Exploring pregnant women's views on influenza vaccination and educational text messages

Narrative versus statistical messages: The interplay of perceived susceptibility and misperceptions on vaccine intention

Although there is enough scientific evidence to show the benefits and safety of vaccines, vaccine rates are low, while misperceptions about vaccines are on the rise. The main purposes of the current study are to 1) examine the effects of narrative vs. statistical messages on vaccine intention, 2) test the mediating role of perceived expectancies, and 3) examine the moderating roles of perceived susceptibility and misperceptions on vaccine intention. Data were collected with an online experiment through Amazon Mturk. The online experiment was conducted via Qualtrics once the study was considered exempt by the Institutional Research Board of a large University in the U.S. A total of 300 participants aged 18 and above completed the survey. Findings show that perceived expectancies mediate the relationship between message manipulation and vaccine intention. Our findings also show a three-way interaction which indicates that among individuals with high misperceptions, statistical messages are more persuasive for individuals with high perceived susceptibility, while narrative messages are more influential for individuals with low perceived susceptibility.

Flu and pertussis vaccination during pregnancy in Geneva during the COVID-19 pandemic: A multicentric, prospective, survey-based study

Objective

Methods

Results

Conclusions

Assessing Influenza Vaccination Behaviors Among Medically Underserved Obstetric Patients

Background: Despite recommendations, maternal influenza vaccine acceptance has stagnated around 50%. Materials and Methods: A prospective cohort study was conducted of pregnant women seen in the clinic from September 2018 to April 2019. Primary outcomes included influenza vaccine uptake and reasons for vaccine refusal, categorized based on the Health Belief Model. We compared characteristics between three vaccination groups (never refused, refused and vaccinated, and refused and not vaccinated) by using chi-square and one-way analysis of variance. We used multivariate logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between patient characteristics and vaccine acceptance. Mixed-effects logistic regression models were used to explore the impact of provider-patient race concordance on influenza vaccine uptake. Results: Among 1666 women, 902 (54.1%) were vaccinated. Of these, 183 (20.3%) initially refused. Those who refused and were never vaccinated were more likely to be non-Hispanic black (aOR: 1.64, 95% CI: 1.05-2.56) and less likely to be Hispanic (aOR: 0.44, 95% CI: 0.24-0.81). Overall, perceived barriers were the most common reason for refusal (52.4%). Women who refused consistently were more likely to cite reasons related to perceived benefits (38.5% vs. 7.6%). Those who eventually accepted were more likely to cite cue to action (22.4% vs. 12.6%). Women who were race discordant with their provider were more likely to be vaccinated compared with those who were race concordant (57.9% vs. 52.9%, aOR: 1.16, 95% CI: 1.07-1.27). Conclusions: Women who refuse influenza vaccination in pregnancy may later choose to be vaccinated. Continued promotion of vaccination throughout pregnancy is crucial for vaccine uptake.

The Role of Text Messaging and Telehealth Messaging Apps

This article focuses on the role of text messaging and messaging applications, discusses technical and legal issues, and reviews current examples of the application of text messaging in the clinical adult and pediatric practice. Reviews of current examples of text messaging in adult and pediatric practice show uptake has been increasing substantially in recent years. In pediatric care text messaging has been used for behavior intervention and outcomes tracking. Although applications are promising, the potential of nonsynchronic messaging in the formal delivery of care is still in the neonatal phase compared with its grown-up existence in day-to-day modern life.

Designing a multi-component intervention (P3-MumBubVax) to promote vaccination in antenatal care in Australia

ISSUE ADDRESSED

Coverage of maternal influenza and pertussis vaccines remains suboptimal in Australia, and pockets of low childhood vaccine coverage persist nationwide. Maternal vaccine uptake is estimated to be between 35% and 60% for influenza vaccination and between 65% and 80% for pertussis vaccination. Australian midwives are highly trusted and ideally placed to discuss vaccines with expectant parents, but there are no evidence-based interventions to optimise these discussions and promote maternal and childhood vaccine acceptance in the Australian public antenatal setting.

METHODS

We gathered qualitative data from Australian midwives, reviewed theoretical models, and adapted existing vaccine communication tools to develop the multi-component P3-MumBubVax intervention. Through 12 interviews at two Australian hospitals, we explored midwives' vaccination attitudes and values, perceived role in vaccine advocacy and delivery, and barriers and enablers to intervention implementation. Applying the theory-based P3 intervention model, we designed intervention components targeting the Practice, Provider and Parent levels. Midwives provided feedback on prototype intervention features through two focus groups.

RESULTS

The P3-MumBubVax intervention includes practice-level prompts and identification of a vaccine champion. Provider-level components are a vaccine communication training module, learning exercise, and website with printable fact sheets. Parent-level intervention components include text message reminders to receive influenza and pertussis vaccines in pregnancy, as well as online information on vaccine safety, effectiveness and disease severity.

