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Research Article
Revised

Regional disparities and their contribution to the coverage of the tetanus toxoid vaccine among women aged 15–49 years in Indonesia

[version 2; peer review: 2 approved, 1 approved with reservations]
PUBLISHED 31 Aug 2021
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Abstract

Background: The prevention of Clostridium tetani bacterial infection through the administration of the tetanus toxoid (TT) vaccine in women is important. The purpose of this study was to determine the regional disparities and factors associated with TT vaccine coverage in women aged 15–49 years in Indonesia.
Methods: The Indonesian Demographic Health Survey (IDHS) 2017 data was used in this study. A total of 36,028 women, aged 15–49 years were recruited using the two-stage stratified cluster sampling technique. The questionnaire used was based on the DHS Questionnaire Phase 7. Chi-squared and binary logistic regression were used in this study as part of the analysis.
Results: We found that the TT vaccine coverage was 75.32% and that the majority were spread across several provinces. The provinces of Bali and Nusa Tenggara, the richer respondents, living in a rural area, visiting the health facility, having health insurance, and those currently working were factors making it more likely that the women would receive the TT vaccine. The respondents aged 15–24 years with a primary education level and the respondents who were divorced were less likely to receive the TT vaccine.
Conclusion: The coverage of the TT vaccine among women can be increased by considering the regional disparities in Indonesia and the socio-economic demographic details of the respondents. Strengthening the policies from the central government in the local governments can improve the screening process and vaccine delivery outcomes. In addition, the importance of giving the TT vaccine to women needs to be relayed through health education in collaboration between health workers and the public.

Keywords

vaccine; tetanus toxoid; tetanus vaccine; demographic health survey, women

Revised Amendments from Version 1

We have improved and take a revision based on reviewers' suggestions. We added up-to-date data and references related to TT Vaccine. Secondly, we make clear the methods and gave more information about the variables. As a result, we revised the table and combine some tables to be more concise as the reviewer suggested. Lastly, in the discussion session, we much improved the sentences to be more relevant and added up-to-date references.

See the authors' detailed response to the review by Heri Kuswanto
See the authors' detailed response to the review by Azza Mehanna
See the authors' detailed response to the review by Muhammad Hardhantyo

Introduction

Neonatal tetanus (NT) is a disease that can be prevented. It has become a global health problem with both high case and high fatality rates among neonates.1 NT refers to tetanus that occurs at 28 days of early life.2 NT occurs due to the toxins produced by Clostridium tetani alongside an unhygienic labor agent. It spreads through the umbilical cord.3 One of the efforts to prevent the incidence of NT is the provision of an adequate tetanus toxoid (TT) vaccine for women of reproductive age.4 In 2006, WHO developed guidelines for the TT vaccine for pregnant women to prevent NT.5 The Government of Indonesia through the regulation of the Minister of Health no 12 of 2017 concerning the implementation of immunization stipulates a national immunization coverage target of at least 90% and in districts/cities of at least 80% for TT vaccination as continued vaccine.6

Two doses of the TT vaccine can provide immunity and reduce neonatal mortality by 94%.7,8 One case–control study also reported that the administration of two doses of the TT vaccine was associated with a decrease in the incidence of NT9,10 and vice versa.11 Minimum two doses of TT vaccine were identified can reduce neonatal mortality.12 TT vaccination contributes to the reduction of neonatal mortality due to tetanus by 85% from 2000 to 2018.1 The Indonesian Health Profile data from the years 2013–2015 show the trend that not receiving the TT vaccine is the leading cause of neonatal mortality.1315 Although NT can be prevented by the TT vaccine, the number of cases is still high. Globally, it is estimated that as many as 3.6 million neonates die every year, among which 59,000 die from tetanus.16 The infant mortality rate in Indonesia according to the Indonesian Demographic and Health Survey in 2007 was 34 deaths per 1,000 live births with the highest number of deaths occurring during the neonatal period.17 The neonatal mortality rate in Indonesia in 2007 was 19 per 1000 live births and NT was one of the main causes of death.18,19

