Effect of Educational program for nurses on their knowledge regarding obligatory vaccination for children

Introduction

Immunization is one of the most cost-effective interventions for the child health promotion.  It is a safe and effective method of preventing many series of major illnesses. Immunization arouses the body's own immune system to defend the individual against different communicable disease such as polio, tuberculosis, diphtheria, pertussis, tetanus, hepatitis B, Hemophilus influenza type B and measles (Swarnkar et al., 2016). Ensuring public and professional confidence is critical to the success of the programs. So, it becomes important to understand the knowledge level and practice of health workers responsible for immunization (Asim et al., 2012).

Nurses need to be confident, knowledgeable and up to date.  A high level of knowledge and practice of immunization in healthcare workers is an important element in achieving and maintaining high vaccine uptake. Nurses have a major role in advising and promoting immunization, as well as administering vaccinations within the childhood immunization program. All staff involved in vaccine administration should be suitably trained and competent to fulfill the role and be able to provide accurate and up to date information about the diseases and vaccines to their patients, to ensure that their practice is safe and effective and to give a high standard of care (WHO, 2015). All vaccine providers should receive education and competency-based training on vaccine administration before providing vaccines to the public (Guide, Canadian Immunization, 2013).

Nurses responsible for handling vaccines should be familiar with the manufacturer's packaging insert for each vaccine including recommendations for handling, storage, administration site, dosage and route to minimize the risk of vaccine failures (Centers for Disease Control and Prevention (CDC), 2011). Recommendations on immunization procedures are based on currently available evidence and experience of best practice. Nurses should follow the professional standards and guidelines (Hockenberry & Wilson, 2018). There are many barriers against immunization including misinformation about vaccination, adverse event reactions of vaccines and negative attitude toward vaccines. Thus, good knowledge and practice regarding immunization is required. Therefore, it is reasonable for nurses and other health care providers to provide parents with comprehensive information about immunization, which in turn will help to shape positive attitude toward vaccinations and improve their practice (Omotara, et al., 2012).

Significance of the study

The World Health Organization (WHO) acknowledges that immunization is one of the most effective health investments, estimated at preventing between two and three million deaths each year (The Australian Immunization Handbook, 2018). Egypt vaccinates over 35 million children every year. Estimated national coverage rates of children that are fully immunized (2014) is 91.0 % (UNICEF, 2015) & (WHO, 2019).Every year in the United States between 3,000 and 4,500 severe vaccine reactions are reported to the Centers for Disease Control.  These severe reactions can land somebody in the hospital, the intensive care unit, cause a permanent disability or death. From 1,244 cases of people reported hospitalized 416 cases of people reported a disability, 122 reported deaths, and 388 reported life-threatening cases (Bob Sears, 2015).

Aim of the Study

The aim of this study is to assess the effect of educational program for nurses on their knowledge regarding obligatory vaccination for children

Research Hypothesis

Nurses involved in educational program will have a higher score of knowledge than before the program.

Subjects and Methods

Research design:

This study used pre/post Quasi- experimental research design.  A Quasi- experimental research design is one type of experimental design that is very similar to the true experimental design except that its losses one criterion which is control or randomization (Burns & Grove, 2012)

Setting:

The selected vaccination office and centers represented all geographic areas of Minia city as this study was conducted in 7 places (all the vaccination centers in Minia City). Four health offices (first health office, Second health office, third health office and fourth health office) in addition to three health centers (Shabab Elmostakbal MCH center {Minia El-Gedida}, first health care center and second health care center).

Sample

The sample involved all nurses who are working in the (7) health office and centers at Minia city and responsible for vaccination of children, the total numbers of nurses were 39 nurses. Numbers of nurses in each heath office and centers as the following:

Four health offices:

• 8 nurses from the first health office
• 9 nurses from the second health office
• 4 nurses from the third health office (western MCH center)
• 5 nurses from the fourth health office

Three health centers:

• 8 nurses from the Shabab Elmostakbal MCH center) Minia El-Gedida)
• 3 nurses from the first health care center
• 2 nurses from the second health care center

Inclusion criteria

All nurses who are responsible for giving vaccination for children and working in the previously mentioned health offices and health centers.

Exclusion criteria

Nurses who attended training courses about infection control or vaccination less than one year ago weren't included in the sample.

Tool for Data Collection

Structured Questionnaire in Arabic language and was developed by the researcher after reviewing related literature. It was comprised from two parts:

Part 1: Demographic data about nurses including nurses' age, qualifications, years of experience and previous training courses about vaccination.