CONCLUSIONS

The P3-MumBubVax intervention is the first Australian antenatal intervention designed to support both maternal and childhood vaccine uptake. A pilot study is underway to inform a planned cluster randomised controlled trial. SO WHAT?: Barriers to vaccine acceptance and uptake are complex. The P3 model is a promising evidence-informed multi-component intervention strategy targeting all three levels influencing health care decision-making.

Factors that influence vaccination decision-making among pregnant women: A systematic review and meta-analysis

BACKGROUND

The most important factor influencing maternal vaccination uptake is healthcare professional (HCP) recommendation. However, where data are available, one-third of pregnant women remain unvaccinated despite receiving a recommendation. Therefore, it is essential to understand the significance of other factors and distinguish between vaccines administered routinely and during outbreaks. This is the first systematic review and meta-analysis (PROSPERO: CRD 42019118299) to examine the strength of the relationships between identified factors and maternal vaccination uptake.

METHODS

We searched MEDLINE, Embase Classic & Embase, PsycINFO, CINAHL Plus, Web of Science, IBSS, LILACS, AfricaWideInfo, IMEMR, and Global Health databases for studies reporting factors that influence maternal vaccination. We used random-effects models to calculate pooled odds ratios (OR) of being vaccinated by vaccine type.

FINDINGS

We screened 17,236 articles and identified 120 studies from 30 countries for inclusion. Of these, 49 studies were eligible for meta-analysis. The odds of receiving a pertussis or influenza vaccination were ten to twelve-times higher among pregnant women who received a recommendation from HCPs. During the 2009 influenza pandemic an HCP recommendation increased the odds of antenatal H1N1 vaccine uptake six times (OR 6.76, 95% CI 3.12-14.64, I2 = 92.00%). Believing there was potential for vaccine-induced harm had a negative influence on seasonal (OR 0.22, 95% CI 0.11-0.44 I2 = 84.00%) and pandemic influenza vaccine uptake (OR 0.16, 95% CI 0.09-0.29, I2 = 89.48%), reducing the odds of being vaccinated five-fold. Combined with our qualitative analysis the relationship between the belief in substantial disease risk and maternal seasonal and pandemic influenza vaccination uptake was limited.

CONCLUSIONS

The effect of an HCP recommendation during an outbreak, whilst still powerful, may be muted by other factors. This requires further research, particularly when vaccines are novel. Public health campaigns which centre on the protectiveness and safety of a maternal vaccine rather than disease threat alone may prove beneficial.

Feasibility and acceptability of the multi-component P3-MumBubVax antenatal intervention to promote maternal and childhood vaccination: A pilot study

BACKGROUND

Pregnancy is a critical time for vaccine decision-making, but coverage remains suboptimal for maternal influenza (45-60%) and pertussis vaccination (65-80%) in Australia. The multi-component P3-MumBubVax intervention has been designed for Australian midwives to optimise antenatal vaccine discussions and improve maternal and childhood vaccine uptake. A pilot study was conducted to assess intervention feasibility and acceptability.

METHODS

P3-MumBubVax includes components at three levels: 1. Practice ('vaccine champions'; stickers to prompt and record vaccine discussions/delivery); 2. Provider (website with vaccine communication training; learning exercise; fact sheets; links to child vaccination resources); 3. Parent (SMS reminders; website; fact sheets). Midwives and pregnant women 18-22 weeks gestation were recruited at the Royal Women's Hospital, Melbourne. Post-intervention online surveys assessed intervention feasibility, implementation, acceptability and impact on vaccine uptake.

RESULTS

Twenty-five midwives and 62 pregnant women were recruited and 19/25 midwives completed training. Surveys were returned by 18/25 midwives and 56/62 women. 14/18 midwives reported using the sticker prompts, 10/18 reported using or referring to the website, and 11/18 reported using the fact sheets. 48/56 pregnant women (86%) reported discussing influenza and 46/56 (82%) discussed pertussis vaccines with their midwives. These conversations were reported to be short (1-3 min) for 48/56 women (87%). All midwives were satisfied with the intervention and 17/18 reported feeling more confident discussing vaccines following the intervention. Women were very satisfied with SMS content (50/56; 94%) and timing (49/55; 89%), and with their vaccine discussions in general (34/56; 63%). However, 16/54 (30%) wanted more discussion about childhood vaccines. Self-reported maternal vaccine uptake was 82% (45/55) and 93% (51/55) for influenza and pertussis (baseline 2017-2018: 43% influenza, 60% pertussis) and 96% (50/52) of infants were fully vaccinated at 12 weeks.

DISCUSSION

The P3-MumBubVax intervention is feasible and acceptable in the Australian public antenatal setting. Further evaluation is required to determine effectiveness.

