A randomized trial of maternal influenza immunization decision-making: A test of persuasive messaging models

Interventions to increase vaccination against COVID-19, influenza and pertussis during pregnancy: a systematic review and meta-analysis

BACKGROUND

Pregnant women and their babies face significant risks from three vaccine-preventable diseases: COVID-19, influenza and pertussis. However, despite these vaccines' proven safety and effectiveness, uptake during pregnancy remains low.

METHODS

We conducted a systematic review (PROSPERO CRD42023399488; January 2012-December 2022 following PRISMA guidelines) of interventions to increase COVID-19/influenza/pertussis vaccination in pregnancy. We searched nine databases, including grey literature. Two independent investigators extracted data; discrepancies were resolved by consensus. Meta-analyses were conducted using random-effects models to estimate pooled effect sizes. Heterogeneity was assessed using the I2 statistics.

RESULTS

From 2681 articles, we identified 39 relevant studies (n = 168 262 participants) across nine countries. Fifteen studies (39%) were randomized controlled trials (RCTs); the remainder were observational cohort, quality-improvement or cross-sectional studies. The quality of 18% (7/39) was strong. Pooled results of interventions to increase influenza vaccine uptake (18 effect estimates from 12 RCTs) showed the interventions were effective but had a small effect (risk ratio = 1.07, 95% CI 1.03, 1.13). However, pooled results of interventions to increase pertussis vaccine uptake (10 effect estimates from six RCTs) showed no clear benefit (risk ratio = 0.98, 95% CI 0.94, 1.03). There were no relevant RCTs for COVID-19. Interventions addressed the 'three Ps': patient-, provider- and policy-level strategies. At the patient level, clear recommendations from healthcare professionals backed by text reminders/written information were strongly associated with increased vaccine uptake, especially tailored face-to-face interventions, which addressed women's concerns, dispelled myths and highlighted benefits. Provider-level interventions included educating healthcare professionals about vaccines' safety and effectiveness and reminders to offer vaccinations routinely. Policy-level interventions included financial incentives, mandatory vaccination data fields in electronic health records and ensuring easy availability of vaccinations.

CONCLUSIONS

Interventions had a small effect on increasing influenza vaccination. Training healthcare providers to promote vaccinations during pregnancy is crucial and could be enhanced by utilizing mobile health technologies.

Interventions to Improve Knowledge, Attitudes, and Uptake of Recommended Vaccines during Pregnancy and Postpartum: A Scoping Review

Tetanus, pertussis, influenza, and COVID-19 vaccines are recommended for the prevention of related morbidity and mortality during pregnancy and postpartum. Despite the established benefits of vaccination for prenatal and postnatal women, maternal vaccination is not universally included in routine antenatal programs, especially in low- and middle-income countries. Furthermore, the uptake of recommended vaccines among pregnant and postpartum women remains below optimum globally. This review aimed to map the evidence on interventions to improve knowledge, attitudes, and uptake of recommended vaccines among pregnant and postpartum women. We conducted a comprehensive and systematic search for relevant literature in PubMed, Scopus, Web of Science, EBSCOhost, and Google Scholar. Overall, 29 studies published between 2010 and 2023 were included in this review. The majority (n = 27) of these studies were from high-income countries. A total of 14 studies focused on the influenza vaccine, 6 on the Tdap vaccine, 8 on both influenza and Tdap vaccines, and only one study on the COVID-19 vaccine. Patient-centered interventions predominated the evidence base (66%), followed by provider-focused (7%), health system-focused (10%), and multilevel interventions (17%). Overall, the effect of these interventions on knowledge, attitudes, and uptake of maternal vaccines was variable.

