INTRODUCTION:

The global incidence of dengue fever has doubled every decade for the last 30 years, with recent estimates of more than 100 million infections and 50 million cases per year and most common in tropical and subtropical regions of the world^1,2. Dengue fever is caused by the dengue virus (DENV) which is transmitted to humans through mosquito bite vectors (Aedes aegypti) with a high morbidity rate of up to 20% of those affected by dengue fever^2,3. The characteristic feature of severe dengue fever is capillary leakage which causes shock and if not treated properly will cause death⁴.

In Indonesia, dengue fever has to get the serious attention from various parties because this disease is endemic and threatening the public health. In 2020, the Ministry of Health recorded around 103,509 cases occurring with 725 deaths. Southeast Sulawesi is recorded as having the highest case fatality rate (CFR) in Indonesia as 1.0%. Hundreds of these diseases were spread across 17 districts/cities, with the 5 highest areas, those were Kendari City with 305 cases, South Konawe with 125 cases, Bau-Bau City with 73 cases, Muna with 67 cases and Wakatobi with 52 cases. The largest age group of sufferers is children (<1-14 years) around 50.65%⁵. At present, irresistible sicknesses are a medical issue, yet in addition a social issue for the prosperity of people and the world in which we live. At the point when somebody is vaccinated against a sickness, they don't get the illness or just experience the ill effects of gentle infection. Vaccination is a mass means to shield however many individuals as could be expected under the circumstances from different irresistible sickness conditions^6–8.

Vaccines are the main component in the implementation of immunization and are proven to be an effort to prevent infectious diseases and have an impact on improving public health. Vaccines themselves make a high contribution to the protection of children by providing immunity so that children are not exposed to infectious diseases so that they can inhibit the development of infectious diseases and reduce morbidity, disability and death rates in society. However, the Indonesian government itself is facing the complex problem of how it can optimize a potential vaccination program, given national budget constraints. Empirical evidence shows that vaccination integration faces several barriers related to acceptance and willingness to pay for vaccines, due to high costs, negative attitudes towards vaccines and fear of side effects of vaccines by parents. Seeing this situation, it is necessary to analyse what factors can directly influence parents' acceptance of the dengue vaccine in Southeast Sulawesi^9–14.

MATERIALS AND DESIGN:

Research Design:

The Multi-centre Cross Sectional approach was carried out on parents in 5 districts/cities spread across Southeast Sulawesi province, those are South Konawe Regency, Wakatobi Regency, Muna Regency, Kendari City, and Bau-Bau City with the survey location is posyandu which was held by each Community Health Centers in each region in September–October 2023. The sample was selected using a convenience sampling technique with the inclusion criteria being parents who had children aged 5 years and under, lived in the research area, were able to communicate well, and agreed to participate in the research. The sample size was determined based on the Lemeshow formula with a confidence level of 95% so that a minimum sample size of 100 respondents was obtained for each district/city with a total number of respondents of at least 500 and 640 participating respondents.

Ethical Statement:

This research has received approval from the Health Research Ethics Commission (KEPK) of Southeast Sulawesi Province with EC number 127/KEPK-IAKMI/IX/2023 and is accordance with the provisions of the Declaration of Helsinki. The details of the research were explained to all respondents. The informed consent sheet was used as a consent form indicating that the respondent was willing to participate and provide written information in the research.

Research Instruments:

The instrument that was used in this research was a modified questionnaire and collected via Pubmed, Google Scholar, Science Direct and others. This research questionnaire was modified from previous similar studies including^9,15–20(Salam et al., 2020;Sunny et al., 2018; Yaita et al., 2018; Nahimana et al., 2017; Getachew et al., 2018; Sadeq and Jabar, 2017; Punarva, 2016) ^9,15–20. All questions about knowledge regarding to the dengue vaccine and dengue fever which can be prevented with the vaccine have been developed into question items to measure the level of knowledge consisting of 13 closed questions and divided into 8 aspects, namely; aspects of disease causes, aspects of disease transmission, aspects of disease impacts, aspects of disease prevention, aspects of risk factors, aspects of side effects of the dengue vaccine, aspects of contraindications and aspects of the vaccine program. In this section, statement items consist of favorable statements which are positive and unfavorable statements which are negative. Meanwhile, the acceptance level question consists of 9 questions divided into 4 aspects, namely; aspects of the benefits of typhoid vaccine, safety aspects of typhoid vaccine, aspects of risk factors and aspects of program financing.

