Pregnant women's perspectives about maternal immunization in Latin America

Barriers and facilitators to vaccination in Latin America: a thematic synthesis of qualitative studies

Vaccines are often undervalued or underused for a variety of reasons, and vaccine hesitancy is a global challenge that threatens vaccine acceptance and the goals of immunization programs. This review aimed to describe the barriers and facilitators to vaccination in Latin America. The study design was a systematic review and thematic synthesis of qualitative studies reporting on the knowledge or attitudes of adults, parents of children at vaccination age, adolescents and health professionals towards vaccination in Latin America. The databases searched were PubMed, CENTRAL, Scopus, LILACS, SciELO, and CINAHL. A total of 56 studies were included. Facilitators included vaccination being recognized as an effective strategy for preventing infectious diseases and as a requirement for access to social assistance programs, schooling or employment. Recommendations from health professionals and positive experiences with health services were also identified as facilitators. The main barriers were lack of information or counseling, structural problems such as shortages of vaccines and limited hours of operation, the inability to afford over-the-counter vaccines or transportation to health facilities, certain religious beliefs, misconceptions and safety concerns. Qualitative research can contribute to understanding perceptions and decision-making about vaccination and to designing policies and interventions to increase coverage.

Attitudes and behaviors of maternal Tdap vaccination in Panama, Peru, and Colombia: An international cross-sectional study

INTRODUCTION

Despite a recommendation by PAHO for Tdap vaccination in pregnant women since 2019, uptake remains suboptimal across Latin America. This study evaluated the knowledge and attitudes of women towards maternal Tdap vaccination in Colombia, Peru, and Panama to identify the critical behavioral and social drivers of Tdap vaccine uptake during pregnancy.

METHODS

A cross-sectional online survey was undertaken between December 8, 2022, and January 11, 2023, targeting women in Colombia, Peru, or Panama with a child 12 months or under. We collected data on respondents' demographics, social and behavioral determinants of vaccine acceptance, determinants of vaccine uptake (using the validated 5As taxonomy), and previous vaccination experience.

RESULTS

In the 938 respondents who completed the survey (Panama, n = 325; Peru, n = 305; Colombia, n = 308), 73-80 % had received the influenza vaccine, whereas only 30-39 % had received a Tdap vaccine. Significant correlates of Tdap vaccine uptake common to all three countries included a health professional recommendation, knowledge of the vaccine and location of vaccination, perceived vulnerability to pertussis infection, perceived importance of immunization, and receipt of a reminder. In specific countries, nonvaccinated women were more likely to cite issues with ease of access (Panama, Colombia), affordability (opportunity costs; Peru, Colombia), and understanding the rationale for vaccination in pregnancy (Panama, Colombia).

CONCLUSION

To increase maternal Tdap vaccine uptake, health professionals should be encouraged to recommend vaccination consistently, and pregnant women should receive reminders explaining why and where to be vaccinated.

A Mother's Dilemma: The 5-P Model for Vaccine Decision-Making in Pregnancy

Pregnant women are a highly vaccine-resistant population and face unique circumstances that complicate vaccine decision-making. Pregnant women are also at increased risk of adverse maternal and neonatal outcomes to many vaccine-preventable diseases. Several models have been proposed to describe factors informing vaccine hesitancy and acceptance. However, none of these existing models are applicable to the complex decision-making involved with vaccine acceptance during pregnancy. We propose a model for vaccine decision-making in pregnancy that incorporates the following key factors: (1) perceived information sufficiency regarding vaccination risks during pregnancy, (2) harm avoidance to protect the fetus, (3) relationship with a healthcare provider, (4) perceived benefits of vaccination, and (5) perceived disease susceptibility and severity during pregnancy. In addition to these factors, the availability of research on vaccine safety during pregnancy, social determinants of health, structural barriers to vaccine access, prior vaccine acceptance, and trust in the healthcare system play roles in decision-making. As a final step, the pregnant individual must balance the risks and benefits of vaccination for themselves and their fetus, which adds greater complexity to the decision. Our model represents a first step in synthesizing factors informing vaccine decision-making by pregnant women, who represent a highly vaccine-resistant population and who are also at high risk for adverse outcomes for many infectious diseases.

