Vaccine communication training using the Brief Motivational Interviewing for Maternal Immunization intervention: A PRISM implementation evaluation

Improving clinician-patient communication can increase uptake of recommended vaccinations during pregnancy. To evaluate adaptations to and pragmatism of the brief Motivational Interviewing for Maternal Immunizations (MI4MI) intervention and to use the Practical Robust Implementation and Sustainability Model (PRISM) to describe context and implementation outcomes among clinician and staff participants. We incorporated data from study team members, clinicians and staff participants, pregnant patients at participating clinics, and patient medical records. Quantitative and qualitative data were collected using surveys, chart reviews, study team notes, interviews, and focus groups. Adaptations were evaluated using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) and pragmatism was measured with PRagmatic Explanatory Continuum Indicator Summary (PRECIS-2). MI4MI was effective at improving participants' vaccine communication experiences. Adoption was limited by our recruitment approach. MI4MI implementation was shaped by contextual factors and associated adaptations related to the COVID pandemic and clinic and participant characteristics. Virtual asynchronous intervention delivery had mixed effects on adoption and implementation that varied across clinics and participants. Participants expressed interest in maintaining the MI4MI intervention moving forward; however, identification of sustainability infrastructure was limited. MI4MI was evaluated to be relatively pragmatic. Contextual factors strongly shaped implementation of MI4MI. Future iterations of MI4MI should include training delivery modes and incentives that accommodate a range of participants across job roles and organizational settings. Future studies including control clinics are needed to measure effectiveness for increasing vaccination and comparing virtual versus hybrid implementation strategies.

Development of PIVOT with MI: A motivational Interviewing-Based vaccine communication training for pediatric clinicians

Delay or refusal of childhood vaccines is common and may be increasing. Pediatricians are parents' most trusted source for vaccine information, yet many struggle with how to communicate with parents who resist recommended vaccines. Evidence-based communication strategies for vaccine conversations are lacking. In this manuscript, we describe the development and perceived usefulness of a curriculum to train clinicians on a specific vaccine communication strategy as part of the PIVOT with MI study, a cluster randomized trial testing the effectiveness of this communication strategy on increasing childhood vaccination uptake among 24 pediatric practices in Colorado and Washington. The communication strategy is based on the existing evidence-based communication strategies of a presumptive format for initiating vaccine conversations and use of motivational interviewing if hesitancy persists. Focus groups and semi-structured interviews with pediatric clinicians helped inform the development of the training curriculum, which consisted of an introductory video module followed by 3 training sessions. Between September 2019 and January 2021, 134 pediatric clinicians (92 pediatricians, 42 advanced practice providers) participated in the training as part of the PIVOT with MI study. Of these, 92 % viewed an introductory video module, 93 % attended or viewed a baseline synchronous training, 82 % attended or viewed a 1st refresher training, and 77 % attended or viewed a 2nd refresher training. A follow-up survey was administered August 2020 through March 2021; among respondents (n = 100), >95 % of participants reported that each component of the training program was very or somewhat useful. These data suggest that the PIVOT with MI training intervention is a useful vaccine communication resource with the potential for high engagement among pediatric clinicians.

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.

MomsTalkShots, tailored educational app, improves vaccine attitudes: a randomized controlled trial

BACKGROUND

Many pregnant women and parents have concerns about vaccines. This analysis examined the impact of MomsTalkShots, an individually tailored educational application, on vaccine attitudes of pregnant women and mothers.

METHODS

MomsTalkShots was the patient-level component of a multi-level intervention to improve maternal and infant vaccine uptake that also included provider- and practice-level interventions. The impact of these interventions was studied using a two-by-two factorial design, randomizing at both the patient- and the practice-level. Study staff recruited pregnant women from a diverse set of prenatal care practices in Colorado and Georgia between June 2017 and July 2018. All participants (n = 2087) received a baseline survey of maternal and infant vaccine intentions and attitudes, and two follow-up surveys at least 1 month and 1 year after their infant's birth, respectively. Half of participants (n = 1041) were randomly assigned to receive educational videos through MomsTalkShots, algorithmically tailored to their vaccine intentions, attitudes, and demographics. Since the practice/provider intervention did not appear impactful, this analysis focused on MomsTalkShots regardless of the practice/provider intervention.

