Millennials’ and Z Generation’s Knowledge on Child Immunization and the Role of Media in the Digital Era in Jabodetabek,Indonesia

Millennials and Gen Z: In Whom Our Future Holds

Around 67% of Indonesia population were born on 1980 and above, which categorized them into the millennials and Z generation. Indonesia’s economy depends on these generations where 52% of economy activity comes from them who are around 20 to 40 years old at the moment. The youngest age of a marriage according to law in Indonesia is 19 years old, where in 2019, 20 to 23 years old are the most common age. This data informs that in 5 to 10 years ahead, millennials and Z generation are becoming parents that carry the obligation to take care of their children’s health. The important decisions about our youngest populations, including the decision to vaccinate, will be soon depending on them.^3,7-10 Unless we can make reasonable projections, we cannot address or mitigate healthcare needs and health care demands for this key segment of our population. ¹¹

Vaccine Hesitancy

The definition of vaccine hesitancy referring to SAGE Working Group on Vaccine Hesitancy is the delay in acceptance or refusal of vaccination despite availability of vaccination services. This is a complex issue that varies across time, place and vaccine types. ¹² Vaccine hesitancy is included as one of the 10 threats to global health in 2019 according to World Health Organization (WHO) report. ¹³ In another blow, the COVID-19 pandemic threatens to set back hard-won global health progress achieved over the past 2 decades—in fighting infectious diseases, for example, and improving maternal and child health. ¹⁴ American Academy of Family Physicians (AAFP) cited that millennials give the most uncorrect answer on a questionnaire about vaccination knowledge in a research with 1500 subjects in the United States. From the same research, more than 50% of the subjects that agree about the anti-vaccine statements are also millennials. ⁸ No data was found yet about vaccine hesitancy in millennials and Z generation in Indonesia while this study shows that 357 (94.9%) subjects agree that basic immunization is crucial for children and they willing to fully vaccinate their children in the future. Most of them also are fully vaccinated (212 subjects, 56.4%) while some do not aware of their basic immunization status (147 subjects, 39.1% (Table 1). These findings are found similar between all education backgrounds.

In this study, Table 2 shows that subjects with complete basic immunization are more willing to fully vaccinate their future children (P .03, OR 22.6, CI (2.9-173.5)) and different source of health information does not affect this perception. The future of our children also depends on the situation of previous generation. Studies explained that biological, epidemiological, economic, and logistical are known to affect the achievement of immunization program. In the other hand, social-determinants such as parental education, financial support, parenting practice and cultural tradition also play role in low-middle income countries. ¹⁵ A published literature from a research done in 200 mothers whose child were 9 to 59 months in Pekan Baru, Indonesia found that Measles-Rubella immunization uptake increases with high maternal education, maternal knowledge, strong family support, high perceived susceptibility. ¹⁶

Most common reasons behind vaccine hesitancy were risk-benefit (scientific evidence), knowledge and awareness and religion/culture/gender/socio-economic, however data validity still needs to be improved since not many country are doing evaluation regarding this problem. ¹⁷

A Challenging Milestones for Health Promotion to the Digital Natives Generation

Online platform is the main information source for 357 (94.9%) subjects on this research (Table 1). Besides Instagram (129 subjects, 34.3%), search engine website is the most used platforms for the millennials and gen-Z to find information related to immunization and other medical conditions (96 subjects, 25.5%). Most subjects choose video (216, 57.4%) as the most convenient of information form followed by infographic posters (98, 26.1%). There is no difference between subjects’ and parent’s education background toward these findings (P > .05).

Health misinformation needs to be prevented by having a good digital literacy. This study shows that high school students are more at risk to be affected by others’ opinion compared with doing more research themselves about the account’s credibility while trusting online sources of health information; P .02, OR 3.6, CI (1.6-8) (Table 3). A research held by Harvard School of Dental Medicine and Northeastern University College of Social Sciences and Humanities acknowledge that the most influential online sources about immunization were the health community (National Institutes of Health, Centers for Disease Control and Prevention) or mainstream media (New York Times). It said that the vaccine-hesitant community simultaneously used primary pro-vaccine article within vaccine-hesitant narratives. ¹⁸ In Indonesia, The third International Conference on Transformation in Communication (ICoTiC 2017) mentions that 54 000 articles related to immunization on June-July 2016 are titled with misleading headlines according to Indonesia Police Criminal Investigation Department (BARESKRIM Polri). ¹⁹ These findings demonstrate an unsafe online environment where rules are not strict enough to prevent the media to mislead young populations and affecting their decision about health-related choices. Evidence based literature are available more in scientific platform with medical narratives that are not quite accessible for young or non-medical populations. On the other hand, vaccine-hesitant communities are still grow in numbers. ¹⁸

The importance of online media in the evolving medicine practice 4.0 should be a drive for all health related professionals to participate in improving the online environment. Indonesia still needs to improve the legal policy that restrict online health misinformation. A specific digital policy can be collaborated with technology innovations where strict restriction and blockage of online health misinformation was done by the server itself through keywords analyzing. ²⁰ Indonesia Ministry of Health mentioned that medical professionals need to be prepared with a more complex competency such as data and technology literation and equipped with interprofessional knowledge to build an interdisciplinary health care services in the digital era.^21,22

Other than media, high school students compared with university students and workers aged group are more likely to trust health information from family members although they do not have medical background; P .01, OR 2.7, CI (1.5-4.8). Attention to improve the delivery of health promotion and medical practice needs to start soon with an agility that fits the evolving generations, therefore they can become a prepared parents in the following decades. Millennials and Z generation was raised in a constant state of connectedness through the Internet, smartphones, and fast-moving digital technology but they are also more individualistic and diverse in values. This unique characteristic may make it difficult for them to engage with traditional health communication culture. Literature suggests the SHAPE frameworks which consist of Seek to understand, Humbly communicate, Authentic, Partner with others and Engage in future thinking to prevent the pitfalls in communicating with the digital natives generation. ⁹ International Training of Trainers of International Pediatric Association (IPA) Vaccine Hesitancy Project 2018 addressed that community advocacy can be an effective tools to reach vaccine-hesitant populations. Deep research regarding the reasons behind this community and the cultural characteristic should be prepared continued with 3 main messages: the facts about the problems that we find in their community, the solution that we suggest to make their community better and the action we propose to be taken collaboratively with them.