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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 2  |  Page : 71-76

Knowledge, attitude, and practice of cold chain management among primary health care workers in Giwa, Northwestern Nigeria


1 Department of Community Medicine, Kaduna State University, Kaduna, Nigeria
2 Department of Medicine, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria
3 Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
4 Nigerian Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
5 Department of Community Medicine, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria

Date of Web Publication19-Mar-2019

Correspondence Address:
Dr. Bilkisu Nwankwo
Department of Community Medicine, College of Medicine, Kaduna State University, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/archms.archms_26_18

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  Abstract 

Background: Cold chain management is a system of transport and storage of vaccines in a potent state from the time of manufacture to the time of administration. Preserving vaccines from its manufacture through administration requires adequate cold chain infrastructure, compliance with standards, and effective management. At the end of the chain, are healthcare providers who should have adequate knowledge to manage the cold chain. Aim: The aim of this study is to assess knowledge, attitude, and practice of cold chain management among primary health care (PHC) workers. Materials and Methods: A cross-sectional study was carried out using a pretested, structured, interviewer-administered questionnaire. A multistage sampling method was used in selecting the 78 respondents. Data were collated and analyzed using Statistical Package for Social Sciences version 23. Data were presented using frequencies and proportions. Results: Majority (71.8%) of the respondents knew the correct temperature range for which vaccines should be stored. Only 3.8% of the respondents had good knowledge of cold chain management. About two-thirds (75.6%) of the respondents agreed that cold chain management is important. Most respondents (78.5%) showed a positive attitude toward cold chain management. Only over half (51.3%) of the respondents had appropriate practice. Conclusion: This study has shown that the PHC workers in the study area had poor knowledge, about two-thirds had a positive attitude and only about half of them had appropriate practice on cold chain management. The local government department should improve on training and retraining of PHC workers on cold chain management.

Keywords: Attitude, cold chain management, knowledge, practice


How to cite this article:
Nwankwo B, Joga SJ, Olorukooba AA, Amadu L, Onoja-Alexander MO, Hamza KL. Knowledge, attitude, and practice of cold chain management among primary health care workers in Giwa, Northwestern Nigeria. Arch Med Surg 2018;3:71-6

How to cite this URL:
Nwankwo B, Joga SJ, Olorukooba AA, Amadu L, Onoja-Alexander MO, Hamza KL. Knowledge, attitude, and practice of cold chain management among primary health care workers in Giwa, Northwestern Nigeria. Arch Med Surg [serial online] 2018 [cited 2019 Jun 19];3:71-6. Available from: http://www.archms.org/text.asp?2018/3/2/71/254575


  Introduction Top


Vaccines are sensitive biological substances which can lose their potency with time, and this loss of potency can be accelerated when they are not stored within the recommended temperature range.[1] Vaccination is a powerful and cost-effective health intervention.[2] Some challenges are encountered in implementing the various programs aimed at achieving immunization for the world children. Apart from the problems of availability, accessibility, and overcoming the scourge of ignorance among target populations, the efficacy of these vaccines when they finally reach the relatively few people who have access to them is a major issue that should be evaluated.[2],[3]

The efficacy of vaccines is greatly affected by physical conditions, especially ambient temperature, to which they are subjected during transportation and storage. Although a few vaccines retain their potency after undergoing relatively wide temperature variations, most lose their potency, especially the live vaccines.[4] To these vaccines, the cold chain system is very important to provide the optimum conditions during storage, transportation, or distribution.[4] The cold chain system ensures that the vaccines are kept at the optimum temperature right from the point of manufacture down to distribution at the primary health care (PHC) levels.[4]

Vaccine-preventable diseases are a major contributor to child morbidity and mortality, especially in Sub-Saharan Africa and Nigeria in particular. It accounts for 17% of global total under-five mortality per year and 22% of child mortality in Nigeria, and as such, this system is necessary as vaccine failure may occur due to failure to store and transport them under strictly controlled temperature conditions. This is of concern in view of the fact that there have been reported epidemics of vaccine-preventable diseases in populations thought to have been fully immunized.[5]

Maintaining vaccines perfectly preserved from its manufacture through administration requires an adequate cold chain infrastructure, compliance to standards, and effective management.[6] At the end of the chain, PHC providers must have adequate knowledge to manage the cold chain.[3],[7] Maintaining the vaccine cold chain is an essential part of a successful immunization program because vaccines lose their potency easily. Healthcare workers play a vital role in cold chain management, and so it is pertinent to assess their knowledge, attitude, and practice.

