|Year : 2018 | Volume
| Issue : 1 | Page : 81-86
Knowledge, perception and reporting attitude of adverse effects following immunization among primary healthcare workers in sabon gari local government area Zaria, Kaduna State, Nigeria
Lawal A Mohammed1, Alhaji A Aliyu1, Bilkisu B Maiha2, Abdulkadir Isa3
1 Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
2 Department of Clinical Pharmacology, Ahmadu Bello University, Zaria, Nigeria
3 Department of Paediatrics, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||23-Mar-2018|
Prof. Alhaji A Aliyu
Department of Community Medicine, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
Background: Although vaccines currently approved for routine childhood immunization are safe and effective, frequent adverse events following immunization (AEFI) often cause ill-health and sometimes loss of public trust in immunization programs. This study assessed the level of knowledge, perception, and reporting attitude of primary healthcare (PHC) workers of AEFI in Sabon Gari local government area of Kaduna state. Materials and Methods: A descriptive cross-sectional survey using simple random sample method was used to select 110 PHC workers. Data were analyzed using IBM Statistical Package for the Social Sciences version 21. Results: Majority (92.2%) knew about AEFI and over 80% of the healthcare workers had been trained on AEFI and knew signs and symptoms of AEFI. More than 50% of respondents had good knowledge on AEFI but only 17.8% had good reporting practices. Sixty-six percent of healthcare workers had encountered an AEFI and 56.7% had ever reported an AEFI. There was a statistically significant relationship between age of healthcare workers (P = 0.001), previous training (P = 0.036), working experience (P = 0.001), and knowledge on AEFIs. Conclusion: The study revealed that PHC workers had good knowledge, perception, and reporting attitude toward AEFI surveillance. There is a need for training and retraining of staff as well as provision of internet access to ease electronic reporting system of AEFI surveillance.
Keywords: Adverse events, healthcare workers, immunization, knowledge, reporting practices
|How to cite this article:|
Mohammed LA, Aliyu AA, Maiha BB, Isa A. Knowledge, perception and reporting attitude of adverse effects following immunization among primary healthcare workers in sabon gari local government area Zaria, Kaduna State, Nigeria. Niger J Basic Clin Sci 2018;15:81-6
|How to cite this URL:|
Mohammed LA, Aliyu AA, Maiha BB, Isa A. Knowledge, perception and reporting attitude of adverse effects following immunization among primary healthcare workers in sabon gari local government area Zaria, Kaduna State, Nigeria. Niger J Basic Clin Sci [serial online] 2018 [cited 2021 Jun 16];15:81-6. Available from: https://www.njbcs.net/text.asp?2018/15/1/81/228354
| Introduction|| |
The successful implementation of large-scale comprehensive national immunization programs and the subsequent eradication or control of smallpox, measles, pertussis, meningococcal meningitis, hepatitis B, tetanus etc. are among the most notable achievements of the 20th century. Immunization has been regarded as the most cost-effective intervention for child health promotion by World Health Organization (WHO). The benefits of immunization apart from reducing cost of disease treatment include ensuring a healthy childhood, alleviation of family poverty, and suffering. Currently, immunization averts an estimated 2–3 million deaths from diphtheria, pertussis, tetanus, and measles every year in all age groups. The diseases targeted by routine immunization are all preventable and are among the leading causes of childhood morbidity and mortality. Immunization needs to be offered at every opportunity with the aim of eliminating these vaccine-preventable diseases. Despite significant progress in vaccine-preventable disease control, immunization is not free of controversy. Vaccine safety is increasingly becoming important because of alleged safety issues derailing vaccine programs worldwide.