RESULTS

By 1 month post-birth, MomsTalkShots increased perceived risk of maternal influenza disease (61% among MomsTalkShots recipients vs 55% among controls; Odds Ratio: 1.61, 95% Confidence Interval: 1.23-2.09), confidence in influenza vaccine efficacy (73% vs 63%; OR: 1.97, 95%CI: 1.47-2.65), and perceived vaccine knowledge (55% vs 48%; OR: 1.39, 95%CI: 1.13-1.72). Among those intending not to vaccinate at baseline, MomsTalkShots increased perceived risk of maternal influenza disease (38% vs 32%; OR: 2.07, 95%CI: 1.15-3.71) and confidence in influenza vaccine efficacy (44% vs 28%; OR: 2.62, 95%CI: 1.46-4.69). By 1 year post-birth, MomsTalkShots increased perceived vaccine knowledge (62% vs 50%; OR: 1.74, 95%CI: 1.36-2.24) and trust in vaccine information from obstetricians and pediatricians (64% vs 55%; OR: 1.53, 95%CI: 1.17-2.00). Among those uncertain about vaccinating at baseline, MomsTalkShots increased perceived vaccine knowledge (47% vs 12%; OR: 6.89, 95%CI: 1.52-31.25) and reduced infant vaccine safety concerns (71% vs 91%; OR: 0.24, 95%CI: 0.06-0.98).

CONCLUSIONS

MomsTalkShots improved pregnant women's and mothers' knowledge and perceptions of maternal and infant vaccines and the diseases they prevent, and offers a scalable tool to address vaccine hesitancy.

TRIAL REGISTRATION

Registered at Clinicaltrials.gov on 13/09/2016 (registration number: NCT02898688).

Multi-tiered intervention to increase maternal immunization coverage: A randomized, controlled trial

OBJECTIVE

To evaluate the impact of a multi-component intervention package of maternal immunization uptake in obstetric care clinics.

METHODS

In a multi-level, cluster- and individually-randomized controlled trial we implemented an evidence-based intervention that targeted practice-, provider- and patient-level barriers to vaccine uptake. Obstetric practices were randomized to receive the practice and provider-level interventions or continue their normal standard of care. We enrolled pregnant women at practices in Georgia and Colorado and randomized women into patient-level intervention and control groups, resulting in four study arms. The primary outcomes were receipt of the influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccines during pregnancy. A sample size of 550 women per arm (2200 total) was planned and enrolled to compare the intervention between the four study arms.

RESULTS

Between June 2017 and July 2018, 4907 women were screened and 2200 women were randomized, 550 to each of the four study arms. We were unable to follow-up with 108 women, for a final sample size of 2092. Sample characteristics and sample size were similar among study arms. There was no significant increase in Tdap or influenza vaccine uptake overall. Among women who had no intention of or were unsure about receiving the influenza vaccine during pregnancy, those who received just the patient-level intervention were 61% more likely to receive the influenza vaccine than those in the control arm (Relative risk: 1.61; 95% Confidence Interval: 1.18-2.21). There was no significant difference in vaccine uptake for either influenza or tetanus, diphtheria and acellular pertussis between the four arms of the study.

CONCLUSIONS

This trial highlights the need for more targeted interventions to improve vaccine uptake. Future work should focus on clinics with low baseline vaccine uptake and the patient-level intervention should be expanded and targeted towards women with low vaccine confidence.

Ethical and policy implications of vaccinomics in the United States: community members' perspectives

Objectives: We aimed to elucidate public values regarding the use of genomics to improve vaccine development and use (vaccinomics).

Methods: Adults ≥18 years-old were recruited through social media and community organizations, and randomly assigned to one of four nested discussion groups in Boulder, CO and Baltimore, MD. Participants rated their confidence in vaccine safety and effectiveness prior to and after discussing vaccinomics. Before departing, they prioritized funding for vaccinomics versus federal priorities (vaccine safety and efficacy, new vaccines, and free vaccines) and chronic diseases (cancer, heart disease, and diabetes). Grounded Theory-influenced methods were used to identify themes.

Results: Participants broadly supported vaccinomics. Emergent themes: concerns about reduced privacy/confidentiality, increased genetically based stigma/discrimination, and reduced agency to make vaccine-related decisions through genetically based prioritization. Participants supported vaccinomics’ potential for increased personalization. Some participants favored prioritizing others over themselves during a vaccine shortage, while others did not. Some participants worried health insurance companies would discriminate against them based on information discovered through vaccinomics. Participants feared inequitable implementation of vaccinomics would contribute to discrimination and marginalization of vulnerable populations. Discussing vaccinomics did not impact perceptions of vaccine safety and effectiveness. Federal funding for vaccinomics was broadly supported.

