Midwives' perceptions of vaccines and their role as vaccinators: The emergence of a new immunization corps

Vaccine Hesitancy among Healthcare Workers in Europe: A Systematic Review

This study analyzes vaccine hesitancy (VH) among healthcare workers (HCWs) in 15 European countries. We have undertaken a systematic review by synthesizing data from 46 articles (between 2015 and 2022) encompassing 55,612 subjects. Despite the heterogeneity of the methods in the various studies, we found that physicians had consistently higher vaccination rates than nurses across different countries and different vaccines. Physicians' average vaccination rate was 79% across a selection of vaccines, while that of nurses was 62%. Concerns regarding vaccine safety, information gaps, and the responsibility of healthcare authorities in managing VH are highlighted by qualitative insights. This research contributes to our comprehension of the ways in which VH among HCWs is impacted by healthcare roles, vaccine types, and regional disparities. The insights gleaned from this analysis can serve as a guide for targeted interventions aimed at increasing vaccine acceptance and coverage in Europe, ultimately strengthening public health.

Immunization during pregnancy: do healthcare workers recommend vaccination against influenza?

Background

A variety of circumstances can influence how widely vaccination during pregnancy is accepted. Healthcare workers (HCWs) are often seen as the main resource for recommending vaccination. The purpose of the current study was to determine whether Italian HCWs advise and recommend pregnant people to receive the influenza vaccinations, as well as what knowledge and attitudes affect their practices. A secondary aim of the study was to evaluate HCWs' knowledge and attitudes towards COVID-19 vaccination.

Methods

This cross-sectional study, took place between August 2021 and June 2022 in a randomly selected sample of HCWs in three Italian regions. The target population comprised obstetricians-gynecologists, midwives and primary care physicians, who provide medical care to pregnant people. The questionnaire consisted of 19 items divided into 5 parts gathered information about the participants' sociodemographic and professional characteristics, general knowledge about vaccinations during pregnancy, and vaccine-preventable diseases (VPDs), attitudes and practices towards immunization, and strategies to potentially increase vaccination uptake during pregnancy.

Results

Among the participants, 78.3% knew that pregnant people are at increased risk of severe complications from influenza, 57.8% that the influenza vaccine is not provided only in the 2nd/3rd trimester of pregnancy and 60% that pregnancy is a risk factor for severe COVID-19 infection. Of the enrolled HCWs, 10.8% believed that the potential risks of vaccines administered during pregnancy are greater than the benefits. An even higher proportion of the participants was unsure (24.3%) or did not deem (15.9%) that vaccinating against influenza during pregnancy reduces the risk of preterm birth and abortion. Moreover, 11.8% of the sample did not believe or was uncertain that COVID-19 vaccine must be offered to all pregnant people. Among HCWs, 71.8% advised women about influenza vaccination during pregnancy, and 68.8% recommended getting vaccinated against influenza during pregnancy. Results showed that good knowledge and positive attitudes were the strongest factors positively associated with advising women about influenza vaccination during pregnancy.

Conclusion

The gathered data showed that a sizable portion of the HCWs lacks up-to-date knowledge, underestimates the risks of contracting a VPD, and overestimates the risks of vaccine side effects during pregnancy. The findings shed light on such attributes useful to promote adherence to evidence-based recommendations among HCWs.

Factors influencing healthcare professionals' confidence in vaccination in Europe: a literature review

Health-care professionals (HCPs) have a fundamental role in vaccination, their own beliefs and attitudes affecting both their uptake and recommendation of vaccines. This literature review (n = 89) summarises evidence on HCPs’ perceptions of the risks and benefits of vaccination, trust, and perceptions of mandatory vaccination in Europe. HCPs across studies believed that vaccination is important to protect themselves and their patients. However, beliefs that some diseases such as influenza are less risky were reported by some HCPs as a reason for not getting vaccinated. Concerns about both short- and long-term side effects were identified among HCPs in most studies, such as those affecting the immune or neurological system. Mistrust toward health authorities and pharmaceutical industry was reported in some studies. The question of mandatory vaccination revealed mixed opinions, with some favoring self-determination and others viewing vaccination as a duty. This review highlights key factors influencing HCPs’ confidence in vaccination in Europe.