Part 2: Knowledge assessment questionnaires: To assess the nurses' knowledge about vaccination. Which involves 66 multiple choice questions and divided into 7 sections: Section 1 contains 11 questions regarding general information about vaccination. Section 2 contains 5 questions about infection control measures. Section 3 contains 11 questions about oral polio vaccine. Section 4 contains 12 questions about BCG vaccine. Section 5 contains 12 questions about pentavalent {DPT, hepatitis B, Haemophilus influenza type B (Hib) vaccine}. Section 6 contains 12 questions about MMR vaccine. Finally, section 7 which contain 3 questions about vitamin A capsule.  

Scoring system:

• The nurses' knowledge was compared with model key answer and accordingly scored as correct or incorrect answer. A score of one for correct answers and a zero for incorrect answers.
• The total score of knowledge was 66 degrees and the scores were converted into a percentage score. The nurses' knowledge was considered satisfactory if the percentage score is 60% or more and unsatisfactory if less than 60%.

Validity and Reliability

• The tool was tested for content validity by a jury of three experts in the pediatric nursing field and necessary modifications were done.
• Reliability of the tool that to be tested by using Cronbach's Alpha, to insure the internal consistency of the tools. Test-retest reliability of a structured interview questionnaire was (0.75).

Pilot study

A pilot study was conducted on 10% (4) nurses from the selected centers using the previously mentioned tool, to evaluate their applicability and clarity as well as to determine the time required for filling the data for the tool. Nurses involved in the pilot study excluded from the main study subjects.

The program

The educational program was designed by the researcher about vaccination and infection control information (vaccine and immunity definitions, types of immunity and vaccines, storage and cold chain system regarding general and specific guidelines for each vaccine, vaccine schedule information about types, child age, sites, route, and dosage for each vaccine, health teaching related to each vaccine and parent education, vaccines waste management and health hazards, precautions and side effects for each type of vaccines, methods of transmission of infection and infection universal precaution{hand washing, hand rubbing, wearing gloves and safe disposal}.

1- Preparatory phase Included:

• An official permission was obtained from the concerned immunization centers authorities to conduct the study. The aim and nature of the study were explained to the administrators and nurses.
• The researcher prepared the following:
• The objective, content of the program, strategies (timetable of sessions, teaching methods, media used, learner's activities and evaluation methods), selected the teaching sitting inside each health office and centers and learning content of the program.
• The program finances (supplied by the researcher) and providing the program resources and facilities such as printed materials, doll, gloves, hand gel, soap, tissue papers, cotton, adhesive tab and syringe.
• The teaching methods and media such as lectures, group discussions, pictures, data show on the researcher's personal laptop, demonstrations and hand out Arabic booklet developed by researcher.
• The data collection tool was constructed (structured questionnaire sheet in Arabic language)

2- Assessment phase included:

A pre-test was conducted before program implementation by using the knowledge assessment tool. The research investigator attended in each health office or center two days during the rest days (non-vaccination days) according to the availability of nurses' time and according the numbers of nurses inside each center. Through an individual interview with each nurse, the research investigator introduced himself and explained the aim and nature of the study and gave them structured questionnaire to be answered it, in the present of the research investigator for more clarification whenever needed. The duration was 30-45 mints to fill the tool. 

3- Intervention phase included: 

• The program sessions conducted during the rest days (non-vaccination days), it was two days according to the availability of nurses' time and number of nurses in each center. Each group of nurses choose their optimal time for receiving the program whenever they have minimal workload. The centers which contained large number of nurses were scheduled for two smalls groups, the total nurses' groups were 10 groups (each group ranged between 2 to 5 nurses). Two teaching hours for each group at the same day were performed. From nine to eleven O’clock for group one and from eleven to one O’clock for the other group. Each session usually started by a summary of what has been taught during the preceding session. 
• The program was conducted over 8 sessions for each group, as the research conducted two sessions per week, the duration for every session was 2 hours to cover all information regarding the vaccination program. the program included definitions of vaccination, immunity, types of vaccines, type of immunity, site and dose, precaution, side effects for each vaccine, storage and cold chain system, vaccine waste management, benefits and risks associated with each vaccine and parent education related each vaccine.
• Method of teaching involved modified lectures, group discussions, pictures, videos shown by using the researcher’s personal laptop.  Different methods were used to motivate nurses and reinforce correct information such as recognition during the program sessions.
• The researcher developed an Arabic booklet for nurses about immunization. It contained general updated knowledge. Copy of the program booklet was given to each participant nurse before starting the program implementation.

4- Evaluation phase:

All nurses were reassessed by using the same knowledge assessment tool, immediately after the end of the program and after three months as a follow up phase. The study work was conducted through 4 months starting from July to October 2017.

Ethical consideration

Approval was obtained from the ethical committee; Faculty of nursing, Minia University. The purpose and nature of the study was explained to the nurses and oral consent was obtained from each of them to participate in this study. They were informed that they can withdraw from the study without giving a reason and they were assured that anonymity and confidentiality of information was protected. Ethics, values, culture, and beliefs were respected.