Addressing common barriers in adult immunizations: a review of interventions

Introduction: Low levels of adult vaccination have been documented in the United States and globally. Research has been conducted to identify reasons for low immunization rates; however, the most useful studies are those that implemented interventions for identified barriers to evaluate their impact on rates of immunization. Identifying successful interventions provides immunization providers with evidence-based methods that can be utilized to increase the uptake of recommended vaccines.Areas covered: This review focuses on known barriers to adult immunizations and the interventions available in the literature to overcome these barriers. It outlines interventions that may increase vaccine uptake in the adult population through addressing barriers related to lack of vaccine knowledge, cost, access, provider and practice-based challenges, and racial and ethnic disparities.Expert opinion: Improving adult immunization rates is critical to protecting a population against vaccine-preventable diseases. Those interventions that appeared to increase immunization rates in the adult population included education and reminders about vaccination using text and telephone calls, low-cost or subsidized vaccines, easy access to immunization services, and understanding the cultural and social needs of different racial and ethnic populations. It is likely that an evidence-based multimodal approach using different categories of interventions is necessary to significantly improve adult immunization rates.

Clients' perceptions and experiences of targeted digital communication accessible via mobile devices for reproductive, maternal, newborn, child, and adolescent health: a qualitative evidence synthesis

BACKGROUND

Governments and health systems are increasingly using mobile devices to communicate with patients and the public. Targeted digital client communication is when the health system transmits information to particular individuals or groups of people, based on their health or demographic status. Common types of targeted client communication are text messages that remind people to go to appointments or take their medicines. Other types include phone calls, interactive voice response, or multimedia messages that offer healthcare information, advice, monitoring, and support.

OBJECTIVES

To explore clients' perceptions and experiences of targeted digital communication via mobile devices on topics related to reproductive, maternal, newborn, child, or adolescent health (RMNCAH).

SEARCH METHODS

We searched MEDLINE (OvidSP), MEDLINE In-Process & Other Non-Indexed Citations (OvidSP), Embase (Ovid), World Health Organization Global Health Library, and POPLINE databases for eligible studies from inception to 3-6 July 2017 dependant on the database (See appendix 2).

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis; that explored clinets' perceptions and experiences of targeted digital communication via mobile device in the areas of RMNCAH; and were from any setting globally.

DATA COLLECTION AND ANALYSIS

We used maximum variation purposive sampling for data synthesis, employing a three-step sampling frame. We conducted a framework thematic analysis using the Supporting the Use of Research Evidence (SURE) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether potential implementation barriers identified in our synthesis had been addressed in the trials included in the related Cochrane Reviews of effectiveness.

MAIN RESULTS

We included 35 studies, from a wide range of countries on six continents. Nineteen studies were conducted in low- and middle-income settings and sixteen in high-income settings. Some of the studies explored the views of people who had experienced the interventions, whereas others were hypothetical in nature, asking what people felt they would like from a digital health intervention. The studies covered a range of digital targeted client communication, for example medication or appointment reminders, prenatal health information, support for smoking cessation while pregnant, or general sexual health information.Our synthesis showed that clients' experiences of these types of programmes were mixed. Some felt that these programmes provided them with feelings of support and connectedness, as they felt that someone was taking the time to send them messages (moderate confidence in the evidence). They also described sharing the messages with their friends and family (moderate confidence).However, clients also pointed to problems when using these programmes. Some clients had poor access to cell networks and to the internet (high confidence). Others had no phone, had lost or broken their phone, could not afford airtime, or had changed their phone number (moderate confidence). Some clients, particularly women and teenagers, had their access to phones controlled by others (moderate confidence). The cost of messages could also be a problem, and many thought that messages should be free of charge (high confidence). Language issues as well as skills in reading, writing, and using mobile phones could also be a problem (moderate confidence).Clients dealing with stigmatised or personal health conditions such as HIV, family planning, or abortion care were also concerned about privacy and confidentiality (high confidence). Some clients suggested strategies to deal with these issues, such as using neutral language and tailoring the content, timing, and frequency of messages (high confidence).Clients wanted messages at a time and frequency that was convenient for them (moderate confidence). They had preferences for different delivery channels (e.g. short message service (SMS) or interactive voice response) (moderate confidence). They also had preferences about message content, including new knowledge, reminders, solutions, and suggestions about health issues (moderate confidence). Clients' views about who sent the digital health communication could influence their views of the programme (moderate confidence).For an overview of the findings and our confidence in the evidence, please see the 'Summary of qualitative findings' tables.Our matrix shows that many of the trials assessing these types of programmes did not try to address the problems we identified, although this may have been a reporting issue.

AUTHORS' CONCLUSIONS

Our synthesis identified several factors that can influence the successful implementation of targeted client communication programmes using mobile devices. These include barriers to use that have equity implications. Programme planners should take these factors into account when designing and implementing programmes. Future trial authors also need to actively address these factors and to report their efforts in their trial publications.

