MINISTRY OF HEALTH
UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH
AND
MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH
HANOI UNIVERSITY OF PUBLIC HEALTH

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MANYVANH VONGSY

KNOWLEDGE AND PRACTICE REGARDING THE ADNINISTRATION

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OF THE PENTAVALENT VACCINE AMONG HEALTH CARE WORKER
IN VIENTIAN CAPITAL, LAO PDR, 2019

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MASTER OF PUBLIC HEALTH
CODE: 8720701

HANOI, 2020


MINISTRY OF HEALTH
UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH
AND
MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH
HANOI UNIVERSITY OF PUBLIC HEALTH

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MANYVANH VONGSY

KNOWLEDGE AND PRACTICE REGARDING THE ADNINISTRATION
OF THE PENTAVALENT VACCINE AMONG HEALTH CARE WORKER
IN VIENTIAN CAPITAL, LAO PDR, 2019

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MASTER OF PUBLIC HEALTH

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CODE: 8720701
SUPERVISOR:

VANPHANOM SYCHAREUN, MD, PhD

DEAN OF THE FACULTY OF PUBLIC HEALTH
UNIVERSITY OF HEALTH SCIENCE
MINISTRY OF HEALTH
VIEANTIANE, LAO PDR

HANOI, 2020


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ACKNOWLEDGEMENTs
This independent study would not have been possible without the help and
support of many people.
I am very thankful to the Ministry of Health of the Lao PDR, the LEARN project,
the University of Health Science (UHS), and the Hanoi University of Public Health
(HUPH) for funding and providing support during my period of study at the UHS in
Laos and the HUPH in Vietnam.
The help of the Xaythany District Hospital is also gratefully acknowledged for
allowing me to study at the UHS and the HUPH.
My sincere and deep gratitude goes to my advisors Dr. Vanphanom Sychareun, PhD

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(Dean, Faculty of Public Health of Laos), and Dr. Do Thi Hanh Trang, PhD
(Department of Disaster Management, Faculty of Environmental and Occupational
Health Hanoi University of Public Health) for their valuable advice, as well as their
constant supervision and encouragement throughout the challenging time of
completing my dissertation.

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I would like to express my sincere gratitude to Dr. Kongmany Chaleunvong for his
kind suggestions and valuable comments with respect to data analysis.
I would like to acknowledge the valuable comments and encouragement from Prof.

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Bui Thi Thu Ha who was the examination chair of my Independent Study Committee.

I wish to thank Dr. Nguyen Ngoc Bich, and Dr. Alongkone Phengsavanh, who were
members of the study committee

I am most grateful to the headmaster, teachers and students of Vientiane High School
who kindly accepted to help and participate in this research. This study could not
have been completed without their generous assistance.
I am grateful to all the lecturers, teachers, coordinators and all staff of the UHS and
the HUPH for their continuous assistance and helpful advice.


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I would like to thank my classmates for their kindness during the period of my studies
at the UHS and the HUPH.
Finally, I would like to thank my family for their love, understanding, support, and
encouragement during the time I studied at the UHS and the HUPH.
Ms. Manyvanh VONGSY

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Contents
ACKNOWLEDGEMENTS ...................................................................................... i

LIST OF TABLES ................................................................................................. vi
ABSTRACT ......................................................................................................... viii
INTRODUCTION ................................................................................................... 1
RESEARCH QUESTION ....................................................................................... 3
RESEARCH OBJECTIVES .................................................................................... 3
CHAPTER 1: LITERATURE REVIEW.................................................................. 4
1.1. Definitions ........................................................................................................ 4
1.2 Situation of pentavalent immunization in Laos and the world ............................ 6

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1.3 Knowledge and practice among health care workers and their importance ......... 8
1.4 Determinants of knowledge and practice regarding child immunization .......... 11
CHAPTER 2: METHOD ....................................................................................... 19
2.1. Study design ................................................................................................... 19
2.2. Study location ................................................................................................. 19
2.3. Study population............................................................................................. 20

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Quantitative research ............................................................................................. 20
2.4. Sampling method ............................................................................................ 20
Qualitative method ................................................................................................ 21

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2.5. Data collection ................................................................................................ 22
Quantitative data collection ................................................................................... 22
Qualitative data collection ..................................................................................... 22

2.6 Study instruments ............................................................................................ 23
2.7 Variables ......................................................................................................... 24
2.8 Measures for outcomes .................................................................................... 24
2.9 Data analysis ................................................................................................... 26
2.10 Ethical approval. ............................................................................................ 28
CHAPTER 3 RESULTS ........................................................................................ 30
3.1. Background information of participants. ......................................................... 30