Today, with the availability of more expensive vaccines, it becomes paramount that the knowledge of health workers on cold chain management be assessed to avoid costly wastages that are bound to result from inappropriate practice as a result of poor knowledge.[8]

An often neglected issue requiring close assessment is the knowledge of the people charged with the responsibility of ensuring an uninterrupted cold chain at the operational level and their attitude toward maintaining cold chain. This is the realm within which this study is intended to be. In this part of the world, as in many tropical areas where the high environmental temperature is a problem, cold chain managers' struggle with keeping the vaccines away from heat.[8] Poor understanding of the dangers of vaccine freezing contribute to the weakness of the existing cold chain in many countries. Emphasis has long been placed on keeping vaccines cold, with less attention devoted to prevention of vaccine damage from freezing. Freezing of vaccines in the cold chain is commonplace, potentially resulting in the widespread delivery of vaccines whose potency has been compromised.[9] Vaccine exposure to temperatures below recommended ranges in the cold chain may decrease vaccine potency of freeze-sensitive vaccines leading to a loss of vaccine investments and potentially places children at risk of contracting vaccine-preventable diseases.[10]

Studies that focus on cold chain management of vaccines in northern Nigeria are limited. As a result, this study aims to assess the knowledge, attitude, and practice on the cold chain management of vaccines of healthcare workers in Giwa, Northwestern Nigeria.


  Materials and Methods Top


Study area

Giwa Local Government has three districts, 11 political wards. It has one tertiary hospital, a general hospital, 17 PHCs, 28 health centers, and 9 private clinics. The PHC facilities have a total staff strength of 302 (technical and nontechnical). Technical staff were 168 and were made up of nurse-midwives, midwives, community health workers, community health extension workers (CHEWs), junior CHEWs, pharmacist technicians, pharmacist assistants, laboratory technicians, and laboratory assistants.

Study design

This descriptive, cross-sectional study was conducted among PHC workers in Giwa local government area (LGA) of Kaduna state.

Eligibility criterion

PHC workers involved in vaccination for a minimum of 6 months.

Sample size estimation

The sample size was determined using the formula[11]n = (Z2 pq)/d2, where P is the prevalence of knowledge on cold chain management from a previous study (0.14).[12]Z is standard normal deviate at 95% confidence level, q is the complementary probability (1-p) and d = degree of accuracy desired at 95% confidence interval, = 0.05. Also applying the formula for sample size when the population is <10,000, nf = n/(1 + n/N),[11] a final sample size of 78 was obtained.

Study design

A multistage sampling technique was used to select the respondents. From the list of PHC facilities, one PHC facility was selected from each of the 11 wards using simple random sampling by balloting. At each of the selected PHC facilities, eligible healthcare workers were selected using proportionate sampling method to obtain the sample size.

Ethical consideration

Permission was obtained from the PHC coordinator of Giwa LGA and from the supervising heads of the PHC facilities before the study was conducted. Information about the study was provided to each respondent, following which written consent was obtained from each respondent.

Data analysis

A pretested, structured, interviewer-administered questionnaire was used to collect data. Data were collated and analyzed using International Business Machines SPSS Statistics for Windows, Version 23 (IBM Corp., Armonk, NY, USA). The knowledge questions were scored one mark for each correct answer, while incorrect or “don't know” responses were scored zero. The scores were added up and the percentage scores were obtained. The scoring system then graded knowledge as 0%–33% for poor, 34%–66% for fair and 67%–100% for good. For the questions on attitude, the five-point Likert scale was used with responses from strongly disagree to strongly agree. Each question on attitude had a score that ranged from −2 to +2, moving from less to more favorable attitude score. For positive statements about healthcare workers attitude toward cold chain management, a maximum score of ±2 was assigned to the strongly agree option whereas for statements that capture negative attitude a maximum of ±2 was assigned to strongly disagree option. The maximum possible score for attitude was 20. Scores of 10 points and above (≥50%) were regarded as a positive score <10 points (<50%) was regarded as a negative score. Practice score was assessed using 10 questions, each correct response was assigned a score of 1 while wrong response, a score of zero. A respondent has appropriate practice if the total score was 50 and above and inappropriate practice if the total score was <50.