Knowledge and Attitudes about the Flu Vaccine among Pregnant Women in the Valencian Community (Spain)

Background and Objectives: To describe the knowledge and attitudes related to the acceptance of the flu vaccine during pregnancy in women, from two Health Departments of the Valencian Community (VC), during the 2015–2016 season, after receiving prenatal care. Materials and Methods: A prospective observational study was conducted during the annual vaccine season of women ascribed to prenatal care. A midwife offered flu vaccine advice and afterwards conducted a telephone poll of a representative sample, in order to find out the reason for accepting or rejecting the vaccine. Results: Of the 1017 expectant women who received advice about the vaccine, 77.4% (95% CI: 74.8–79.9%) declared their intention to vaccinate. After the recommendation, the vaccine coverage was 61.6%, with a percentage of accordance of 98.8% (95% CI: 98.0–99.6%) between the coverage declared and the Nominal Vaccination Registry (NVR) of the VC. Additionally, 67.2% of the expectant women were interviewed (n = 683). Most were aware of the recommendation and identified the health center and the midwife as the main sources of information. The internet was a consistent source in favor of vaccination 80.8% (n = 42). The obstetric variables (risk during the pregnancy, end of pregnancy, and feeding the newborn) did not have a statistically significant relationship with the vaccination. The women declared a high adherence to the vaccinations present in the child vaccination calendar, but rejected (31.3%) the flu vaccine, as they had not received it previously and did not want it because of their expectant state. Conclusions: The women positively evaluated the effectiveness and safety of the vaccines. However, with the flu vaccine, “not being previously vaccinated” and the “doubts about its safety” represented more than half of the reasons put forth for its rejection. Ensuring that the flu vaccine is perceived as more effective and acceptable through the messages directed towards the expectant mothers, directly through the midwives or through the communication media and social networks, will result in an increase of vaccine coverage.

Determinants of Influenza and Pertussis Vaccination Uptake in Pregnancy: A Multicenter Questionnaire Study of Pregnant Women and Healthcare Professionals

INTRODUCTION

Uptake rates of antenatal vaccination remain suboptimal. Our aims were to determine (1) the acceptability of routine vaccination among pregnant women, (2) the confidence of maternity healthcare professionals (HCPs) discussing vaccination and (3) HCP opinion regarding the optimum healthcare site for vaccine administration.

METHODS

Separate questionnaires for pregnant women and HCPs were distributed within 4 national health service (NHS) trusts in South England (July 2017 to January 2018).

RESULTS

Responses from 314 pregnant women and 204 HCPs (18% obstetricians, 75% midwives, 7% unidentified) were analyzed. Previous/intended uptake of influenza and pertussis vaccination was 78% and 92%, respectively. The commonest reason for declining vaccination was feared side effects for their child. White British women (79%) were significantly more accepting of influenza [85% vs. 61%; odds ratio (OR) 3.25; 95% confidence interval [CI], 1.67-6.32] and pertussis vaccination (96% vs. 83%; OR 4.83; 95% CI: 1.77-13.19) compared with nonwhite British women. Among HCPs, 25% were slightly or not at all confident discussing vaccination. Obstetricians felt significantly more confident discussing pertussis vaccination than midwives (68% vs. 55% were very/moderately confident; OR 2.05; 95% CI: 1.02-4.12). Among HCPs, 53%, 25% and 16% thought vaccines should be administered in primary care (general practice), community midwifery and in hospital, respectively.

CONCLUSION

Misconceptions exist regarding safety/efficacy of antenatal vaccination, and framing information towards the child's safety may increase uptake. Education of HCPs is essential, and vaccine promotion should be incorporated into routine antenatal care, with an emphasis on women from ethnic minorities. Administration of vaccines in primary care presents logistical barriers; however, support for alternative sites appears low among HCPs.

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.

A systematic review of interventions to improve uptake of pertussis vaccination in pregnancy

BACKGROUND

Maternal pertussis vaccination has been introduced in several countries to prevent pertussis morbidity and mortality in infants too young to be vaccinated. Our review aimed to systematically collect and summarize the available evidence on the effectiveness of interventions used to improve pertussis vaccination uptake in pregnant women.

METHODS

We conducted a systematic search of MEDLINE/PubMed, PMC and CINAHL. Before and after studies and those with a concurrent control group were considered for inclusion. Standardized effect sizes were described as the ratio of the odds to be vaccinated in the intervention group compared with the standard care group and absolute benefit increase (ABI) were calculated.

