































 

 Epidemiology and Society Health Review| ESHR 
Vol. 5, No. 2, 2023, pp. 98-113 ISSN 2656-6052 (online) | 2656-1107 (print) 
      http://journal2.uad.ac.id/index.php/eshr/index                                                   eshr@ikm.uad.ac.id 

 

 

      10.26555/eshr.v5i2.9026  

 
 

98 

 
 

  

  
Review Article 
 
Relationship Between Knowledge, Attitude and Motivation 
of Officers in Managing the COVID-19 Vaccine Cold Chain: 
A Systematic Review 
 
Sudarto Edi Hartono1,2*, Solikhah Solikhah3, Sulistyawati Sulistyawati3  
1 Magister of Public Health, Universitas Ahmad Dahlan, Yogyakarta, Indonesia 
2 Sleman Health Office, Daerah Istimewa Yogyakarta, Indonesia 
3 Faculty of Public Health, Universitas Ahmad Dahlan, Yogyakarta,Indonesia 
 
* Correspondence: yudistiraedi.kd@gmail.com. Phone: +628211177369  
 
Received 12 September 2023; Accepted 10 October 2023; Published 11 October 2023 
 

ABSTRACT 

Background: Vaccines are an important tool in preventing serious infectious diseases. Cold 
chain management is essential to maintain vaccine quality, including storage, transportation, 
and distribution at appropriate temperatures. This study aims to investigate the relationship 
between knowledge, attitudes, and motivation of health workers responsible for cold chain 
management of the COVID-19 vaccine. 
Method: This was a systematic literature review study by searching through databases: Google 
Scholar, PubMed, Semantic Scholar, and Frontiers, using some keywords. 76 relevant previous 
studies were found. After filtering for publication year (post-2019), they reviewed 19 articles' 
abstracts. However, 10 articles lacked information on vaccine officers' knowledge, attitudes, and 
motivation in cold chain management. Thus, only 9 articles were included in the review. 
Results: The results show that adequate knowledge, training, and understanding of guidelines 
significantly influence desired vaccine cold chain management practices. These studies also 
highlight the importance of understanding guidelines, efficient implementation, and sustainability 
aspects in vaccine management. 
Conclusion: This research concludes that to increase the effectiveness of vaccination 
programs, efforts are needed to increase knowledge, training, and implementation of guidelines 
among health workers responsible for the vaccine cold chain. Efforts to understand and 
implement sustainable practices are also crucial. The conclusions from this research can help 
decision-makers improve vaccine cold chain management to ensure the success of the 
vaccination program. 

Keywords: Vaccine; Cold Chain; Knowledge; Attitude; Motivation 

 

http://journal2.uad.ac.id/index.php/eshr/index
mailto:eshr@ikm.uad.ac.id
https://doi.org/10.26555/eshr.v3i1.3629
https://doi.org/10.26555/eshr.v3i1.3629
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Hartono, et al (Relationship Between Knowledge, Attitude and Motivation of Officers….) 

 
 

 
Vol. 5, No. 2, 2023, pp. 98-113 99   10.26555/eshr.v5i2.9026 

  

INTRODUCTION 

The vaccination program is an important step in efforts to prevent serious infectious diseases 
such as, measles, mumps, tetanus, polio, HPV, and others, and their spread throughout the 
world.1 To ensure the success of this vaccination program, vaccine cold chain management 
is a key factor. This cold chain involves the process of storing, transporting and distributing 
vaccines at the right temperature,2 so that the vaccine remains effective and safe to use. In 
practice, vaccine officers who are responsible for the vaccine cold chain are a key element in 
maintaining the quality of the vaccine. 

Vaccine management is part of vaccine quality which can prevent irregularities in vaccine 
storage and distribution so that the vaccine's potency is maintained when it is used.3 This 
study examined the knowledge, attitude, and motivation of healthcare workers responsible for 
vaccine cold chain management. It assessed their adherence to guidelines, their training 
status, and the influence of these factors on vaccine management practices in primary health 
facilities. This research is important for improving immunization programs by identifying areas 
where healthcare workers may need additional support or training. In addition, this research 
can be used as basic data for evaluating the implementation of the vaccine cold chain because 
it will be related to vaccine efficacy/effectiveness. 

Vaccines possess specific characteristics and require a cold chain system from their 
production in factories to their use in healthcare facilities.4 Deviations from established 
guidelines can result in vaccine damage, potentially reducing or even eliminating their 
effectiveness when administered to recipients, thus failing to provide immunity.5 Monitoring 
the storage temperature of vaccines is crucial for quickly determining whether vaccines remain 
viable or if they have become vulnerable and prone to damage.6 This research discusses the 
cold chain Covid-19 vaccine. Various tools such as thermometers, Vaccine Vial Monitors 
(VVMs), and Freeze-tags greatly assist healthcare workers in monitoring the storage and 
transportation temperatures of Covid-19 vaccines. The appropriate temperature for managing 
vaccines and other factors that can affect vaccine damage include not exceeding the 
expiration date, the quality of vaccine management, and the method of transporting vaccines 
from one location to another.7 The cold chain is a procedure used to maintain vaccines at 
specific temperatures until they are administered or delivered to their intended recipients.8 

