Knowledge and practice of vaccination logistics management among primary health care workers in Nigeria

ABSTRACT

Vaccines are highly thermo-sensitive materials whose potency requires a functional cold chain system which is dependent on the ability of health care workers to effectively manage the system toward eliminating vaccine-preventable diseases.

This study assessed knowledge and practice of vaccination logistic management systems among primary health care workers in Osun state Nigeria.

It was a descriptive cross-sectional study among 180 randomly selected health care workers who took part in a larger study on the design and pretesting of vaccine cold chain (VACOC) coolers. Research instruments were self-administered semi-structured pretested questionnaire that was analyzed using the SPSS version 23.0.

The mean age was 36.7 ± 8.9 years, 87 (48.3%) could correctly explain the vaccination logistic management system, 132 (73.3%) had been trained on the system, 129 (71.7%) could assemble the ice packs used in the vaccine career box, 135 (75.0%) could assemble the vaccines, while 145 (80.6%) could assemble the diluents and thermometer. One hundred and fifty-one (83.9%) and 146 (81.1%) were found to have good knowledge and attitude to the management systems, respectively. Spending more than 5 years in profession, being a male, being a Community Health Officer were significant predictors of having a good practice of immunization logistic management system.

Some gaps in knowledge, attitude, and practice of vaccination cold chain logistic system still exist among studied respondents, and these should be addressed by stakeholders in immunization programs.

KEYWORDS:

• Immunization
• vaccination
• logistic management system
• nigeria
• health care workers

Introduction

The development, trial, and deployment of vaccines to prevent vaccine preventable diseases is the greatest achievement of public health in the last century.^1,2 Vaccine-preventable diseases (VPDs) are responsible for nearly 20% of the 8.8 million deaths per year among children under-5 years,³ mostly preventable deaths from diarrheal diseases, pneumonia, and measles, which accounts for 40% of all deaths among under-five children in Nigeria.⁴ Several strategies were adopted to achieving this objective including provision of door to door vaccination services.⁴

Vaccines are thermo-sensitive and have a fixed shelf life with possible loss of viability over time.⁵ This loss is irreversible and accelerated if proper storage and temperature conditions are not maintained.⁶ Thus, vaccines require a well-functioning cold chain system that ensures maintenance of potency at all timepoints, including during house-to-house vaccination programs.⁷ The ‘cold chain’ is a system of storing and transporting vaccines at recommended temperatures from the point of manufacture to the point of use.⁸ It consists of a series of links that are designed to keep vaccines within WHO-recommended temperature ranges, from the point of manufacture to the point of administration. To maintain a reliable vaccine cold chain at the peripheral level, vaccines and diluents must be stored within the required temperature range at all sites, they should be packed and transported to and from outreach sites according to recommended procedures (use of cold boxes and vaccine carriers containing ice packs) and they must be kept within recommended cold chain conditions during vaccination sessions.⁹ In Nigeria, the National Primary Health Care Development Agency (NPHCDA) is saddled with the responsibility of ensuring vaccine availability and adequate immunization coverage through routine vaccine supply and supportive supervision of health care workers involved in vaccination services.⁴

In some settings in Nigeria, many health facilities offer vaccination services without adequate knowledge of vaccine administration and management. Whether VPDs prevalence would reduce or not depends on the quality of vaccination services^5,7 and these are related to several factors including adequate knowledge among health workers regarding cold chain management.⁴ Good knowledge of the cold chain management systems, the equipment and methodology would go a long way in assisting immunization programs in Nigeria. The goal of the study is therefore to assess the knowledge and practice of vaccination logistic management systems among primary health care workers in Osun state, Nigeria.

Materials and methods

Study area

Osun state is in Southwestern Nigeria with a population of about 3.5 million people divided among 30 local government areas (LGAs). The immunization coverage rate was 57.8% which is short of the recommended 80% WHO target for immunization,¹⁰ while the under 5 mortality rate in Osun state stood at 68 deaths per 1000 live birth, which is comparable to the national average.¹⁰ Door to door immunization was among the prominent intervention being implemented to boost immunization at State level and most of these are being implemented at primary health care level.

Study design

The study was a descriptive cross-sectional survey.