  Results Top


A total of 78 questionnaires were administered and all were completely filled. This gave a response rate of 100%. The mean age of the respondents was 35.1 ± 8.9 years. CHEWs made up the highest proportion of respondents (42.3%) and 55.1% were male. The respondents mean duration of work experience was 2.5 years, though 62.8% had worked for between 1 and 10 years. Only 57.7% had been trained on cold chain management and 77.8% was more than 6 months before the study [Table 1].
Table 1: Sociodemographic characteristics, work experience and training on cold chain management of the respondents (n=78)

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Majority of the respondents (87.2%) knew that temperature changes alter vaccine effectiveness. Most respondents (91.0%) were aware that vaccines should be maintained at a particular temperature range, but only 69.0% knew the correct temperature range of 2°C–8°C [Table 2].
Table 2: Respondents' knowledge on cold chain management (n=78)

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Majority of the respondents (76.5%) and (74.2%) knew that PENTA and hepatitis B vaccines, respectively, can be damaged by freezing. On ways vaccines can be damaged, exposure to light was the most common response (89.4%). The majority (85.9%) of the respondents were aware of shake test and 81.0% of whom knew that shake test is for checking if a freeze sensitive vaccine has been subjected to freezing temperatures [Table 2].

Only (3.8%) of the respondents had good knowledge on cold chain management [Table 3].
Table 3: Aggregated knowledge score on cold chain management (n=78)

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About half of the respondents (51.3%) strongly agreed that vaccines in the refrigerator should be regularly monitored. A third (29.5%) strongly disagreed with putting vaccines with drugs, food, and reagent. With 41.0% strongly agreeing that staff training in cold chain delivery system is important [Table 4].
Table 4: Attitude of the respondent toward cold chain management

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Majority (78.5%) of the respondents had a positive attitude toward cold chain management [Table 5].
Table 5: Aggregated attitude score (n=78)

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Only above half of the respondents (55.1%) said that vaccines were stored in their health centers. Majority (97.7%) stored vaccines for a month or less and 83.7% of the respondents always checked the temperature of the refrigerator before removing the vaccines. Most (81.4%) respondents did not keep other items such as drugs, reagents, or food in the same refrigerator with vaccines. About half (55.8%) of the respondents had conducted a shake test in the past 3 months. More respondents (53.5%) assessed the power supply to their health centers as poor. About half the respondents had appropriate self-reported practice on cold chain management [Table 6].
Table 6: Respondents self-reported practice of storing vaccines in their health centers

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About half the respondents had appropriate self-reported practice on cold chain management [Table 7].
Table 7: Aggregated self-reported practice score (n=78)

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  Discussion Top


This study showed that most respondents (91%) were aware that vaccines should be stored at a particular temperature range, but only 71.8% knew the correct range. In a study in Niassa, Mozambique, just over half the respondents knew the correct temperature range for storage of vaccines.[13] The difference found between this study and the Niassa study could be due to a higher proportion of trained health workers in this study. All health workers should know the temperature range for storing vaccines. Vaccines are sensitive biological products and if exposed to the inappropriate temperature they would lose their potency and once potency is lost it cannot be regained.[14]

About two-thirds of the respondents in this study were aware of freeze-sensitive vaccines. This is lower than what was found in a study in India.[15] Most of the cold chain handlers in the Indian study were aware of freeze-sensitive vaccines which could be accounted for by 86% of them having been trained. In this study 60.1% and 50.5% of respondents knew that vaccines could be damaged by heat and freezing, respectively. This is lower than what was observed in the Kelantan study were majority of the respondent knew that vaccines could be damaged by heat and freezing.[16] The correct storage of vaccines is crucial as both too low and too high temperatures can cause damage to specific vaccines. In this part of the world, where the high environmental temperature is a problem, in trying to keep vaccines away from heat, the tendency is that of exposure to freezing temperatures with the skewed belief that low temperatures pose no problem at all.[8] If, at any time in the cold chain, vaccines are exposed to temperatures outside of the defined range, irreversible damage can occur, resulting in loss of product. Administering vaccines that have lost their potency will lead to failed immunization against vaccine-preventable diseases.