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

A Systematic Review of Behaviour Change Techniques within Interventions to Increase Vaccine Uptake among Ethnic Minority Populations

COVID-19 caused significant morbidity and mortality amongst ethnic minority groups, but vaccine uptake remained lower than non-minoritised groups. Interventions to increase vaccine uptake among ethnic minority communities are crucial. This systematic review synthesises and evaluates behaviour change techniques (BCTs) in interventions to increase vaccination uptake in ethnic minority populations. We searched five databases and grey literature sources. From 7637 records identified, 23 studies were included in the review. Interventions were categorised using the Behaviour Change Wheel (BCW) and Behaviour Change Taxonomy v1. Vaccines included influenza, pertussis, tetanus, diphtheria, meningitis and hepatitis. Interventions were primarily delivered in health centres/clinics and community settings. Six BCW intervention functions and policy categories and 26 BCTs were identified. The main intervention functions used were education, persuasion and enablement. Overall, effective interventions had multi-components and were tailored to specific populations. No strong evidence was observed to recommend specific interventions, but raising awareness and involvement of community organisations was associated with positive effects. Several strategies are used to increase vaccine uptake among ethnic minority communities; however, these do not address all issues related to low vaccine acceptance. There is a strong need for an increased understanding of addressing vaccine hesitancy among ethnic minority groups.

The use of technology in vaccine safety communication: A systematic review of randomised controlled trials

OBJECTIVES

To identify technologies used in vaccine safety communication and evaluate their impact on vaccination intention, uptake, knowledge, attitude, and perceptions of consumers.

METHODS

We searched 6 electronic databases to identify randomised controlled trials assessing the impact of using technology in vaccine safety communication. The Cochrane Collaboration's tool for assessing risk of bias was used to evaluate each study.

RESULTS

We included 22 studies involving 27,109 participants from 8 countries; 15 studies assessed the use of videos and 7 examined innovative technologies. Using videos significantly improved knowledge (n = 3) and participant engagement (n = 2) compared to printed material. Among the innovative technologies, the use of virtual reality, and smartphone applications incorporating social networking or gamification significantly increased vaccination knowledge, confidence, and engagement. The studies showed that narrative messaging increased perceived disease severity (n = 2) and vaccination intention (n = 2).

CONCLUSIONS

While the use of innovative technologies is increasing, videos currently remain the most popular technology for vaccine safety communication. Communication technology, particularly with narrative messaging, improves patient engagement and comprehension.

PRACTICE IMPLICATIONS

Health authorities should increase focus on using videos and smartphone applications for vaccine safety communication. Collaboration among stakeholders is essential to develop guidelines on effective message content to complement the technology.

Maternal Vaccination and Vaccine Hesitancy

The American College of Obstetrics and Gynecology recommends influenza vaccine annually, Tdap with each pregnancy, and COVID-19 vaccine for those not previously vaccinated or who are due for boosters. The influenza and COVID-19 vaccines are safe during pregnancy and are effective in reducing morbidity in both the pregnant person and infant. The Tdap vaccine is given primarily to protect the newborn from pertussis through transplacental antibody transfer. Methods to enhance vaccination rates include stocking and giving vaccines in the obstetric office, recommending eligible vaccines at each visit, and focusing on the health of the infant in conversations with patients.

Protecting pregnant people & infants against influenza: A landscape review of influenza vaccine hesitancy during pregnancy and strategies for vaccine promotion

Before COVID-19, influenza vaccines were the most widely recommended vaccine during pregnancy worldwide. In response to immunization during pregnancy, maternal antibodies offer protection against potentially life-threatening disease in both pregnant people and their infants up to six months of age. Despite this, influenza vaccine hesitancy is common, with few countries reporting immunization rates in pregnant people above 50%. In this review, we highlight individual, institutional, and social factors associated with influenza vaccine hesitancy during pregnancy. In addition, we present an overview of the evidence evaluating interventions to address influenza vaccine hesitancy during pregnancy. While some studies have indicated promising results, no single intervention has consistently effectively increased influenza vaccine uptake during pregnancy. Using a social-ecological model of health framework, future strategies addressing multiple levels of vaccine hesitancy will be needed to realize the potential health benefits of prenatal immunization programs.