RESULTS

Six studies were included in the review, of which three were randomized controlled trials (RCTs). Strategies to improve uptake were focused on healthcare providers, pregnant women, or enhancing vaccine access. Healthcare provider interventions included provider reminder, education, feedback and standing orders. Interventions directed at pregnant women focused solely on education. Observational studies showed: (1) the provision of maternal pertussis vaccination by midwives at the place of antenatal care has improved uptake of pertussis vaccine during pregnancy from 20% to 90%; (2) introduction of an automated reminder within the electronic medical record was associated with an improvement in the pertussis immunization rate from 48% to 97%; (3) an increase in prenatal pertussis vaccine uptake from 36% to 61% after strategies to increase provider awareness of recommendations were introduced. In contrast to these findings, interventions in all three RCTs (2 involved education of pregnant women, 1 had multi-component interventions) did not demonstrate improved vaccination uptake.

CONCLUSIONS

Based on the existing research, we recommend incorporating midwife delivered maternal immunization programs at antenatal clinics, use of a provider reminder system to target unvaccinated pregnant women and include maternal pertussis immunization as part of standard antenatal care.

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.

Influenza and pertussis vaccination in pregnancy: Portrayal in online media articles and perceptions of pregnant women and healthcare professionals

Introduction

Online media may influence women’s decision to undergo vaccination during pregnancy. The aims of this mixed-methods study were to: (1) examine the portrayal of maternal vaccination in online media and (2) establish the perceived target of vaccine protection as viewed by pregnant women and maternity healthcare professionals (HCPs).

Methods

Online media articles on maternal vaccination (published July-December 2012 or November 2015-April 2016) were identified through the London School of Hygiene & Tropical Medicine’s Vaccine Confidence Database and thematically analysed. Questionnaires for pregnant women and HCPs were distributed within four English hospitals (July 2017-January 2018).

Results

Of 203 articles identified, 60% related to pertussis vaccination, 33% to influenza and 6% both. The majority positively portrayed vaccination in pregnancy (97%), but inaccurate, negative articles persist which criticize pertussis vaccination’s safety and efficacy. Positively-worded articles about pertussis tended to focus on infant protection and highlight examples of recent cases, whereas positively-worded articles about influenza focused on maternal protection. These themes were reflected in questionnaire responses from 314 pregnant women and 204 HCPs, who perceived pertussis vaccination as protecting the baby, and influenza vaccination as protecting the mother, or mother and baby equally. A minority of the pregnant women surveyed intended to decline influenza (22%) or pertussis (8%) vaccination.

Conclusions

The majority of online articles support pertussis and influenza vaccination during pregnancy. The portrayal of pertussis vaccination as primarily benefiting the child, using real-examples, may influence its higher uptake compared with influenza. This approach should be considered by HCPs when recommending vaccination. HCPs should be prepared to provide advice to women hesitant about vaccination, including addressing any negative media, and consider educational strategies to counteract inaccurate information. Future studies should directly assess the influence of media on vaccine decision-making and establish which media platforms are typically used by pregnant women to gather information.

Surveillance of Adverse Events After Seasonal Influenza Vaccination in Pregnant Women and Their Infants in the Vaccine Adverse Event Reporting System, July 2010-May 2016

INTRODUCTION

Routine immunization of pregnant women with seasonal inactivated influenza vaccines (IIVs) is recommended in all trimesters of pregnancy. A review of the Vaccine Adverse Event Reporting System (VAERS) during 1990-2009 did not find any unexpected patterns of pregnancy complications or fetal outcomes after administration of IIV or live attenuated influenza vaccines (LAIVs). During the 2009-2010 pandemic influenza A (H1N1) vaccination campaign, a study noted that the number of VAERS reports from pregnant women who received the H1N1 2009 inactivated monovalent vaccine (n = 288) increased compared with 1990-2009 seasonal IIV pregnancy reports (n = 148).

OBJECTIVES

The objective of this study was to assess the safety of seasonal influenza vaccines in pregnant women and their infants whose reports were submitted to VAERS during 2010-2016.

METHODS

We searched VAERS for US reports of adverse events (AEs) in pregnant women who received IIV or LAIV from 1 July 2010 through 6 May 2016. Clinicians reviewed reports and available medical records and assigned a primary clinical category for each report. Reports were coded as serious based on the Code of Federal Regulations.

RESULTS

We identified 671 reports after seasonal influenza vaccines administered to pregnant women: 544 after IIV and 127 after LAIV. Serious events occurred among 61 (11.2%) reports following IIV and one (0.8%) report following LAIV. No deaths were reported. Among reports with trimester information (n = 296), IIV was administered during the first trimester in 116 (39.2%). Among IIV reports, the most frequent pregnancy-specific AE was spontaneous abortion in 62 (11.4%) reports, followed by stillbirth in ten (1.8%) and preterm delivery in six (1.1%). The most common non-pregnancy-specific AEs were injection-site reactions (55 [10.1%]). Neonatal or infant outcomes were reported in 22 (4.0%) reports, seven of which had major birth defects of different types and no neonatal deaths.

