|Year : 2016 | Volume
| Issue : 4 | Page : 1018-1024
Knowledge and practice of healthcare providers as regards routine children vaccination in primary healthcare facilities of Quewisna District, Menoufia Governorate
Hewaida M El Shazly1, Nora A Khalil2, Reda A Ibrahem1, Shaimaa A Abdel Wahed2
1 Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of Family Medicine, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
|Date of Submission||13-Jun-2015|
|Date of Acceptance||29-Sep-2015|
|Date of Web Publication||21-Mar-2017|
Shaimaa A Abdel Wahed
Department of Family Medicine, Faculty of Medicine, Menoufia University, Queswina El Balad in front of the Agriculture Society, Queswina, Menoufia, 32632
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess the knowledge and practice of healthcare providers (HCPs) as regards the safe practice during routine children vaccination in primary healthcare facilities.
Primary vaccine failures can occur after high immunization coverage has been achieved. Healthcare workers' knowledge and practices are influential factors in preventing vaccine failures. Adequate knowledge and practices in the cold chain system, as well as handling and administration of different vaccines, are important to maintain the potency of vaccines and effectiveness of immunization.
Participants and methods
This cross-sectional study included 140 HCPs and 14 primary healthcare units and one center in Quewisna District, Menoufia, Egypt. A self-administered questionnaire and observational checklist were applied to collect data. The questionnaire assessed the knowledge of HCPs about the storage, handling, administration, scheduling, doses, routes, and contraindications of the different vaccines routinely used for children under 5 years of age in primary healthcare facilities. The checklist assessed the practice of HCPs as regards cold chain, room layout, preparation for vaccination session, and general and specific practice related to each vaccine.
The total knowledge score was higher among high nurses (nurses with nursing bachelor degree) and HCPs who received training courses. The postvaccination practice was poor compared with prevaccination and during-vaccination practice.
According to these findings, the knowledge of HCPs as regards all vaccines is satisfactory, except for Hib vaccine. A regular training course to improve the HCPs' knowledge about immunization is highly recommended.
Keywords: cold chain, handling, immunization, knowledge, practice, vaccines
|How to cite this article:|
El Shazly HM, Khalil NA, Ibrahem RA, Abdel Wahed SA. Knowledge and practice of healthcare providers as regards routine children vaccination in primary healthcare facilities of Quewisna District, Menoufia Governorate. Menoufia Med J 2016;29:1018-24
|How to cite this URL:|
El Shazly HM, Khalil NA, Ibrahem RA, Abdel Wahed SA. Knowledge and practice of healthcare providers as regards routine children vaccination in primary healthcare facilities of Quewisna District, Menoufia Governorate. Menoufia Med J [serial online] 2016 [cited 2020 Apr 2];29:1018-24. Available from: http://www.mmj.eg.net/text.asp?2016/29/4/1018/202507
| Introduction|| |
Vaccination has proved to be one of the most cost-effective part of health promotion . Success of immunization includes worldwide eradication of smallpox, control of poliomyelitis with hopes of eradication, and elimination of indigenous measles and rubella . The incidence of most other vaccine-preventable diseases, excluding pertussis and tetanus, has shown a reduction of at least 99%, compared with the annual morbidity before development of the corresponding vaccine .
Immunizations are a cornerstone of public health. The WHO estimates that, in 2006, immunizations saved two to three million lives. Nonetheless, in that same year 1.4 million children are estimated to have died from vaccine preventable diseases (measles, Haemophilus influenza type B, pertussis, tetanus, yellow fever, and poliomyelitis), a reflection of incomplete coverage with existing vaccines that persists in many parts of the world .
Health authorities in Egypt have also taken important steps to strengthen the immunization coverage. These steps include bolstering of the cold chain, introduction of vaccine vial monitors used both routine immunization and campaigns, preparation of local registers based on frequent community census, strengthening of the system for defaulter tracing, vaccine potency testing, and the conduct of sero surveys .
