Immunization is at the core of severe communicable disease control and prevention in Thailand because immunization or vaccinations suppress the spread of many types of infectious diseases. Therefore, vaccines are of no less importance for the health of an individual than medications. Thailand has been praised by the World Health Organization in providing immunization services as one of thirteen countries worldwide that was successful in developing a system for monitoring access and use of vaccinations for preventing diseases in children [1]. In practice, however, many problems persist. For example, according to an immunization assessment by the Ministry of Public Health’s Disease Prevention Vaccine Division of the Department of Disease Control, primary care units in Thailand’s government sector earned assessment scores of only 63.90 percent consistency with standards, meaning vaccination services remain incomplete according to all immunization standards. When categorized by activity, immunization service delivery was found to have the highest mean score (90.1%), followed by vaccine management and cold chain monitoring, while information system management had the lowest score [2]. The vaccine management problem showed an immunization service that was inconsistent with standards, causing a loss of vaccine efficiency and ineffective immunization services.

Success in developing immunization services in Thailand depends on four main elements: 1) vaccines; 2) budgets; 3) management of production, storage, transportation and service units; and 4) immunization staff or service providers, which is highly important as the main mechanism in working according to achieve goals [3]. Findings from the studies on service knowledge and skills of the Thai EPI staff found most of the staff possessed confidence in their skills but displayed improper practices in vaccine storage and cold-chain system, scheduling immunization appointments and vaccine screening. Furthermore, the staff was found to lack confidence and conducted improper practices in vaccine estimation and dealing with AEFI, causing erroneous vaccine disbursement in data management and registration, lacking procedures to assist patients with abnormal symptoms and providing care for emergency patients who had anaphylaxis. Problems were also found in cold chain system management for vaccine storage and improper vaccination services [4]. Similarly, the findings from research conducted abroad found most EPI staff to lack knowledge and understanding of vaccine estimation and vaccine-report registration due to a lack of proper training on providing vaccination services. Thus, performance has to be monitored and assessed, and training has to continually be provided to enhance knowledge among staff [2, 5]. The data mentioned above reflected inaccurate knowledge, understanding and skills, causing immunization staff to have an insufficient capacity for immunization work.

For these reasons, immunization staff knowledge and skills development is considered essential in effective vaccine management. The development of staff depends on systematic and effective staff methods. Training in essential knowledge and skills to meet work requirements is a major factor in enabling the staff to work effectively and with confidence leading to a high standard of work. Knowledge and skills development, in particular, has significant effects on the development of immunization work competency [6, 7]. However, data from a survey on Immunization Program Evaluation, monitoring and assessment found that 90 percent of the staff received vaccination knowledge from in-service training, while the remaining 10 percent received practical knowledge and skills development from the Disease Prevention Vaccine Division and the National Vaccine Institute [8]. Training on immunization has not been given to all staff members. Furthermore, turnover rates due to transfers or resignations are another major barrier to immunization staff development, causing many new staff members to enter the system each year and creating a threat to developing overall immunization staff capacity. Therefore, a staff training model capable of supporting immunization staff with broad training access and no limits to the number of trainees in each class needs to be developed in accordance with budget allocations.

The immunization service provider development plans of the National Vaccine Institute emphasize lifelong learning. In addition, the Thailand 4.0 policy emphasizes generative learning and innovation. Therefore, the use of technology to create learning innovations is a good option for reducing or eliminating barriers, as well as providing EPI staff members with sufficient knowledge and skills to provide immunization services. E-learning is an effective option allowing participants from various fields to gain more knowledge and understanding as well as enable the application of their knowledge at work [9]. According to Labeau [10], training medical staff online on the topic of hospital infection prevention was able to help medical staff or personnel acquire knowledge and understanding about infection prevention. Therefore, the use of e-learning technology to improve staff is a viable option for replacing previous models.

Another important issue in developing staff knowledge and skills is training course content. According to an evaluation by the “Capacity Building Workshop Program for Expanded Program Immunization Staff” Project, recommendations were provided by trainees from professions such as pharmacists, registered nurses and public health technical officers. Additionally, some topics were considered inappropriate and unnecessary in training, such as vaccine estimation and vaccine-report registration [8]. Similarly, Rutchanagul [11], who studied nurses’ content needs in immunization services, found nurses do not require all the immunization content in the training that is included in the staff development policy of the National Vaccine Institute. This resulted in observations on how models of training content could be developed to improve immunization staff knowledge and skills for training models and content to be consistent with the real needs and requirements of staff members in each profession.

With these issues in mind, the researcher was interested in focusing on E-course training content to improve immunization staff knowledge and skills by using a mixed method research methodology combining quantitative and qualitative research. This study aims to explain and build a clearer understanding of knowledge and skill needs for designing suitable E-course training learning content and educational media for staff in diverse professions. Furthermore, this study will seek data from staff members’ work experience and needs at both the policy and practitioner levels. The findings will provide empirical knowledge for developing integrated knowledge and meeting staff needs at every level. These findings will be important for developing and creating applicable knowledge media, leading to self-improvement and effective immunization work development. In addition, this study will provide evidence-based practice that can serve as policy recommendations for future immunization staff development in Thailand.