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3.1.1 Work experience ........................................................................................... 31
3.2 Description of knowledge ................................................................................ 32
3.2.1 Knowledge of possible precautions and contraindications to vaccinations .... 32
3.2.2 Knowledge of health care workers on doses and routes of administration ..... 33
3.2.3 Knowledge of health care workers on time of vaccine administration ........... 34
3.2.4 Knowledge of health care workers on side effects of the pentavalent vaccine 35
3.2.5 Overall knowledge of health care workers regarding children’s
immunization ........................................................................................................ 37
3.3 Description of practice ..................................................................................... 37
3.3.1 Practice relating to preparatory steps............................................................. 37

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3.3.2 Practice relating to general vaccine measure ................................................. 39
3.3.3 Practice relating to specific measures for the pentavalent vaccine ................. 40
3.3.4 Overall vaccination practice of health care workers ...................................... 40
3.4 Association of knowledge and practice of HCWs regarding the pentavalent
vaccine .................................................................................................................. 41

3.5 Determinant of knowledge regarding the pentavalent vaccine .......................... 42

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3.5.1 Association between individual factors and knowledge ................................ 42
3.5.2 Association between organization factors and knowledge ............................. 43
3.6 Determinant of practice regarding the pentavalent vaccine .............................. 44

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3.6.2 Association between organization factors and practice.................................. 45
3.7 Multivariate logistic regression analysis of factors associated with a knowledge
of the pentavalent vaccine ..................................................................................... 48
3.8 Multivariate logistic regression analysis of factors associated with the practice ...
of the pentavalent vaccine………………………………………………………….49
CHAPTER 4 ......................................................................................................... 52
DISCUSSION ....................................................................................................... 52
CONCLUSION ..................................................................................................... 61
RECOMMENDATIONS ....................................................................................... 62
REFERENCES ...................................................................................................... 63
ANNEXES ............................................................................................................ 69


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Abbreviations and Acronyms

AEFI

Adverse Events Following Immunization


CDC

Centers for Disease Control and Prevention

DTP3

Diphtheria-Tetanus-Pertussis three-in-one vaccine

EPI

Expanded Program on Immunization

Hib B

Haemophilus influenzae Type B

Hep B

Hepatitis B

HCWs

Health Care Workers

HCPs

Health Care Providers

PHCPs


Primary Health Care Providers

PCU

Primary Care Unit

SDG

Sustainable Development Goal

VRE

Vaccine safety Related Event

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List of Tables
Table 3.1 Socio-demographic characteristics of participants………………………29

Table 3.2 Work related experiences of participants …...………………………….31
Table3.3 Knowledge of possible precautions and contraindications to vaccinations

……………………………………………………………………………………...32
Table 3.3.1 Knowledge of health care workers on doses and routes of
administration
...................................................................................................................................32

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Table3.3.2 Knowledge of health care workers about the time for vaccine
administration………………………………………………………………………34
Table 3.3.3 Knowledge of health care workers about side effects………...………35
Table 3.4 Preparatory steps………...………………………………………….......37
Table3.5 General vaccine measures………………………..……………………...39

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Table 3.6 Specific measures for the pentavalent vaccine………………………...40
Table 3.7 Association of knowledge and practice of HCWs regarding the
pentavalent vaccine …………..……………………………………………………41

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Table 3.8 Socio-demographic characteristics associated with a knowledge regarding
the pentavalent vaccine.............................................................................................42
Table 3.9 Association between organizational factors and knowledge....................44
Table 3.10 Socio-demographic characteristics associated with the practice of the
pentavalent vaccine...................................................................................................46
Table 3.11 Association between organizational factors of practice........................ 47
Table 3.12 Multivariate logistic regression analysis of factors associated with
knowledge and the pentavalent vaccine …………………………………………...50



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Table 3.13 Multivariate logistic regression analysis of factors associated with the
practice of the pentavalent vaccine ……………...………………………………...52
Figure 3.1 Overall knowledge of health care workers regarding children’s
immunization……………..………………………………………………………..37
Figure 3.2 Overall vaccination practice of HCWs………………………...………41

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Abstract
The pentavalent vaccination is an essential, cost-effective public health measure
to reduce preventable, premature, child mortality and childhood morbidity. The
pentavalent vaccination contributes to lowering the spread of vaccine-preventable
diseases. Health care workers’ knowledge and practices with the use of the
pentavalent vaccination are influential factors in preventing pentavalent vaccine
failures. One of the main reasons parents accept immunization for their children is
that it is recommended by health care providers. This fact underlines the important
role of health care providers in increasing parents’ confidence in immunization by