Shifting the Demand for Vaccines: A Review of Strategies

Vaccines prevent millions of deaths, and yet millions of people die each year from vaccine-preventable diseases. The primary reason for these deaths is that a significant fraction of the population chooses not to vaccinate. Why don't people vaccinate, and what can be done to increase vaccination rates besides providing free and easy access to vaccines? This review presents a conceptual framework, motivated by economic theory, of which factors shift the demand for vaccines. Next, it critically examines the literature on these demand shifters and interventions that target these demand shifters. The review concludes with offering directions for future research and lessons for public health decision-making. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

A systematic review of narrative interventions: Lessons for countering anti-vaccination conspiracy theories and misinformation

Even if a small portion of the population refuses vaccination due to anti-vaccination conspiracy theories or misinformation, this poses a threat to public health. We argue that addressing conspiracy theories with only corrective information is not enough. Instead, considering that they are complex narratives embedded in personal and cultural worldviews, they should be encountered with counternarratives. To identify existing narrative interventions aimed at countering anti-vaccination conspiracy theories and, more generally, map prerequisites for a narrative intervention to be successful, we present a systematic review of experimental effects of exposure to pro-vaccine narratives on a range of vaccination outcomes, based on 17 studies and 97 comparisons. We did not find any narrative interventions aimed directly at conspiracy theories. However, the review allowed us to make evidence-based recommendations for future research and for public communicators. This might help pro-vaccine communication match anti-vaccine communication in its potential to spread and go viral.

Racial disparities in influenza immunization during pregnancy in the United States: A narrative review of the evidence for disparities and potential interventions

OBJECTIVE

The objectives of this review were to summarize existing data on racial disparities in maternal immunization for influenza in the U.S. and to review the literature on interventions to improve the uptake of the influenza vaccine among Black pregnant women.

DATA SOURCES

U.S. survey data on maternal influenza immunization by racial and ethnic group were summarized in narrative form. To review intervention studies, PubMed, CINAHL, EMBASE, and the Cochrane Library databases were searched for English language articles published 2017 to 2021, in addition to studies identified by a previous systematic review.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed studies conducted in the U.S. and reporting interventions designed to increase the uptake of the influenza vaccine in pregnancy with study populations including at least 20% of participants identifying as Black were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies were grouped and reviewed in a narrative manner according to whether they were conducted in predominantly Black populations or in more racially diverse populations, and whether they tested multicomponent or single-component interventions.

RESULTS

A decade of survey data show that Black women in the U.S. consistently have the lowest rate of influenza immunization in pregnancy. Black women report a lower rate of being recommended or offered the vaccine, and provider recommendation is associated with greater vaccine uptake. Intervention studies to increase influenza immunization among Black pregnant women have reported mixed results. Successful interventions include multicomponent practice-based interventions, group prenatal care, and culturally competent patient educational messages.

CONCLUSIONS

Racial disparities in maternal uptake of the influenza vaccine are long-standing, but not intractable. More research is needed to test interventions to address this disparity, with a focus on increasing provider recommendation and offer of the vaccine, addressing patients' concerns about vaccine safety and efficacy, improving providers' cultural competence, and building trust between providers and patients.

"From my phone, I could rule the world": Critical engagement with maternal vaccine information, vaccine confidence builders and post-Zika outbreak rumours in Brazil

Maternal immunization is key to protecting maternal and newborn health. We interviewed pregnant women in Brazil to identify barriers to and enablers of maternal immunization in the country. In-depth interviews and focus groups were conducted in Brazil with 60 pregnant women from São Paulo and Rio de Janeiro at different stages of their pregnancies. Participants were encouraged to discuss views on safety, efficacy and importance of maternal vaccines, access to vaccines, interactions with healthcare professionals, and sources of information on vaccine-related matters. There was generally a positive regard for maternal immunization among the interviewed women, many of whom associated vaccination with protection of their unborn child. The interviewees cited several reasons for adherence to immunization guidelines, including recommendations from healthcare professionals, targeted communication campaigns, and active use of a vaccination card or booklet. There were no reported barriers for maternal vaccines. Some women using private healthcare services reported not having been asked about vaccines at check-ups, which could adversely affect vaccination rates. A rumour that vaccines caused microcephaly which emerged during the Zika outbreak was the most commonly cited reason for choosing not to vaccinate among the interviewees. This study identified important vaccine confidence builders. Many of the interviewees critically reflected upon information received, placing themselves as the decision makers over their health choices. A prominent barrier to maternal immunization was a rumour linking vaccines to microcephaly. To the best of our knowledge, this has not been previously reported in the literature and requires further investigation into the extent of this issue and how it can be mitigated.