Pilot Study of Evaluating Attitudes toward Childhood Immunization among Healthcare Workers in Japan

Providing appropriate immunization information during the perinatal period is important for improving immunization rates among infants and children; however, the distribution of immunization information by healthcare workers (HCWs) is not standardized in Japan. We investigated HCWs’ attitudes toward childhood immunization and factors related to vaccine hesitancy. We conducted a cross-sectional descriptive survey of HCWs involved in childhood immunization in Niigata City, Japan, from November 2017 to January 2018. We assessed contextual, individual and group, and vaccine/vaccination-specific influences. Of 290 HCWs, 139 (47.9%) returned completed questionnaires. Most HCWs (87/139, 64.9%) reported providing immunization information verbally to parents; 51/87 (58.6%) spent fewer than five minutes doing so. Pediatricians provided vaccines based on the parents’ best interest, whereas public health nurses and midwives emphasized government policy. Nurses had greater hesitancy related to personal perceptions and social/peer factors than pediatricians (p < 0.001). Nurses were significantly more likely than pediatricians to suggest that children receive more shots than necessary (p < 0.01). Nurses tended to have more negative attitudes toward vaccination and little awareness of immunization promotion compared to pediatricians. Thus, all HCWs involved in childhood immunization should receive sufficient information to provide timely and appropriate immunization to infants and children.

Vaccine hesitancy in health-care providers in Western countries: a narrative review

INTRODUCTION

Vaccine hesitancy (VH) is a leading cause of suboptimal vaccine uptake rates worldwide. The interaction between patients and health-care providers (HCPs) is the keystone in addressing VH. However, significant proportions of HCPs, including those who administer vaccines, are personally and professionally vaccine-hesitant.

AREAS COVERED

This narrative review sought to characterize the nature, extent, correlates, and consequences of VH among HCPs. We included 39 quantitative and qualitative studies conducted in Western countries, published since 2015, that assessed VH among HCPs in general, for several vaccines. Studies were reviewed using the WHO 3Cs model - (lack of) confidence, complacency, and (lack of) convenience.

EXPERT OPINION

Despite the lack of validated tools and substantial heterogeneity in the methods used to measure VH among HCPs, this review confirms its presence in this population, at frequencies that vary by country, profession type, setting, and level of medical education. Lack of knowledge and mistrust in health authorities/pharmaceutical industry/experts were among its principal drivers. Improving the content about vaccination in HCPs' training programs, facilitating access to reliable information for use during consultations, and developing and validating instruments to measure HCPs' VH and its determinants are key to addressing VH among HCPs.

Is the pre-natal period a missed opportunity for communicating with parents about immunizations? Evidence from a longitudinal qualitative study in Victoria, British Columbia

Background

Growing evidence shows that many parents begin the decision-making process about infant vaccination during pregnancy and these decisions – once established – may be resistant to change. Despite this, many interventions targeting vaccination are focused on communicating with parents after their baby is born. This suggests that the prenatal period may constitute a missed opportunity for communicating with expectant parents about infant vaccination.

Methods

Using a longitudinal qualitative design, we conducted two interviews (prepartum and postpartum) with women (n = 19) to explore the optimal timing of vaccination information. The data were analyzed thematically, and examined across all sets of pre- and post-partum interviews as well as within each individual participant to draw out salient themes.

Results

Most participants formed their intentions to vaccinate before the baby was born and indicated that they would welcome information about vaccination from their maternity care providers. However, few individuals recalled their maternity care providers initiating vaccination-related conversations with them.

Conclusion

The prenatal period is an important time to begin conversations with expectant parents about vaccinating their infants, particularly if these conversations are initiated by trusted maternity care providers. More information is needed on how maternity care providers can be better supported to have these conversations with their patients.