Study population

Study population were health care workers (HCWs) at the primary health level of care who participated in a larger study on the design and pretesting of vaccine cold chain (VACOC) coolers sponsored by Tertiary Education Trust Fund (TETFund) in Nigeria. Criteria for being included in the study was that the HCW must have taken part in immunization field work in the past and have stayed not less than 1 year in their current place of work.

Sampling method

The sample size was calculated using Leslie Fishers formula for population less than 10,000,¹¹ and the prevalence of HCWs (87.2%) who had knowledge that temperature changes alter vaccine effectiveness from a previous study.¹² A minimum sample of 166 was calculated; this was however increased to 180 to cater for improperly completed questionnaire and non-responses.

Sampling

A total of 15 out of the 30 LGAs in the State were randomly sampled employing simple balloting. The 12 health care workers per LGA who took part in the VACOC trials and met the inclusion criteria were serially recruited at one of the preparatory LGA level meeting as they arrived for the meeting.

Research instrument

A semi-structured pretested questionnaire that was divided into 4 sections to cover personal data, knowledge, attitude, practice, and determinants of practices was self-administered to the respondents. Questions related to knowledge were scored accordingly with Score 1 given to right knowledge for those with “Yes” response and Score 0 given to wrong knowledge for those with “No” response. Total score on knowledge was computed and mean score determined. Respondents with scores equal to and above the mean were classified as having adequate knowledge, while those below the mean score were classified as having inadequate knowledge. A similar scoring was done to “practice and attitude”. Data were collected before exposure of respondents to the VACOC coolers study and before given health education on immunization logistic. The data were therefore collected at the first LGA level preparatory meetings.

Ethical approval

The ethical approval to conduct the study was obtained from Osun State University research ethics committee. Participation for the study was clearly made to be voluntary.

Data analysis

Data were entered into the computer system and analyzed using SPSS software version 23.0 after data cleaning. Univariate data were presented as tables and charts. Logistic regression was carried out to demonstrate strength of association between selected socio-demographic data and outcome variables of interest. P value was considered significant at levels equal to or less than 0.05 for all inferential analysis.

Results

The questionnaires were administered to 180 respondents and they all participated in the study, thus giving a response rate of 100%.

The mean age of respondents was 36.7 ± 8.9 years, with the majority [80 (44.4%)] being 30–39 years while the age group 50–59 years were the least numbers of participants [20 (11.1%)]. One hundred and fifty-six (86.7%) were females, and 165 (91.7%) were married. Most of the respondents [93 (51.7%)] were Junior Community Health Extension Workers (JCHEW), 119 (66.1%) have practiced for 1–6 years and 128 (71.1%) were practicing in urban region (Table 1).

Table 1. Socio-demographic data of respondents

Variable	Frequency (n = 180)	Percentage (%)
Age in years
Mean ± SD	36.7 ± 8.9
20–29 yrs	37	20.6
30–39 yrs	80	44.4
40–49 yrs	43	23.9
50–59 yrs	20	11.1
Sex
Male	24	13.3
Female	156	86.7
Designation
Public Health Nurse	29	16.1
JCHEW	93	51.7
SCHEW	38	21.1
CHO	20	11.1
Marital Status
Never Married/Single	15	8.3
Ever Married	165	91.7
Years of Practice
Mean ± SD	4.8 ± 2.5
1–5 yrs	119	66.1
6–10 yrs	57	31.7
11–15 yrs	4	2.2
Location of Practice
Urban	128	71.1
Rural	52	28.9

Abbreviations: PH Nurse – Public Health Nurse, JCHEW – Junior Community Health Extension Worker, SCHEW – Senior Community Health Extension Worker, CHO – Community Health Officer.

Table 2 shows the vaccine logistics management systems practice by the healthcare workers. Eighty-seven (48.3%) could explain the system, 143 (79.4%) have participated in house to house immunization exercise in the past, and 132 (73.3%) had been trained on the logistics system. A hundred and twenty-nine (71.7%) could assemble the ice packs used for the cold chain maintenance, 135 (75.0%) could assemble vaccines, and 145 (80.6%) could assemble the diluents used for the vaccines.