Vaccine officers have a crucial role in maintaining the vaccine cold chain so that it remains 
effective and safe. Even though there are officers in charge of vaccines at each community 
health center, it is unfortunate that until now, they have never received special training 
regarding vaccine cold chain management. Previous research shows that vaccine officers 
must meet certain qualifications and competencies obtained through education and training 
that are recognized with competency certificates.9 Although specific cold chain training has 
not been carried out by the Ministry of Health, socialization training via the Zoom application 
has been provided.10 However, vaccine officers also need to actively seek additional training 
and carry out independent supervision of the vaccine cold chain to ensure that vaccination 
can run well and is safe for the community.11  

In order to increase the effectiveness of vaccination programs, a deeper understanding of the 
relationship between knowledge, attitudes and motivation of vaccine workers is needed in 

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Vol. 5, No. 2, 2023, pp. 98-113 100   10.26555/eshr.v5i2.9026 

  

vaccine cold chain management. Therefore, this research will conduct a systematic review of 
existing literature to comprehensively investigate the relationship between these three factors. 
It is hoped that the results of this research will provide better insight into the factors that 
influence vaccine cold chain management and encourage more effective improvement 
measures in the implementation of vaccination programs. 

METHOD 

This research is a systematic literature review which aims to reveal the relationship between 
knowledge, attitudes and motivation of officers in managing the COVID-19 vaccine cold chain. 
This research method is based on a literature review process that explains, summarizes, and 
evaluates scientific articles that have been previously published on the topic. This process 
begins with determining the background and objectives of the research. Then, research 
questions were created to guide the literature search. Literature searches were carried out 
through various databases in as Google Scholar, PubMed, Semantic Scholar and Frontiers 
with predetermined keywords. The search results obtained were checked and grouped based 
on selection standards, and after eliminating duplicates, there were 5 journals that were 
relevant to the research topic. The articles found are then sorted based on research quality 
using predetermined inclusion and exclusion criteria. A total of 5 journal articles met the 
inclusion criteria and were used as material for analysis in this research. 

During the systematic review process, this research followed the PRISMA (Preferred 
Reporting Items for Systematic Reviews and Meta-Analysis) guidelines for search results and 
study selection.12 The principle of systematic review is a research method that summarizes 
primary research results to present more comprehensive and balanced facts. In the entire 
process, the systematic review method provides a strong basis for exploring the relationship 
between knowledge, attitudes and motivation in managing the vaccine cold chain, by 
combining previously existing research results and presenting them systematically and 
objectively. 

1. Data Search Strategy 
Data search strategies include the methods used to search for information relevant to the 
research topic. In this case, the data search strategy involved using various databases 
such as Google Scholar, PubMed, Semantic Scholar, and Frontiers with the keyword 
“Knowledge”; "Attitude"; "Motivation"; "Vaccine Officer"; and "Vaccine Cold Chain". The aim 
of the data search strategy is to identify sources of information that are relevant to the 
research topic. 

2. Resources 
Information sources are places or media where data and information can be found. In this 
research, the main sources of information are various databases and scientific literature 
related to the research topic, namely scientific articles obtained from Google Scholar, 
PubMed, Semantic Scholar, and Frontiers. These information sources are used to collect 
data relevant to research. 

3. Eligibility Criteria 
Eligibility criteria are criteria used to determine whether an information source or article can 
be included in research or not. In this case, eligibility criteria include aspects such as topic, 

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source, publication time period, language, and research design. Only information sources 
that meet these criteria will be included in the analysis 

4. Quality Assessment 
Quality assessment is a process for evaluating the quality of information sources used in 
research. In this research, quality assessment was carried out by reading the abstract and 
full text manuscript to assess whether the information source had a clear methodology and 
was relevant to the research topic. 

5. Data Extraction 
Data extraction is the process of retrieving relevant information from selected information 
sources. In this research, data extraction includes obtaining information related to the 
relationship between knowledge, attitudes and motivation of officers in the management of 
the COVID-19 vaccine cold chain. The extracted data will be used for further analysis in 
the research. 

6. Synthesis Data 
Data synthesis is the stage where information from various sources is combined, analyzed 
and presented systematically. In this research, data synthesis includes the process of 
grouping articles based on inclusion and exclusion criteria as well as analysis of articles 
that meet these criteria. The following inclusion and exclusion criteria in this study are 
outlined in table 1 below:  

Table 1. Inclusion and Exclusion Aspects of Literature in this Research 
Aspects Inclusion Exclusion 

Topic  Articles should focus on the topic of the 
relationship between knowledge, attitudes 
and motivation of officers in managing the 
COVID-19 vaccine cold chain. 

Articles that are not related to the knowledge, 
attitudes and motivation of officers in 
managing the COVID-19 vaccine cold chain. 
 

Source Only scientific articles, empirical research, 
systematic reviews, or literature reviews 
published in scientific journals are accepted. 

Articles published in unrecognized journals or 
sources that cannot be verified. 

Time Period Published between 2019-2023 Published before 2019 
Language Articles written in English or Indonesian that 

researchers can understand. 
Articles written in a language that the 
researcher cannot understand, which is 
except Indonesian or English. 
 

Research 
Design 

Articles must have a clear methodology and 
be relevant to the research topic, such as 
empirical research, systematic reviews, or 
literature reviews. 