Neonatal tetanus cases still cannot be handled completely because the coverage of the TT vaccine is still lacking, both nationally and regionally. Nationally, the coverage of the TT vaccine for both pregnant and reproductive age women tends to fluctuate and has not yet reached the target. The TT vaccine coverage for pregnant and reproductive age women from 2007 to 2011 was 26% and 27.1%, 65.2% and 24.7%, 73.5% and 11.2%, 69.5% and 8, 6%, and 63.6% and 11.8%, respectively.17 If the regional data is examined randomly, the coverage of the TT vaccine in select regions has also not reached the target.20 The difference in coverage from the highest and lowest during the period was possible due to differences in perceptions of the operational definition, problems in recording, reporting formats, and others. So there needs to be an effort to organize a recording and reporting system for pregnant women TT vaccination.17

The low coverage of the TT vaccine is largely influenced by inadequate knowledge.21,22 Women with poor knowledge of MNT and TT vaccine are 0.435 times less likely to receive the TT vaccine.23 Insufficient knowledge of the TT vaccine among prospective brides of reproductive age are one of the factors for the low TT vaccine coverage.24 Based on the data above, to overcome this inadequate knowledge, health education about TT is needed. Good health education pays attention to and identifies people’s characteristics in the intended category so then the health education provided can be more effective.25 This study is focused on revealing TT vaccine coverage and the determinant factors of the TT vaccine being received in relation to women of reproductive age.

Several previous Indonesian studies have revealed the coverage and determinants of the TT vaccine. Research into the TT coverage is still reported on a regional scale.26,27 Research on the determinants of the vaccine for women of childbearing age specifically includes knowledge, family support, attitudes, and the behavior of the health workers.22,28,29 This study used available national data including age, education level, wealth quintile, residence, marital status, visiting the health facilities, health insurance, occupational status, the sex of the household head, pregnancy, and the different regional areas in relation to the TT vaccine. It is expected that the results of this study can be used when devising effective approaches for the education of women of reproductive age to promote the TT vaccine.

Methods

Study design

A cross-sectional study design was undertaken. We used secondary data from the Indonesian Demographic Health Survey (IDHS) 2017 and parts of the Inner-City Fund (ICF) International data.

Sample

The survey was conducted in December 2017. We used the IDIR71FL dataset (Indonesian Individual Recode phase 7). The total study population was 49,627 women aged 15–49 years. We then weighted the data based on the number of provinces in Indonesia in order to obtain the average for each region. We managed to reach 36,028 women aged 15–49 years who have not received the TT vaccine in Indonesia. Furthermore, there was missing data. Two-stage stratified cluster sampling was used in this study by selecting clusters from each stratum and a list of families from the selected clusters. Then the families’ questionnaire responses were investigated (Demographic Health Survey, 2017).

Variables

The independent variables in this study included age, education level, wealth quintile, residence, marital status, visiting the health facility, health insurance, occupational status, sex of household head, pregnancy, regional disparities. Age was categorized into 15–24 years old, 25–34 years old and 35–49 years old (Health Ministry of Republic Indonesia, 2009). Based on Law No. 20 of 2003 concerning the National Education System in Indonesia, education level was categorized into high, secondary, primary, and no education.30 The wealth quintiles were divided into five categories based on principal component analysis (PCA). The wealth quintiles were measured by the percentage distribution of the de jure population using the wealth quintiles and the Gini coefficient. For the percentage distribution, the numerators were divided by the denominators multiplied by 100. The results were then divided into five equal parts from quintile one (poorest) to quintile five (richest); each included 20% of the total population. Then, it was categorized into poorest, poorer, middle, richer, and richest respectively.31,32 Residence was categorized into either an urban or rural area.33 Marital status was classified as either married, partnered, widowed, divorced or separated. The respondents who had visited a health facility in the last six months, whether they had health insurance, if they were currently working, and their pregnancy status were all categorized as either yes or no.31 We identified the sex of the household head as either male or female. For the regions in Indonesia, we classified the country based on the big islands as follows: Sumatera, Riau, Java, Bali and Nusa Tenggara, Kalimantan, Sulawesi, Maluku, and Papua.34

The dependent variable in this study was the TT vaccine. We identified women aged 15–49 years who either received or did not receive the TT Vaccine. Then we categorized them according to their answer of either yes or no (Demographic Health Survey, 2017). To enhance the quality and transparency of reporting the study results, the researchers applied The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).35

Data analysis

We used the STATA version 16.1: “A Software resource for statistical analysis and presentation of graphics (Stata, RRID:SCR_012763)”. We used Chi-squared to analyze the bivariate data and binary logistic regression to analyze the multivariate data. We used the adjusted odds ratio (AOR) with a 95% confidence interval (CI) and a significance level of p < 0.05.