Statistical analysis

Data entry was done using compatible personal computer. The statistical analysis was done using SPSS Version 20 statistical software package. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables. Qualitative studied variables were compared using chi-square test. Pearson correlation analysis was used for assessment of the inter-relationships between the nurses' knowledge about infection control of procedure, statistical significance difference at p value <0.05.

Results

Table (1): Demographic Characteristics of the Studied Nurses (N=39)

Table (1) illustrated that more than one third of the studied nurses (38.5%) their age was ranged between 40: >50 years old with a mean and SD of age 41.5±9.1. More than one quadrant of them (28.2%) had years of experience ranged from 15 to > 20 years with a mean and SD of years of experience 20.02±4.9. Majority of the nurses (97.4%) had diploma degree in nursing. More than four fifth (82.1%) of the studied nurses didn’t attend any training courses. On the other hand, less than three fourth of nurses (71.4%) who exposed to training courses, attended training courses related to infection control. All nurses (100%) attended the training courses for during a period of one and more than one year before this study.

Table (2): Nurses' knowledge about General Information of Vaccination Pre, Immediate and Follow up of the Educational Program (N= 39)

The benefit of routine vaccinations for children

Role of vaccination in protecting the child from the disease

Reasons of giving vaccines at specific intervals

Reasons of given more than one dose of the same vaccine

Vaccines not given permanently to children

Vaccines that contraindicated to children with HIV

Conditions which considers not contraindication for vaccination

Necessary to vaccinate the child

χ²: chi-square test        * P ≤ 0.05         ** P ≤ 0.01      *** p ≤ 0.001

Regarding nurses' knowledge about general information of vaccination table (2) proved that, there were highly statistical significant differences between pretest, immediate and follow-up posttest in most of  items regarding general information about vaccination (role of vaccination in protecting child from diseases, reason of giving vaccines at specific intervals, reason of giving more than  one dose of the same vaccine, purpose of using the combined vaccines, the permanent contraindication of vaccination for children with HIV, and the conditions which consider not contraindicated for children vaccination) (P=0.001).

Table (3): Nurses' knowledge about General Information Regarding Infection Control Pre, Immediate and Follow up of Educational Program (N= 39)

The most important reasons for emergence & serious problems which appears on children after vaccinations

Importance of hand washing (or cleanse them with a hand gel) before starting administration of vaccine and between each child

The glove must be changed between each child

Method of cleaning the injection site before vaccination

χ²: chi-square test        * P ≤ 0.05         ** P ≤ 0.01      *** p ≤ 0.001

Concerning nurses' knowledge about infection control table (3) clarified that there were highly statistical significance differences were observed between pretest, immediate and follow up posttests in two items only which are, gloves must be changed between each child and the methods of cleaning the injection site before vaccination at p-value = 0.001. On the other hand, no statistical significance differences were detected between pretest, immediate and follow up posttests about causes of serious vaccine problems, hand washing and wearing gloves. As the majority of nurses had correct information about most important reason for emergency and serious problem, important of hand washing and gloves must be used during vaccination in pretest (94.9%, 100% & 87.2% respectively), while all of them (100%) had correct information in immediate posttest with no statistical significance differences between pre, immediate and follow up posttests.

Table (4): Nurses' Total Score of Knowledge about Vaccination and Infection Control Pre, Immediate, and Follow up of Educational Program N= 39

χ²: chi-square test        * P ≤ 0.05         ** P ≤ 0.01      *** p ≤ 0.001

Table (4) showed that nurses' knowledge was significantly  improved immediately and during follow up posttests after the educational program than preprogram test, regarding their general information about vaccination (χ²=18.4, P=0.001), infection control (χ²=15.7, P=0.003), BCG vaccine (χ²=14.2, P= 0.001) and pentavalent vaccine (χ²=25.1, P=0.001). While no statistical significance differences were detected between nurse's knowledge in the pre and posttests concerning oral polio, MMR vaccine and vitamin A capsule as well as in the total information. 

Table (5): Relation between Nurses' Demographic Data and Their Total Score of Knowledge (N= 39)

R: correlation        * P ≤ 0.05         ** P ≤ 0.01      *** p ≤ 0.001

Regarding correlation between nurses' demographic data and their knowledge table (5) clarified that, nurses' age had negative correlation with their knowledge in the pre-program test (R= -0.49, P=0.001), and follow up posttest (R= - 0.45, P=0.001). Another negative correlation was found between years of experiences and their knowledge in the pretest (R= -0.51, P=0.001) and follow up posttest (R= -0.37 P=0.01). While a positive correlation was detected between nurses' knowledge and their training courses in the immediate posttest of the educational program (R= 0.33, P= 0.01).