How effective are digital interventions in increasing flu vaccination among pregnant women? A systematic review and meta-analysis

BACKGROUND

Flu can have serious consequences for pregnant woman and unborn babies. Vaccination provides safe and effective protection, yet uptake among pregnant women is below national targets. Digital interventions are effective at increasing adherence to health interventions.

AIMS

This review aimed to establish whether digital interventions are effective at increasing rates of flu vaccination among pregnant women, and to determine the overall effect size.

METHOD

Systematic searches identified digital intervention trials, aiming to increase rate of flu vaccination among pregnant women. Random-effects meta-analysis provided a combined effect size and examined which mode of digital interventions had the largest effects on flu vaccination.

RESULTS

Ten studies were included in the review. The majority of digital interventions were more effective at increasing rates of flu vaccination (7-81.3% uptake) than usual care or non-digital interventions (7.3-47.1% uptake). When meta-analysed, digital interventions had a small, non-significant effect (odds ratio [OR] = 1.29, 95% confidence interval [CI]: 0.71, 2.31), P = 0.40. Text messages (OR = 1.25, 95% CI: 0.58, 2.67), P = 0.57 appeared less effective than other digital interventions (OR = 1.58, 95% CI: 1.02, 2.46), P = 0.04.

CONCLUSIONS

Overall, there is a lack of high-quality studies reporting the effectiveness of digital interventions at increasing flu vaccination during pregnancy. Future interventions may benefit from using video or social media to communicate messages for maximum success in targeting an increase in rates of flu vaccination in pregnancy.

Efficacy and safety of influenza vaccination during pregnancy: realizing the potential of maternal influenza immunization

Introduction: Pregnant women are at higher risk of severe complications following influenza infection compared to the general population. Influenza vaccination during pregnancy can offer direct protection to pregnant women and passive immunity to infants up to 6 months of age via maternal antibodies. Pregnant women are a high priority group for influenza immunization.Areas covered: This review provides an overview of the basis for recommending influenza vaccine to pregnant women, current immunization policies, the evidence supporting the safety and effectiveness of maternal vaccination, and future research needed. We conducted a search of PubMed for articles describing the safety or efficacy of influenza vaccines administered during pregnancy. Published articles from inception to 17 November 2020 were reviewed.Expert opinion: Experimental and observational evidence support the efficacy, effectiveness and safety of influenza immunization during pregnancy. These data support the continued provision of inactivated influenza vaccine to pregnant women, as recommended by global immunization policies. To achieve success with maternal influenza immunization programs, further work is needed to inform policy development in low- and middle-income settings and implementation and promotion in high-income settings.

Health Communication and Decision Making about Vaccine Clinical Trials during a Pandemic

The COVID-19 pandemic has magnified the importance of clinical trials for finding a safe and effective vaccine to protect against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. Although communication about vaccines and vaccine hesitancy were challenges long before COVID-19, the twin facts of a pandemic and an "infodemic" of health information, misinformation, and disinformation have raised new challenges for vaccine-related communication and decision-making. The goal of this commentary is to highlight strategies to improve communication and decision-making for adults considering participation in COVID-19 vaccine clinical trials. First, I present a general conceptual model for clinical trial participation that can be applied to various vaccine and other clinical trial contexts. Next, I introduce the ASK (Assume, Seek, Know) approach for enhancing clinical trial participation: (1) assume that all patients will want to know their options, (2) seek the counsel of stakeholders, and (3) know your numbers. The ideas presented in this commentary are intended to enhance vaccine-specific clinical trial communication, decision-making, and literacy, while dually offering strategies and resources that may help reduce vaccine hesitancy and increase vaccine uptake over time.

Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study

BACKGROUND

There is growing evidence of vaccine delays or refusals due to a lack of trust in the importance, safety, or effectiveness of vaccines, alongside persisting access issues. Although immunisation coverage is reported administratively across the world, no similarly robust monitoring system exists for vaccine confidence. In this study, vaccine confidence was mapped across 149 countries between 2015 and 2019.

METHODS

In this large-scale retrospective data-driven analysis, we examined global trends in vaccine confidence using data from 290 surveys done between September, 2015, and December, 2019, across 149 countries, and including 284 381 individuals. We used a Bayesian multinomial logit Gaussian process model to produce estimates of public perceptions towards the safety, importance, and effectiveness of vaccines. Associations between vaccine uptake and a large range of putative drivers of uptake, including vaccine confidence, socioeconomic status, and sources of trust, were determined using univariate Bayesian logistic regressions. Gibbs sampling was used for Bayesian model inference, with 95% Bayesian highest posterior density intervals used to capture uncertainty.

FINDINGS

Between November, 2015, and December, 2019, we estimate that confidence in the importance, safety, and effectiveness of vaccines fell in Afghanistan, Indonesia, Pakistan, the Philippines, and South Korea. We found significant increases in respondents strongly disagreeing that vaccines are safe between 2015 and 2019 in six countries: Afghanistan, Azerbaijan, Indonesia, Nigeria, Pakistan, and Serbia. We find signs that confidence has improved between 2018 and 2019 in some EU member states, including Finland, France, Ireland, and Italy, with recent losses detected in Poland. Confidence in the importance of vaccines (rather than in their safety or effectiveness) had the strongest univariate association with vaccine uptake compared with other determinants considered. When a link was found between individuals' religious beliefs and uptake, findings indicated that minority religious groups tended to have lower probabilities of uptake.

INTERPRETATION

To our knowledge, this is the largest study of global vaccine confidence to date, allowing for cross-country comparisons and changes over time. Our findings highlight the importance of regular monitoring to detect emerging trends to prompt interventions to build and sustain vaccine confidence.

FUNDING

European Commission, Wellcome, and Engineering and Physical Sciences Research Council.

Global Perspectives on Immunization During Pregnancy and Priorities for Future Research and Development: An International Consensus Statement

Immunization during pregnancy has been recommended in an increasing number of countries. The aim of this strategy is to protect pregnant women and infants from severe infectious disease, morbidity and mortality and is currently limited to tetanus, inactivated influenza, and pertussis-containing vaccines. There have been recent advancements in the development of vaccines designed primarily for use in pregnant women (respiratory syncytial virus and group B Streptococcus vaccines). Although there is increasing evidence to support vaccination in pregnancy, important gaps in knowledge still exist and need to be addressed by future studies. This collaborative consensus paper provides a review of the current literature on immunization during pregnancy and highlights the gaps in knowledge and a consensus of priorities for future research initiatives, in order to optimize protection for both the mother and the infant.

Factors associated with referring close contacts to an app with individually-tailored vaccine information

BACKGROUND

Infants too young to be fully vaccinated are vulnerable to potentially deadly influenza and pertussis infections. The cocooning strategy limits this risk by vaccinating those likely to interact with the infant and mother during this vulnerable time, such as close friends and family members. Distribution of accurate and accessible vaccine information through existing social networks could be an important tool in increasing vaccine confidence and coverage.

METHODS

We surveyed 1095 pregnant women from diverse prenatal care practices in Georgia and Colorado. These women were surveyed through a mobile app to assess vaccine intentions, attitudes, beliefs, norms, and levels of trust, and then presented brief individually-tailored educational videos about maternal and infant vaccines and the cocooning strategy. They were then given the opportunity to refer up to six contacts to enroll in the app and receive similar vaccine education.