Ethical considerations

Ethical approval for the secondary dataset was not required. The dataset policy is available on the official website. We received approval to use the dataset from ICF International with number AuthLetter_154679.

Results

In this study, we found that the coverage of the TT vaccine in Indonesia reached 75.32% out of the 36,028 respondents. More than half of the total respondents who received the vaccine aged 35–49 years were educated to secondary school level. The distribution of wealth quintiles was almost the same, ranging from poorest to richest. The majority were in the poorest quintile. In addition, the distribution of residence was almost the same across both urban and rural areas. The majority of the respondents in this study were married and they had regularly visited health facilities in the last six months. We found that the majority of respondents had health insurance, were working, and were not pregnant. The majority of the household heads were male.

Upon examining the regional distribution data in Indonesia, the TT vaccine coverage was more than 70% in Riau, Java, Bali and Nusa Tenggara, Kalimantan, Sulawesi, and Papua. The majority of respondents aged 35–49 years were spread across Indonesia. The distribution data indicate that the majority of respondents were educated to secondary school level, followed by those with primary education. The majority of respondents in the richest quintile and living in an urban area in Riau and Java. The majority of respondents in the poorest quintile and living in a rural area were in Bali and Nusa Tenggara, Sulawesi, Maluku, and Papua. Most of the respondents were married, had health insurance, were working, were not pregnant, and the household head was male. The respondents in Riau, Maluku, and the Papua islands responded stating that they had rarely visited the health facilities in the last six months (Table 1).

Table 1. Socio-demographic characteristic based on region (n = 36,028).

Variablen%Region
Sumatera (n = 8,344)Riau (n = 753)Java (n = 12,336)Bali & Nusa Tenggara (n = 3,053)Kalimantan (n = 3,291)Sulawesi (n = 5,415)Maluku (n = 1,945)Papua (n = 891)
n%n%n%n%n%n%n%n%
TT vaccine
No
Yes

8,893
27,135

24.68
75.32

2,618
5,726

31.38
68.62

199
554

26.43
73.57

3,157
9,179

25.59
74.41

499
2,554

16.34
83.66

701
2,590

21.30
78.70

898
4,517

16.58
83.42

608
1,337

31.26
68.74

213
678

23.91
76.09
Age
35–49 years old
25–34 years old
15–24 years old

19,697
12,325
4,006

54.67
34.21
11.12

4,540
2,955
849

54.41
35.41
10.17

448
253
52

59.50
33.60
6.91

7,077
3,970
1,289

57.37
32.18
10.45

1,649
1,060
344

54.01
34.72
11.27

1,678
1,216
397

50.99
36.95
12.06

2,910
1,812
693

53.74
33.46
12.80

987
700
258

50.75
35.99
13.26

408
359
124

45.79
40.29
13.92
Education level
High education
Secondary education
Primary education
No education