Content Validity Test:

In this research, content validity and face validity tests were used. The element assessed in this validity test is the suitability of the statement being measured by scale of 1 (not relevant), 2 (slightly relevant), 3 (quite relevant), and 4 (very relevant).

Face Validity Test:

The research was done with the aimed to find out which statement items the respondents did not understand or were difficult to understand. The questionnaire was distributed to 10 respondents for trial and then the respondents provided the input and the suggestions regarding to the statement items that were not understood and were difficult for the respondents to understand. The revised results of face validity were tested for validity again by experts and then the experts were free to assess whether this instrument is valid or not. An instrument would be declared as valid if the experts had accepted the instrument both in content and format without any revisions. If after revision the experts still ask for improvements, then the revisions still need to be carried out until the experts actually accept the instrument without any further improvements.

Data Analysis:

Data were analysed by using IBM SPSS Statistics 26 with descriptive and inferential analysis methods. To analyse sample characteristics, descriptive analysis was used where the analysis describing the entire research sample data in the form of sociodemographic data, knowledge data and acceptance data. Knowledge and acceptance values are obtained from each respondent's answer score. It is high if the value was > average and it is low if the value is ≤ the average value. The inferential analysis used was Chi-square to look at factors that influenced respondents' acceptance and knowledge across sociodemographic and level of knowledge of dengue fever and dengue vaccine with significance value determined based on p value <0.05.

RESULTS:

1. Sociodemographic Characteristics, Experiences, and Knowledge Level of Dengue Fever Disease and Vaccine of Respondents in Southeast Sulawesi:

The research was conducted during the 5 September - 5 October 2023 in Southeast Sulawesi Province which is spread across South Konawe Regency, Kendari City, Wakatobi Regency, Bau-Bau City and Raha Regency. Overall, 642 respondents were participated in the research. The majority of respondents were 574 (86.4%) women with an average age of 32.8 years, 623 (97%) and had income below the Southeast Sulawesi Province Minimum Wage (UMP) 365 (56.9%).

Table 1. Distribution of Sociodemographic Characteristics, Experience, and Knowledge Level of Dengue Fever Disease and Vaccine of Respondents in Southeast Sulawesi

Characteristics

(n=642)

Age (Mean±SD)(32,8 ±6,4)

Young Adults (≤ 25 Years)

Middle Adult (> 25 Years)

589

Gender

Male

Female

574

10.6

86.4

Education

High (High School, College)

Low (No School, Elementary, Middle School)

504

138

78.5

21.5

Marriage Status

Married

Widow/Widower

623

97.0

3.0

Occupation

Working

Not Working

365

277

56.9

43.1

Income

< 2.758.985

> 2.758.985

152

490

23.7

76.3

Hearing About Dengue Fever

Yes

604

94.1

5.9

Experiencing Dengue Fever

Yes

235

407

36.6

63.4

Hearing About Dengue Vaccine

Yes

265

377

41.3

58.7

10.

Sources Of Information About Dengue Vaccine

Health Workers, Friends, Family

Information Media

264

378

41.1

58.9

11.

Knowledge Level

High

Low

335

307

52.1

47.8

Respondents' experience of dengue fever and dengue fever vaccine was quite diverse, where almost all respondents had heard of dengue fever as many as 604 (94.1%) and experienced directly or occurred in the respondents' neighborhood 235 (36.6%). However, most had never heard of the dengue fever vaccine at 377 (58.7%), and information media in the form of the internet, TV, newspapers, magazines, posters brochures became the source of information for respondents to find out about dengue fever and dengue fever vaccine at 378 (58.9%). The respondents' level of knowledge of dengue fever vaccine was quite high as many as 335 respondents (52.1%) had a high level of knowledge or above 71.1%.Adequate knowledge can have positive impact on parents' access to vaccine preventable infectious disease prevention services^9,21.

2. Characteristics of Respondents' Acceptance of Dengue Vaccine:

The results of data analysis on respondents' acceptance of the dengue vaccine showed that the average level of acceptance of the dengue vaccine was quite good as 71.1%. Respondents said that the government should be able to cover dengue vaccination as shown by the number of respondents who agreed as 93.8% and 75.2% were willing if their children were given the dengue vaccine. Respondents were also able to reach the price of the dengue fever vaccine, however, there were respondents' concerns about the pork content in the dengue fever vaccine being 60%.