RESULTS

Twenty-eight percent of these women referred at least one contact, with an average of 2.67 contacts per referring woman. Most referrals (93%) were partners, parents, siblings, relatives, or close friends. Attitudinal constructs significantly associated with increased likelihood of referring contacts included: intention to receive maternal influenza vaccine, perceived safety of maternal Tdap vaccine, perceived efficacy of maternal influenza vaccine, perceived susceptibility to and severity of influenza during pregnancy, and trust in vaccine information from the Centers for Disease Control and Prevention (CDC) and academic institutions. Uncertainty about infant vaccine intentions was associated with decreased likelihood of referring contacts.

CONCLUSIONS

Pregnant women who valued vaccination and trusted vaccine information from academic institutions were more likely to refer an educational app about vaccines than those who did not. Further research is needed to determine the potential impact of this strategy on vaccine coverage when implemented on a large scale.

TRIAL REGISTRATION

The survey informing this article was part of a randomized controlled trial funded by the National Institutes of Health [clinicaltrials.gov registration number NCT02898688].

Prior Vaccination and Effectiveness of Communication Strategies Used to Describe Infectious Diseases

We tested the effect of prior vaccination on response to communication strategies in a hypothetical news article about an influenza pandemic. Vaccinated were more likely than nonvaccinated participants to plan future vaccination, and future vaccination intent was greater with certain communication strategies. Using these findings to target communication may increase vaccination rates.

Office-Based Educational Handout for Influenza Vaccination: A Randomized Controlled Trial

OBJECTIVES

To assess the impact of a parent educational intervention about influenza disease on child vaccine receipt.

METHODS

A convenience sample of parents of children ≥6 months old with a visit at 2 New York City pediatric clinics between August 2016 and March 2017 were randomly assigned (1:1:1) to receive either usual care, an educational handout about influenza disease that was based on local data, or an educational handout about influenza disease that was based on national data. Parents received the handout in the waiting room before their visit. Primary outcomes were child influenza vaccine receipt on the day of the clinic visit and by the end of the season. A multivariable logistic regression was used to assess associations between intervention and vaccination, with adjustment for variables that were significantly different between arms.

RESULTS

Parents who received an intervention (versus usual care) had greater odds of child influenza vaccine receipt by the end of the season (74.9% vs 65.4%; adjusted odds ratio 1.68; 95% confidence interval: 1.06-2.67) but not on the day of the clinic visit. Parents who received the national data handout (versus usual care) had greater odds of child influenza vaccine receipt on the day of the clinic visit (59.0% vs 52.6%; adjusted odds ratio 1.79; 95% confidence interval: 1.04-3.08) but not by the end of the season.

CONCLUSIONS

Providing an educational intervention in the waiting room before a pediatric provider visit may help increase child influenza vaccine receipt.

Enhancing uptake of influenza maternal vaccine

INTRODUCTION

Influenza vaccination during pregnancy can offer many benefits to both mother and infant. Despite recommendations from the Advisory Committee on Immunization Practices, vaccine coverage rates among pregnant women during pregnancy are below 40% in the United States. There is a need for a greater understanding of what interventions can improve vaccine uptake among pregnant women.

AREAS COVERED

This review synthesizes the existing evidence on the effectiveness of interventions to improve maternal influenza vaccine uptake. These interventions are examined within the framework of the three psychological propositions: thoughts and feelings, social processes and changing behavior directly.

EXPERT COMMENTARY

A number of promising and effective interventions were identified in this review. Nudge-based interventions that build on favorable intentions to vaccinate such as provider prompts and standing orders have demonstrated significant success in improving influenza vaccine uptake. However, substantial gaps in the literature still exist. Provider recommendations are the most important predictor of vaccine receipt among pregnant women, yet few studies evaluated intervening to improve the dialogue between patient and provider. With the potential for even more vaccines to be added to the maternal immunization schedule, it is vitally important to understand how to improve uptake.

Understanding barriers and predictors of maternal immunization: Identifying gaps through an exploratory literature review

BACKGROUND

The Advisory Committee for Immunization Practices recommends that all pregnant women receive the seasonal influenza vaccine and the tetanus toxoid, diphtheria toxoid, and acellular pertussis (Tdap) vaccine during every pregnancy. However, vaccination coverage rates are suboptimal among pregnant women in the United States, leaving these women and their unborn children at risk of vaccine-preventable diseases and their complications.