Table 2. Pattern of practice of vaccine logistics management systems

Variable	Frequency (n = 180)	Percentage (%)
Could explain it Yes No	87 93	48.3 51.7
Have taken part in house to house before Yes No	143 37	79.4 20.6
Had training on Logistics Yes No	132 48	73.3 26.7
Could assemble the ice packs Yes No	129 51	71.7 28.3
Could assemble vaccines Yes No	135 45	75.0 25.0
Could assemble diluent / others Yes No	145 35	80.6 19.4

In Figure 1, the scoring for the knowledge and practice of vaccine logistics management systems was shown. One hundred and fifty-one (83.9%) respondents were found to have good knowledge of vaccine logistics management systems, and 139 (77.2%) have good practices. One hundred and forty-six respondents (81.1%) were also found to have good attitude to vaccine logistic management system.

Figure 1. Knowledge, attitude, and practice scores of logistic management systems

The association between the sociodemographic characteristics of respondents and knowledge of vaccine logistics management systems is shown in Table 3. More proportion of respondents in the age group 20–29 years (94.8%) had significantly good knowledge compared to other age groups (p = .01). All the Senior CHEW (SCHEW) and Community Health Officers (CHO) had good knowledge compared to the JCHEW and Public Health Nurses, while a larger proportion of those practicing in the urban areas were also found to have good knowledge compared to those practicing in the rural areas. The differences were significant (p < .05).

Table 3. Predictors of knowledge of logistics management systems

VARIABLES	Knowledge of logistics
	Poor n (%)	Good n (%)	Pearson Chi-Square	df	P-value (P)	Odd Ratio	95% CI
							LCI	UCI
Age in years 20–29yrs^R 30–39 yrs 40–49 yrs 50–59 yrs	2(5.4) 12(15.0) 7(16.3) 8(40.0)	35(94.8) 68(85.0) 36(83.7) 12(60.0)	11.66	3	0.01*	0.18	0.04	0.74
Sex Male^R Female	7(29.2) 22(14.1)	17(70.8) 134(85.9)	3.49	1	0.06	3.00	1.07	8.43
Designation PH Nurse^R JCHEW SCHEW CHO	4(13.8) 25(26.9) 0(0.0) 0(0.0)	25(86.2) 68(73.1) 38(100.0) 20(100.0)	19.24	3	<0.001*	2.31	0.35	15.11
Marital Status Never Married^R Ever Married	4(26.7) 15(15.2)	11(73.3) 140(84.8)	1.35	1	0.25	2.19	0.62	7.72
Year of Practice 1–5 yrs^R 6–10 yrs 11–15 yrs	24(20.2) 5(8.8) 0(0.0)	95(79.8) 52(91.2) 4(100.0)	4.49	2	0.11	3.31	1.35	8.11
Location of Practice Urban^R Rural	25(19.5) 4(7.7)	103(80.5) 48(92.3)	3.84	1	0.05*	2.95	0.95	9.13

*Significant, Reference category^R.

Abbreviations: PH Nurse – Public Health Nurse; JCHEW – Junior Community Health Extension Worker; SCHEW – Senior Community Health Extension Worker; CHO – Community Health Officer.

Table 4 shows the association between the sociodemographic characteristics of respondents and the practice of vaccine logistics management systems. More community health officers were found to have practiced vaccine logistics management systems significantly more than the other cadres (p = .03). Likewise, health care workers who have spent more than 5 years in practice and being a male health care worker were significant predictors of good practice of immunization logistic management system.

Table 4. Predictors of practice of logistics management systems

VARIABLES	Practice of vaccine logistics management
	Poor n (%)	Good n (%)	Pearson Chi-Square	df	P-value (P)	Odd Ratio	95% CI
							LCI	UCI
Age in years 20–29yrs^R 30–39 yrs 40–49 yrs 50–59 yrs	5(13.5) 23(28.8) 7(16.3) 6(30.0)	32(86.5) 57(71.3) 36(83.7) 14(70.0)	5.05	3	0.17	0.45	0.11	1.86
Sex Male^R Female	7(29.2) 34(21.8)	17(70.8) 122(78.2)	0.64	1	0.42	1.52	0.58	4.01
Designation PH Nurse^R CHEW SCHEW CHO	4(13.8) 29(31.2) 7(18.4) 1(5.0)	25(86.2) 64(68.8) 31(81.6) 19(95.0)	9.07	3	0.03*	3.34	0.33	33.96
Marital Status Never Married^R Ever Married	4(26.7) 37(22.4)	11(73.3) 128(77.6)	0.14	1	0.71	1.35	0.39	4.58
Year of Practice 1–5yrs^R 6–10 yrs 11–15 yrs	22(18.5) 19(33.3) 0(0.0)	97(81.5) 38(66.7) 4(100.0)	6.04	2	0.05*	1.57	0.25	1.27
Location of Practice Urban^R Rural	29(22.7) 12(23.1)	99(77.3) 40(76.9)	0.004	1	0.95	0.97	0.45	2.10

*Significant, Reference category^R.