CONCLUSION

As in 2009-2010, no new or unexpected patterns in maternal or fetal outcomes were observed during 2010-2016.

Improving rates of maternal immunization: Challenges and opportunities

OBJECTIVES

An increasing number of vaccines are recommended or are being developed for use during pregnancy to protect women, fetuses, and/or newborns. For vaccines that are already recommended, vaccine uptake is variable and well below desired target. We reviewed the literature related to factors that affect a healthcare provider's recommendation and a woman's willingness to be vaccinated during pregnancy.

DESIGN

A scoping review of published literature from 2005 to 2015 was undertaken and all relevant articles were abstracted, summarized, and organized thematically.

RESULTS

Barriers and facilitators were identified that either decreased or increased the likelihood of a healthcare provider offering and a pregnant woman accepting vaccination during pregnancy. Concern about the safety of vaccines given during pregnancy was the most often cited barrier among both the public and healthcare providers. Other barriers included doubt about the effectiveness of the vaccine, lack of knowledge about the burden of disease, and not feeling oneself to be at risk of the infection. Major facilitators for maternal immunization included specific safety information about the vaccine in pregnant women, strong national recommendations, and healthcare providers who both recommended and provided the vaccine to their patients. Systems barriers such as inadequate facilities and staffing, vaccine purchase and storage, and reimbursement for vaccination were also cited. Evidence-based interventions were few, and included text messaging reminders, chart reminders, and standing orders.

CONCLUSIONS

In order to have an effective vaccination program, improvements in the uptake of recommended vaccines during pregnancy are needed. A maternal immunization platform is required that normalizes vaccination practice among obstetrical care providers and is supported by basic and continuing education, communication strategy, and a broad range of research.

Feasibility of Text Message Influenza Vaccine Safety Monitoring During Pregnancy

INTRODUCTION

The feasibility and accuracy of text messaging to monitor events after influenza vaccination throughout pregnancy and the neonatal period has not been studied, but may be important for seasonal and pandemic influenza vaccines and future maternal vaccines.

METHODS

This prospective observational study was conducted during 2013-2014 and analyzed in 2015-2016. Enrolled pregnant women receiving inactivated influenza vaccination at a gestational age <20 weeks were sent text messages intermittently through participant-reported pregnancy end to request fever, health events, and neonatal outcomes. Text message response rates, Day 0-2 fever (≥100.4°F), health events, and birth/neonatal outcomes were assessed.

RESULTS

Most (80.2%, n=166) eligible women enrolled. Median gestational age was 8.9 (SD=3.9) weeks at vaccination. Response rates remained high (80.0%-95.2%). Only one Day 0-2 fever was reported. Women reported via text both pregnancy- and non-pregnancy-specific health events, not all associated with medical visits. Most pregnancy-specific events in the electronic medical record (EMR) were reported via text message. Of all enrollees, 84.9% completed the study (131 reported live birth, ten reported pregnancy loss). Two losses reported via text were not medically attended; there was one additional EMR-identified loss. Gestational age and weight at birth were similar between text message-reported and EMR-abstracted data and 95% CIs were overlapping for proportions of prematurity, low birth weight, small for gestational age, and major birth defects, as identified by text message-reported versus EMR-abstracted plus text message-reported versus EMR-abstracted data only.

CONCLUSIONS

This study demonstrated the feasibility of text messaging for influenza vaccine safety surveillance sustained throughout pregnancy. In these women receiving inactivated influenza vaccination during pregnancy, post-vaccination fever was infrequent and a typical pattern of maternal and neonatal health outcomes was observed.

Barriers and Facilitators for the Use of a Medical Mobile App to Prevent Work-Related Risks in Pregnancy: A Qualitative Analysis

Background

The number of women participating in the labor market in Europe has increased over the last several decades. At the same time, there is growing evidence that certain conditions of employment during pregnancy may have a negative influence on pregnancy outcomes. In order to better inform pregnant women, we aim to develop an app to help assess the health risk as a result of personal and work-related factors and provide personal advice for these women and their health care providers.

Objective

The aim of this study was to compose a thematic overview of the perceived facilitators and barriers according to pregnant women, medical professionals, and employers for the use of a mobile app in obstetrical care to prevent occupational-related pregnancy complications.

Methods

Two multidisciplinary focus group meetings with in total 14 participants were conducted with pregnant women, occupational physicians, general practitioners, midwives, obstetricians, and representatives of trade unions and employer organizations. Transcripts were analyzed by qualitatively coding procedures and constant comparative methods.

Results

We identified 24 potential facilitators and 12 potential barriers for the use of the app in 4 categories: content of the app, the app as a mean to provide information, ease of use, and external factors. The 3 main facilitators identified were the need for a good interaction between the app and the user, apps were viewed as a more practical source of information, and the information should be understandable, according to the existing guidelines, and well-dosed. The 2 main barriers for use were extensive battery and memory use of the smartphone and sending frequent push notifications.

