarding vaccine
safety. Expert Rev Vaccines 2010;9(5):497502.
Luthy KE, Beckstrand RL, Peterson NE. Parental hesitation as a factor in delayed
childhood immunization. J Pediatr Health Care 2009;23(6):38893.
Guerra FA. Delays in immunization have potentially serious health consequences. Paediatr Drugs 2007;9(3):1438.
Rodenburg GD, van Gils EJ, Veenhoven RH, Jones N, Tcherniaeva I, Hak E, et al.
Comparability of antibody response to a booster dose of 7-valent pneumococcal conjugate vaccine in infants primed with either 2 or 3 doses. Vaccine
2010;28(5):13916.
Waisbord S, Larson H. Why Invest in Communication for Immunization: Evidence and Lessons Learned. New York: a joint publication of the Health
Communication Partnership based at Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (Baltimore) and the United
Nations Childrens Fund; 2005.

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