Factors associated with pediatric vaccine hesitancy of parents: a cross-sectional study in Turkey

Aim: This study aims to determine the prevalence and associated factors of vaccine hesitancy in females with children aged 12 months to 6 years who receive service from the antenatal class of a tertiary hospital in Turkey.Method: The study group includes 370 parents receiving service from a tertiary hospital. The data collection tools of the study were a descriptive data form and the Parent Attitudes about Childhood Vaccines survey.The data were analyzed using chi-square analysis and logistic regression analysis.Results: In our study, the prevalence of vaccine hesitancy was determined as 13.8% and vaccine refusal prevalence as 4.8%. In univariate analysis, vaccine hesitancy was found to be significantly higher in mothers with a university education, who got pregnant with treatment, who were not trained about pediatric vaccines in the antenatal follow-up, who followed anti-vaccine groups on social media, and who did not use vitamin D and iron supplements regularly or never used for their child. Vaccine hesitancy was significantly higher in parents who stated that their information sources of vaccines were not scientific, who were worried about vaccine ingredients (aluminum, mercury, pig gelatine) and who used alternative medicine practices (p < .05). In multivariate analysis, the risk of vaccine hesitancy increases 3.05 times in pregnancies with treatment, 3.74 times in those who did not use vitamin D or iron preparations, 3.01 times in those who followed anti-vaccine groups on social media,2.93 times in parents who were worried about the vaccine ingredients.Conclusion: Our findings suggest that the prevalence of vaccine hesitancy and risk factors should be monitored closely in the following years.

The knowledge, attitudes and beliefs of midwives on the vaccination coverage rates in Perth's Aboriginal children

BACKGROUND

Midwives are well placed to promote vaccination awareness throughout a women's pregnancy and strengthen childhood vaccination demand following hospital discharge. In Perth, Western Australia, Aboriginal children experience some of the lowest vaccination coverage rates across the nation. To identify factors preventing greater vaccination uptake amongst the target population, a theory-based study was conducted with midwives across two Perth maternity hospitals to explore behavioural attributes, knowledge, attitudes and beliefs surrounding vaccination provision and the vaccines administered to Aboriginal children.

METHODS

A purpose-designed questionnaire was distributed to midwives working in two Perth public maternity hospitals. The proximal constructs of The Theory of Planned Behavior were used to frame the questionnaire to enable the barriers to greater vaccination coverage to be identified and behaviourally situated. Descriptive statistics described the demographics of the study sample. Chi-square and the Fisher's exact test were used to identify associations between midwife characteristics and awareness of the coverage rates. Significance was set at α = 0.05.

RESULTS

Of the 58 midwives who completed the study questionnaire, 77.2% were unaware of the sub-optimal vaccination coverage in Perth's Aboriginal children. Level of education (p = 0.53) and years worked as a practising midwife (p = 0.47) were not found to be associated with an awareness of the coverage rates. Approximately, 50% of midwives reported some concern over the efficacy of childhood vaccines, 44.4% did not feel confident with their knowledge of vaccines, while 33.3% do not routinely discuss childhood vaccinations with parents prior to hospital discharge.

CONCLUSIONS

Key findings in the study identified that a range of educational, leadership and system-based issues are affecting midwives' capacity to play a more substantial role in influencing vaccination coverage in Perth's Aboriginal children.

Beyond the "information deficit model" - understanding vaccine-hesitant attitudes of midwives in Austria: a qualitative study

BACKGROUND

Healthcare workers are considered key stakeholders in efforts to address vaccine hesitancy. Midwives' influence in advising expectant parents on early-childhood vaccinations is unquestioned, yet they remain an understudied group. The literature on midwives' attitudes towards vaccinations is also inconclusive. We therefore conducted an explorative qualitative study on midwives' vaccine-hesitant attitudes towards MMR (measles-mumps-rubella) vaccinations in Austria.

METHODS

We conducted 12 in-depth interviews on their knowledge, concerns, and beliefs with midwives who self-identified as hesitant or resistant towards early-childhood MMR vaccinations. We analyzed the data using a grounded theory approach to distill common themes and meanings.