An adverse event following immunization (AEFI) is defined as any untoward medical occurrence that follows immunization and which does not necessarily have a causal relationship with the usage of the vaccine. The adverse event may be any unfavorable or unintended sign, abnormal laboratory finding, symptom, or disease. This type of surveillance typically relies on health professionals associating an adverse event in an individual as a possible consequence of vaccination and reporting it to the appropriate authority. Adverse events have been categorized into the following: vaccine product-related, vaccine quality defect-related, immunization anxiety-related coincidental events, and immunization error-related events. Making sure that vaccines are safe, effective, and of good quality is a pivotal element of vaccine development and deployment. However, even if vaccines are produced and regulated in keeping with WHO standards for safety, no vaccine is without risk of potential adverse reaction. In addition to the vaccines themselves, the process of immunization is a potential source of adverse events. When an AEFI raises concerns among the public to the extent that they refuse further immunizations for their children, the children are more likely to get a vaccine-preventable disease and suffer the consequences.
These adverse events are global phenomena; in the USA, for every 10,000 cases of vaccinations, 1.14 cases of AEFIs were reported with 1.4% deaths, in Australia, 14.1 cases of AEFIs were reported per 100,000 doses in 2009, and in 2012, 129.5 per 100,000 vaccine doses in Sri Lanka, respectively. A study from Ilorin, Nigeria reported 19.3% in 2005, while another report from Port Harcourt, south Nigeria, revealed that about 57% of mothers admitted that children had one or more AEFIs following pentavalent vaccine administration, fever (88%), swelling (34%), and irritability (40%). In Africa, poliomyelitis vaccine was suspended in Nigeria for one year following quality and safety issues alleged by religious leaders. This led to massive rebound of polio cases. Vaccine safety surveillance and follow-up are, therefore, central to addressing both actual and perceived AEFI-related issues in order to increase the public confidence and patronage of vaccination program.
Immunization safety surveillance needs to include training that will enable appropriate response at all levels in the system. The person responsible for immunization safety surveillance needs to keep informed about the latest developments in safety, monitoring, and current concerns regarding immunization.
The influence of nurses' perception toward AEFI surveillance is not well studied and documented. Lack of motivation and staff anxiety about implications of programmatic errors negatively contribute to AEFI surveillance, especially on reporting of adverse events. These include ignorance, lack of awareness of reporting system, fear of litigation, and lack of time are some of the reasons.,,, However, motivation combined with training and supervision contributed significantly to improving AEFI reporting rates in Ghana.
Even though AEFIs are common and well known, not much is known about how healthcare workers recognize or report them. It is likely that differences in healthcare professionals' AEFI knowledge, and practice of reporting result in inconsistent adverse event data collection. In Nigeria, studies  have shown that immunization coverage was on the decline. Reasons include failure to assess immunization status of children during visit to health facilities, failure to administer all the needed vaccines simultaneously, and probably fears of adverse events, as is seen in developed countries today. Poor AEFI surveillance impacts negatively on immunization. To reduce the occurrence of vaccine adverse events and maintain public confidence in vaccines, it is important to improve understanding of vaccine safety and thereby foster the development and use of safer vaccines.
Health workers have essential and pivotal role to play in gaining and maintaining public confidence in the safety of vaccines through operational AEFI surveillance. These roles include providing evidence-based information on the benefits and risks of vaccines: identifying and reporting adverse events following immunization. The paucity of literature on AEFI in this part of the country prompted this study to assess knowledge, perception, and reporting attitude among primary healthcare (PHC) workers in Sabon local government area (LGA), Zaria Kaduna state of Nigeria.
| Materials and Methods|| |
Sabon Gari local government was created on August 27, 1991 from the defunct Soba LGA of Kaduna state. It is located in guinea savannah zone of the northern Nigeria, about 5 km from Zaria city and 65 km from Kaduna town, the state capital.
According to the 2006 population census, Sabon Gari had a population of 286,671 in its two districts with 11 wards and about 235 settlements. It is an urban LGA with Hausa as the predominant tribe who are Muslims, and there are also Christians living in the area. The local government has 24 PHC facilities consisting of 8 family health units, 9 health clinics, and 5 health posts. These health facilities are distributed between 6 health districts; they all provide maternal and child health services, including antenatal care services.
Study design: A cross-sectional descriptive study design was employed.
Study population: PHC workers in PHC centers in Sabon Gari LGA Kaduna state, Nigeria who provide routine immunization services.