Health Systems Determinants of Delivery and Uptake of Maternal Vaccines in Low- and Middle-Income Countries: A Qualitative Systematic Review

Maternal vaccination is considered a key component of the antenatal care package for improving maternal and child health. Low- and middle-income countries (LMICs) fall short of global targets to prevent maternal and neonatal deaths, with a disproportionate burden of vaccine-preventable diseases. Strategies towards ending preventable maternal mortality necessitate a health systems approach to adequately respond to this burden. This review explores the health systems determinants of delivery and uptake of essential maternal vaccines in LMICs. We conducted a qualitative systematic review of articles on maternal vaccination in LMICs, published between 2009 and 2023 in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Thematic analysis was conducted to identify key themes in the literature, interpreted within a conceptual framing that explores the systems determinants influencing maternal vaccines. Our search yielded 1309 records, of which 54 were included, covering 34 LMICs. Most of the included studies were from South America (28/54) and included pregnant women as the primary study population (34/54). The studies explored influenza (25/54) and tetanus toxoid (20/54) vaccines predominantly. The findings suggest that systems hardware (lack of clear policy guidelines, ineffective cold-chain management, limited reporting and monitoring systems) are barriers to vaccine delivery. Systems software (healthcare provider recommendations, increased trust, higher levels of maternal education) are enablers to maternal vaccine uptake. Findings show that formulation, dissemination and communication of context-specific policies and guidelines on maternal vaccines should be a priority for decision-makers in LMICs.

Knowledge, Attitudes, and Practices Concerning Maternal Immunization Among Pregnant/Postpartum Women and Health Care Professionals in Peru

INTRODUCTION

For pregnant women, vaccination with inactivated influenza vaccine (IIV) and tetanus, diphtheria, acellular pertussis vaccine (Tdap) is recommended. In Peru, uptake is nonetheless low. A study was conducted to identify factors affecting maternal vaccination coverage. The study's primary objectives were to describe the knowledge, attitudes, and practices regarding maternal immunization among pregnant/postpartum women and health care professionals (HCPs). The secondary objective was to determine the vaccination coverage and the impact of Ministry of Health (MOH) recommendations.

METHODS

An observational multicenter, cross-sectional survey study was conducted from February 1, 2021 to June 30, 2021 in five cities in Peru. Two surveys were conducted to assess knowledge, attitudes, and practices concerning maternal immunization: one among pregnant/postpartum women and one among HCPs.

RESULTS

Participants were 668 pregnant/postpartum women with a mean age of 29.6 years and 219 HCPs-mostly midwives (46.6%) and obstetricians/gynecologists (44.7%). Of the pregnant/postpartum women, 66.9% knew that, in general, vaccinations are given for prevention, and 98.5% believed vaccines are important. Nonetheless, 69.6% of pregnant/postpartum women had poor or moderate knowledge of maternal vaccination. Disease knowledge of influenza (89.1%) and tetanus (87.0%) was high, while knowledge of pertussis (37.7%) was low. Women agreed/strongly agreed that they would get vaccinated with Tdap if a doctor (96.3%), midwife (88.9%), or nurse (72.0%) recommended it. Of the HCPs, 81.3% routinely recommended Tdap vaccination for pregnant women.

CONCLUSIONS

To enhance vaccine acceptance in pregnant women in Peru, we must improve knowledge of the diseases, MOH recommendations, and benefits of the offered vaccinations. HCPs could provide this vaccination knowledge and information along with their vaccination recommendation as the pregnant/postpartum women indicated they would take the vaccines if recommended by their HCPs. Our findings are important for the successful implementation of maternal immunization programs in Peru.

Zika virus knowledge and vaccine acceptance among undergraduate students in Guayaquil, Ecuador

Purpose

Zika virus (ZIKV) was declared a Public Health Emergency of International Concern (PHEIC) in 2016. Concerns surrounding the effects of ZIKV persist today and several vaccine candidates are currently in various stages of development worldwide. There is limited research on ZIKV vaccine acceptability worldwide, and little research specific to Latin American countries. This research aims to identify the general beliefs and acceptance of a potential ZIKV vaccine in the undergraduate population at Escuela Superior Politécnica del Litoral (ESPOL) in Guayaquil, Ecuador.

Methods

Between January and November 2019, 429 undergraduate students at ESPOL responded anonymously to a ZIKV vaccine survey. Frequencies, percentages, simple correspondence analysis, and bivariate inferential analyses were conducted using Kendall's tau-b test. Tests explored associations between likelihood of receiving a ZIKV vaccine and demographic, ZIKV information seeking, ZIKV psychosocial variables, and ZIKV information source variables.

Results

Among the eligible participants, 241 (56.2%) were willing to receive a ZIKV vaccine if one was made commercially available. Most students were male (61.5%), age 20-25 (63.3%), and of mixed (Mestizo) race (95.3%). Results provided insight into student's knowledge on ZIKV, revealed television as the most common information source, and found most students were willing to receive a ZIKV vaccine were one to become available. Bivariate results revealed most respondents reported feeling neutral or likely to receive a ZIKV vaccine regardless of their agreeability with ZIKV information seeking behavior and psychosocial variables.

Conclusions

This study provides insight into ZIKV knowledge among ESPOL university students and reveals most respondents obtained ZIKV related information from television. The most common reason for not wanting to receive a hypothetical ZIKV vaccine was vaccine hesitancy. Likelihood of receiving a ZIKV vaccine was associated with several information seeking behavior and psychosocial variables. Public health campaigns should focus on comprehensive ZIKV education efforts in this population.