Conclusion: Participants supported vaccinomics’ potential for increased personalization, noting policy safeguards to facilitate equitable implementation and protect privacy were needed. Despite some concerns, participants hoped vaccinomics would improve vaccine safety and effectiveness. Policies regarding vaccinomics’ implementation must address public concerns about the privacy and confidentiality of genetic information and potential inequities in access to vaccinomics’ benefits.

Racial/Ethnic Disparities in Maternal Vaccine Knowledge, Attitudes, and Intentions

OBJECTIVES

Although disparities in maternal vaccine acceptance among racial/ethnic groups are well documented, the reasons for these disparities are unclear. The objective of this study was to describe differences in pregnant women's knowledge, attitudes, beliefs, intentions, and trust regarding maternal and infant vaccines by race/ethnicity.

METHODS

We collected survey data from 1862 pregnant women from diverse prenatal care practices in Georgia and Colorado from June 2017 through July 2018. We performed multiple logistic regressions to determine differences in intentions, knowledge, attitudes, beliefs, and trust by race/ethnicity and calculated odds ratios (ORs) and 95% CIs.

RESULTS

Compared with White women, Black and Hispanic women were less confident in vaccine safety and efficacy and less likely to perceive risk of acquiring vaccine-preventable diseases, report provaccine social norms, indicate having enough vaccine knowledge, and trust vaccine information from health care providers and public health authorities. Black women were the least confident in the safety of the maternal influenza vaccine (OR = 0.37; 95% CI, 0.27-0.49); maternal tetanus, diphtheria, and acellular pertussis vaccine (OR = 0.37; 95% CI, 0.27-0.52); and infant vaccines overall (OR = 0.40; 95% CI, 0.28-0.58), and were least likely to intend to receive both maternal vaccines (OR = 0.35; 95% CI, 0.27-0.47) or all infant vaccines on time (OR = 0.45; 95% CI, 0.34-0.61) as compared with White women.

CONCLUSIONS

Understanding differences in behavioral constructs integral to vaccine decision making among women of different races/ethnicities can lead to tailored interventions to improve vaccine acceptance.

Adapting Center for Disease Control and Prevention's immunization quality improvement program to improve maternal vaccination uptake in obstetrics

INTRODUCTION

Maternal vaccination is critical for improving maternal and child health. Quality Improvement (QI) models¹, such as the Centers for Disease Control and Prevention's (CDC) Assessment, Feedback, Incentives, eXchange (AFIX)² model, have not yet been adapted to maternal vaccinations. This study assesses the impact of AFIX-OB, an adapted version of AFIX for obstetric settings, on maternal vaccination rates.

METHODS

Between December 2016 and May 2018, state health departments and obstetric practices in Colorado and Georgia implemented the adapted AFIX-OB model. The model addressed unique patterns in patient encounters, practice flow, health records systems and competing clinical priorities in the obstetric setting through a menu of clearly-defined QI strategies, bi-weekly technical assistance meetings with designated immunization champions, incentives for champions/staff, and adapted tools to aid each practice during implementation. Vaccination rates were assessed by random chart reviews pre- and post-intervention.

RESULTS

The AFIX-OB model was evaluated in eleven obstetric practices in two states as part of a multi-level intervention to increase maternal vaccination. Post AFIX-OB implementation, documented influenza vaccination rates increased from 56% at baseline to 65% (p < 0.01); and tetanus, diphtheria, and acellular pertussis (Tdap) vaccination rates increased from 77% at baseline to 84% (p < 0.02) across all practices.

CONCLUSIONS

The AFIX-OB model showed improvement in maternal vaccination rates for both influenza and Tdap vaccines. AFIX-OB may provide a useful framework for obstetric practices, as well as for other health care specialties. The focused goal should be on broader dissemination among those interested in adopting an evidence-based model for increasing vaccine uptake.

Latent Class Analysis of Maternal Vaccine Attitudes and Beliefs

Background. Maternal vaccine coverage is suboptimal, and a substantial proportion of parents have concerns about vaccines. Most parents seek out vaccine information during and immediately after their first pregnancy. No study to our knowledge has analyzed survey data to identify homogeneous groups of pregnant women based on their vaccine attitudes and beliefs. Aims. To identify homogeneity among groups of pregnant women based on their vaccine attitudes and beliefs to facilitate audience segmentation and targeting of tailored educational interventions. Method. Between June 2017 and July 2018, we surveyed 2,196 pregnant women recruited from geographically and sociodemographically diverse prenatal care practices in Georgia and Colorado. We then performed a latent class analysis to identify homogeneity among groups of pregnant women. Results. Our latent class analysis produced three groups of pregnant women: vaccine supporters (36% of women), vaccine acceptors (41%), and vaccine skeptics (23%). Discussion. The major difference between the supporters and the acceptors were whether they mostly “strongly agreed” or just “agreed” to Likert-type scale survey items assessing their vaccine attitudes and beliefs. The skeptics most frequently chose “disagree” or “don’t know” for items assessing attitudinal constructs such as confidence in vaccine safety and efficacy and disease susceptibility. However, even skeptics often chose “agree” for items assessing constructs such as disease severity and self-efficacy. Conclusions. This article provides useful insight into the homogeneity among groups of pregnant women based on their vaccine attitudes and beliefs. This knowledge should help facilitate audience segmentation and targeting of tailored educational interventions among this population.

