Commentary on “Moniz and Beigi's maternal immunization clinical experiences, challenges, and opportunities in vaccine acceptance”

Abstract

Maternal immunization faces an array of structural, sociocultural, and individual challenges that must be effectively addressed to realize widespread improvements in vaccination uptake. As Moniz and Beigi correctly detail in their review, immunization during this period offers unique opportunity to make substantial improvements in maternal and neonatal health. Moving beyond the existing Health Belief Model, we learn that immunization uptake can be significantly improved by shaping messages, addressing logistical challenges such as out-of-pocket (i.e., “copay”) barriers, and delivering provider education on maternal immunization to encourage future provider recommendations and facilitate the patient convenience of in-office vaccine administration. The resulting approach of “Educate, Recommend, Normalize, Maximize Convenience” is consistent with the evidence on maternal immunization. In its systematic application, such a model may usher in unprecedented opportunity to improve immunization uptake in decades ahead.

Keywords:

• Health belief model
• immunization coverage
• immunization uptake
• maternal immunization
• pregnant women
• vaccine acceptance

The sweeping analyses given to the subject of maternal immunization by Moniz and Beigi provide insight on the unique challenges associated with improving vaccine uptake during pregnancy. As the authors correctly describe, immunization during this period offers unique opportunity to make substantial improvements in maternal and neonatal health. Despite recommendations from a number of entities including The Advisory Committee on Immunization Practices (ACIP) and The American College of Obstetricians and Gynecologists (ACOG), the authors highlight key coverage concerns in this field.^1-5 Notably, immunization uptake among pregnant women lacking contraindication remains suboptimal (at rates estimated to be ≤50%) for inactivated seasonal influenza, and tetanus and diphtheria toxoid and acellular pertussis (Tdap) vaccination.^6-8 As the influenza vaccination rate has stabilized over the past four years following the introduction of the H1N1 vaccine (over the previous 15% influenza vaccine coverage rate), they call attention to the fact that it is unlikely that the Healthy People 2020 goal of 80% coverage among this population will be attained.⁹ The situation is even more concerning for Tdap with an estimated baseline uptake in 2011 of 3% among pregnant women and a broader need to promote Tdap “cocooning” immunization strategies among close contacts of infants.^10,11 Moreover, there is a possibility that candidate vaccines in the development pipeline (e.g., group B streptococcus and respiratory syncytial virus) will yield even more use recommendations for pregnant women thus intensifying pressure to find effective immunization promotion approaches.^12,13

Improving maternal immunization begins with understanding why people do or do not choose to immunize.¹⁴ Moniz and Beigi provide an excellent overview of the results from maternal immunization studies of which they detail an array of socioecological influences ranging from ability to pay (i.e., a healthcare “structural” determinant) to social norms and personal perceived illness vulnerability (i.e.,”individual” factors). They situate several of these factors within the Health Belief Model (HBM), a conceptual framework that has been used for understanding immunization compliance.¹⁵

Moniz and Beigi offer advancement over the existing HBM model that is limited in its guidance on directionality or effect magnitude of its component influences.¹⁶ In their adapted maternal immunization version, Moniz and Beigi incorporate the HBM components of perceived disease vulnerability (susceptibility and severity), perceived immunization benefits and costs, cues to action and self-efficacy yet they provide more explanatory power of the model. In this current version, the authors conceptualize maternal immunization pathway influences by placing message framing effects and social norm influences (“cues to action”) and perceived regret associated with immunization decision-making (“to vaccinate or not”) as mediating factors on pregnant women's vaccination acceptance. Thus, Figure 1 provides visual insight on how to trigger a positive “chain reaction” associated with favorable immunization decision-making. The related narrative on this figure describes the manner in which immunization uptake can be significantly improved by shaping messages, addressing logistical challenges such as out-of-pocket (i.e., “copay”) barriers, and delivering provider education on maternal immunization to encourage future provider recommendations and facilitate the patient convenience of in-office vaccine administration.

Figure 1. Modified health belief model as a theoretical framework for maternal acceptance of vaccination.³²

The resulting approach of “Educate, Recommend, Normalize, Maximize Convenience” proposed by the authors is consistent with the evidence on maternal immunization. In its systematic application, the authors correctly assert that it brings forth unprecedented opportunity to improve immunization uptake in decades ahead. It is important to recognize that education is viewed as a two-pronged endeavor. In this model, education starts with the provider who is a key influencer and facilitator of vaccine outcomes. The authors envision the provider as benefitting from education on vaccine messaging, counseling, and mediation. Inasmuch, the provider is much better equipped to manage multiple and often conflicting personal viewpoints women present, but also those of spouses, partners, family members, and larger social influences including those presented by media when women come into their offices.

Provider-delivered recommendations and office-based immunization administration are also key factors highlighted in the strategy to improve maternal immunization acceptance. The authors found overwhelming evidence on the need for provider recommendation to facilitate pregnant women's immunization decision-making.^14,17-20 Yet, provider recommendation results from effective continuing medical education provided by ACOG and others on the need for immunization during pregnancy. This model suggests a need for more evidence-based information about vaccine safety and immunogenicity profiles as well as neonatal protection directed to providers who, in turn, will be able to recommend immunization to women for whom contraindication does not exist.

By adding immunization reminders to electronic medical records and offering the “in-house” convenience of vaccine administration in the course of a clinical encounter, the authors also bring forth the important issue of convenience that leads to immunization normalization in health care delivery. For many pregnant women who may hear what their provider says, but lack the ability (or “self-efficacy”) to act on the immunization recommendation due to cost constraints or lack of transportation to get the vaccine, the convenience of getting immunized in the doctor's office offers enormous advantage to achieve greater population uptake. This model offers compelling reasons to therefore introduce immunization into standard obstetrical care delivery.

Moniz and Beigi offer provocative findings on the relationship of several structurally- and socially-driven clinical and health delivery realities. By combining the results from several studies, they have introduced an excellent opportunity to implement a new evidence-based, integrative model that combines education, provider persuasion, shifts in social norms, and convenience to patients in order to facilitate greater maternal immunization well into the future.

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.