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dealing with their concerns, answering their questions and convincingly resolving
their doubts. The aim of this study is to assess the knowledge and practice of
providing pentavalent vaccines and their related factors among health care workers
This was a cross-sectional analytical study, using the mixed-method approach that
combines qualitative and quantitative methods. This study was conducted in nine

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district hospitals and 33 health centers in Vientiane Capital. In total, 184 health care
workers were involved in the study and 12 HCWs were involved in the in-depth
interviews. The quantitative data was entered using the EpiData programme and

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analyzed using the Stata 14.1 programme. Descriptive and inferential statistics were
applied to determine the factors associated with the knowledge and practice of
pentavalent vaccines. A thematic analysis was applied for the qualitative data.
From among the 184 respondents, the results showed that under two thirds of them
(63.3%) had a poor knowledge of the pentavalent vaccine and that slightly less than
two thirds of health care workers (65.7%) had a good practice of the pentavalent
vaccine. The findings from the in-depth interviews which were also supported by the
quantitative method showed that the HCWs in this study had a poor knowledge of the
side effects of pentavalent vaccines as they had incorrect answers about the severe
side effects of pentavalent vaccines such as analphylactic shock and the loss of
appetite after receiving the pentavalent vaccine.



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Factors significantly related to a knowledge of pentavalent vaccines included HCWs
who received (or did not receive? This seems unusual) training related to vaccines
who were nearly three times more likely to have a risk of low knowledge (AOR=2.8,
p=0.007, 95% CI=1.3-5.9). There were no factors significantly associated with the
practice of the pentavalent vaccine among HCWs. The study also found that all
participants on the supply side suggested that training would be the first option to
improve the health staff’s competency, improved knowledge and the practice of
immunization. The data from this research indicated that more than half of the health
care workers had a low level of knowledge about the pentavalent vaccine, while the
vaccination practice level of the studied health care workers was good. The

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knowledge score was higher among midwives compared to other HCWs. The
attainment of higher education was a better predictor of knowledge and practice
among health care workers. The work experience of HCWs was also linked to
improved knowledge and practice. Training related to vaccines was an important
factor associated with the knowledge and practice of HCWs.

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This study field requires more efficient training and continuous education for health
care workers in the field of immunization. Therefore proper training and professional
advice are important to increase the knowledge and confidence of vaccination use
among HCWs.

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Keywords: Pentavalent vaccine, health care workers, knowledge and practice


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Introduction
The pentavalent vaccination is an essential, cost-effective public health measure
to reduce preventable, premature, child mortality and childhood morbidity, and
contributes to lowering the spread of vaccine-preventable diseases (Sychareun,
Rowlands, Vilay, Durham & Morgan, 2019; Xeuatvongsa, Hachiya, Miyano, Mizoue
& Kitamura, 2017). During 2010-2016 immunization coverage rates in Laos increased steadily for the Diphtheria-Tetanus-Pertussis three-in-one vaccine (DTP3)
from 74% to 82%. However, compared to other countries with similar income levels
the coverage in Laos is much lower (Phoummalaysith et al., 2018). The prevalence

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of vaccine-preventable diseases is high in the Lao PDR. For example, diphtheria
outbreaks have been reported in the last decade (Black et al., 2014). Between October
and mid-December 2012, the National Centre for Laboratory and Epidemiology
(NCLE) reported 93 suspected cases of diphtheria, including six deaths, from the
Xamtai and Huameuang districts, Houaphan province (Nanthavong et al., 2015). The
pentavalent vaccine coverage in Laos for the first dose in 2017 was 72.5%, while the

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second dose was 67.2% and the third dose was 60.8%, However, the coverage of the
pentavalent vaccine in Vientiane Capital for the first dose was 76.2%, 73.6% for the


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second, and 68.3% for the third (Lao Statistics Bureau, 2018) .
Health care workers’ knowledge and practices in immunization, especially the
pentavalent vaccine are influential factors in preventing vaccine failures (El Shazly,
Khalil, Ibrahem & Wahed, 2016). One of the main reasons for parents to accept
pentavalent immunizations for their children is the recommendations given by health
care providers. This fact underlines the important role of health care providers in
increasing parents’ confidence in immunization by dealing with their concerns,
answering their questions and convincingly resolving their doubts (Schuler et al.,
2017). The health care provider’s recommendation is the most consistently cited
factor associated with vaccine acceptance and uptake, even among parents and
patients with negative vaccine attitudes. Understanding the gaps in knowledge and
factors associated with vaccine provider practices may contribute to the development