- All PHC workers working in PHC centers in Sabon Gari local government Kaduna state that provide routine immunization services
- Having worked at the above facilities for at least six consecutive months.
- Health workers working in private and other non-PHC facilities in Sabon Gari LGA
- Eligible PHC workers who were on leave at the time of the study.
Sample size: The minimum sample size was calculated using the formula:
Where n = desired sample size
z = standard normal deviate which corresponds to 95% confidence interval
p = proportion of the target population estimated to be aware of filling of AEFI form = 93.
q = 1 – 0.93 = 0.07
d = degree of precision (0.05 ± 5.0%)
n = 100
Correcting for 10% nonresponse rate = 10
Sample size = 100 + 10 = 110. Therefore, a total of 110 questionnaires were administered.
Sampling technique: The study was conducted in all the PHCs within the local government. The number of respondents included in the study were distributed proportionately to each of the health centers. Eligible members from each facility were selected using simple random sampling method until the required sample size was obtained for that facility.
Study instrument, data collection, and analysis
A self-administered, open-ended questionnaire was adopted from previous study. Data collected were on demographic details, knowledge of AEFI, reportable AEFIs, and methods of reporting AEFI. Respondents were asked about training on AEFI and if they had encountered AEFIs and their reporting practices. Perceived barriers to reporting AEFI were also sought. The questionnaire was pretest among 22 healthcare workers in another LGA after which necessary amendments were made in the final questionnaire.
The questionnaires were manually checked for completeness and consistency before entering into IBM Statistical Package for the Social Sciences version 21 for analyses. Data were presented in tables with the output of their analyses. Chi-square was used to test for statistical associations of interest at P ≤ 0.05.
Measurement of variables
The responses in each section were scored one for every correct answer and zero for every wrong answer for section knowledge and reporting practice, while perception was assessed using 14 statements on a five-point Likert scale (Agree, Neutral, and Disagree). Positive statements were scored as: +5 (Agree); +3 (Neutral); +1 (Disagree). Negative statements were scored as: +1 (Agree); +3 (Neutral); +5 (Disagree). They were graded as poor, fair, or good, respectively, if their summed scores fell <40%, between 41 and 49%, and ≥50% of the total score. For knowledge of AEFI, there were five questions with a total score of 15. For reporting attitude toward AEFI, there were 11 questions with a total score of 17.
Ethical approval for the study was obtained from the Health Research and Ethics committee of Ahmadu Bello University Teaching Hospital Shika-Zaria, Nigeria. Letter of introduction was also sent to the Chairman through the Head of Health Department (PHC Coordinator) for permission and cooperation to conduct the study, while written informed consent was obtained from study participants who were assured of confidentiality of data collected.
| Results|| |
A total of 110 questionnaires were distributed, 90 duly completed, retrieved, and analyzed, giving a response rate of 82%. Most of the respondents (42.3%) were in the age range of 26–35 years, mean age was 33.7 ± 3.3, majority (74.4%) were females, Community Health Officers (66.7%), mean years of working experience 7.7 (Q = 5, Q = 35) [Table 1]. Majority of respondents (92.2%) knew about AEFIs, 85.6% of respondents have had training on AEFI through on-job/seminars/workshops (62.2%), on-job training alone (23.3%), and others (2.2%), respectively [Table 2]. Common symptoms of AEFIs that occur were: swelling at injection site (32.2%), fever (30.0%), and redness at injection site (23.3%) [Table 3]. Majority of respondents (75.6%) stated that AEFIs are not a common event in the area, while 66% had ever managed AEFI.
|Table 1: Distribution of socio-demographic characteristics of respondents|
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On perception, 84% of respondents each believed poor monitoring of AEFI can cause reduction in immunization coverage and that AEFI surveillance can help build public trust on immunization program. Eighty-two percent were ready to learn more on AEFI (diagnose, investigate, manage, and report) and 45.6% believed reporting AEFI can lead to personal consequences.