RESULTS

Healthcare workers' stewardship to address vaccine hesitancy is commonly framed in terms of the "information deficit model": disseminate the right information and remedy publics' information deficits. Our findings suggest that this approach is too simplistic: Midwives' professional self-understanding, their notions of "good care" and "good parenthood" inflect how they engage with vaccine information and how they address it to their clients. Midwives' model of care prioritized good counseling rather than sharing scientific information in a "right the wrong"-manner. They saw themselves as critical consumers of that information and as promoting "empowered patients" who were free, and affluent enough, to make their own choices about vaccinations. In so doing, they also often promoted traditional notions of motherhood.

CONCLUSIONS

Research shows that, for parents, vaccine decision-making builds on trust and dialogue with healthcare professionals and is more than a technical issue. In order to foster these interactions, understanding healthcare professionals' means of engaging with information is key to understanding how they engage with their constituents. Healthcare workers are more than neutral resources; their daily praxis influenced by their professional standing in the healthcare system. Similarly, healthcare professionals' views on vaccinations cannot be remedied with more information either. Building better and more diverse curricula for different groups of healthcare workers must attend to their respective roles, ethics of care, and professional beliefs. Taken together, better models for addressing vaccine hesitancy can only be developed by espousing a multi-faceted view of decision-making processes and interactions of healthcare workers with constituents.

Prevalence and identification of the determinants of influenza vaccination among French midwifery students

INTRODUCTION

Midwifery students in France are requested to be vaccinated against influīenza every year before the winter epidemic. The rationale is to protect pregnant women and newborns, the "frail" populations with whom students are in regular contact. The aims of the present study were to assess the prevalence of influenza vaccination among midwifery students and to identify the obstacles to its implementation.

METHOD

This is a descriptive study carried out by questionnaire among all midwifery students enrolled in one of the 35 midwifery schools in France for the year 2018-2019.

RESULTS

The 1092 questionnaires received showed that 47.9% of the students had been vaccinated during the previous winter, mainly in order to protect their patients. For those who had not been vaccinated, the main obstacles were a lack of time (64.7%), the vaccine was considered to be ineffective (57.3%) and forgetting to be vaccinated (43.4%). Most students reported that a midwifery school-based vaccination session would be effective in improving coverage. The decision to take up vaccination was influenced by the opinion of the student's entourage and information received in class.

CONCLUSION

Although the objectives of vaccine protection have not yet been achieved, influenza vaccination is not compulsory and midwifery students are free to choose. Students should be provided with all the information necessary to make their decision, including education on the subject, and have easy access to vaccination.

Mandatory vaccination in France: perception by outpatients and self-evaluation of its impact on their vaccine confidence

In France, for many vaccines, vaccine coverage is below the 95% cutoff. One reason is mistrust from a growing proportion of the general population toward vaccination. In 2017, a new law was promulgated, extending the number of mandatory vaccines from 3 to 11. Our objectives were twofold: to assess the population's perception of the extension of mandatory vaccination (MV) 1 year after its introduction, and to evaluate how it affected their vaccine confidence. We performed a descriptive cross-sectional study using a questionnaire for adults who consulted a family physician in south-east France. Overall, 453 questionnaires were analyzed. The median age of respondents (female 78.4%) was 43 years; 85% had children. On a 0 to 100 scale, respondents evaluated their confidence in vaccination at a median of 75 (IQR 50-90). For 60% of respondents, MV was a good public health measure; for 47%, it was poorly explained by the Ministry of Health; for 46%, it was a violation of personal freedom; and for 49%, it resulted from pharmaceutical industry lobbying. When asked about the influence of the extension of MV, only 26.2% declared that it had changed (a little/a lot) their opinion, and this change was for the majority (74.7%) toward less confidence. Respondents who declared an increased level of confidence already had a better perception of vaccination (and inversely). In conclusion, our results show that MV only changed the perception of vaccination among a small proportion of respondents. For most respondents, MV reinforced their initial views about vaccination.