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of interventions to improve vaccine recommendations and ultimately immunization
coverage rates (Dempsey et al., 2016). The intensification of immunization
programmes has contributed to a significant decline in the infant mortality rate in the
last few years, but there is still a lack of knowledge regarding immunization among
health workers. Adequate knowledge and practices in vaccination are important to
keeping the potency of vaccines and the effectiveness of immunization (Swarnkar,
Baig, Soni, Shukla & Ali, 2016). Therefore, health workers are grassroot agencies for
immunization in rural and urban populations. An inadequate knowledge of
vaccinations and their incorrect administration may reduce the potency of vaccines
and lead to adverse effects also. So, it becomes important to understand the

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knowledge level and practices of this huge workforce regarding the important mission
of preventing diseases with vaccines (Swarnkar et al., 2016).

There is limited research evidence both published and unpublished about the
knowledge and practice of the pentavalent vaccine by health care workers. Therefore,
the aim of this study is to assess the knowledge and practice of pentavalent vaccine

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administration and its related factors among health care workers. This study is
focused on the pentavalent vaccine because this vaccine’s coverage was low and there
is limited information about the knowledge and practice of the pentavalent vaccine

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among HCWs in the Lao PDR. The outcomes from this study are expected to provide
evidence to fill our gaps in the knowledge and practice for the implementation of
routines and outreach vaccinations for children under two years of age among health
care workers in Vientiane Capital. This study will also help policy makers,
programme implementers and service providers to eliminate the obstacles and
improve the child immunization coverage in order to attain the intended preventions
as well as pave the way for future studies.


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Research Questions
1. What is the current situation for the knowledge and practices related to the

pentavalent vaccine’s use among health care workers in Vientiane Capital, in the Lao
PDR?
2. What are the factors that affect the knowledge and practice of the pentavalent
vaccine among health care worker in Vientiane Capital?

Research Objectives
Specific Objectives

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1. To assess the knowledge and practice of the pentavalent vaccine among health
care workers in Vientiane Capital, Laos, during the year 2019.

2. To identify the factors associated with the knowledge and practice of the
pentavalent vaccine among health care workers in Vientiane Capital, in 2019.

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Chapter 1: Literature Review
1.1. Definition
Vaccination: The word ‘vaccine’ originates from the Latin Variolae vaccinae
(cowpox), which Edward Jenner demonstrated in 1798 could prevent smallpox in
humans. Today the term ‘vaccine’ applies to all biological preparations, produced
from living organisms, that enhance immunity against disease and either prevent

(prophylactic vaccines) or, in some cases, treat disease (therapeutic vaccines).
Vaccines are administered in liquid form, either by injection, by oral, or by intranasal
routes (WHO, 2008). This study is focused on the pentavalent vaccine which includes
diphtheria, tetanus, pertussis, Hepatitis B, and Haemophilus influenza Type B. Table

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1 shows the Expanded Program on Immunization (EPI) schedule implemented in the
Lao PDR.
Table 1: EPI schedule in Laos
N0

Immunization

1

Hep B0

2

BCG

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Pentavalent: Diphtheria, Tetanus, Pertussis, Hep B,

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Schedule

< 7 days old
0–11 months
2, 4, 6 months

Haemophilus influenza Type B
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Oral Poliovirus vaccine

2, 4, 6 and 18 months

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Pneumococcal Conjugate vaccine

2, 4 and 6 months

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Measles, Rubella

9-11 months

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Japanese Encephalitis vaccine


9-11 months

Health care worker: The term ‘Health care worker’ refers to all personnel regardless
of training in medicine, who have contact with the patients. According to the United
States Centers for Disease Control and Prevention (CDC), this group includes a


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variety of professionals with various levels of exposure and patient contact, such as
doctors, nurses, physiotherapists, dietitians, chaplains, cleaning, catering and
laboratory personnel (Ozisik, Tanriover, Altınel & Unal, 2017). Health care workers
in this study referred to the health personnel providing vaccines and keeping the
vaccination records.
Knowledge of health care workers regarding the pentavalent vaccination
The term ‘knowledge of health care workers regarding the pentavalent vaccination’
refers to the vaccination procedure, knowing about possible precautions and
contraindications to pentavalent vaccinations (Al-Ayed & Sheik, 2006), time

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intervals between doses and the time of vaccine administration, doses and routes of
administration, and contraindication of the vaccine’s storage such as the refrigerator
for holding the vaccine may have vulnerabilities relating to heat, light and freezing
which threaten the vaccines’ integrity (El Shazly et al., 2016).