Articles that do not have a clear methodology 
or are not relevant to the research topic. 
 

Information Articles must provide relevant information 
about the knowledge, attitudes and motivation 
of officers in the context of managing the 
COVID-19 vaccine cold chain. 

Article portrays irrelevant information, articles 
did not contain one of the variables in this 
research (knowledge, attitude, or motivation) 

 

After applying keywords, researchers obtained 76 relevant previous studies. After applying a 
publication year filter (after 2019), researchers found 57 articles published before 2019. Next, 
researchers read the abstracts of the remaining articles, namely 19 articles. However, of the 
19 articles, there are 10 articles that do not contain information regarding the 
knowledge/attitude/motivation of vaccine officers in managing vaccine cold chains. Thus, of 
the 19 articles, 10 articles were excluded leaving 9 articles for review. As for the 9 articles, 5 
articles were obtained from Google Scholar, 2 articles from PubMed, 1 article from Semantic 

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Scholar, and 1 article from Frontiers. Thus, in this research, only 9 journal articles were 
reviewed to describe the relationship between knowledge, attitudes and motivation of officers 
in managing the vaccine cold chain.  
 
The nine literatures were obtained through the elimination stage as depicted in the Figure 1. 

 

 

 

 

 

 

 

Figure 1. Data collection procedure 

RESULTS 

After searching on Google Scholar, PubMed, Semantic Scholar, and Frontiers using the 
keyword "Knowledge"; "Attitude"; "Motivation"; "Vaccine Officer"; and "Vaccine Cold Chain", 
Researchers found nine relevant articles. These nine articles also contained established 
inclusion criteria and did not have a single established exclusion criterion. The following is a 
summary of the literature reviewed in this research are outlined in Table 2. 
 

Table 2. Summary of Literature Used in this Research 
No Research 

Title/Author/Year 
Research 
Location 

Research Aims Methods Population 
and sample 

Result 

1 Adherence to WHO 
vaccine storage 
codes and vaccine 
cold chain 
management 
practices at primary 
healthcare facilities 
in Dalocha District of 
Silt'e Zone, Ethiopia. 
Feyisa et al. (2022)  

Dalocha 
District, 
Ethiopia 

The aim of this 
study was to 
evaluate vaccine 
cold chain 
management in 
primary health 
facilities in 
Dalocha District, 
Silt'e Zone, 
Ethiopia. The 
research aims to 
measure the 
knowledge of 
vaccine cold chain 
officers, the level 
of compliance with 
WHO vaccine 
storage guidelines, 
and vaccine cold 
chain 
management 
practices. This 
study also aims to 
identify the 
relationship 
between primary 

The research 
method used is 
institutional-based 
cross-sectional 
study. This study 
was conducted in 
twenty-eight 
primary health 
facilities located in 
Dalocha District, 
Silt'e Zone, 
SNNPR, Ethiopia. 
A total of one 
hundred and forty 
primary health 
workers were 
recruited as 
respondents from 
four health centers 
and twenty-four 
health posts 
operating in the 
Dalocha area. Data 
were collected 
through 
questionnaires 

In this 
research, the 
sample used 
was 153 
respondents. 
The population 
on which this 
sample 
calculation is 
based is the 
total number of 
primary health 
workers in 
primary health 
facilities, 
totaling 205 
people. In the 
calculations, a 
single 
population 
proportion 
formula for 
cross-sectoral 
research is 
used, with a 
confidence 

The research 
results show that 
the majority of 
respondents 
have adequate 
knowledge about 
storing vaccines 
in the 
temperature 
range 
recommended 
by WHO. Most 
respondents also 
record vaccine 
temperatures 
twice a day, 
maintain vaccine 
inventory 
records, and 
know the 
principle of First 
Expiry First Out 
(EEFO). 
However, most 
respondents did 
not understand 

  

 76 records screened  

 

76 studies assessed for 
eligibility 

 

9 studies included 

- 57 studies excluded because of publishing period 
(published before 2019) 

- 10 studies excluded because provide irrelevant 
information 

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No Research 
Title/Author/Year 

Research 
Location 

Research Aims Methods Population 
and sample 

Result 

health workers' 
knowledge, 
officers' training 
status, primary 
health facilities' 
compliance with 
WHO vaccine 
storage guidelines, 
and the length of 
officers' work 
experience with 
vaccine cold chain 
management 
practices. 
 

completed by 
respondents 
themselves and 
direct observation 
checklists adapted 
from WHO and 
WHO-UNICEF 
effective vaccine 
management 
assessment tools. 
The collected data 
was input using EPI 
version 3.1 
software, then 
exported and 
analyzed using 
SPSS version 22. 
Statistical analysis 
was carried out to 
determine the level 
of knowledge, level 
of compliance with 
WHO cold chain 
management 
guidelines, and 
vaccine handling 
practices. 
 

level of 95%. 
Based on these 
calculations, 
the initial 
sample 
required was 
384. However, 
using a 
reduction 
formula, the 
final sample 
was 
determined to 
be 133 
respondents. 
This is 
calculated by 
taking into 
account a 
limited target 
population of 
205 people. 
Then, samples 
were taken 
using a 
stratified 
sampling 
method based 
on primary 
health facilities, 
and selected 
proportionally 
from each 
facility. 

about vaccines 
that are 
susceptible to 
low 
temperatures, 
vaccines that are 
susceptible to 
high 
temperatures 
and light, and the 
use of Vaccine 
Vial Monitors 
(VVM). Primary 
healthcare 
facilities' 
compliance with 
WHO vaccine 
storage 
guidelines 
varies, with some 
facilities having 
poor practices, 
some with 
adequate 
practices, and a 
few with good 
practices. The 
results also 
showed that 
training, length of 
work experience, 
and knowledge 
of primary health 
workers were 
significantly 
related to desired 
vaccine cold 
chain 
management 
practices. 
 

