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Objective: Due to lack of
information regarding attitudes and behaviors of pregnant women towards
vaccines, we sought to study the acceptability of influenza, pertussis and a
hypothetical Group B Streptococcus (GBS) vaccine during pregnancy from a global
perspective.
Method: Data were
abstracted from responses of 782 pregnant women from North America, Europe and
Brazil to an industry sponsored online survey in 2014. Participants were
provided brief disease and vaccine synopses prior to completing the survey.
Results: Significant
differences in vaccine acceptance were observed across regions and vaccine
types. Women from Brazil had the highest rate while those from Europe had the
lowest rate of acceptance for all vaccines. For all regions and all vaccine
types, physician recommendation positively influenced patient acceptance of
vaccines (p<0.05). The GBS vaccine was the highest rated for vaccine
acceptance globally. Neonatal protection was a significantly stronger motivator
compared to self-protection for each region and vaccine type. Working status,
income, parity and compliance with medical care were significantly associated
with vaccine acceptance but in an inconsistent manner for region and vaccine
type. Health care providers were considered as the most credible source and
medical and pregnancy specific websites were considered the most credible
online source of pregnancy related information across all regions.
Conclusion: Understanding
regional differences in the acceptability of vaccines among pregnant women,
effective use of the internet and most importantly involvement of the physician
in disseminating vaccine related information to the public is key to increasing
the uptake of vaccines during pregnancy.
Keywords: Group B
Streptococcus, Pregnancy, Global diversity, Vaccine
Abbreviations: GBS: Group B Streptococcus
INTRODUCTION
We had the unique opportunity to examine globally acquired data extracted
from an industry sponsored patient survey to address some of the above issues.
We opted to examine three vaccines, two of which are already commercially
available and one is a hypothetical vaccine in development. The influenza
vaccine was selected because of the anticipated well-recognized disease burden
and long established recommendation for use in pregnancy. This vaccine has been
supported primarily for its benefit to maternal health, although benefits to
the neonate have also been reported [8-12]. The second vaccine, the pertussis
vaccine, is less recognized for its disease burden in adults and to the
newborn, and has only recently been advocated for use in pregnancy. Although
benefits to the mother from pertussis vaccination are identifiable, the main
scope of the current recommendations focuses on protection of the newborn child
[14,15]. The last (hypothetical) vaccine is directed against Group B
Streptococcus (GBS) and is currently being investigated for use in pregnancy
with an exclusive focus on neonatal benefit [22]. We sought to better
understand the perspectives of pregnant patients for each of these vaccines and
their willingness to receive them during pregnancy.
MATERIALS AND METHODS
A total of 782 women between 12 and 40 weeks of pregnancy from USA,
Canada, Brazil, France, Germany, Ireland and the Netherlands participated in a
twenty minute online survey in 2014. Written informed consent for participation
in the study was obtained from participants. This industry sponsored survey was
primarily focused on attitudes and behaviors of pregnant women regarding
influenza, pertussis and GBS vaccination during pregnancy. It consisted of five
sections with total 54 questions related to general prenatal health behavior,
demographic data of participants, acceptability of the three vaccines,
motivation for receiving these vaccines and sources of pregnancy related
information. Being up-to-date with other vaccines and laboratory testing was
considered as being compliant with healthcare. Participants were supplied
disease profiles and vaccine synopses prior to completing the survey (available
upon request). Questions related to the acceptability of the three vaccines
were answered using a scale of 1 to 10, with 1 being “Not at all
likely/strongly disagree” and 10 being “Extremely likely/strongly agree”. No
exclusion criteria were applied. Willingness to undertake the online survey was
the only requirement.
Hierarchical cluster analyses demonstrated that data from countries
within each region e.g. countries within Europe as well as countries within
North America exhibited similar patterns. Hence, further analysis was performed
by grouping data into 3 regions– North America (USA and Canada - 400 women),
Europe (France, Germany, Ireland and the Netherlands - 282 women) and Brazil
(100 women). Acceptability of vaccines scored on a scale of 1 to 10, was
divided into dichotomous variables: A score of 8-10 was considered as an
affirmatory response and 1-3 was considered as declinatory response. Mean
scores were also calculated for a comparison of acceptability of vaccines.
Descriptive statistical analysis was performed by utilizing a z test
for dichotomous variables and a t test for continuous variables. Factors
associated with acceptability of vaccines were analyzed using univariate linear
and logistic regression analysis. Linear regression models were based on
acceptability of vaccines as dependent variable (ranging from 1 to 10) with
factors controlled for collinearity. A sample size calculation was not performed
in this cross sectional survey study.