Public concerns about the safety of vaccines have grown significantly. Immunization safety programs are an important component of maintaining the public trust in our national immunization program. Close monitoring of vaccine safety also protects the public's health and contributes to safer vaccines and vaccination practices .
Appropriate vaccine administration is essential for the optimal safety and efficacy of vaccines. Vaccine administration practices are based on clinical trials that determine the dose, route, and schedule for each vaccine. Professional standards for medication, vaccine administration, and procedures also guide vaccination practices .
| Aim of the Work|| |
The aim of this study was to assess the knowledge and practice of healthcare providers (HCPs) about the safe practice during routine children vaccination.
| Participants and Methods|| |
Type of study
The study protocol was reviewed and formally approved by ethical committee of Faculty of Medicine, Menoufia University.
Time of study
The study was conducted in the context of time frame of 13 months (starting from first of April 2014 to the end of May 2015).
Fifteen healthcare facilities (14 rural units and one urban center) were chosen randomly out of the 30 healthcare facilities in Quewisna District selected using the simple random sampling technique.
Participants and methods
The study was conducted using a predesigned questionnaire and observational checklist to assess the knowledge of HCPs and practice of the studied primary care facilities in Quewisna District,
Menoufia Governorate. The practical part was in a period of 3 months (from first of May 2014 to the end of July 2014).
The structured interviewing questionnaire for HCPs covered the following items:
- The first part included the sociodemographic characteristics of HCPs such as age, sex, education, qualification, duration of experience, and previous courses, which is composed of seven items
- The second part included HCPs' knowledge related to different vaccines routinely used for children under 5 years of age in primary healthcare facilities oral polio vaccine (OPV), tuberculosis vaccine (BCG), diphtheria, pertussis (whooping cough), and tetanus (DPT), hepatitis B vaccine (HBV), mumps, measles and rubella (MMR), Haemophilus influenzae pe b (Hib). It was composed of questions such as dose, route, and time of administration of each vaccine, contraindications, and storage of the vaccines.
The observation checklist was developed for the purpose of assessing HCPs' practice in relation to vaccination procedures.
- The first part included 16 items related to cold chain and storage of vaccines
- The second part included five items related to the room layout and supplies needed for vaccination
- The third part included five items related to preparation for vaccination session
- The fourth part included four items related to general practice related to all vaccines
- The fifth part included 15 items to evaluate the practice of each vaccine individually (BCG, DPT, HBV, Hib, MMR, and OPV)
- The sixth part included two items related to postvaccination practice.
The data were collected, tabulated, and analyzed using SPSS (Statistical Package for Social Science) version 17.0 on IBM compatible computer (SPSS Inc., Chicago, Illinois, USA).
Two types of statistics were performed
- Descriptive statistics [e.g., percentage (%), mean and SD].
- Analytic statistics included the following tests.
- The χ2-test was used to study the association between two qualitative variables.
- The t-test is a test of significance used for comparison between two groups normally distributed having quantitative variables.
- The Kruskal–Wallis test, a nonparametric test of significance, was used for comparison between more than two groups not normally distributed having quantitative variables.
- Spearman correlation (r) is a test used to measure the association between two not normally distributed quantitative variables or one quantitative and one qualitative ordinal variable.
P value of less than 0.05 was considered statistically significant.
Total score of 50% or more was satisfactory.
| Results|| |
The majority of the sample (88.6%) comprised female population and 66.4% of them were nurses. Only 11.4% of them worked at vaccination room ([Table 1]).
The percentage of knowledge of HCPs about different vaccines as regards time, dose, and route of administration, storage, and contraindications are high, except for Hib vaccine knowledge, which was less than that for the other vaccines ([Table 2]).