2 Knowledge of 
Health 
Professionals on 
Cold Chain 
Management and 
Associated Factors 
in Ezha District, 
Gurage Zone, 
Ethiopia. Yassin et 
al. (2019) 

Ezha 
District, 
Gurage 
Zone, 
Ethiopia 

Maintaining the 
quality of vaccines 
poses a significant 
challenge to 
immunization 
programs in Africa, 
including Ethiopia. 
This challenge is 
often attributed to 
the level of 
knowledge among 
health 
professionals 
regarding cold 
chain 
management. 
There is a scarcity 
of studies 
conducted in 
Ethiopia that 
directly investigate 
the knowledge of 
health 
professionals 
concerning cold 
chain 
management, 
prompting the 
need for this 
research. 

A cross-sectional 
study was 
conducted within 
selected health 
facilities, involving 
all available health 
professionals, 
totaling 232 
individuals. Data 
collection occurred 
through face-to-
face interviews 
utilizing a semi-
structured 
questionnaire 
during September 
to October 2016. 
An observational 
checklist was 
employed to 
assess the 
availability and 
functionality of 
refrigerators. Data 
were entered and 
cleaned using Epi 
Info software and 
subsequently 
analyzed using 
SPSS. A 

The population 
in this study 
was all health 
professionals 
available at the 
selected health 
facilities, with a 
total of 232 
individuals. 
Meanwhile, the 
sample in this 
study also 
consisted of all 
health 
professionals in 
the selected 
health facilities, 
totaling 232 
individuals. So, 
the entire 
population is 
the sample in 
this study. 

The response 
rate was 92.43%, 
and the study 
revealed that 119 
(51.3%; 95% CI; 
44.9%, 57.6%) 
health 
professionals 
possessed 
satisfactory 
knowledge about 
cold chain 
management. 
Several factors 
were found to be 
associated with 
improved 
knowledge in this 
area, including 
receiving training 
on the 
immunization 
program (AOR = 
5.1; 95% CI: 
2.68, 10.13), 
having more than 
six years of work 
experience (AOR 
= 2.1; 95% CI: 
1.8, 4.15), using 

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No Research 
Title/Author/Year 

Research 
Location 

Research Aims Methods Population 
and sample 

Result 

multivariable 
logistic regression 
model was 
employed to 
identify factors 
associated with the 
knowledge of 
health 
professionals 
regarding cold 
chain 
management. 
 

EPI guidelines 
(AOR = 2.58; 
95% CI: 1.47, 
5.57), and being 
a BSc 
nurse/health 
officer (AOR = 
2.4; 95% CI: 
1.47, 14.4). 

3 Investigating 
sustainable 
development for the 
COVID-19 vaccine 
supply chain: a 
structural equation 
modelling approach. 
Mukherjee & Baral 
(2023) 

India Immunization is 
one of the most 
effective and cost-
effective ways to 
save lives while 
promoting good 
health and 
happiness. The 
coronavirus 
disease 2019 
(COVID-19) 
pandemic has 
served as a stark 
reminder of the 
ability of vaccines 
to prevent 
transmission, save 
lives, and create a 
healthier, safer, 
and more 
prosperous future. 
This research aims 
to investigate 
sustainable 
development (SD) 
in the COVID-19 
vaccine supply 
chain (VSC) 

This study 
investigates the 
relationship 
between internal 
processes, 
organizational 
growth, and its 
three SD pillars, 
namely 
environmental 
sustainability, 
economic 
sustainability, and 
social 
sustainability. 
Survey-based 
research was 
conducted at 
hospitals providing 
the COVID-19 
vaccine. Nine 
hypotheses were 
proposed for this 
study, and all 
hypotheses were 
accepted. The 
survey was sent to 
428 respondents 
and received 291 
responses from 
health 
professionals for a 
response rate of 
68%. For this 
study, healthcare 
professionals 
working in private 
and public 
hospitals across 
India were 
selected. 

The total 
population in 
this study was 
428 health 
professionals, 
while the 
research 
sample was 
291 of these 
respondents. 

A structural 
equation 
modeling (SEM) 
approach was 
used to test the 
hypotheses. 
These nine 
hypotheses all 
found support. 
This study 
explores the 
relationship 
between internal 
processes and 
organizational 
learning with the 
three pillars of 
sustainability 
(environmental 
sustainability, 
economic 
sustainability, 
and social 
sustainability). 