Barriers Associated with the Uptake Ratio of Seasonal Flu Vaccine and Ways to Improve Influenza Vaccination Coverage among Young Health Care Workers in Poland

Despite not being full-time health care workers, annual flu vaccination is nevertheless an important consideration for medical students. This study examined the reasons for refusing flu vaccination among medical students, a group characterized by low vaccination coverage, despite the fact that the flu vaccine is arguably the most effective way of preventing serious flu complications. A cross-sectional survey was performed of 1313 students at the Medical University of Lodz. The findings indicate that the main sites of vaccination were primary care centers, and main source of information about influenza vaccination (about 90% of cases) was the general practitioner (GP). The most common motivations for vaccination were a recommendation by the family doctor or the belief that it was an important factor for protection against influenza. Most students reported various adverse effects after vaccination, usually mild pain at the site of vaccination, malaise, or fever. The main reasons for rejecting influenza vaccination were the apparent low risk of disease, the need for annual vaccination, the need to pay for it, lack of time or opportunity, lack of vaccination promotion, negative attitudes toward the flu vaccine, or the belief that there are other methods of preventing flu. To increase long-term vaccine acceptance and increase the vaccination rate among medical students and qualified health care workers, there is a need to adapt the health system and to initiate ongoing promotion programs at university to raise consciousness, promote vaccinations, and develop clinical skills for immunization.

Vaccine mistrust among family healthcare professionals and vaccine hesitancy in the communities they serve in Turkey in 2019: a cross-sectional study

AIM

This study aims to determine the causes of vaccine mistrust among family healthcare professionals (FHP) in the unit where they serve and vaccine hesitancy of families.

METHOD

The study group consisted of 682 FHPs working in a primary health care institution. The data collection tools of the study included a sociodemographic data form and a vaccine hesitancy data form. Pearson's chi-square analysis and logistic regression analysis were performed to analyze the data.

FINDINGS

To the question of "Do you trust the active ingredient in the vaccines?", only 2.1% of FHPs responded "I do not trust" and 18.9% answered "I am indecisive". 70.7% of FHPs said that at least one vaccine hesitant family was in the unit where they served. The most important reasons stated by FHPs on behalf of such families were vaccine mistrust (73.2%), the belief that they may be harmful for the child (58.7%), and the belief that vaccines cause autism (55.6%). In the univariate analysis, vaccine mistrust was significantly higher in FHPs who were measles-hesitant and responded "The decision to get vaccinated or not should belong to the family voluntarily". From logistic regression analysis, vaccine mistrust in FHPs increased 2.8-fold for those who did not think vaccination should be compulsory, 2.7-fold for those who did not think that vaccination refusal should be legally enforced, and 1.61-fold for those under age 35 years.

CONCLUSION

It was observed that FHPs had high sensitivity and positive attitudes toward vaccination in general.

A Comparison of the Attitudes to Influenza Vaccination Held by Nursing, Midwifery, Pharmacy, and Public Health Students and Their Knowledge of Viral Infections

Influenza is a viral vaccine-preventable disease. The present study aims to explore the attitude to influenza immunization and the knowledge of influenza among students in Poland. A cross-sectional survey was conducted at the end of 2019 and the beginning of 2020 among students of Nursing, Midwifery, Pharmacy, and Public health in all years of study. Data was obtained from 1137 students (90.7% female, 9.3% male), mean age 21.3 ± 1.62 years. The urban students were more likely to be vaccinated against seasonal influenza than rural students (OR: 1.52; 95% CI [1.10-2.10], p = 0.010362). The students of Public health were more likely to be vaccinated against influenza (48.9%, regularly annually 1.1%) than Pharmacy (31%, regularly annually 2.5%), Nursing (30.7%, regularly annually 1.3%) or Midwifery (25.1%, regularly annually 2.4%). First-year and second-year students were vaccinated more often (OR: 2.75; 95% CI [1.99-3.82], p = 0.00000; OR: 1.84; 95% CI [1.32-2.59], p = 0.0004, respectively) than later-year students. All students reported the main reasons for vaccination to be their own protection and parental decision. Concluded, present findings demonstrate a low prevalence of flu vaccination among medical students. Therefore, strategies are needed to increase the uptake of influenza vaccine in students, especially considering the future contact between this group of future health care workers and higher risk groups.

A critical interpretive synthesis of the roles of midwives in health systems

BACKGROUND

Midwives' roles in sexual and reproductive health and rights continues to evolve. Understanding the profession's role and how midwives can be integrated into health systems is essential in creating evidence-informed policies. Our objective was to develop a theoretical framework of how political system factors and health systems arrangements influence the roles of midwives within the health system.