Practice of health care workers regarding child immunization

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By practice we mean the application of rules and knowledge that lead to action.
Good practice is an art that is linked to the progress of knowledge and technology
and is executed in an ethical manner (Badran, 1995).

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An important component of an immunization provider’s practice is ensuring that
the vaccines reach all people who need them. While attention to the appropriate
administration of vaccinations is essential, it cannot be assumed that these
vaccinations are being given to every person at the recommended age (CDC, 2012).
Components of practice in the application of the pentavalent vaccine include:
 General Precautions: Infection Control and Sterile Technique.
 Vaccine Administration: Preparation and Timely Disposal, and Safe Use of
Needles and Syringes.
 Routes of Administration: Injectable Route (Intramuscular Injections,
Subcutaneous Injections), Oral Route and Intranasal Route.


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 Multiple Injections: If multiple vaccines are administered during a single
visit, administer each preparation at a different anatomic site (Kroger,
Duchin & Vázquez, 1917).
1.2 Situation of pentavalent immunization in Laos and around the world
EPI in the Lao People’s Democratic Republic is widely regarded as one of the
country’s most successful public health programs. Launched in 1979, the program
has established a system of outreach health care providers covering all villages
nationwide. Approximately 70% of children are vaccinated through outreach


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activities. Funding for outreach, however, is insecure and often delayed. Donors fund
over 90% of the vaccine and program operational costs (UNICEF, 2019).
In Houaphan Province based on vaccination certificates, the so called ‘yellow
cards’, [ (n = 66) or, if not available, on parents’ responses (n = 66),] (Maybe move
this to the end of the sentence) the rates of immunization coverage for the DTP
vaccine were 85.6% for the first dose, 69.7% for the second dose, and only 59.8% for

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the third dose. Children of villages close to health centers were more often fully
vaccinated against BCG, DTP, polio and measles than those from remote villages

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(61% vs. 42%, p = 0.03) (Nanthavong et al., 2015). The National Immunization
Programme for the Lao PDR includes the following vaccinations for children: three
doses of the pentavalent vaccine containing DTP, Hepatitis B, and Haemophilus
influenzae Type B (Hib B) antigens. All vaccinations should be received during the
first year of life. Taking into consideration this vaccination schedule (Table 1), the
estimates for full immunization coverage from the Lao PDR, in 2017, were based on
children age 12-23 months (LSB, MOH, UNFPA & UNICEF, 2018).
Overall, immunization coverage has been improving. However, notwithstanding the
improvement in the immunization coverage and the supplementary immunization
activities, there have been diphtheria outbreaks in the country. The recent multicounty study of household health surveys revealed that the Lao PDR was one of the
countries where the in-country economic related inequality in the delivery of three



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doses of the combined DTP vaccine was highest (Xeuatvongsa, Hachiya, Miyano,
Mizoue & Kitamura, 2017). Only 30% of infants received a first dose of DTP, Hep
B and Hib B vaccine by the recommended two months of age and only 13% had
received three doses of DTP-Hep B-Hib B vaccine by the recommended four months
of age. Increasing the proportion of infants who are fully vaccinated to at least 90%
by 2015 required increasing the number of outreach rounds to at least six rounds per
year, or increasing the proportion of target children found during each outreach
session to at least 98%. Approximately 70% of infants in the Lao PDR are vaccinated
through outreach services offered four times per year (UNICEF, 2019). All children
in a study in Laos had documented vaccinations for three doses of DTP3-Hep B-Hib

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B (You vary the way you write this. Stick to one format. I suggest DTP3-Hep B-Hib
B) from December 2013 to July 2014. Girls were well represented with 573 (50.7%)
from 1131 children, and about 776 (68.9%) from 1127 children were born in
healthcare facilities (Evdokimov et al., 2017). The achievements of the Lao PDR in
immunization are considerable, over the past five years routine vaccination coverage

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has increased steadily. This increase follows more than a decade of stagnation.
Supplementary immunization activities have successfully accelerated the control of
poliomyelitis, measles, and maternal and neonatal tetanus. Several new life-saving

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vaccines have been recently added to the national immunization schedule (UNICEF,
2017).