4 The Relationship 
between Mother's 
Knowledge about 
Immunization and 
Mother's 
Compliance with 
Carrying Toddlers to 
Immunization in 
Hamlet V, Tanah 
Jawa District, 
Simalungun 
Regency. Manurung 
(2022) 

Tanah 
Java Area, 
Indonesia 

This study aims to 
evaluate the 
mother's level of 
knowledge, the 
level of compliance 
in bringing toddlers 
to get 
immunizations, 
and identify the 
relationship 
between the 
mother's level of 
knowledge and her 
level of compliance 
in bringing toddlers 
to get 
immunizations. 

This research uses 
a descriptive 
correlational 
research design 
and applies total 
sampling in 
sampling. The 
number of 
respondents 
involved in this 
research was 40 
people. The 
measurement 
instruments used 
were 
questionnaires and 
medical records 

The population 
in this study 
were mothers 
with toddlers 
who met certain 
criteria in the 
Tanah Java 
area. The 
sample was 
taken as a 
whole (total 
sampling) 
involving 40 
respondents 
who met the 
inclusion 
criteria. 

The research 
results showed 
that 45% of 
respondents had 
insufficient 
knowledge and 
did not comply 
with the 
implementation 
of immunization 
at 88.9%. The 
results of the Chi-
square test show 
that there is a 
statistically 
significant 
relationship 

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No Research 
Title/Author/Year 

Research 
Location 

Research Aims Methods Population 
and sample 

Result 

 from community 
health centers in 
the Tanah Java 
area. The data 
analysis 
techniques used 
include the Chi-
square test, as well 
as presenting data 
in the form of tables 
and diagrams. 
 

 between the 
mother's level of 
knowledge and 
her level of 
compliance in 
bringing her 
toddler to get 
immunization, 
with a p value of 
0.004 < 0.05. 

5 Description of Cakin 
Cold Chain 
Management 
System in Some 
Puskesmas 
Kecamatan in 
Jakarta Timur 
Region in 2019. 
Kusumadewi & 
Lestari (2020). 

East 
Jakarta, 
Indonesia 

This research aims 
to investigate the 
vaccine cold chain 
management 
system in several 
sub-district health 
centers in the East 
Jakarta area in 
July 2019. 

The method used 
in this research is 
qualitative, with 
samples taken 
using a purposive 
sampling 
technique. Primary 
data was obtained 
through in-depth 
interviews, while 
secondary data 
was obtained from 
document review 
and observation of 
2019 data. All 
officers involved in 
managing the 
vaccine cold chain 
have attended 
training at least 
once and have a 
higher education 
background. 

The population 
in this study 
was 10 sub-
district health 
centers in the 
East Jakarta 
area. The 
sampling 
technique used 
was the Non-
Probability 
Sampling 
(Quota 
Sampling) 
method. 

The research 
results show that 
in managing the 
vaccine cold 
chain, all 
community 
health centers 
have complied 
with the 
guidelines set 
out in the 
Vaccine Storage 
and Handling 
Toolkit (CDC 
2014). The 
vaccine 
distribution 
process has 
been carried out 
well using cold 
boxes and cold 
packs. Apart 
from that, the 
vaccine is placed 
in a vaccine 
carrier which 
contains a cool 
pack and 
thermometer to 
ensure that the 
vaccine 
temperature is 
maintained 
properly. 

6 Knowledge, 
Attitude, and 
Implementation of 
Cold Chain 
Management in 
Boalemo District, 
Gorontalo, 
Indonesia. Pangalo 
et al. (2020) 

Gorontalo, 
Indonesia 

The primary aim of 
this study is to 
investigate the 
relationship 
between three key 
factors: 
knowledge, 
attitude, and the 
implementation of 
cold chain 
management in 
the context of 
immunization 
programs aimed at 
improving 
children's health. 

This research 
employed a cross-
sectional design 
and was carried out 
in September 2018 
across 11 health 
centers located in 
the Boalemo 
District of 
Gorontalo, 
Indonesia. Data 
collection was 
conducted through 
the utilization of 
questionnaires and 
observation sheets, 
and the 
subsequent data 
analysis was 
performed using 
the Chi-square 
statistical method. 

The study 
sample 
consisted of 34 
health officers, 
specifically 
selected for this 
purpose. 

Elevated 
knowledge levels 
were associated 
with a higher 
likelihood of 
fostering a 
favorable attitude 
toward cold 
chain 
management 
implementation 
(OR= 5.87; p= 
0.061). 
Additionally, 
increased 
knowledge (OR= 
2.17; p= 0.448) 
and a positive 
attitude (OR= 
2.69; p= 0.405) 
were linked to 
enhanced cold 
chain 
management 
implementation, 

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No Research 
Title/Author/Year 

Research 
Location 

Research Aims Methods Population 
and sample 

Result 

but these 
associations did 
not reach 
statistical 
significance. 

7 Vaccine cold chain 
management 
practices in primary 
health centers 
providing an 
expanded 
immunization 
program in 
Northwest Ethiopia: 
self-reported and 
actual practice 
observational study. 
Ergetie et al. (2023) 

Nortwest 
Ethiopia 

The research aims 
to evaluate the 
practices related to 
the management 
of vaccine cold 
chains within 
primary health 
centers that 
provide the 
Expanded 
Program of 
Immunization 
(EPI) in Bahir Dar, 
Northwest 
Ethiopia. 
Specifically, it 
focuses on 
assessing how 
vaccines, crucial 
health 
commodities, are 
handled 
concerning their 
transportation, 
storage, and 
maintenance at the 
appropriate 
temperature levels 
to ensure their 
efficacy and 
safety. 