(1) To study E-course training content needed for improving the knowledge and skills of immunization staff members in the positions of registered nurse, pharmacist and public health technical officer.

(2) To study and compare differences in content needs among the positions of the registered nurse, pharmacist and public health technical officer.

(3) To study E-course training models for improving immunization knowledge and skills.

Good immunization services that meet standards need an adequately trained workforce with relevant work skills for roles and duties. Staff training programs without sufficient quality were one of the main causes of suboptimal immunization program performance, making training interventions important mechanisms for improving immunization staff knowledge, skills and competencies [5, 12]. Therefore, staff training programs were highly important for suitability and consistency with necessary work skills [13, 14].

Under EPI contexts, immunization staff in the EPI of Thailand had three groups of staff members holding positions nurses, public health technical officers and pharmacists. Each group was responsible for different but connected work. Pharmacists stored and disbursed vaccines, registered nurses vaccinated patients, and public health technical officers dealt with AEFI, disease investigations and vaccine-report registration. Due to differences in roles, duties and responsibilities, each group of staff members had different views concerning necessary immunization knowledge and skills development. For example, public health technical officers needed more knowledge and skill content than other professions on the topic of vaccine estimation and vaccine-report registration, registered nurses needed more knowledge and skills content on vaccine preparation and administering vaccines, and pharmacists needed more knowledge and skills content on the topics of vaccines and the cold-chain system in order to support the roles, duties and responsibilities of each profession.

Based on the quantitative and qualitative findings in this study, the staff members of all three professional groups (registered nurses, pharmacists and public health technical officers) should receive the same basic knowledge and skills development on the following topics: 1. Basic knowledge pertaining to immunization; 2. Vaccine-preventable infectious diseases; 3. Vaccine storage and cold-chain system; and 4. Dealing with adverse events following immunization. In the meantime, content on certain topics such as vaccine-report registration making preparations and administering the vaccines should contain different knowledge details based on job characteristics. This was consistent with the findings of a study conducted by Arogundade [15] on the training needs assessment of health workers and pre-service tutors, which found that courses in the EPI did not meet staff needs because the staff needed the training to improve knowledge and skills pertaining to real work or duties and responsibilities. Furthermore, training content that every staff member must understand accurately should be clear on the topics of basic immunization concepts, data management and cold chain management [16]. Therefore, training course content for EPI staff must be consistent and suitable for duties and responsibilities.

EPI training course content should be divided into two parts consisting of Part 1 – Necessary Content or Basic Knowledge Required for All Staff and Part 2 Knowledge Content of Responsibilities. This is consistent with the WHO concept which specified immunization competency domains in two parts consisting of: 1. Foundational competencies such as (a) management and leadership and (b) vaccine-preventable diseases and programs; and 2. Technical competencies on (a) effective communication on matters related to EPI, (b) monitoring, evaluation and data use, (c) vaccine service delivery and (d) vaccine supplies and logistics [17]. Therefore, immunization content in E-course training should consist of: 1. Foundational immunization knowledge such as vaccine-preventable diseases, vaccines, cold chain management and the handling of adverse vaccine events and 2.Technical knowledge (knowledge required to perform a specific role or task) such as EPI documentation (estimating EPI targets, calculating coverage), administering vaccines, cold chain monitoring, and supplies and logistics.

Furthermore, the findings from this study revealed training courses for improving staff knowledge and skills should be divided into the following three levels: basic, intermediate and advanced, depending on work experience. Basic knowledge and skills development should be included in training for all staff members regardless of the profession when beginning immunization work as it requires basic knowledge on the topics of immunization policy, epidemiological concepts, basic immunization knowledge, diseases that can be prevented by vaccines, each type of vaccine used in immunization plans for children and adults including new vaccines, target group designation and vaccine coverage. Intermediate knowledge and skills development should consist of knowledge reviews and more complex training. For example, nurses should have training focused on the topic of administering vaccines, while pharmacists should focus on vaccine storage and cold-chain system. Public health technical officers should have training focused on vaccine-report registration. Advanced knowledge and skills development should be suitable for educator staff members that educate and plan work systems vital to training content preparations which must be suitable for trainee experience levels in order to enable trainees to use knowledge from training in practice [18-21]. Currently, many countries have developed EPI training courses to have quality and effective immunization performance based on standards. However, problems were found, and training courses may not have met all staff members needs. For example, in a study conducted by Carrico [19], almost 50 percent of the sample determined training in immunization programs to be insufficient for real work, and gaps remained between knowledge and implementation in practice. Therefore, immunization programs need to be developed to be specific to responsibilities and consistent with key performance indicators of workers with experience at different levels. Staff experience was, therefore, another major factor that should be considered when designing EPI training courses to input details and determine the scope of content and knowledge on each issue to be consistent with staff experience to close gaps between vaccination theory and practice.

Immunization staff knowledge and skills development should be suitable for staff member roles and duties at each level in order to provide the participants with the necessary knowledge to reduce work problems and mistakes, leading to the achievement of immunization work standards. Therefore, workers at the policy level should specify the necessary content and skills. Specifically, they should describe in concrete terms those areas that are in need of improvement in each profession. Models tailored for diverse personnel with flexibility and suitability for individual staff characteristics should be developed.