 Benefits related to immunization
About 85% of infants worldwide (116.2 million infants) received three doses of
the DTP3 vaccine, protecting them against these infectious diseases that can cause
serious illness and disabilities or even be fatal. By 2017, 123 countries had reached
at least 90% coverage of the DTP3 vaccine (WHO, 2019). Many of the benefits of
immunization are realized over decades, and may not be immediately obvious. For
example, preventing disease in childhood is linked to better educational performance
and higher earnings later in life (Roed et al., 2013). An efficacious vaccine protects
individuals if administered before exposure. Pre-exposure vaccination of infants with


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several antigens is the cornerstone of successful immunization programmes against a
cluster of childhood diseases.
Vaccination is assumed to reduce the number of individuals susceptible to a
disease. Vaccinations lead the progress towards the fourth Sustainable Development
Goal (SDG) which is to reduce child mortality (Bärnighausen et al., 2011). In a study
in Bangladesh, it was found prior to immunization and again after 1985, childhood
mortality rates were 10% lower in the areas that had received immunization (Aaby et
al., 2003). The WHO estimated that in 2006, immunizations saved two to three
million lives. Nonetheless, in that same year 1.4 million children were estimated to

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have died from vaccine preventable diseases (Hib B, pertussis and tetanus), a

reflection of the incomplete coverage with existing vaccines that persists in many
parts of the world (El Shazly et al., 2016). However, 12.9 million infants, nearly 1 in
10, did not receive any vaccinations in 2016. Critically, this meant that these infants
missed the first dose of the DTP3 vaccine, which put them at serious risk of these

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potentially fatal diseases (WHO, 2019).

1.3 Knowledge and practice among health care workers and their importance

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The knowledge of HCWs on the principles of vaccination and routine antigen
use of pentavalent was mentioned by 91.82% of respondents in a study in Ghana as
vaccines/antigens that required multiple doses to elicit an immune response (Ansong,
Osei, Enimil, Boateng & Nyanor, 2018). In a study of health care workers with a
correct knowledge of the DTP3 vaccine it was found that those familiar with the
dosage and route of administration accounted for 87.1% of respondents, the time of
vaccine administration 91.4% and the contraindication of vaccine 87.9%) (El Shazly
et al., 2016). Meanwhile knowledge about the immunization schedule of school
children was only 55.6%. If sufficient vaccine manual guidelines are available, health
care workers can deal correctly with the dose and route of vaccine by following the
guidelines, so as to rectify the few correct answers given concerning the dose and
route of DPT3 which was a lowly 63.2% (Widsanugorn, Suwattana, Harun-Or-


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Rashid & Sakamoto, 2011). In another study 97.27% of HCWs mentioned that

pentavalent administration starts at 6 weeks in a child’s life, while an overwhelming
majority (98.18%) of the respondents rightly indicated with a visual aid that
pentavalent vaccines are given per the intramuscular route at a 90° angle (Ansong et
al., 2018). Only 21.9% of the HCWs claimed to know the current guidelines for
vaccinations. First, the knowledge of HCWs about recommended vaccines was
assessed and then it showed there were significant differences between HCWs’
claims to know the guidelines and those who were not informed about them. The vast
majority of HCWs (98.2%) recognized Hepatitis B as an immunization target, while
less than half (48.7%) thought that tetanus was a disease of concern. Vaccines against

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diphtheria were also not considered as part of the guidelines by most HCWs, with
significant differences found in their knowledge of the recommendations (pvalue=0.04) (Harrison et al., 2016).

There is evidence suggesting that the knowledge and practices of primary health
care providers (PHCPs) may have an important contributing effect on parental

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decisions to accept or forget vaccinations (Salmon et al., 2008). The knowledge of
the health care workers is correlated with higher vaccination coverage rates.
Additionally, other research has shown that parents and other individuals cite health

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care professionals as the most important factor influencing their decisions to
vaccinate their children or themselves (Cvjetkovic, Jeremic & Tiosavljevic, 2017). In
certain cases, adverse effects and misconceptions about vaccines cause some parents

to reject the vaccination programme. Hence, the role of health care providers is very
important in determining the decision making of parents regarding vaccination
(Allela, 2017). Most parents followed the advice of their HCPs and comply with state
school immunization requirements by fully vaccinating their children before school
entrance (Salmon et al., 2008). A knowledge about particular vaccines, their efficacy
and safety, helped to build HCPs own confidence in vaccines and their willingness to
recommend them to others. Knowledge alone though is not enough, as indicated in
the study in South Africa that also identified the importance of societal endorsement
and support from colleagues (Hoque, Monokoane & van Hal, 2014). The level of


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vaccine knowledge among HCPs was not the only aspect for feeling prepared or
unprepared to recommend vaccinations and/or address vaccine hesitancy (Ishola Jr,
Permalloo, Cordery & Anderson, 2013). The appropriate administration and handling
of vaccines is important for effective immunization practice (Strohfus, Collins,
Phillips & Remington, 2013). In terms of confidence, HCPs with more knowledge
about the vaccine were also more likely to recommend vaccination, although more
support is needed, especially for managing difficult conversations with a vaccine
reluctant patient or parent (Hough-Telford et al., 2016). Knowledge deficits in
vaccine management can cause ineffective handling, administration resulting in
lower coverage rates and a decrease in vaccine protection (Strohfus et al., 2013).