A cross-sectional 
study involving self-
reported data and 
direct observational 
practices was 
conducted at 
primary public 
health centers 
within the Bahir Dar 
city administration 
from August 15 to 
30, 2021. Study 
participants were 
randomly selected 
using a simple 
random sampling 
method. Data 
collection involved 
the use of an 
interview-
administered 
questionnaire and 
direct observation 
of actual practices. 
Subsequently, the 
collected data were 
entered into the 
Epidata 4.6 
software and 
subjected to 
analysis using 
SPSS version 25. 
The study 
assessed 
participants' 
knowledge, storage 
and transportation 
conditions, 
Integrated 
Pharmaceutical 
Logistics System 
(IPLS) 
management, and 
practices related to 
vaccine cold chain 
management 
through 
independent 
samples t-tests and 
one-way ANOVA 
tests. 

Sample 50 
respondents, 
sampling 
technique use a 
random 
sampling.  

The majority of 
EPI service 
providers 
exhibited a 
favorable level of 
knowledge 
(60%) and 
demonstrated 
proficient 
practices in 
vaccine storage 
and 
transportation 
(74%). 
Nevertheless, a 
significant 
proportion, 
comprising 68% 
of EPI service 
providers, 
exhibited 
inadequate 
proficiency in 
managing the 
Integrated 
Pharmaceutical 
Logistics System 
(IPLS). 
Furthermore, 
only half (50%) of 
the health 
centers 
demonstrated 
commendable 
actual practices 
in vaccine cold 
chain 
management. 
The study 
revealed that 
individuals with 
higher levels of 
education, 
lengthier work 
experience, and 
who had 
received training 
and supervision 
in EPI services, 
IPLS 
management, 
and vaccine 
inventory 
management 
exhibited higher 
levels of 
knowledge, 
proficiency in 
storage and 
transportation 
management, 
IPLS 
management, 
and vaccine cold 
chain 

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No Research 
Title/Author/Year 

Research 
Location 

Research Aims Methods Population 
and sample 

Result 

management 
practices. 

8 Knowledge, attitude 
and practice of 
vaccinators and 
vaccine handlers on 
vaccine cold chain 
management in 
public health 
facilities, Ethiopia: 
Cross-sectional 
study. Mohammed 
et al. (2021) 

Oromoia 
Special 
Zone, 
Ethiopia 

The research aims 
to evaluate the 
knowledge, 
attitude, and 
practice of 
individuals 
responsible for 
vaccine handling 
and storage, 
specifically 
vaccinators and 
vaccine handlers, 
within public health 
facilities. It 
recognizes the 
critical importance 
of effective 
management of 
the vaccine cold 
chain system to 
preserve vaccine 
potency, 
particularly in light 
of vaccines' 
increased 
temperature 
sensitivity and 
complex 
immunization 
schedules. 
Therefore, this 
study seeks to 
assess the level of 
understanding, 
attitudes, and 
practices among 
these healthcare 
professionals in 
ensuring the 
proper handling 
and storage of 
vaccines within 
public health 
facilities. 

The research 
employed an 
institutional-based 
cross-sectional 
study design to 
investigate the 
knowledge, 
attitude, and 
practice of 127 
vaccinators and 
vaccine handlers 
within public health 
facilities in Oromia 
Special Zone. The 
data collection 
period spanned 
from September 1 
to 30, 2019. To 
gather information, 
self-administered 
questionnaires and 
a structured 
observation 
checklist were 
utilized. The data 
were then 
subjected to both 
descriptive and 
inferential 
statistical analyses 
using the Statistical 
Package for the 
Social Sciences 
(SPSS) version 20.  

the population 
in this research 
are all 
vaccinators and 
vaccine 
handlers who 
engaged in 
vaccine cold 
chain 
management. 
The sample in 
this research 
are 127 
vaccinators and 
vaccine 
handlers within 
public health 
facilities in 
Oromia Special 
Zone.  

The response 
rate for the study 
reached 96.94%. 
Among the 
participants, 68 
individuals, 
constituting 
53.5% (with a 
95% confidence 
interval ranging 
from 46.5% to 
61.4%), 
demonstrated 
satisfactory 
knowledge, while 
58 individuals, 
equivalent to 
45.7% (with a 
95% confidence 
interval ranging 
from 37.8% to 
53.5%), 
exhibited a 
positive attitude. 
Moreover, 62 
participants, 
accounting for 
48.8% (with a 
95% confidence 
interval ranging 
from 41.7% to 
56.7%), 
displayed good 
practice in their 
roles as 
vaccinators and 
vaccine 
handlers. It is 
worth noting that 
receiving training 
in cold chain 
management 
exhibited a 
statistically 
significant 
association with 
a higher level of 
knowledge 
concerning cold 
chain 
management 
(with an adjusted 
odds ratio of 3.04 
and a 95% 
confidence 
interval between 
1.04 and 8.88). 