OBJECTIVES

We sought to understand the current landscape of published literature regarding maternal immunization, including barriers to and predictors of vaccine acceptance, and identify gaps in the research in order to inform strategies for future programmatic improvement.

METHODS

We conducted a literature search using MEDLINE (OVID), PsychINFO, and CINAHL (Ebsco) databases. The search included published, English-language manuscripts that identified patient, provider, or system-level barriers to, predictors of, or interventions that improved uptake of maternal vaccines among pregnant women in the US. Studies were reviewed using an inductive thematic analysis approach.

RESULTS

We included 75 studies in our review. Pregnant women identified 25 different barriers to accepting recommended maternal immunizations; barriers related to vaccine safety perceptions were the most common. Healthcare providers identified 24 different barriers to vaccinating their pregnant patients. The most commonly cited barriers among healthcare providers were financial concerns. Eighteen different predictors of vaccine acceptance were identified. Receipt of a healthcare provider's recommendation was the factor most frequently reported as a reason for vaccination among pregnant women.

CONCLUSIONS

We were able to identify gaps in the literature regarding maternal immunization and make recommendations for future research. Efforts to address the challenges of maternal immunization in the United States should include increasing the focus on Tdap, implementing more high-level assessments of safety perceptions and associated concerns, and determining most effective interventions.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Clinician perspectives on strategies to improve patient maternal immunization acceptability in obstetrics and gynecology practice settings

Pregnancy is an ideal time to communicate with women about vaccines for themselves and their infants, yet maternal immunization rates remain suboptimal. This study aimed to identify clinic, provider, and staff-related attributes and facilitators to be utilized for a comprehensive vaccine intervention in ob-gyn clinical settings. We conducted in-depth interviews with 24 providers, both healthcare providers (e.g., physicians, nurse practitioners, midwives) and practice managers, from urban and suburban ob-gyn practices in Georgia and Colorado about their immunization attitudes, practices, and patient experiences. Qualitative analyses included Pearson correlation tests to evaluate patterns and relationships within the data to determine themes. Six major themes emerged: 1) strong provider "buy in" for maternal immunization; 2) the supporting role of clinical/interpersonal cues for vaccine promotion; 3) varying provider-patient communication approaches and its influence on maternal and pediatric uptake; 4) an urgent need for a designated office immunization champion; 5) reimbursement and practice implementation challenges; and 6) region differences in attitudes and values toward maternal immunization. Although providers expressed strong support for maternal immunization practices and offered environmental cues for vaccine promotion, practices often lacked a designated, structured role for an immunization champion equipped to manage delicate conversations with patients. The findings reflect needs for immunization champion identification, training, and support, along with best practices guidelines to improve coordination of vaccine promotion and delivery efforts in ob-gyn provider offices. Additionally, provider training on communication approaches to enhance acceptance and uptake of maternal vaccines is warranted.

Interventions to increase pediatric vaccine uptake: An overview of recent findings

Although much is known about factors contributing to variation in pediatric immunization uptake, there is a need for synthesis of effective vaccine promotion strategies. With growing public health concern on how to best sustain high pediatric immunization rates, and improve where the rates are suboptimal, this review offers evidence gathered from several studies on the achievement of these goals. We identified and analyzed reported findings on childhood (primarily ≤ 7 years) immunization outcomes from tested intervention strategies that focused on parents, guardians, and caregivers, as well as providers, clinics/practices, and communities. The findings suggest that targeted and tailored interventions offer substantial possibilities, especially in a combined manner. We describe promising intervention models that have been operationalized with success and provide evidence for scalability across contexts. Moreover, they are sensitive to parents' and providers' needs, are feasibly integrated in daily clinical practice, and account for broader community concerns and issues.