5,251
18,770
11,254
753

14.57
52.10
31.24
2.09

1,321
4,550
2,323
150

15.83
54.53
27.84
1.80

118
475
152
8

15.67
63.08
20.19
1.06

1,467
6,587
4,127
155

11.89
53.40
33.45
1.26

431
1,349
1,122
151

14.12
44.19
36.75
4.95

429
1,719
1,075
68

13.04
52.23
32.66
2.07

960
2,579
1,754
122

17.73
47.63
32.39
2.25

378
1,074
477
16

19.43
55.22
24.52
0.82

147
437
224
83

16.50
49.05
25.14
9.32
Wealth quintiles
Poorest
Poorer
Middle
Richer
Richest

8,374
7,016
6,945
6,952
6,741

23.24
19.47
19.28
19.30
18.71

1,730
1,908
1,820
1,584
1,302

20.73
22.87
21.81
18.98
15.60

36
77
152
207
281

4.78
10.23
20.19
27.49
37.32

1,145
2,047
2,594
3,168
3,382

9.28
16.59
21.03
25.68
27.42

1,477
543
364
335
334

48.38
17.79
11.92
10.97
10.94

671
683
774
609
554

20.39
20.75
23.52
18.51
16.83

1,891
1,216
862
714
732

34.92
22.46
15.92
13.19
13.52

995
376
259
222
93

51.16
19.33
13.32
11.41
4.78

429
166
120
113
63

48.15
18.63
13.47
12.68
7.07
Residence
Urban
Rural

18,316
17,712

50.84
49.16

3,478
4,866

41.68
58.32

680
73

90.31
9.69

8,228
4,108

66.70
33.30

1,212
1,841

39.70
60.30

1,729
1,562

52.54
47.46

1,978
3,437

36.53
63.47

774
1,171

39.79
60.21

237
654

26.60
73.40
Marital status
Married
Partner
Widowed
Divorced
Separated

33,294
369
884
1,319
162

92.41
1.02
2.45
3.66
0.45

7,816
5
217
294
12

93.67
0.06
2.60
3.52
0.14

698
2
18
35
0

92.70
0.27
2.39
4.65
0.00

11,542
12
281
472
29

93.56
0.10
2.28
3.83
0.24

2,677
169
84
78
45

87.68
5.54
2.75
2.55
1.47

3,068
6
78
136
3

93.22
0.18
2.37
4.13
0.09

5,016
19
128
235
17

92.63
0.35
2.36
4.34
0.31

1,764
61
46
49
25

90.69
3.14
2.37
2.52
1.29

713
95
32
20
31

80.02
10.66
3.59
2.24
3.48
Visiting health facility
No
Yes

16,639
19,389

46.18
53.82

3,751
4,593

44.95
55.05

384
369

51.00
49.00

5,544
6,792

44.94
55.06

1,406
1,647

46.05
53.95

1,454
1,837

44.18
55.82

2,529
2,886

46.70
53.30

1,066
879

54.81
45.19

505
386

56.68
43.32
Health insurance
No
Yes

13,839
22,189

38.41
61.59

3,080
5,264

36.91
63.09

275
478

36.52
63.48

5,032
7,304

40.79
59.21

1,174
1,879

38.45
61.55

1,475
1,816

44.82
55.18

1,732
3,683

31.99
68.01

853
1,092

43.86
56.14

218
673

24.47
75.53
Currently working
No
Yes

14,978
21,050

41.57
58.43

3,393
4,951

40.66
59.34

335
418

44.49
55.51

5,478
6,858

44.41
55.59

1,054
1,999

34.52
65.48

1,300
1,991

39.50
60.50

2,247
3,168

41.50
58.50

840
1,105

43.19
56.81

331
560

37.15
62.85
Sex of household head
Male
Female

32,233
3,795

89.47
10.53

7,487
857

89.73
10.27

684
69

90.84
9.16

11,057
1,279

89.63
10.37

2,618
435

85.75
14.25

3,011
280

91.49
8.51

4,847
568

89.51
10.49

1,727
218

88.79
88.79

802
89

90.01
9.99
Pregnancy
No
Yes

34,081
1,947

94.60
5.40

7,832
512

93.86
6.14

711
42

94.42
5.58

11,766
570

95.38
4.62

2,896
157

94.86
5.14

3,106
185

94.38
5.62

5,139
276

94.90
5.10

1,796
149

92.34
7.66

835
56

93.71
6.29

The bivariate analysis showed that the regional variables, age, education level, wealth quintile, residence, marital status, whether they visited the health facilities, health insurance, whether they were currently working, and the sex of the household head have a significant relationship with TT vaccine coverage in women aged 15–49 years. However, the pregnancy variable did not have a significant relationship with TT vaccine coverage (Table 2).

Table 2. Bivariate analysis of tetanus toxoid vaccine coverage among women aged 15–49 years in Indonesia (n = 36,028).

VariableTetanus toxoid vaccine coverage
NoYesχ2
n%n%
Regional (island)
Sumatera
Riau
Java
Bali & Nusa Tenggara
Kalimantan
Sulawesi
Maluku
Papua

2,618
199
3,157
499
701
898
608
213

7.27
0.55
8.76
1.39
1.95
2.49
1.69
0.59

5,726
554
9,179
2,554
2,590
4,517
1,337
678

15.89
1.54
25.48
7.09
7.19
12.54
3.71
1.88

578.813***
Age
35–49 years old
25–34 years old
15–24 years old

4,940
2,830
1,123

13.71
7.86
3.12

14,757
9,495
2,883

40.96
26.35
8.00

45.499***
Education level
High education
Secondary education
Primary education
No education