Table 2. Description and Average of Respondents' Acceptance of the Dengue Vaccine

No	Statement	Strongly Agree (%)	Agree (%)	Disagree (%)	Strongly Disagree (%)
1.	Q1	16 (2.5)	58 (9.0)	428 (66.7)	140 (21.8)
2.	Q2	35 (5.5)	257 (40.0)	303 (47.2)	47 (7.3)
3.	Q3	12 (1.9)	112 (17.4)	427 (66.5)	91 (14.2)
4.	Q4	14 (2.2)	198 (30.8)	344 (53.6)	86 (13.4)
5.	Q5	3 (0.5)	37 (5.8)	364 (56.7)	238 (37.1)
6.	Q6	9 (1.4)	242 (37.7)	272 (42.4)	119 (18.5)
7.	Q7	76(11.8)	309 (48.1)	207 (32.2)	50 (7.8)
8.	Q8	16 (2.5)	143 (22.3)	405 (63.1)	78 (12.1)
9.	Q9	11 (1.7)	85 (13.2)	465 (72.4)	81 (12.6)
Acceptance Score		n	Minimum	Maximum	Mean ± SD
Acceptance Score		642	50	100	71.1 ±7.6

Table 3. Impact of Sociodemographic, Experience, Level of Knowledge on Respondents' Acceptance of the Dengue Vaccine

Independent Variable

Acceptance

AOR with 95% Cl

P-Value

Low

High

Age

Young Adults (≤ 25 years)

Middle Adult (> 25 years)

642

21 (3.3)

279 (43.5)

32 (5.0)

310 (48.3)

0.7 (0.4–1.3)

0.279

Gender

Male

Female

642

30 (4.7)

270 (42.1)

38 (5.9)

304 (47.4)

0.9 (0.5–1.5)

0.648

Education

High (high school, college)

Low (No School, Elementary, Middle School)

642

229 (35.7)

71 (11.1)

275 (42.8)

67 (10.4)

0.8 (0.5–1.1)

0.213

Marriage Status

Married

Widow/Widower

642

287 (44.7)

13 (2.0)

336 (52.3)

6 (0.9)

0.4 (0.1–1.1)

0.054

Job

Working

Not Working

642

167 (26.0)

133 (20.7)

198 (30.8)

144 (22.4)

0.9 (0.7–1.2)

0.570

Income

> Regional Minimum Wage

< Regional Minimum Wage

642

55 (8.6)

245 (38.2)

97 (15.1)

245 (38.2)

0,6 (0.4–0.9)

0.003*

Hearing About Dengue Fever

Yes

642

282 (43.9)

18 (2.8)

322 (50,2)

20 (3.1)

1.0 (0.5–1.9)

0.935

Experiencing Dengue Fever

Yes

642

106 (16.5)

194 (30.2)

129 (20,1)

213 (33,2)

0.9 (0.7–1.3)

0.531

Hearing About Dengue Vaccine

Yes

642

108 (16.8)

192 (29.9)

157 (24.5)

185 (28.8)

0.7 (0.5–0.9)

0.013*

10.

Sources of Information

Health Workers, Friends, Family

Information Media

642

99 (15.4)

201 (31.3)

165 (25.7)

177 (27.60)

0,5 (0.4–0.7)

0.000*

11.

Knowledge Level

Low (< Mean 71,1)

High (≥ Mean 71,1)

642

163 (25.4)

137 (21.3)

144 (22.4)

198 (30.8)

1.6 (1.2– 2.2)

0.002*

(*) P Significance < 0,05

AOR = Adjust Odds Ratio

Cl = Confidence Interval 95%

Table 5. shows the determinant factors that influence acceptance of the dengue vaccine. The results of statistical tests show that the income, hearing about dengue vaccine, sources of information about dengue vaccine and the level of community knowledge impacted the level of vaccine acceptance with a p value <0.05.