METHODS

A critical interpretive synthesis was used to develop the theoretical framework. A range of electronic bibliographic databases (CINAHL, EMBASE, Global Health database, HealthSTAR, Health Systems Evidence, MEDLINE and Web of Science) was searched through to 14 May 2020 as were policy and health systems-related and midwifery organisation websites. A coding structure was created to guide the data extraction.

RESULTS

A total of 4533 unique documents were retrieved through electronic searches, of which 4132 were excluded using explicit criteria, leaving 401 potentially relevant records, in addition to the 29 records that were purposively sampled through grey literature. A total of 100 documents were included in the critical interpretive synthesis. The resulting theoretical framework identified the range of political and health system components that can work together to facilitate the integration of midwifery into health systems or act as barriers that restrict the roles of the profession.

CONCLUSIONS

Any changes to the roles of midwives in health systems need to take into account the political system where decisions about their integration will be made as well as the nature of the health system in which they are being integrated. The theoretical framework, which can be thought of as a heuristic, identifies the core contextual factors that governments can use to best leverage their position when working to improve sexual and reproductive health and rights.

Perception of mandatory infant vaccines and trust in vaccination among first-year healthcare students: An opportunity window for the training of future healthcare workers

INTRODUCTION

A high level of vaccine hesitancy is observed in France; to maintain a high level of vaccine coverage, a policy of mandatory vaccines has been applied since January 2019. As vaccine hesitancy has been described among healthcare workers, we aimed to assess the adhesion to vaccination in students enrolled in the first common year of healthcare studies (PACES), and their perceptions regarding the mandatory vaccine policy.

METHODS

We elaborated an anonymous online questionnaire and asked the 35 French universities offering PACES studies to diffuse it to their students; 26 accepted.

RESULTS

Overall, 4326 participants completed the questionnaire (age 18.7 ± 1.5 years, female 76.1%). They evaluated vaccine usefulness and harmfulness at a median of 90 [IQT:80-100] and 25 [IQT:10-50], respectively; on the same scale, their median trust in vaccines was 82 [IQT:70-94]. Among the five main age classes (17 to 21 years), the positive perceptions of vaccination declined with age. A majority declared that making vaccines mandatory was morally and scientifically justified (65.7% and 84.7%, respectively); in response to the questionnaire showing a blatant anti-mandatory vaccine billboard, 52.3% and 28.6%, respectively, strongly disagreed or rather disagreed with it. Again, these proportions declined between 17 and 21 years. Participants were asked whether the mandatory vaccine policy would improve their perceptions of vaccination; those with poorer perceptions were less likely to answer this question positively.

CONCLUSION

The perceptions of vaccination and the recent mandatory vaccine policy are positive in first-year students but better in younger ones, thus suggesting that vaccination should be taught early, during this study year. The mandatory vaccine policy may not improve the perceptions of those with a high level of vaccine hesitancy.

Influenza vaccination of pregnant women in Paris, France: Knowledge, attitudes and practices among midwives

INTRODUCTION

In France, midwives have been authorized to prescribe vaccines since 2016. Yet vaccination coverage among pregnant women remains low. Understanding the knowledge, attitudes and practices of midwives regarding influenza vaccination could help improve coverage.

METHODS

A cross-sectional survey was conducted in 2017 among midwives practicing in the public and private sectors in Paris using an online questionnaire. Multivariate logistic regression analysis of the data was conducted.

RESULTS

The response rate was 31% (n = 208/669). Overall, knowledge of influenza vaccine recommendations and of vaccine safety and effectiveness was high except regarding new-born immunity and influenza vaccine characteristics. Only 10% of midwives systematically prescribed the vaccine. Reported influenza vaccine uptake among midwives was 39%.

CONCLUSION

Efforts to improve the knowledge of midwives regarding the safety and effectiveness of vaccinating pregnant women in order to prevent influenza infection in newborns are necessary. Increasing vaccine uptake in both midwives and pregnant women will require adjusting education strategies.