914
3,879
3,631
469

2.54
10.77
10.08
1.30

4,337
14,891
7,623
284

12.04
41.33
21.16
0.79

1,200***
Wealth quintiles
Poorest
Poorer
Middle
Richer
Richest

2,710
1,756
1,627
1,461
1,339

7.52
4.87
4.52
4.06
3.72

5,664
5,260
5,318
5,491
5,402

15.72
14.60
14.76
15.24
14.99

406.478***
Residence
Urban
Rural

4,220
4,673

11.71
12.97

14,096
13,039

39.13
36.19

54.138***
Marital status
Married
Partner
Widowed
Divorced
Separated

7,978
113
313
430
59

22.14
0.31
0.87
1.19
0.16

25,316
256
571
889
103

70.27
0.71
1.58
2.47
0.29

127.472***
Visiting health facility
No
Yes

5,108
3,785

14.18
10.51

11,531
15,604

32.01
43.31

601.783***
Health insurance
No
Yes

3,865
5,028

10.73
13.96

9,974
17,161

27.68
47.63

127.253***
Currently working
No
Yes

3,911
4,982

10.86
13.83

11,067
16,068

30.72
44.60

28.121***
Sex of household head
Male
Female

7,825
1,068

21.72
2.96

24,408
2,727

67.75
7.57

27.295***
Pregnancy
No
Yes

8,418
475

23.37
1.32

25,663
1,472

71.23
4.09

0.091

*** p < 0.01.

** p < 0.05.

* p < 0.1.

Table 3 shows the results of the multivariate analysis. The data indicate that regional disparities, age, education level, wealth quintile, residence, marital status, whether they had visited the health facilities recently, and having health insurance are likely to be associated with TT vaccine coverage in women aged 15–49 years in Indonesia. The regional data shows that the respondents in Bali and Nusa Tenggara are 3.363-times more likely to receive the TT vaccine than the respondents in Sumatera (AOR = 3.363; 95%CI = 2.997–3.773). The respondents aged –24 years old are 0.71-times less likely to receive the TT vaccine than those aged 35–49 years (AOR = 0.71; 95%CI = 0.653–0.772). Regarding education level, the respondents with a primary school level of education were 0.544-times less likely to receive the TT vaccine than the respondents with a higher level of education (AOR = 0.544; 95%CI = 0.494–0.599). Furthermore, the richer respondents were 1.645-times more likely to receive the TT vaccine than the poorest respondents (AOR = 1.645; 95%CI = 1.506–1.798). The respondents living in rural areas were 1.106-times more likely to have had the TT vaccine than those living in urban areas (AOR = 1.106; 95%CI = 1.044–1.173). Divorced respondents were 0.693-times less likely to receive the TT vaccine than married respondents (AOR = 0.693; 95%CI = 0.608–0.79). The respondents who had regularly visited a health facility in the last six months were 1.693-times more likely to receive the vaccine than those who had not (AOR = 1.693; 95%CI = 1.609–1.781). The respondents who had health insurance were 1.176-times more likely to receive the vaccine than those who did not (AOR = 1.176; 95%CI = 1.117–1.239). The respondents who worked were 1.147-times more likely to receive the vaccine than those who did not (AOR = 1.147; 95%CI = 1.088–1.208).

Table 3. Multivariate analysis of tetanus toxoid vaccine coverage among women aged 15–49 years in Indonesia (n = 36,028).

VariableTetanus toxoid vaccine coverage
AORp95%CI
LowerUpper
Regional (island)
Sumatera
Riau
Java
Bali & Nusa Tenggara
Kalimantan
Sulawesi
Maluku
Papua

Ref.
1.197**
1.353***
3.363***
1.874***
2.752***
1.217***
2.247***


0.044
0.000
0.000
0.000
0.000
0.001
0.000


1.005
1.266
2.997
1.697
2.517
1.086
1.88


1.427
1.445
3.773
2.07
3.01
1.362
2.686
Age
35–49 years old
25–34 years old
15–24 years old

Ref.
0.939**
0.71***


0.031
0.000


0.886
0.653


0.994
0.772
Education level
High education
Secondary education
Primary education
No education

Ref.
0.994
0.544***
0.149***


0.901
0.000
0.000


0.911
0.494
0.125


1.085
0.599
0.179
Wealth quintiles
Poorest
Poorer
Middle
Richer
Richest

Ref.
1.442***
1.544***
1.645***
1.527***


0.000
0.000
0.000
0.000


1.334
1.421
1.506
1.382


1.558
1.676
1.798
1.687
Residence
Urban
Rural

Ref.
1.106***


0.001


1.044


1.173
Marital status
Married
Partner
Widowed
Divorced
Separated

Ref.
0.691***
0.675***
0.693***
0.585***


0.003
0.000
0.000
0.002


0.541
0.573
0.608
0.415


0.882
0.796
0.79
0.824
Visiting health facility
No
Yes

Ref.
1.693***


0.000


1.609


1.781
Health insurance
No
Yes

Ref.
1.176***


0.000


1.117


1.239
Currently working
No
Yes

Ref.
1.147***


0.000


1.088


1.208
Sex of household head
Male
Female

Ref.
0.939


0.177


0.857


1.029

*** p < 0.01.

** p < 0.05.

* p < 0.1.

