Majority of students strongly agreed that all students should get vaccination against HBV before proceeding to their practical placement because of the risk of contracting HBV during procedures. There was also strong agreement that HBV vaccination should be mandatory for all HCWs and students (Figure 3).
Practices
Vaccination against HBV
Majority of the respondents (355/466;76.18%) reported to ever having been vaccinated against HBV. However, full vaccination was reported by only 21.78% of the students with majority of the students having received partial vaccination: 1 dose (19.55%) or 2 doses (50%). No vaccination was reported by 19.10% (89/466) students. The main reason for not having received the recommended 3 doses was that the vaccine was not available when they went for it (35.78%). Most students received the vaccine within their campuses (63.57% in the students/staff clinic; 31.01% within the college premises other than the clinic. In most cases, a college healthcare worker vaccinated the students (73.11%). There were no side effects reported by the majority of vaccinated students (67.80%) while those who reported side effects mostly had swelling at the site of injection (57.58%).
Infection prevention during practical placement
During practical placement, 84.23% of students reported that they always put on gloves when carrying out clinical procedures such as cleaning wounds and cuts. However, 20.99% reported to having had a needle stick injury (NSI). Of those who reported NSIs, 18.28% took no action with only 38.71% reporting the matter immediately and getting post exposure prophylaxis that included the HBV vaccine.
Vaccine Accessibility
Majority of students (85.26%) reported that the cost for HBV vaccination was included in the college fees. However, only 40.76% reported that the HBV vaccine is available in their colleges on a continuous basis, with 41.33% reporting that the schedule for each round of the HBV vaccination program is not being well publicized. Despite this, 70.06% of respondents still prefer to receive the HBV vaccination within their campuses.
Association of vaccine uptake with sociodemographic characteristics
Pearson’s chi was used to investigate the association between HBV vaccine uptake and selected sociodemographic characteristics. The campus, year of study and length of time as a student had a statistically significant association with vaccine uptake (Table 5).
Qualitative findings
The main themes that emerged from the two focus group discussions were (i) availability and accessibility of the HBV vaccines in the campuses; (ii) attitude towards the vaccination exercise; and (iii) institutionalization of the vaccination program
Availability and accessibility of HBV vaccine in the colleges
The availability of the vaccine in the campuses, especially in those far away from KMTC’s headquarters (Nairobi), was a recurring challenge. The main factors cited were inadequate HCWs to carry out the vaccination exercise, inconsistent supply of vaccines; lack of appropriate vaccine storage facilities in some campuses, and shortage of supplies needed for the vaccination exercise. Insufficient management support, in terms of vaccine transportation was also mentioned by some campuses located within Nairobi.
"It has not been very easy, at times the vaccines are not there and no storage facility especially outside Nairobi and of course transportation” [Staff, SF]
“…we do not have fridges and at some point, I store in the kitchen fridge where we store milk.”[SF]
“Financials [is a challenge] especially when it comes to the purchase of syringes. Personally I have used my money to purchase syringes.” [SF]
“Whenever you request [for the vaccine], the response is always ‘the headquarters have not delivered’…..”[Student, SD]
The lack of consistency of the vaccine supply posed a major challenge in getting the required doses on time. Further, it led to some students completing their practical experience in certain courses without receiving the vaccine at all or only having it after they had already started their practical attachment.
"It [vaccine supply] is not [consistent] because some doses are missing and therefore, we are forced to give unrecommended doses. We have back logs and at times the students refuse to [go to] the wards.” [SF]
“They are given, I can say partially. May be dose 1 and 2nd dose delay[s] or go[es] missing.” [SF]
“…..we don’t start the first dose if we are not sure..we cannot give all the doses….in our college we have decided to vaccinate only nurses, clinical officers and asked the occupational therapy students to wait….”[SF]
“The students have to push for the vaccines for about five months”[SD]
“There is laxity in our colleges….they take us for placement without vaccination”[SD]
A major cause of concern that was expressed during both FGDs was the shortage of staff to carry out the vaccination exercise. This led to the campuses using senior students to vaccinate which respondents felt had the potential to expose students to risks of vaccination.
“Workload. We have the role of vaccination amongst other like 40 roles, it’s too much to handle.”[SF]
“Workload…….you find three lecturers are suppose[d] to handle 6 or 15 classes…and they are the people who should give the vaccine too!”[SF]
“…..risky because we use senior students to vaccinate which is really illegal for the student to carry out a procedure alone….”[SF]
“Lack of qualified vaccinators [is a challenge]. In most colleges, we use senior students to help in the vaccination process”[SF]
“…..it [vaccination] is done by senior students who are not qualified….”[SD]
“My main concern is that the vaccination is done by senior students, not health workers…”[SD]
Poor timing of the HBV vaccine doses also arose in the discussions. Due to delays in supply of the vaccine, students were exposed to the practical attachment without having received the recommended doses.