There was a satisfactory level of knowledge for all vaccines except for Hib vaccine
|Figure 1: Level of knowledge of healthcare providers as regards each vaccine.|
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The total knowledge level was very good, good, poor, and fair in 30, 29, 22, and 19% of the studied HCPs, respectively [Figure 2].
|Figure 2: Total knowledge level of healthcare providers about all vaccines.|
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The total knowledge score was higher among high nurses and HCPs who received training courses (P < 0.05) ([Table 3]).
|Table 3 Relationship between total knowledge score and demographic characters of the studied healthcare providers|
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There was a significant negative correlation between total knowledge score and duration since last courses (P = 0.003) [Figure 3].
|Figure 3: Relationship between total knowledge score and duration since last training course.|
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The prevaccination and during-vaccination practice was good, whereas postvaccination practice was poor (P < 0.001)
|Figure 4: Practice level of vaccination among the studied units and center.|
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All practices as regards cold chain were carried out by 100% of the HCPs, except for the right place and position of refrigerator, which was found in 93.3% of the studied healthcare facilities ([Table 4]).
|Table 4 Practice of the studied healthcare facilities as regards cold chain measurements|
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The practice of the studied group concerning room layout and general measures for vaccination were 100%, whereas for preparatory steps there were only 26.7% of them who asked about contraindication and explained about nature of the vaccines and the disease prevented by it
|Table 5 Practice of the studied healthcare facilities as regards room layout, preparatory steps, and general measures for vaccination|
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The practice of the studied group as regards proper administration of different vaccines was good, whereas the instructions that should be given for caregivers after vaccination were poor ([Table 6]).
|Table 6 Practice of the studied healthcare facilities as regards specific measures for each vaccine|
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| Discussion|| |
As regards the knowledge of HCPs about storage sites of different types of vaccines, the majority of them showed satisfactory knowledge about proper sites of vaccines' storage in the refrigerator (89.3, 84.3, 79.3, 87.9, 79.3, and 77.9% for OPV, BCG, DPT, HBV, MMR, and Hib vaccines, respectively). These results are in agreement with the study by Esa et al. , who studied 80 nurses in Zagazig city, Sharqiua, to assess their performance in vaccination session and reported that the majority of their participants had high knowledge about sites in the refrigerator of 100, 81.2, 73.8, and 85% for OPV, DPT, MMR, and HBV vaccines, respectively. However, their knowledge as regards BCG vaccine storage in the refrigerator was 5% only. Moreover, a study conducted in Benishangul Gumuz region (Ethiopia) showed that 83.1% of respondents knew the recommended temperature range for storage of vaccines .
Our participants reported that the sensitivity of DPT and HBV vaccines to freezing were 88.6 and 86.3%, respectively, and 82.7% of our HCPs stated that OPV is the most sensitive vaccine to heat, whereas only 67.1 and 68.4% of HCPs stated that direct light spoil BCG and MMR vaccines, respectively. Our results were better than that reported by Rogie et al. , who studied 116 health workers included to assess cold chain status for immunization in central Ethiopia; they documented that 44.8, 21.6, and 50% of health workers had knowledge on which vaccines were most sensitive to heat, extreme cold, or light, respectively. However, our results were similar to those of Noor et al. , who conducted their study on 89 practitioners in Kelantan, Malaysia, to assess and document that the majority of respondents knew that vaccine will be spoiled if exposed to heat (98.8%) and frozen state (88.8%). Al-Ayed  illustrated that 86.5% of his participants were aware that DPT and HBV vaccines should not be kept frozen; this is in agreement with our findings. However, unfortunately, his result concerning the sensitivity of BCG vaccine to light, which was 96.5%, was better than our results.
The current work documented that most of the HCPs knew the proper dose and route of OPV, BCG, DPT, and HBV vaccines (98.6, 97.1, 87.1, and 95%, respectively). The same result was obtained by Al-Ayed  as 92 and 96.5% of his participants knew the proper dose and route of OPV and BCG vaccination, respectively. This similarity in both results was due to more interest to vaccination process in Egypt. These results were better than that reported by Widsanugorn et al. , who assessed the knowledge and practice of 117 healthcare workers and 90 primary care units (PCUs) as regards expanded program on immunization in Kalasin, Thailand; they reported that 78.6, 63.2, and 68.4% knew the proper dose and route of BCG, DPT, and HBV vaccines, respectively. Their results coincide with our results as regards the dose and route of MMR vaccine, which was 59% for both studies.