Discussion

In this study, we discussed the gap in the reception of the TT vaccine among women aged 15–49 years in Indonesia by looking at the regional disparities. We also were able to determine the contributions behind the achievement of the TT vaccine coverage in Indonesia as it stands. We found that regional disparities were significantly associated with TT vaccine performance. In addition, the factors of age, education level, wealth quintile, residence, marital status, whether they visited the health facilities, health insurance, and whether they were currently working also contribute to the TT vaccine coverage among women aged 15–49 years in Indonesia.

Regional disparities are one of the demographic factors that contribute greatly to the TT vaccine coverage among women. Indonesia, an archipelago region, can be an inhibiting factor regarding vaccine coverage.36,37 This geographical condition can affect the coverage in vaccination because it affects the access, availability, distribution of the vaccine supply chain between islands. Differences in culture, region, ethnicity, language, knowledge, and access in Indonesia are important factors to consider when seeking to facilitate access to get a vaccine.38,39 According to this study, the Bali and Nusa Tenggara regions have a greater chance of administering the TT vaccine to their respective populations than other regions. When viewed according to socio-economic development, Bali and Nusa Tenggara, which are included within Eastern Indonesia, are far behind compared with the Java, Sumatera and Riau.40,41 This is consistent with the previous research which states that vaccine coverage can be influenced by region, development, knowledge and awareness of the disease and vaccine.42,43

We found that the younger respondents, aged 15–24 years, were less likely to receive the TT vaccine than the respondents who were older (35–49 years old). A previous study showed that age is related to the knowledge of the importance of vaccines and the ability to make decisions.44,45 Therefore, health education is needed among those of a young age about the importance of vaccines. In addition, in this study it is also known that this is less likely for those of a primary education level compared with those with a higher level of education. This is because with a good level of knowledge, TT vaccination coverage can be achieved. In this case, the government and health workers have an important role in distributing knowledge about vaccines to the public. Both previous studies have shown that vaccine performance is influenced by a good level of knowledge.46,47 Moreover, respondents aged 15-24 years have less experience, beliefs, and family non-supporting about vaccine.48,49 This condition tendency of less likely to to receive the TT vaccine.

In this study, we found that economic status contributed to the achievement of TT vaccine coverage in women. Based on the finding in this study, respondents with a wealth quintile that is higher and those with a job are more likely to receive the TT vaccine compared with the respondents whose economic level is low and who do not work. Previous research has shown that the respondents with a stable income can easily access private and government health facilities and get vaccines.50,51 In addition, the respondents who had health insurance were found to be more likely to receive the TT vaccine. This is because the respondent feels calm that their medical costs will be covered by their health insurance. Previous research has shown that with health insurance, vaccine coverage can increase. It was because people should not think about the payment for TT vaccine.5254 It can be one of the program from government to reach high vaccination coverage.

In terms of the rural areas, the study found that the residents of these areas are more likely to receive the TT vaccine. This is related to the obedience of the rural population where doctors, nurses and midwives have been able to gain the trust of the community.55 This closeness is also obtained through the routine outreach process used to engage with the community members.56 The information obtained by the rural residents tends to be more centralized and there is no intervention from other sources such as the internet and minimizing false news; the information will be centered on the doctors, nurses and midwives visited at the health facility as a result.57,58 Also, rural residents rely more on health workers where they live. In this context, it is the midwife who mostly works in remote villages.17 Rural residents trust these midwives and regard the midwife as a link between them and the health care facilities provided by the government. This is in contrast to the urban residents who prefer to obtain their health-related information independently. They tend to compare the results of the information obtained from the internet with that of the doctors, nurses and midwives at the health facilities. The gaps in the information obtained trigger doubts about the TT vaccine and in the end, there is a delay in getting the vaccine even after marriage.