Conclusions

The results of this study are important considerations in the developing process of a medical app implementing a guideline or evidence-based information in practice.

No association between influenza vaccination during pregnancy and adverse birth outcomes

BACKGROUND

Pregnant women are recommended to receive inactivated influenza vaccination anytime during pregnancy. Studies have investigated the impact of influenza vaccination during pregnancy on birth outcomes and results on preterm birth have been inconsistent.

METHODS

We conducted a retrospective cohort study among children born at a gestational age≥24weeks from January 1, 2010 to December 31, 2015 at Kaiser Permanente Northern California facilities (KPNC). We evaluated the association between maternal influenza vaccination during pregnancy and risk of preterm birth, small and large for gestational age, admission to the neonatal intensive care unit (NICU), respiratory distress syndrome, low birth weight, and low Apgar score. We ascertained the dates of maternal influenza vaccination, conception, and delivery, as well as birth outcomes from KPNC inpatient and outpatient databases. Conditional multivariate Cox regression and logistic regression analyses were used to determine the association between maternal vaccination during pregnancy and risk of each birth outcome.

RESULTS

The study included 145,869 children. Maternal influenza vaccination during pregnancy was not associated with risk of small or large for gestational age births, preterm birth, need for mechanical ventilation at birth, respiratory distress syndrome, admission to the NICU, low birth weight, or low Apgar score. However, when we did not control for immortal time bias, the risk of preterm birth (odds ratio [OR]=0.69, 95% confidence interval [CI] 0.66-0.72) was lower among infants of vaccinated mothers.

CONCLUSION

We found no association between maternal influenza vaccination during pregnancy and adverse birth outcomes. When investigating preterm birth outcome in association with vaccination during pregnancy, immortal time bias should be taken into account in the analysis.

Seasonal influenza vaccination in pregnant women: knowledge, attitudes, and behaviors in Italy

Background

The aims of this study were to assess the knowledge, attitudes, and behaviors towards seasonal influenza and its vaccination among pregnant women.

Methods

A cross-sectional survey was carried out among a sample of women in the second or third trimester of pregnancy in Italy.

Results

The 64.2% of the sample knew that the influenza is more dangerous for pregnant women. Women of older age, Italian, and who had a pregnancy at high-risk were more likely to have this knowledge. This knowledge was lower among women with none, primary or secondary school education. The majority of the respondents considered the vaccine not very useful during pregnancy. Those younger, unmarried, who knew that influenza is more dangerous for pregnant women, who knew that the vaccine could protect them, who reported a higher self-rated health status, and who had received information about influenza and its vaccination were more likely to have a positive attitude toward the usefulness of influenza vaccination in pregnancy. Women with secondary school education and with more than one child revealed a lower perception. Only 9.7% had received the vaccine and 21.4% of those unvaccinated would be willing to receive it. This positive attitude was higher among women with one child, who knew that the vaccine could protect them against the influenza, and who have a positive attitude toward the usefulness of the vaccination during pregnancy.

Conclusions

Health educational programs are needed to improve the knowledge about seasonal influenza and vaccination rate in pregnancy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-2138-2) contains supplementary material, which is available to authorized users.

Attitudes and Beliefs of Pregnant Women and New Mothers Regarding Influenza Vaccination in British Columbia

OBJECTIVE

Although pregnant women have increased risks for influenza morbidity and mortality, influenza vaccination rates among pregnant women in Canada are consistently very low. This mixed-methods study investigated the attitudes and behaviour of pregnant women and new mothers regarding seasonal and pandemic influenza vaccination.

METHODS

We conducted a baseline survey and qualitative focus groups with 34 women (26 pregnant women and 8 mothers of newborns), with a follow-up survey to assess outcomes at the end of the subsequent influenza season. Data analysis included descriptive statistics and directed content analysis based on the health belief model.

RESULTS

Most women did not consider influenza vaccination to be an important preventative measure to take while pregnant, although some were more willing to consider vaccination during a pandemic. Omission bias played a substantial role as justification for not vaccinating. Participants expressed confusion about recommendations regarding vaccination during pregnancy and frustration with inconsistent messages from health care providers (HCPs), particularly with regard to pandemic vaccines. Women were vaccinated when they perceived themselves and/or their babies to be at increased risk for influenza. Vaccinated women had strong normative influences (usually an HCP or a family member) that affected their decision. Intentions accurately predicted behaviour for women who did and did not intend to be vaccinated.

CONCLUSION

Pregnant women did not perceive themselves to be at increased risk for influenza and did not believe that influenza vaccination was a necessary preventative health measure. A lack of safety information about vaccination during pregnancy and inconsistent messages from HCPs were barriers to vaccine acceptance. Recommendations from maternity care providers and communication about the severity of and susceptibility to influenza for pregnant women would facilitate vaccine uptake.