Abbreviations: PH Nurse – Public Health Nurse; JCHEW – Junior Community Health Extension Worker; SCHEW – Senior Community Health Extension Worker; CHO – Community Health Officer.

Discussion

The importance of a functional vaccination logistic system with efficient and technical health care workforce to manage it cannot be over emphasized. About two-thirds of the respondents in our study were 20 to 39 years old., like another study.¹³ Eight out of ten were also found to be females. This is in keeping with the World Health Organization’s Health Workforce Working paper where women were found to form 70% of workers in the health and social sector.¹⁴

Our study showed that 70% of respondents had undergone training on vaccine logistics management system. This finding is in line with a similar study conducted among health workers in primary health-care facilities Edo state, Nigeria.¹⁵ However, another similar study carried out in North-western part of Nigeria had about 6 out of 10 of the respondents to have been trained on cold chain management.¹² This difference may be due to the varying years of practice of the respondents in the two studies;^12,15 the mean years of practice in our study was 4.8 years, while that of the North-western study was 2.5 years. Healthcare workers are likely to be exposed to trainings as they stay more on their jobs. Even though, majority of the respondents in our study have been trained on vaccine logistics management and have taken part in house to house immunization programs in the past, less than half of them could explain the cold chain system properly. Regular hands-on training is very important as this will give healthcare workers an opportunity to obtain up-to-date information on cold chain management in line with the world’s best practices and be able to step down the training by explaining it to others.

About four-fifth of the respondents in this study were found to have good knowledge about the cold chain system. This is not surprising as similar proportion of respondents were found to have undergone training. However, in the Edo State study by Ogboghodo et al,¹⁵ only about a third of the respondents had an overall good knowledge of cold chain management. In the Edo study, more technical questions such as knowledge of freeze sensitive vaccines and heat-sensitive vaccines were asked and used to calculate knowledge score, and this may account for the difference compared to our study.

Age was found to be a determinant of knowledge of cold chain management in our study as knowledge decreases with increase in age. A plausible reason for this may be that the time that the older age groups were trained was longer while the training for the younger age group may be recent. Better knowledge on cold chain management has been associated with healthcare workers who had training recently (less than a year) compared to those whose training is not recent.¹⁵ Those practicing in the rural areas were also found to have better knowledge in our study. The usual poor power supply in the rural areas in Nigeria may make the healthcare workers practicing in this region to be more sensitive to the importance of maintaining cold chain, practice it more and have better knowledge.

The attitude of healthcare workers toward a health program determines the success or otherwise of the program. Cold chain management is not an exception as its success would also depend on the attitude of healthcare workers toward it.^12,16 Majority of the respondents in our study had positive attitude toward cold chain management. This is like findings from previous studies carried out in other regions of Nigeria.^12,15

Conclusion

Some gaps in knowledge and practice exist among the respondents studied. Thus, it is crucial for stakeholders in the vaccination program to prioritize stepping up the knowledge base of HCWs at the primary health care level. Improving the knowledge of HCWs could be in the form of formal training, on-the-job training, mentoring, and supportive supervision. Increasing the knowledge base of HCWs will move the country a step further toward addressing critical aspects of the sustainable development goals.

Limitations of the study

Since the study population were extracted from a larger survey funded by TETFund, the cadres of health care workers were only those working in Primary Healthcare facilities. Healthcare workers in private health facilities, secondary health facilities and tertiary health facilities were not part of the study.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Acknowledgments

The authors wish to thank the Local Government health authority of the selected LGAs used in data collection, and more importantly, the health care workers who willingly volunteered to participate in the data collection process.

The outcome of the larger study on the design and pretesting of vaccine cold chain (VACOC) coolers sponsored by Tertiary Education Trust Fund (TETFund) is yet to be published.