Motivational interviewing for maternal Immunizations: Intervention development

BACKGROUND AND OBJECTIVE

Vaccine uptake during pregnancy remains low. Our objectives were to describe 1) development and adaptation of a clinician communication training intervention for maternal immunizations and 2) obstetrics and gynecology (ob-gyn) clinician and staff perspectives on the intervention and fit for the prenatal care context.

METHODS

Design of the Motivational Interviewing for Maternal Immunizations (MI4MI) intervention was based on similar communication training interventions for pediatric settings and included presumptive initiation of vaccine recommendations ("You're due for two vaccines today") combined with motivational interviewing (MI) for hesitant patients. Interviews and focus group discussions were conducted with ob-gyn clinicians and staff in five Colorado clinics including settings with obstetric physicians, certified nurse midwives (CNMs), and clinician-trainees. Participants were asked about adapting training to the ob-gyn setting and their implementation experiences. Feedback was incorporated through iterative changes to training components.

RESULTS

Interview and focus group discussion results from participants before (n = 3), during (n = 11) and after (n = 25) implementation guided intervention development and adaptation. Three virtual, asynchronous training components were created: a video and two interactive modules. This virtual format was favored due to challenges attending group meetings; however, participants noted opportunities to practice skills through role-play were lacking. Training modules were adapted to include common challenging vaccine conversations and live-action videos. Participants liked interactive training components and use of adult learning strategies. Some participants initially resisted the presumptive approach but later found it useful after applying it in their practices. Overall, participants reported that MI4MI training fit well with the prenatal context and recommended more inclusion of non-clinician staff.

CONCLUSIONS

MI4MI training was viewed as relevant and useful for ob-gyn clinicians and staff. Suggestions included making training more interactive, and including more complex scenarios and non-clinician staff.

A socio-ecological exploration to identify factors influencing the COVID-19 vaccine decision-making process among pregnant and lactating women: Findings from Kenya

The vaccine decision-making process of pregnant and lactating women is complex. Regarding COVID-19, pregnant women are at increased risk for severe disease and poor health outcomes. While pregnant and lactating women were excluded from COVID-19 vaccine trials, available evidence suggests that COVID-19 vaccines are safe and protective during pregnancy. In this study, we used a socio-ecological approach to explore factors influencing the decision-making process for COVID-19 vaccines in pregnant and lactating women in Kenya, for the purpose of informing demand generation strategies. As pregnant and lactating women are influenced by many factors, we conducted 84 in-depth interviews with a variety of stakeholders, including 31 pregnant or lactating women, 20 healthcare workers such as nurses, midwives, doctors, and frontline workers, 25 male family members of pregnant or lactating women, and 8 gatekeepers such as community leaders and faith-based leaders. These individuals were recruited from six communities in Kenya: three urban, and three rural. We applied a grounded theory approach to identify emerging themes and organized emerging themes using the SAGE Vaccine Hesitancy model, which includes three categories of determinants of vaccine acceptance, including contextual influences, individual and group influences, and vaccine and vaccination specific issues. Myths, interpersonal norms, and religion emerged as themes related to contextual influences. Safety, risk perception, and the role of the healthcare worker emerged as themes related to individual and group influences. For vaccine and vaccination specific issues, emerging themes included availability, accessibility, and eligibility. While maternal immunization can substantially reduce the effect of infectious diseases in mothers and infants, vaccine acceptance is critical. However, vaccines do not save lives; vaccination does. We hope the results of this study can be used to tailor communication efforts to increase vaccine demand among pregnant and lactating women.

Conceptualizing the COVID-19 Pandemic: Perspectives of Pregnant and Lactating Women, Male Community Members, and Health Workers in Kenya

Pregnant women are at greater risk of adverse outcomes from SARS-CoV-2 infection. There are several factors which can influence the ways in which pregnant women perceive COVID-19 disease and behaviorally respond to the pandemic. This study seeks to understand how three key audiences-pregnant and lactating women (PLW), male community members, and health workers-in Kenya conceptualize COVID-19 to better understand determinants of COVID-19 related behaviors. This study used qualitative methods to conduct 84 in-depth interviews in three counties in Kenya. Data were analyzed using a grounded theory approach. Emerging themes were organized based on common behavioral constructs thought to influence COVID-19 related behaviors and included myths, risk perception, economic implications, stigma, and self-efficacy. Results suggest that risk perception and behavioral attitudes substantially influence the experiences of PLW, male community members, and health workers in Kenya during the COVID-19 pandemic. Public health prevention and communication responses targeting these groups should address potential barriers to preventive health behaviors, such as the spread of misinformation, financial constraints, and fear of social ostracization.