RESULTS
The results of this survey demonstrate a relatively strong, positive
attitude towards acceptability of the influenza, pertussis and the hypothetical
GBS vaccines in North America and Brazil, with more of a restrained response
from women in Europe. However, no region in our study achieved a level of
acceptability comparable to that anticipated if pediatric vaccination was being
discussed [23]. These numbers also fall short of Healthy People 2020 and WHO
goals related to adult vaccination [24,25]. Physician recommendation appears to
be an important factor in acceptability of vaccines in all regions evaluated.
This is consistent with previous studies that have reported increased
acceptability to vaccination during pregnancy when a health care provider was
involved in the process [19,26,27].
This study has demonstrated that there are striking regional variations
in acceptability of vaccines during pregnancy despite the fact that the same
information regarding these diseases and vaccines was provided to all the study
participants. Generally, women in North America accepted all vaccines at
similar rates and did not discriminate between the types of vaccines. This
likely reflects a general positive attitude toward vaccination in this region.
Furthermore, women in North America, who were compliant with their health, were
more receptive toward vaccination.
Similarly, there was a strong positive response in favor of all three
vaccines among women in Brazil. Along with protection of baby, there was an
increase in vaccine acceptability in these women due to concerns of risk to
self-health. Thus the very high rate of vaccine acceptance in this region could
be a reflection of dual motivation for protecting baby as well as self.
Women vaccine acceptance during pregnancy was the lowest in Europe.
Although they followed similar trends toward the desire to protect their
neonates via maternal vaccination, their negativity towards vaccine uptake may
be reflected in overall attitudes toward health care, in that, these same
individuals reported reduced compliance with health related concerns.
Although there were no regional differences in demographic factors like
age and parity, women in the study differed with respect to their education,
working status, household income and area of residence. These demographic
differences were associated with and may have contributed to the regional
variations in vaccine acceptance.
Several studies have looked at potential barriers for vaccination. It
seems clear that physician knowledge and positive attitude towards vaccination
is an important contributor for increasing vaccine uptake among women
[19,20,27-33]. Fear of vaccines and lack of disease-related knowledge in the
pregnant population have been shown as hindrances to vaccine uptake [34,35]. It
is not only the provision of information but also its content that is crucial.
For example, women were more willing to accept the influenza vaccine when they
were informed about a “two for one” benefit of the vaccine [36]. There is a
need for health messages like these to be efficiently conveyed to women.
Communication strategies to improve vaccination rates among pregnant
women are being evaluated with randomized controlled trials [37-39]. Patient
targeted educational interventions through verbal discussion, information
pamphlets, and text messaging [35,37,40-42] have made moderate improvements in
vaccination uptake rates in regional studies, yet there is a need for continued
efforts to achieve additional advancements on a more global level. Our study
demonstrated that the internet was the second most common resource that many
women relied upon for pregnancy related information. Updating medical websites
with maternal immunization topics and using the internet as a means of
propagation of relevant vaccine information, their availability and cost should
be a focused initiative. Although these resources were viewed by many
participants in our study as credible to obtain health related information,
health professionals were still prioritized as the most reliable resource.
Thus, dissemination of relevant risk vs. benefit information of maternal
immunization towards fetal and neonatal disease prevention by health care providers
remains key to increasing vaccine uptake among pregnant women globally. Most
importantly, understanding regional variations during such efforts may yield
better results than the adoption of universal policies and campaigns to promote
the use of vaccines during pregnancy.
ACKNOWLEDGEMENT
We acknowledge Borislav Domuschiev (Managing Partner, cQuest Ltd.) and
Martin Dimov (Director, Data Science, cQuest Ltd.) for their assistance with
statistical analysis of the data. cQuest is a market research and consulting
service located in Amsterdam, Netherland). Dr. Bernard Gonik and Dr. Manasi
Patwardhan have no financial disclosures pertaining to this study or manuscript
development.
We also acknowledge Elvira Ponce, MD and Catalina Rios Driscoll, MBA
from GlaxoSmithKline LLC, Cambridge, MA 02139 for their contribution with
providing the questionnaire and editing the manuscript.
DISCLOSURE
Novartis Vaccines and Diagnostics, Inc. provided unrestricted access to
the global survey database referred to in this paper and also provided
financial support for the independent statistical analysis of data cited on
this manuscript. On March 2, 2015, GlaxoSmithkline completed acquisition of
Novartis Vaccines Non-flu vaccines business and now owns the data cited.
CONSENT TO PARTICIPATE
Written informed consent for participation in the study was obtained
from participants.
ETHICS APPROVAL
We have used already existing data that has no identifiers attached.
This falls under the Exemption categories according to Wayne State
University IRB.
CONSENT TO PUBLISH
Not applicable
COMPETING INTERESTS
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