DISCUSSION:

This study aims to analyze the determinant factors that directly influence the acceptance of the dengue fever vaccine based on sociodemographic characteristics, experience and level of knowledge among parents in Southeast Sulawesi. The research results showed that the majority of parents had good acceptance of the dengue fever vaccine, namely around 77.1%. In this study, mothers are the parties who influence their children's vaccination status. It can be seen from the total respondents, mothers representing 574 (86.4%).This strengthens the results of previous research in Indonesia which stated that women use puskesmas more often and intensively than men.Other published research also states that women pay more attention to dengue fever than men because of their economic and emotional nature²³.This research showed that the majority of respondents who visit posyandu are in the age group > 25 years. This is because some of them do not work, so they have free time to take their children to participate in posyandu activities.

In the context of respondents' experience, almost all respondents had heard of dengue fever. Respondents' experience of the disease can affect attitudes and knowledge of the disease so as to increase better awareness for preventive measures²³.

This research also reported that there are significant differences in the level of knowledge between respondents in each region. The highest percentage was reported to be around 79% in Wakatobi Regency and the lowest was around 67% in South Konawe Regency. It can be underlined that respondents' knowledge is varies in each region with different demographic and epidemiological characteristics, so that specific motive and preventive actions need to be taken to improve the prevention and control of dengue fever which means that specific health promotion and dengue prevention strategies need to be implemented in various regions²⁴. In addition, previous research states that knowledge has an impact on dengue prevention practices. Therefore, public knowledge data would be useful for the government to plan, to design and to initiate the dengue control programs. This is important because knowledge about dengue fever will have a significant and positive impact on dengue prevention practices, as reported in several published studies²⁵.

Vaccine acceptance rates were known varies over certain time intervals. Based on the results of this study, the respondent's income has a significant influence on vaccine acceptance (AOR = 0.6, 95% CI = 0.4–0.9; P = 0.003). Income is the basis for decision makers in receiving the dengue vaccine. Some respondents received the vaccine if part or all of the vaccination costs were borne by the government. Previous similar research also showed that the majority of respondents received vaccination but were hampered by low income²⁶. This is also proven by some respondents who think that the price of vaccines is expensive, so they could not reach it. However, in this study, respondents accepted vaccination because of the huge benefits of it even though the price was expensive.

The experience is gained from the effectiveness and safety of vaccines in general is a factor in public acceptance of dengue fever vaccination. This experience can build a positive opinion about receiving vaccination³. The previous research stated that experience can be the basis for decision making to vaccinate as preventive action²⁷.

In our research, social media, television and the internet were the main sources of information in terms of frequency of accessing news about vaccine. A similar study conducted by Heriyanto et al., (2023)indicated that social media is the main source of accessing information about vaccines, while television and newspapers are popular choices for those who are offline. The source of this information can determined community in accepting or rejecting of vaccines, so it is important to disseminate transparent and accurate information about the safety and efficacy of vaccines to gain community trust, especially those who are doubtful and sceptical²⁹. However, when the community was asked about the most trusted source of information, health service providers are the most trusted source of information for the community to be aware of the enormous benefits of vaccines. Similar research also stated that trust in health workers was the most important thing in accepting vaccination^28,29 .

Respondents who had higher knowledge of dengue fever and the dengue vaccine have a higher chance of receiving dengue vaccination. Previous research states that high knowledge has a higher chance of receiving vaccination than respondents who have low^30,31. Thuss, the government and health workers needed to increase knowledge through outreach to educate people who had low knowledge about the importance of dengue vaccination so that they can increase willingness to receive the vaccine. Previous research also confirms that knowledge will influence acceptance of dengue vaccination³².

CONCLUSION:

This research provided an overview and factors that impact parents' knowledge and acceptance of the dengue vaccine in Southeast Sulawesi. The research data overall showed that the average parental acceptance of the dengue vaccine in Southeast Sulawesi was 71.1%. There were several determining factors that impact parents to receive the dengue vaccine, those were income, experience of hearing about dengue vaccine, source of information and level of knowledge with p value <0.05. Acceptance of the dengue vaccine is very high among the parents who had incomes above the regional minimum wage.

CONFLICT OF INTEREST:

There is no conflict of interest in this research.

ACKNOWLEDGMENTS:

Acknowledgments to the Ministry of Education and Culture for supporting funding for this research.

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Received on 24.10.2023 Revised on 20.04.2024

Accepted on 31.08.2024 Published on 24.12.2024

Available online from December 27, 2024

Research J. Pharmacy and Technology. 2024;17(12):5937-5943.

DOI: 10.52711/0974-360X.2024.00900