Of the 85.9% respondents who were aware of shake test, 81% knew that it is a method used to detect whether absorbed vaccines have been affected by freezing. More than two-thirds of health workers in a study in north-central Nigeria were aware of Shake's test as a test for detecting if vaccines had been previously frozen.[17] When a vaccine is damaged by freezing, the potency lost can never be restored. Freeze-damaged vaccines have lower immunogenicity and are more likely to cause local reactions like sterile abscesses.[18]

The study showed that only 3.8% of the respondents had good knowledge. The finding in this study is in contrast with studies conducted in Malaysia and Turkey where 78.7% and 96.3% of respondents had good knowledge on cold chain management knowledge, respectively. The Malaysian study attributed the high knowledge score to the long duration of work experience of the health workers. Most respondents had a work experience of 15 years while the average work experience in this study was 2.5 years.[13],[16]

The success of cold chain management could depend on the attitude of handlers.[16] This study showed that the attitude of the PHC workers was positive (78.5%). This is similar to a study done in China where 80.1% of the respondents had a positive attitude toward cold chain management,[19] but in contrast with a study done in Kelantan, Malaysia where only a fifth (20.2%) of the respondents had a positive attitude toward cold chain management.[16] This study also showed that 44.5% of the respondents agreed that cold chain delivery system is affected by harsh weather and poor equipment. This is lower than the study in China where 59.9% of respondents believed that cold chain delivery system is affected by difficult service delivery 87.7% due to geographical factors and poor condition of cold chain equipment.[19]

In this study, 46.2% of the respondents agreed that refrigerators containing vaccines should not be opened more than 3 times a day. This is in contrast with the study in Kelantan, Malaysia where 75%–85% could not be bothered if the refrigerator is opened more than 3 times a day.[16]

Less than a third (28.2%) of the respondents believed that keeping vaccines with food, drinks, and laboratory specimen in the same refrigerator will not cause damage them. This is higher than the Kelantan study, where only 4.5% believed they could place vaccine with food, drinks, and laboratory specimens.[16] This shows that respondents were aware of the potential damage that not having a refrigerator dedicated to vaccines could cause.

About 50.6% of respondents agreed that putting vaccines in a refrigerator door shelf could damage vaccines. This is in contrast with a study in Kelantan, Malaysia where only 11.2% of respondents believed that placing vaccines in a refrigerator door shelf could damage vaccine.[16]

The respondents in this study that reported that temperature reading should be taken inside the refrigerator were about half while only a few of the respondents in the Kelantan study reported same.

Only 2.3% of respondents said more than a month's supply of vaccines was kept in their health facility. This is lower than a study in South Africa where 47.1% of the respondents kept more than a month's supply in the refrigerator.[8] This might be due to poor power supply to the health centers reported by respondents in this study.

Majority of respondents in this study did not keep items like drugs, reagents or food in the same refrigerator. This is similar to a study in South Africa where of the respondents agreed that no food or drinks were ever stored in the refrigerator.[8]

Most respondents kept records routinely. This is similar to a study in South Africa, where a majority of the respondents kept stock cards for vaccines.[8]

Just over half (54.7%) of the respondents had conducted a shake test in the past 3 months. This is lower than what was found in a study in South Africa, where 71.0% of the respondents had conducted a shake test to identify frozen vaccines.[8] This implies that freeze-sensitive vaccines that are frozen might go undetected, leading to children been vaccinated with vaccines that are not viable.

About half the respondents in this study had appropriate practice (51.3%). This is lower than a study in Australia where 76% of the respondents had appropriate practice.[20]


  Conclusion Top


Only 3.8% of the respondents had good knowledge of cold chain management, however, most had positive attitude toward cold chain management and more than half had appropriate practice. Primary healthcare workers must have good knowledge and regular in-service training on cold chain management.

Acknowledgment

We wish to express our gratitude to the chief medical director, heads of departments, chief matron and matrons in charge of wards of ABUTH for their cooperation. We also wish to thank the healthcare workers for consenting to participate in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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