This study found that the women who visit the health facility are more likely to receive the TT vaccine. Visiting the health facility will increase their information and knowledge related to vaccines.59 In addition, each visit can increase their closeness and bond with the health workers. This can convince the women aged 15–49 years old to have the TT vaccine. A visit to a health care facility provides an opportunity for women to clarify and address their concerns regarding the side effects of vaccines by consulting directly with their doctor or nurse.60 Rumors circulating in the community regarding the TT vaccine also can be explained through counselling during the visits. One of the rumors is that the content of the vaccine material is not halal, so there is resistance from some women. Health workers like the doctors and nurses are needed to clarify the problem.61

Those who are divorced are less likely to receive the TT vaccine. This is associated by the decrease or non-existence of motivation from a partner. Women who have lived alone tend to have different views after a divorce. Focus and priorities in life may no longer lead to the fulfillment of health support such as vaccines, but rather to be economically independent and able to meet the needs of daily life. Divorced women do not feel the need to receive the TT vaccine because one of the goals of this vaccine is to reduce the risk of tetanus in women and their unborn baby.62 If they are divorced, there is no need for the TT vaccine. Indonesian government have many efforts to increase the TT vaccination coverage, such as equitable availability of midwives in rural to remote areas17 and regulations that require brides to be vaccinated TT according to government regulation number 02 of 1989 about Tetanus Toxoid Immunization before marriage.63

The strength of our study is that it provides information on the TT vaccine coverage nationally while highlighting the regional disparities in Indonesia. The results of this study can become basic data for the Indonesian government to use to determine further policies to achieve an improved level of TT vaccine coverage among women. However, this study has limitations in that the researchers looked at the distribution based only on the major islands in Indonesia. Descriptions at the provincial level are needed for the formulation of more specific policies. Meanwhile, the study has assumption of no significant correlation among predictors.

Conclusion

In this study, we found there to be a gap in the TT vaccine uptake among women aged 15–49 years in Indonesia. Indonesia as an archipelago country become one of the considerations and constraints involved in the coverage of the TT vaccine among women. The findings of this study provide an overview about the TT vaccine coverage according to several factors such as the regional disparities and the respondents’ socio-economic demographic information. Furthermore, the government can collaborate across different sectors between the central and local governments to achieve the desired TT vaccine coverage. Providing accurate and precise information about the TT vaccine needs to be promoted by healthcare workers in collaboration with the community through online methods to reach the urban population areas in Indonesia. An in-depth exploration with additional factors and sectors involved is needed in terms of the direction of further research.

Data availability

Data used in this study is available online from the Indonesian 2017 Demographic and Health Survey (DHS) website under the ‘Individual Recode’ section. Access to the dataset requires registration and is granted only for legitimate research purposes. A guide for how to apply for dataset access is available at: https://dhsprogram.com/data/Access-Instructions.cfm.

Comments on this article Comments (1)

Version 2
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Discussion is closed on this version, please comment on the latest version above.
  • Reader Comment 14 Jul 2021
    Yohanes Andy Rias, Taiwan Medical University, Taipei, Taiwan
    14 Jul 2021
    Reader Comment
    It is an interesting topic where the authors raised the topic of the tetanus toxoid vaccine among women aged 15–49 years in Indonesia. It can be useful information to readers ... Continue reading
  • Discussion is closed on this version, please comment on the latest version above.
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Arifin H, Widiasih R, Pradipta RO and Kurniawati Y. Regional disparities and their contribution to the coverage of the tetanus toxoid vaccine among women aged 15–49 years in Indonesia [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2021, 10:437 (https://doi.org/10.12688/f1000research.53004.2)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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PUBLISHED 31 Aug 2021
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Reviewer Report 13 Sep 2021
Muhammad Hardhantyo, Faculty of Health Science, Universitas Respati Yogyakarta, Yogyakarta, Indonesia;  Center for Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia 
Approved
VIEWS 5
The manuscript is well-written, including a description of the approach clearly. The authors have addressed all reviewer recommendations given to improve the article's quality. The findings could contribute to enhancing our understanding of tetanus toxoid vaccination coverage of women aged ... Continue reading
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Hardhantyo M. Reviewer Report For: Regional disparities and their contribution to the coverage of the tetanus toxoid vaccine among women aged 15–49 years in Indonesia [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2021, 10:437 (https://doi.org/10.5256/f1000research.76877.r93100)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 19 Aug 2021
Azza Mehanna, Health Administration and Behavioral Sciences Department, HIPH, Alexandria University, Alexandria, Egypt 
Approved with Reservations
VIEWS 24
Introduction:
  • Paragraph 1, last line: Reference 6 is not in English, and on opening it, it seemed to lack some important details such as the target year for national and regional vaccine coverage of at least
... Continue reading
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CITE
HOW TO CITE THIS REPORT
Mehanna A. Reviewer Report For: Regional disparities and their contribution to the coverage of the tetanus toxoid vaccine among women aged 15–49 years in Indonesia [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2021, 10:437 (https://doi.org/10.5256/f1000research.56345.r90139)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 02 Sep 2021
    Hidayat Arifin, Department of Medical-Surgical Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
    02 Sep 2021
    Author Response
    Dear Dr. Azza Mehanna,