9 Knowledge of 
vaccine handlers 
and status of cold 
chain and vaccine 
management in 
primary health care 
facilities of Tigray 
region, Northern 
Ethiopia: 
Institutional based 
crosssectional 

Tigray 
Region, 
Ethiopia 

The primary aim of 
this study is to 
evaluate the 
knowledge of 
vaccine handlers 
and assess the 
status of cold chain 
and vaccine 
management 
within primary 
health care 
facilities located in 

The research 
utilized an 
institutional-based 
cross-sectional 
study design and 
was carried out in 
four randomly 
chosen districts 
within the Tigray 
region of Northern 
Ethiopia. In each of 
the selected 

The sample in 
this research 
are 50 
healtcare 
professional 

In this research, 
a total of fifty 
Primary Health 
Care Facilities 
(PHCFs) were 
included, 
resulting in a 
response rate of 
94.4%. The 
overall 
proportion of 
vaccine handlers 

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No Research 
Title/Author/Year 

Research 
Location 

Research Aims Methods Population 
and sample 

Result 

study. Gebretnsae 
et al. (2022) 

the Tigray region 
of Northern 
Ethiopia. This 
research is 
conducted to 
provide insight into 
the current state of 
cold chain and 
vaccine 
management 
practices, focusing 
on factors 
associated with 
these practices. 
The study aims to 
contribute valuable 
information to the 
efforts of the 
Ethiopia federal 
ministry of health 
in enhancing 
immunization 
services, 
particularly 
through the 
deployment of 
solar refrigerators, 
by addressing the 
existing knowledge 
gaps and 
challenges in cold 
chain and vaccine 
management in 
the specified 
region. 

districts, all primary 
health care 
facilities equipped 
with functional 
vaccine 
refrigerators were 
included as 
participants in the 
study. Data 
collection was 
conducted using a 
pre-tested semi-
structured 
questionnaire. The 
collected data were 
subsequently 
entered into Epi-
data version 3.1 
and later exported 
to Statistical 
Package for Social 
Sciences (SPSS) 
version 21 for the 
purpose of 
analysis. All 
variables 
demonstrating a p-
value of < 0.25 in 
the bivariate 
logistic regression 
analysis were 
incorporated into 
the multi-variable 
model to identify 
predictors of the 
dependent 
variables under 
consideration. 

with a high level 
of knowledge 
and a good 
status of cold 
chain and 
vaccine 
management 
stood at 48% 
(95% CI; 30.7%-
62%) and 46% 
(95%CI; 26.1%-
61.3%), 
respectively. It 
was observed 
that receiving 
training in cold 
chain and 
vaccine 
management 
(AOR = 5.18; 
95% CI: 1.48–
18.18) was 
significantly 
correlated with 
the knowledge of 
vaccine 
handlers. 
Additionally, the 
presence of 
supportive 
supervision 
(AOR = 4.58; 
95% CI: 1.04–
20.17) and a 
strong 
knowledge base 
among vaccine 
handlers (AOR = 
10.97; 95% CI: 
2.67–45.07) 
were found to be 
significantly 
associated with 
effective cold 
chain and 
vaccine 
management. 

DISCUSSION  

The discussion of this research will describe the relationship between knowledge, attitudes 
and motivation of officers in managing the vaccine cold chain based on the nine literatures 
reviewed.  

1. Knowledge of Vaccine Officer in Managing Vaccine Cold Chain 
Several studies have assessed the knowledge of healthcare workers responsible for 
vaccine cold chain management. For instance, a study by Pangalo et al. conducted in 
Boalemo District, Gorontalo, Indonesia, aimed to investigate the relationship between 
knowledge, attitude, and the implementation of cold chain management in the context of 
immunization programs aimed at improving children's health. This cross-sectional study 
found that elevated knowledge levels were associated with a higher likelihood of fostering 

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a favorable attitude toward cold chain management implementation, although the 
associations did not reach statistical significance.13 

A study conducted by Feyisa et al. assessed the knowledge of healthcare workers 
responsible for vaccine cold chain management. It examined their understanding of 
recommended temperature ranges, temperature recording practices, vaccine inventory 
management, and the EEFO (First Expiry First Out) method. While the majority of 
respondents demonstrated sufficient knowledge in these areas, some gaps were identified, 
particularly regarding vaccines sensitive to temperature extremes and the use of Vaccine 
Vial Monitors. The study also found that training, longer work experience, and a better grasp 
of guidelines were significantly associated with desirable vaccine cold chain management 
practices.14 

Similarly, another study conducted in Northwest Ethiopia by Ergetie et al. evaluated the 
practices related to the management of vaccine cold chains within primary health centers 
providing the Expanded Program of Immunization (EPI). While this study did not explicitly 
mention the relationship between knowledge and attitude, it assessed the knowledge, 
storage, and transportation conditions of EPI service providers. Sixty percent of these 
providers demonstrated a favorable level of knowledge regarding vaccine cold chain 
management, indicating a substantial understanding of the subject.15 

Additionally, Mohammed et al. conducted research in Oromia Special Zone, Ethiopia, 
focusing on vaccinators and vaccine handlers' knowledge, attitude, and practice regarding 
vaccine handling and storage. The study revealed that 53.5% of the participants 
demonstrated satisfactory knowledge of vaccine cold chain management. Furthermore, it 
found that receiving training in cold chain management was significantly associated with a 
higher level of knowledge.16 