"In the previous years, students were not allowed to report for attachment before vaccination but [these] days they do because there are no vaccines”[SF]
“I wish the supply [of the vaccine] can be consistent. We should get the vaccines before students go for their attachment…….when the vaccine gets late, the students are already in the rural attachment and [it is] very difficult to get them”[SF]
“…I have always [thought], what would happen if one student who has paid[and has not been vaccinated] is infected with HBV?.”[SF]
“Yes [we should be vaccinated before practical attachment]because we are going to be exposed in the wards”[SD]
Attitude towards the vaccination process at KMTC
The students felt that the delays in getting the vaccine were due to an unconcerned and corrupt administration. There was a feeling of discontentment among students about the cost charged for the vaccination as opposed to the timeliness of administration of the vaccine. In addition, they felt that the administration had not put in place proper awareness channels about the availability of the vaccine to its students.
“I think the management is not taking this [HBV vaccination] serious[ly], someone is sleeping on the job…. "[SD]
“We pay for these vaccines and very expensively but we are not given….”[SD].
“Our college is more strict in academics than our health because if they can arrange for our academics for the whole year, then they can still do the same for the vaccines!”[SD]
“The college is not doing enough because there is no communication. They wait for the students to push for it…”[SD]
“…the students fight for it, I can say it is a struggle.”[SD]
“….the same people who should give us the vaccine are the same people who release us for attachments without being vaccinated.”[SD]
On their part, staff members decried the difficulties experienced in implementing an effective vaccine management system. Poor monitoring and assessment of the vaccine supply chains were reported at all levels. The long procurement process coupled with the campuses’ inability to accurately forecast vaccine requirements contributed to frequent stock-outs.
Frequent changes of staff managing the vaccine program affected the quality of data reporting and coordination. Further, the staff felt that the issue of vaccinating students was not considered as a priority due to other competing tasks.
"…some institutions only remember [to issue first dose to] new students and [are] not able to give the second dose. Major issue is procurement.”[SF]
“…vaccination comes last since we have HIV and other issues to discuss.”[SF]
Students were especially frustrated with the vaccination process. They were concerned about going for their practical placements before the vaccination. On the other hand, there were reports of some students who did not receive the vaccination despite awareness creation.
“….the college is reluctant, the vaccines can be given [once] then the rest is history…not many students get it.”[SD]
“The [students who are enrolled in] March intake are exposed to clinical areas before vaccination.”[SD]
“There are also absentees [students] who do not follow up.”[SD]
Institutionalization and sustainability of the vaccination program
Both students and staff members felt that the HBV vaccination program at KMTC was an important disease prevention strategy for the students. However, it needed to be streamlined for it to be successful. Some issues that arose that negatively impacted the effectiveness of the vaccination program included shortage of staff, inadequate clinics, vaccine storage facilities and supplies, inadequate communication and centralization of vaccine procurement process. The staff members felt frustrated that they were doing a lot to sustain the program but were not benefiting through vaccination.
However, there were also suggestions for KMTC to stop the vaccination program and allow students to get the vaccine outside the college.
“It should be done by KMTC but the cost should be reduced…I think we can get a new system…”[SD]
“I support it [having vaccination done by KMTC] but all campuses should be given their own vaccines without struggle.”[SD]
“The system can be improved…every campus should have its vaccine. Storage should first be improved.”[SF]
“I wish the supply can be consistent….”[SF]
"Staffs are only protecting the students while they are not protected.”[SF]
“No, I don’t support the current structure but I would prefer it outside the KMTC.”[SD]
“It should be stopped…I would suggest [that] we get vaccinated outside KMTC and [bring] the receipt.”[SD]
Members of staff and members of the Student Representative Council actively participated to ensure the sustainability of the program. Some of the suggestions given to improve the program included timely availability of the vaccine to justify value for money. The College needed to disseminate the vaccination policy and manual, and carry out sensitization of all stakeholders. New members in the campus vaccine coordinating committees needed training in managing the program.
“We are volunteering, [giving] timely communication and co-coordinating.”[SF]
“Being there when things are not working out.”[SF]
"We would like the college policy to be disseminated.”[SF]
“The management should allow the process to continue so as to help us protect ourselves from HBV.”[SF]
“It [vaccination] will be difficult only if it’s outside the KMTC. It [should] be done in KMTC but under one condition, system be changed.” [SD]