    Thank you very much for the comments and suggestions. Here we put some revisions based on your suggestions. 

    Paragraph 1, last line: Reference 6 is ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 02 Sep 2021
    Hidayat Arifin, Department of Medical-Surgical Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
    02 Sep 2021
    Author Response
    Dear Dr. Azza Mehanna,

    Thank you very much for the comments and suggestions. Here we put some revisions based on your suggestions. 

    Paragraph 1, last line: Reference 6 is ... Continue reading
Views
23
Cite
Reviewer Report 09 Aug 2021
Muhammad Hardhantyo, Faculty of Health Science, Universitas Respati Yogyakarta, Yogyakarta, Indonesia;  Center for Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia 
Approved with Reservations
VIEWS 23
  1. Please clarify the sudden increase of pregnant TT vaccine coverage in Indonesia from 2007 to 2008. It was mentioned that the vaccine coverage was 26% in 2007 and significantly increased to 65.2% in 2008. The strategies might
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Hardhantyo M. Reviewer Report For: Regional disparities and their contribution to the coverage of the tetanus toxoid vaccine among women aged 15–49 years in Indonesia [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2021, 10:437 (https://doi.org/10.5256/f1000research.56345.r87930)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 02 Sep 2021
    Hidayat Arifin, Department of Medical-Surgical Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
    02 Sep 2021
    Author Response
    Dear Muhammad Hardhantyo, PhD. 

    Thank you very much for the comments and suggestions. Here we put some revisions based on your suggestions. 

    1. Please clarify the sudden increase of ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 02 Sep 2021
    Hidayat Arifin, Department of Medical-Surgical Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
    02 Sep 2021
    Author Response
    Dear Muhammad Hardhantyo, PhD. 

    Thank you very much for the comments and suggestions. Here we put some revisions based on your suggestions. 

    1. Please clarify the sudden increase of ... Continue reading
Views
27
Cite
Reviewer Report 23 Jul 2021
Heri Kuswanto, Center for Disaster Mitigation and Climate Change, Institut Teknologi Sepuluh Nopember, Surabaya, Indonesia 
Approved
VIEWS 27
This paper has been written very well, with a structure that is easily understood. However, there is a minor comment that might be considered to improve the quality of the paper:

The interpretation of the logistic regression ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Kuswanto H. Reviewer Report For: Regional disparities and their contribution to the coverage of the tetanus toxoid vaccine among women aged 15–49 years in Indonesia [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2021, 10:437 (https://doi.org/10.5256/f1000research.56345.r87631)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 02 Sep 2021
    Hidayat Arifin, Department of Medical-Surgical Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
    02 Sep 2021
    Author Response
    Dear Prof. Heri Kuswanto

    Thank you very much for your comments and suggestion to improve the quality of our manuscript. we have added in the limitations of the study that there ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 02 Sep 2021
    Hidayat Arifin, Department of Medical-Surgical Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
    02 Sep 2021
    Author Response
    Dear Prof. Heri Kuswanto

    Thank you very much for your comments and suggestion to improve the quality of our manuscript. we have added in the limitations of the study that there ... Continue reading

Comments on this article Comments (1)

Version 2
VERSION 2 PUBLISHED 31 Aug 2021
Revised
Version 1
VERSION 1 PUBLISHED 03 Jun 2021
Discussion is closed on this version, please comment on the latest version above.
  • Reader Comment 14 Jul 2021
    Yohanes Andy Rias, Taiwan Medical University, Taipei, Taiwan
    14 Jul 2021
    Reader Comment
    It is an interesting topic where the authors raised the topic of the tetanus toxoid vaccine among women aged 15–49 years in Indonesia. It can be useful information to readers ... Continue reading
  • Discussion is closed on this version, please comment on the latest version above.
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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