Lastly, the study conducted by Gebretnsae et al. in the Tigray Region of Ethiopia aimed to 
assess the knowledge of vaccine handlers in managing the vaccine cold chain. The primary 
objective was to understand the extent of knowledge among healthcare professionals 
responsible for handling vaccines and ensuring the cold chain's proper management within 
primary healthcare facilities. In this research, a total of fifty Primary Health Care Facilities 
(PHCFs) were included, resulting in a response rate of 94.4%. The findings revealed that 
approximately 48% of vaccine handlers exhibited a high level of knowledge concerning 
vaccine cold chain management. This knowledge encompassed various aspects related to 
vaccine storage, transportation, and maintenance within the recommended temperature 
ranges. The study emphasized the significant correlation between receiving training in cold 
chain and vaccine management and vaccine handlers' knowledge levels. This underscores 
the importance of ongoing training and education to enhance the proficiency of vaccine 
handlers in maintaining the efficacy and safety of vaccines by ensuring the proper 
management of the vaccine cold chain.17 

A good level of knowledge among officers has a significant impact on their practice in 
vaccine cold chain management. A solid understanding of the importance of temperature 
and proper cold chain management can help prevent potentially dangerous practices, such 
as the use of expired vaccines, and ensure vaccine safety and efficacy.18  The lack of 

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knowledge of cold chain management officers is due to the unavailability of government 
regulations regarding the cold chain system which results in ignorance that vaccine 
refrigerators must be kept at a distance of <15 cm from surrounding walls and protected 
from direct sunlight.19 As a result, there is a lot of vaccine cold chain equipment that is not 
managed properly, resulting in a lot of vaccine damage, as happened in research 
conducted by Prasetyo.20 

2. Attitude of Vaccine Officer in Managing Vaccine Cold Chain 

The success or failure of vaccination programs depends significantly on the perspectives 
and outlooks of healthcare professionals who handle vaccines.21 The success of 
vaccination relies on achieving high immunization coverage and effectively managing 
vaccine inventory, which encompasses the correct storage and handling of vaccines.22 
Delved into the attitudes of healthcare professionals involved in vaccine cold chain 
management. While the study reported a moderate level of knowledge regarding 
recommended temperature ranges, it emphasized that training in cold chain management 
could improve knowledge. The study suggested that the use of guidelines and the length 
of work experience were also factors influencing vaccine cold chain management practices. 
However, it acknowledged the cross-sectional nature of the study and its limited scope, 
which could impact the generalizability of the findings.23 

3. Motivation of Vaccine Officer in Managing Vaccine Cold Chain 

A study explored the motivation of officers in managing the COVID-19 vaccine cold chain, 
with a focus on sustainability in economic, environmental, and social aspects. The research 
highlighted the interplay between organizational learning, social and environmental 
sustainability, and internal processes in vaccine management. It found that knowledge 
acquisition through training and education improved the efficiency of vaccine administration 
processes. Furthermore, the study revealed that social and environmental sustainability 
goals could positively impact economic sustainability. Sustainable practices, such as 
effective resource management and waste control, were linked to cost savings in cold chain 
management.24 

The findings in previous research underscored the influence of healthcare workers' 
attitudes on mothers' compliance with immunization. Negative attitudes, lack of 
friendliness, or inattention from health workers could deter mothers from participating in 
immunization programs. The study also emphasized the importance of efficient vaccine 
distribution, as poor distribution could lead to vaccine unavailability in target areas, 
hampering immunization coverage. Effective health promotion efforts and strong 
relationships between health workers and the community were identified as key factors. 
Lastly, the timing of immunization was noted as critical, as inappropriate timing could 
disrupt mothers' daily activities and affect compliance.25 
 

4. The Relationship Between Knowledge, Attitude, and Motivation of Vaccine Officer in 
Managing Vaccine Cold Chain 

Kusumadewi's study research on the relationship between knowledge, attitudes, and 
motivation of vaccine cold chain management officers in community health centers in East 

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Jakarta. The research revealed that these officers had a higher educational background 
and regularly underwent training related to the vaccine cold chain. It highlighted the 
significance of knowledge in maintaining proper vaccine storage and transportation 
practices. Additionally, the study assessed vaccine cold chain distribution practices, finding 
that health centers adhered to guidelines, used appropriate equipment, and monitored 
vaccine temperatures closely. These practices contributed to maintaining vaccine quality 
during distribution, underscoring the commitment to vaccine cold chain maintenance.3 

The findings of Kusumadewi’s research reflect a commitment to maintaining the vaccine 
cold chain so that vaccines remain effective and safe to use. The combination of the 
knowledge of trained personnel and a careful distribution process is an important factor in 
the success of an immunization program. This is also in line with previous research which 
shows that training of vaccine management officers influences accuracy in administering 
vaccines in health care settings. In conclusion, this study highlights the importance of good 
coordination, adequate knowledge, and strict distribution procedures in maintaining the 
vaccine cold chain. All of this aims to maintain the effectiveness of the immunization 
program and protect public health. 

CONCLUSION 

In conclusion, these studies collectively emphasize the importance of knowledge, attitudes, 
and motivation in effective vaccine cold chain management. Training, adherence to guidelines, 
proper distribution procedures, and good coordination are key elements for maintaining the 
vaccine cold chain and ensuring the success of immunization programs. 

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