Evaluation of two vaccine education interventions to improve pertussis vaccination among pregnant African American women: A randomized controlled trial

BACKGROUND

Vaccination coverage with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in pregnancy or immediately postpartum has been low. Limited data exist on rigorously evaluated interventions to increase maternal vaccination, including Tdap. Tailored messaging based on the Elaboration Likelihood Model (ELM) framework has been successful in improving uptake of some public health interventions. We evaluated the effect of two ELM-based vaccine educational interventions on Tdap vaccination among pregnant African American women, a group of women who tend to have lower vaccine uptake compared with other groups.

METHODS

We conducted a prospective randomized controlled trial to pilot test two interventions - an affective messaging video and a cognitive messaging iBook - among pregnant African American women recruited during routine prenatal care visits. We measured Tdap vaccination during the perinatal period (during pregnancy and immediately postpartum), reasons for non-vaccination, and intention to receive Tdap in the next pregnancy.

RESULTS

Among the enrolled women (n=106), 90% completed follow-up. Tdap vaccination in the perinatal period was 18% in the control group; 50% in the iBook group (Risk Ratio [vs. control group]: 2.83; 95% CI, 1.26-6.37), and 29% in the video group (RR: 1.65; 95% CI, 0.66-4.09). From baseline to follow-up, women's reported intention to receive Tdap during the next pregnancy improved in all three groups. Among unvaccinated women, the most common reason reported for non-vaccination was lack of a recommendation for Tdap by the woman's physician.

CONCLUSIONS

Education interventions that provide targeted information for pregnant women in an interactive manner may be useful to improve Tdap vaccination during the perinatal period. However, larger studies including multiple racial and ethnic groups are needed to evaluate robustness of our findings.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01740310.

Parental experiences with vaccine information statements: Implications for timing, delivery, and parent-provider immunization communication

OBJECTIVE

We examined Vaccine Information Statements (VIS) dissemination practices and parental use and perceptions.

METHODS

We conducted a national online panel survey of 2603 US parents of children aged <7. Primary outcomes included reported VIS receipt, delivery timing, reading experiences, and perceived utility.

RESULTS

Most parents received a VIS (77.2%; [95% CI: 74.5-79.7%]), 59.7% [56.6-62.7%] before vaccination but 14.5% [12.5-16.8%] reported receiving it after their child's immunization; 15.1% [13.0-17.6%] were unsure of receipt status or timing; another 10.7% [9.0-12.6%] reported non-receipt of a VIS. Less than half who received a VIS before vaccination completed it before vaccination (46.2% [42.4, 50.0%]), but most who read at least some found the information useful (95.7% [93.8-97.0%]). Parents who delayed or refused at least one recommended non-influenza vaccine reported fewer opportunities to ask providers VIS questions.

CONCLUSIONS

Most parents report receiving VIS before vaccination as per federal guidelines. Continued effort is needed to enhance VIS distribution practice and parent-provider VIS content communication.

Influenza immunization during pregnancy: Benefits for mother and infant

The serious consequences of influenza infection during pregnancy have been recognized for almost a century. In this article, we reviewed the evidence on the immunogenicity, safety and impact of maternal influenza immunization for both mother and child. After vaccination, pregnant women have similar protective titers of anti-influenza antibodies as non-pregnant women, demonstrating that pregnancy does not alter the trivalent inactivated influenza vaccine immune response. Studies from the United States, Europe and resource-constrained regions demonstrate that maternal vaccination is associated with increased anti-influenza antibody concentrations and protection in the newborn child as well as the immunized mother. Given the acceptable safety profile of influenza vaccines and the World Health Organization's recommendation for its use in pregnant women, maternal vaccination with inactivated influenza vaccine is a cost-effective approach to decrease influenza disease in newborns. However, as seen for influenza immunization in the elderly, the protective efficacy of current inactivated vaccines in protection of newborns is 50% at best, indicating significant room for vaccine improvement, which could potentially be achieved by addition of a safe and effective adjuvant. Thus, global deployment of inactivated influenza immunization during pregnancy would have substantial and measurable health benefits for mothers and their newborns.