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].

Characterizing the vaccine knowledge, attitudes, beliefs, and intentions of pregnant women in Georgia and Colorado

Vaccine coverage for maternal vaccines is suboptimal; only about half of pregnant women received influenza and Tdap vaccines in 2018. We explored knowledge, attitudes, beliefs, intentions, and trust regarding maternal and infant vaccines among pregnant women. Between June 2017 and July 2018, we surveyed 2196 pregnant women recruited from geographically and socio-demographically diverse prenatal care practices in Georgia and Colorado (56% response rate). Fifty-six percent of pregnant women intended to receive both influenza and Tdap vaccines during pregnancy and 68% intended to vaccinate their baby with all recommended vaccines on time. Attitudinal constructs associated with intention to vaccinate include confidence in vaccine safety (ORs: 16–38) and efficacy (ORs: 4–19), perceived risk of vaccine-preventable diseases (ORs: 2–6), social norms (ORs: 4–10), and trust in sources of vaccine information. Women pregnant with their first child were less likely than women who had prior children to intend to vaccinate themselves and their children, more likely to be unsure about their intentions to receive both maternal and infant vaccines, and less likely to report feeling they had enough knowledge or information about vaccines and vaccine safety (p < .01). This demonstrates an opportunity for vaccine education to increase vaccine confidence and informed decision-making, especially among first-time pregnant women.

MomsTalkShots: An individually tailored educational application for maternal and infant vaccines

INTRODUCTION

The development and initial assessment in a clinical setting of a theory-driven, individually tailored educational application (app), MomsTalkShots, focused on increasing uptake of maternal and infant vaccines is described.

METHODS

MomsTalkShots algorithmically tailored videos based on parent needs to deliver an intervention that was specifically responsive to individual vaccine attitudes, beliefs and intentions, demographics, and source credibility. MomsTalkShots was evaluated among 1103 pregnant women recruited from 23 geographically and socio-demographically diverse obstetrician-gynecologist offices in Georgia and Colorado in 2017. Self-reported information needs were assessed pre-and post-videos and participants self-reported factors related to usability and analyzed in 2018.

RESULTS

The vast majority of women reported MomsTalkShots was helpful (95%), trustworthy (94%), interesting (97%) and clear to understand (99%), none of which varied by demographics or parity. Reported usability was slightly lower among vaccine hesitant women, yet the majority reported MomsTalkShots was helpful (91%), trustworthy (85%), interesting (97%) and clear (99%). The majority of women (72%) who did not have enough vaccine information pre-videos reported enough information post-videos.

CONCLUSIONS

MomsTalkShots was designed to provide individually tailored vaccine information to pregnant women from a population with varied vaccine intentions, confidence and vaccine concerns. MomsTalkShots was extremely well-received among pregnant women, even among women who were initially vaccine hesitant and did not intend to vaccinate themselves and their infants according to the recommended immunization schedule. Next steps include evaluation to assess impact on vaccine uptake and expansion to adolescent and adult vaccines.

Development and acceptability of a video-based vaccine promotion tutorial for obstetric care providers

A prenatal care provider's recommendation for maternal vaccines is one of the strongest predictors of vaccine acceptance during pregnancy. Aside from basic talking points, few resources exist to help obstetric care providers effectively navigate conversations with vaccine hesitant patients. This paper describes the development and acceptability of "VaxChat," an hour-long, evidence-based video tutorial aimed at improving obstetric care providers' ability to promote maternal vaccines. Between June and November 2017, 62 obstetric care providers registered to receive continuing medical education credit for viewing VaxChat. Of the post-tutorial responses received, over 90% said VaxChat increased their knowledge of what to say to vaccine hesitant patients, increased their confidence in addressing vaccinations with their pregnant patients, and will help them improve their practice culture regarding maternal vaccine promotion. Eighty percent intend to change how they approach vaccine conversations. These data suggest VaxChat may be a welcome complement to existing provider-to-patient talking points.