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There is a significant association between knowledge and the intention to vaccinate.
Hence the greater the knowledge level, then the greater the intention to vaccinate will
be (Herzog et al., 2013). Any significant knowledge deficit may jeopardize the overall

immunization rates of the practice and the population it serves (Strohfus et al., 2013).
This knowledge deficit accounts for 17% of the total global under-five mortalities per

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year. Augmenting this system is necessary as vaccine failure may occur due to a
failure to store and transport vaccines under strictly controlled temperature
conditions. This is of concern in view of the fact that there have been reported

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epidemics of vaccine preventable diseases in populations thought to have been fully
immunized (Nwankwo et al., 2018). About 41.0% of the respondents in a study in
north-western Nigeria strongly agreeing that staff training in the cold chain delivery
system is important (Nwankwo et al., 2018). Inappropriately administered vaccines
suggest there may be major gaps in the training of health care professionals directly
responsible for administration/handling processes. Little information is available on
health care personnel's knowledge of administration, handling and scheduling of
vaccines or about knowledge differences in types of medical office practices
(Strohfus et al., 2013).


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1.4 Determinants of knowledge and practice regarding child immunization
Determinants of knowledge and practice for child immunization are of special
importance in this study, as there are many factors relating to knowledge and practice
among health care workers. This study is seeking to identify factors associated with
a knowledge and practice regarding children’s vaccinations among health care
workers in Vientiane Capital, Lao PDR, in the year 2019.

Individual factors:
Socio-demographic
There are some significant correlations between knowledge of vaccination with the

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provider’s demographic characteristics (Warner et al., 2017).
 Age

Age has been recognized as an important determinant of vaccination practice
among health providers. An older age has been shown to be a protective factor for
knowledge and practice related to immunization. For example, research by Ogunyem

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et al. showed that younger aged health care workers were found to have a significant
relationship with a knowledge of AEFI (Adverse Events Following Immunization)
(P = 0.029) and a knowledge of immunization (Ogunyemi & Odusanya, 2016). A

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young age was a significant risk factor for a lack of knowledge about the guidelines
for vaccination (AOR 1.1, 95% CI 1.02–1.15). In the youngest age group (20–29
years of age, n = 20), no one knew about the recommendations of vaccination. Gender
and work place were not found to be associated with a knowledge about the guidelines
(Harrison et al., 2016). Furthermore, respondents aged 30–39 years were three times
more likely to have a good perception towards the adverse events following
immunization surveillance [OR: 3.28, 95% CI: 1.51–7.12; 𝑃 =0.003]. Respondents
with previous AEFI training were 2.7 times more likely to have a good perception

towards AEFI surveillance [OR: 2.67, 95% CI: 1.64–4.35; 𝑃< 0.0001] (Masika, Atieli
& Were, 2016).


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Nurses practicing in their thirties were five times more likely to have good
practices towards adverse events following immunization surveillance [OR: 5.01,
95% CI:1.88–13.30; 𝑃 = 0.001]. Those with previous AEFI training were 1.8 times
more likely to have good practices in AEFI surveillance [OR: 1.78, 95% CI: 1.09–
2.89; 𝑃 = 0.021] (Masika et al., 2016). A young age was a significant risk factor for
a lack of knowledge about the guidelines (AOR 1.1, 95% CI 1.02–1.15). In the
youngest age group (20–29 years of age, n = 20) no one knew about the
recommendations (Harrison et al., 2016).
 Sex

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Sex has been recognized as an important determinant of vaccination practice
among health providers. Men and women have been shown to be a protective factor
of knowledge and practice related to immunization. For example, research by Salem
et al. in Egypt has shown that females have a higher knowledge than males (mean ±
SD:50.6 ± 4.8 for males, 52.5 ± 5.4 for females). Most of the participants were

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females with a percentage of 89.9% (Salem, 2018). Gender was not found to be
associated with a knowledge about the guidelines (Harrison et al., 2016).