The current study revealed that receiving training courses has a significant effect on the total knowledge of HCPs about vaccination (P < 0.05). These results are in agreement with those of Widsanugorn et al. , who mentioned that trained healthcare workers had better knowledge compared with untrained healthcare workers, and, to ensure optimal immunization effectiveness, continuous training and regular supervision on EPI and the cold chain system are necessary.
This study documented that high nurses who had bachelor of nursing have better knowledge compared with nurses who had diploma of nursing, health workers, and physicians. This may be due to the high qualification and more practice about vaccination. This result is supported by Esa et al. , who reported the same results.
As regards the findings from direct observation about equipment and practices with respect to the cold chain system in PCUs, it was found that, in 100% of the studied PCUs, the temperature inside refrigerators was in the range of 2–8°C. Moreover, 100% of PCUs kept different vaccines on the normal sites of refrigerator, had a temperature chart and recorded the temperature inside the refrigerator twice daily, and had a flowchart about what to do in case of a power outage.
These results were better than those of Widsanugorn et al. , who found that in 86.7% of PCUs the temperature inside refrigerators was in the range of 2–8°C. A total of 95.6% of PCUs kept OPV on the freezer shelf, and 100% of PCUs kept DPT, DT, and HBV vaccines on the normal shelf. In all, 61.1% of PCUs had a temperature chart and recorded the temperature inside the refrigerator two times daily. Only 63.3% of PCUs had a flowchart about what to do in case of a power outage.
This study revealed that none of the studied units put food or other drugs rather than vaccines in the refrigerator. This result is in line with that of Noor et al.  and Al-Ayed , who illustrated that 97.8 and 97.5% of respondents, respectively, agree that vaccines cannot be placed with food or drugs in vaccine refrigerator. However, this result is in disagreement with the result of Rogie et al. , who showed that vaccines were sharing space with laboratory reagents and other medicines in fridges (40.9%).
As regards taking the number of vaccine vials needed for the entire session, our result was 100%, which is better than that reported by Al-Ayed  and Esa et al. ,who found that 86.6 and 72.5% of their providers take from the refrigerator the number of vaccines vial needed for the entire session.
This study demonstrated that 86.7% of the studied units check the expiry date of the vaccines before use, which is better than that reported by Esa et al. ,who stated that only 2.5% of their respondents check the expiry date of the vaccine before use. Unfortunately, this result was less than that reported by Al-Ayed ,who documented that 99% of his providers stated that they check the expiry date before use.
Concerning infection control, 100% of the studied PCUs reported washing their hands. This is completely opposite to that reported by Esa et al. , who recorded that none of their participants washed their hands.
As regards availability of equipment needed for the session and disposal boxes, it was found that 100% of the studied healthcare facilities have adequate equipment for vaccination session. This result is in agreement with the finding of Esa et al. , who found sterile equipment for the vaccination session in 98.75% and disposal boxes in 76.25% of their studied units.
The practice level of this study was high due to continuous supervision of local authorities on the cold chain and vaccination process.
| Conclusion|| |
This study found that the prevaccination and during-vaccination practice level of the studied health care facilities were good, whereas the postvaccination practice level was poor. The knowledge score was higher among high nurses compared with other HCPs. However, knowledge about Hib vaccine was not satisfactory.
The authors are grateful to all participants in the studied primary healthcare facilities for their invaluable help in facilitating data collection. Authors' special thanks to Dr Hewaida El Shazly, Dr Nora Abdel Hady, and Dr Reda Abdel Latif for theircontinuous encouragement and powerful support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]