Majority of respondents (75.6%) agreed that it is healthcare workers who are responsible for reporting AEFI, but only 56.7% had ever reported AEFI. The main methods of reporting were telephone (44.5%), electronic mail (28.9%), and using AEFI form (24.4%), respectively. Relationship between respondents' characteristics and knowledge score on AEFI revealed that 58.9% of respondents obtained more than 50% of marks on knowledge and were classified as having good knowledge. Age (P = 0.009), working experience (P = 0.001), and previous training (P = 0.001), respectively, were significantly associated with knowledge while gender and qualification were not associated [Table 4]. No healthcare workers' characteristics were significantly associated with perception on AEFI.
|Table 4: Health workers' characteristics and knowledge of score on AEFI in Sabon Gari LGA|
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Finally, perceived barriers to reporting AEFI by respondents were not considering the event as related to immunization (61.1%), forgetfulness (56.7%), cannot find reporting form (38.9%), and did not know about reporting process (34.4%) [Table 5].
|Table 5: Distribution of barriers to reporting AEFI among healthcare workers in Sabon Gari LGA|
Click here to view
| Discussion|| |
The continuous monitoring of the safety of drugs (including vaccines) as they are licensed and in widespread use is a complex and shared responsibility between governments, industry, healthcare providers, and patients. This has become more pertinent for vaccines which are administered on a large scale to healthy children for anticipated benefits. Also vaccines demand a very high degree of safety and parents of infants receiving their routine immunization need reassurance that these vaccines are importantly safe. In this study the mean age of respondents (33.7 ± 3.3 years) is in agreement with report of previous local and international studies , and majority were females.
It is encouraging to note that knowledge level of AEFI was good and a high proportion of respondents had undergone training on AEFI. An earlier study in southwest Nigeria also reported similar findings. The fact that the respondents are receiving training on AEFI will promote a high sense of vigilance and it will make much easier for them to quickly identify any suspected case of AEFI in their service areas. All these will go a long way in ensuring public confidence in immunization program of the country. They were also knowledgeable on common symptoms associated with AEFI such as fever, pain and swelling at injection site etc. This is similar to the report of a study in Lagos, southwest Nigeria  and other studies elsewhere.,,
Generally, a high proportion of respondents had good perception and believed that poor monitoring of AEFI can lead to reduction in immunization coverage and that AEFI surveillance can build public confidence on immunization program. This underscores the importance to provide adequate education to nurses, both pre- and in-service training as evidenced by a good proportion of them willing to learn more on AEFI surveillance. One of the best ways to do this would be to incorporate AEFI surveillance training into continuing professional education programs. Less than half of respondents entertained fear of punitive measures being taken against them for reporting AEFI due to professional negligence. Thus the workers need reorientation, health education on attitudinal change on this wrong perception, and also reassurance as contrary to this misconception, reporting AEFI is meant to enhance supportive supervision and promote quality health service (immunization) delivery.
On reporting AEFI, respondents agreed that it is their responsibility which is consistent with report of previous studies;, more than half had ever reported an adverse event. This willingness to report AEFI is, however, compromised by nonavailability of reporting forms. In this study, the proportion of workers who reported an AEFI is higher than 2.3 and 19.0%, respectively, reported in two international studies.,
Barriers to reporting AEFI in this study (not considering event serious, forgetfulness, forms not been available, etc.) were consistent with report of previous study  but contrasts with a Zimbabwean study  where respondents reported of not been familiar with reporting system. A study from Nigeria also reported about time constraint/resource as obstacles to reporting AEFI. Age of respondents, working experience, and previous training were significantly associated with knowledge on AEFI.
| Conclusion|| |
The study revealed that PHC workers had good knowledge, perception, and good reporting attitude toward AEFI surveillance in Sabon Gari LGA of Kaduna state, Nigeria. There is need for training and retraining of staff as part of professional development coupled with supportive supervision to ensure optimum performance and promote best practices in routine immunization service delivery. It is also recommended that health facilities be provided with internet to ease electronic reporting system of AEFI surveillance.
We acknowledge and appreciate the assistance and cooperation of the LGA and all staff who participated in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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