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 Type of health professional

Qualifications are one of the factors which have an important effect on
knowledge and practice among health care workers. Qualifications are related to
knowledge and practice regarding child vaccination among health care workers as
demonstrated by research in the UK which reported that nurses with high knowledge
scores were more likely to recommend the influenza vaccine to their patients, and be
willing to recommend vaccinations to patients in the future (Zhang, While & Norman,
2012). In Israel, a knowledge about the influenza vaccine was associated with high
vaccination rates among pediatric HCPs and their willingness to recommend
vaccinations for children (Paterson et al., 2016). The odds to be in a more progressive
immunization category were significantly higher for physicians not working in a
private practice (compared with physicians working in a private practice; OR 1.94;


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95% CI 1.27–3.00; P < 0.01), pediatricians (compared with other physicians; OR
2.62; 95% CI 1.99–3.45; P < 0.001), and women (compared with men; OR 1.54; 95%
CI 1.15–2.02; P < 0.01) (Schuler et al., 2017). The total knowledge score was higher
among senior nurses (P < 0.05) (El Shazly et al., 2016). Respondents possessing
diploma or degree training in nursing were 2.5 times more likely to have a good
perception towards as the adverse events following immunization surveillance [OR:
2.54, 95% CI:1.55–4.17; 𝑃< 0.0001] (Masika et al., 2016). It was found that nurses’
willingness to recommend new vaccines was consistently associated with the
perceived safety of the vaccines as well as the perceived professional support for the
vaccines (Paterson et al., 2016). Pediatric practices were consistently more


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knowledgeable overall (Strohfus et al., 2013). An increase in knowledge and practices
was observed with the advancement of HCPs’ qualifications (Swarnkar et al., 2016).
 Education level

The education level of HCPs is a consequential factor for vaccination practice
among health providers. A higher education has been shown to be a protective factor

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of knowledge and practice related to immunization. For example, research by
Swarnkar et al has shown that the higher education of workers has an impact on their
knowledge and practices (Swarnkar et al., 2016). In addition, 56.6% of nurses with a

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diploma or a degree in nursing had a good knowledge of AEFI surveillance (𝜒2: 5.23;
𝑃 = 0.022). Similarly, those with a diploma or a degree in nursing were 1.8 times
more likely to have a good knowledge towards AEFI surveillance [OR: 1.76, 95%
CI: 1.08–2.85; 𝑃 = 0.023] (Masika et al., 2016). A study in Egypt documented that
senior nurses who had a bachelor of nursing have a better knowledge compared with
nurses who had a diploma of nursing, health workers, and physicians (El Shazly et
al., 2016).
 Work experience
Work experience has been broadly accepted as an important determinant of
vaccination practice among health providers. A health care worker who works more
than two years has been shown to be a protective factor of knowledge and practice
related to immunization. For example, research by Widsanugorn et al has shown that



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a knowledge regarding EPI, when comparing a student’s t-test and a Mann-Whitney
U test, the mean in the group with work experience of two years or more was
significantly higher than in the group of respondents who had less than two years
(Widsanugorn et al., 2011). The knowledge of health care workers who had extensive
work experience in EPI was better than that of health care workers who had limited
work experience (de Timóteo Mavimbe & Bjune, 2007). A Malaysian study
attributed a high knowledge score to the long duration of work experience of the
health workers. Several respondents had a work experience of 15 years, while the
average work experience in this study was 2.5 years (Nwankwo et al., 2018). The
practice level towards AEFI surveillance also increased with the years of experience

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since respondents with at least 30 years of experience (75.9%) had good practice (𝜒2
31.47; 𝑃< 0.0001). Respondents with previous training in AEFI (65.9%) had good
practice compared to those without (Masika et al., 2016). Providers in practice for
less than 20 years were more likely to routinely recommended standard pediatric
vaccines (121/123 (98%) vs 73/81 (90%)) (p < 0.05) (Bonville, Domachowske,

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Cibula & Suryadevara, 2017). The participants’ years of experience of immunization
practice at PHC level and their mean scores for all the different types of assessment
conducted showed no significant association (P>0.05) in a study in south-western


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Nigeria (Brown, Oluwatosin & Ogundeji, 2017). HCW respondents who had more
than five years work experience were 1.71 (AOR 95% CI: 1.02-2.86) times more
knowledgeable than those who had two years or less work experience. HCW
respondents who had more than five years work experience were 2.78 (95% CI: 1.545.01) times more knowledgeable about the vaccination schedule than those who had
up to two years of work experience (Asres et al., 2019).
 Workplace
The workplace is also an important factor associated with a knowledge and
practice of pentavalent vaccines. Practices in hospitals were better than those in health
centers (P=0.001). Knowledge and practice comparisons showed that the mean total
score in the group of respondents who worked in hospitals was significantly higher
than in those who worked in health centers (Widsanugorn et al., 2011). As regards to