Impact of an SMS advice programme on maternal and newborn health in rural China: study protocol for a quasi-randomised controlled trial

INTRODUCTION

Expectant mothers in low-income and middle-income countries often lack access to vital information about pregnancy, preparation for birth and best practices when caring for their newborn. Innovative solutions are needed to bridge this knowledge gap and dramatically improve maternal and neonatal health in these settings. This study aims to evaluate the impact of an innovative text messaging intervention on maternal and neonatal health outcomes.

METHODS AND ANALYSIS

This study offers expectant mothers in rural China a package of free short messages via cell phone regarding pregnancy and childbirth. These messages are tailored to each mother's gestational week. It is hypothesised that delivering these short advice messages to pregnant women can improve maternal and newborn health. The study uses factorial quasi-randomisation to compare psychological, behavioural and health outcomes between 4 groups: 2 groups receiving different sets of short message interventions (ie, good household prenatal practices and healthcare seeking), a group receiving both interventions and a control group. Treatment assignment occurs at the individual level. The primary outcome is newborn health, measured by appropriateness of weight for gestational age. Secondary outcomes include severe neonatal and maternal morbidity as well as psychological and behavioural measures. This study has enrolled pregnant women who attend county maternal and child health centres for their prenatal visits.

DISCUSSION

This pilot is the first large-scale effort to build a comprehensive evidence base on the impact of prenatal text messages via cell phone on maternal and newborn health outcomes in China. The study has broad implications for public health policy in China and the implementation of mobile health interventions in low-resource settings around the world.

ETHICS

This study was approved by the Ethics Committee of the School of Medicine at Xi'an Jiaotong University on 18 January 2013.

TRIAL REGISTRATION NUMBER

NCT02037087; Pre-results.

Low-Income First-Time Mothers: Effects of APN Follow-up Using Mobile Technology on Maternal and Infant Outcomes

Background. Low-income mothers have greater challenges in accessing health care services due changes in the health care system and budget cuts. The purpose of this randomized clinical trial was to test a nurse practitioner (NP) intervention using cell phone and texting on maternal/infant outcomes. Methods. The sample included 129 mother-infant pairs. Intervention group mothers received NP 2-way cell phone follow-up intervention post–hospital discharge for 6 months. Results. Intervention mothers’ perceived social support was significantly higher. Intervention infants received their first newborn follow-up visit significantly earlier (6 vs 9 days); significantly more infants were immunized at recommended times (2, 4, and 6 months of age); and there were fewer infant morbidities compared to controls. The intervention saved between $51 030 and $104 277 in health care costs averted. Conclusion. This easy-to-use, safe intervention is an effective way to reach a wide range of populations and demonstrated improved maternal/infant outcomes and decreased cost.

Study protocol for a randomized controlled trial to assess the feasibility of an open label intervention to improve hydroxyurea adherence in youth with sickle cell disease

BACKGROUND

Community health workers (CHW) are increasingly recognized as a strategy to improve health outcomes for the underserved with chronic diseases but has not been formally explored in adolescents with sickle cell disease (SCD). SCD primarily affects African American, Hispanic and other traditionally underserved populations. Hydroxyurea (HU), an oral, once-daily medication, is the only approved therapeutic drug for sickle cell disease and markedly reduces symptoms, morbidity and mortality and improves quality of life largely by increasing hemoglobin F blood levels. This paper presents the rationale, study design and protocol for an open label randomized controlled trial to improve parent-youth partnerships in self-management and medication adherence to HU in adolescents with SCD.

METHODS/DESIGN

A CHW intervention augmented by text messaging was designed for adolescents with SCD ages 10-18years and their parents to improve daily HU adherence. Thirty adolescent parent dyads will be randomized with 2:1 intervention group allocation. Intervention dyads will establish a relationship with a culturally aligned CHW to identify barriers to HU use, identify cues to build a habit, and develop a dyad partnership to improve daily HU adherence and achieve their individualized "personal best" hemoglobin F target. Intervention feasibility, acceptability and efficacy will be assessed via a 2-site trial. Outcomes of interest are HU adherence, dyad self-management communication, quality of life, and resource use.

DISCUSSION

Despite known benefits, poor HU adherence is common. If feasible and acceptable, the proposed intervention may improve health of underserved adolescents with SCD by enhancing long-term HU adherence.

TRIAL REGISTRATION

NCT02029742.

Maternal uptake of pertussis cocooning strategy and other pregnancy related recommended immunizations

Maternal immunization is an important strategy to prevent severe morbidity and mortality in mothers and their offspring. This study aimed to identify whether new parents were following immunization recommendations prior to pregnancy, during pregnancy, and postnatally. A cross-sectional survey was conducted by a questionnaire administered antenatally to pregnant women attending a maternity hospital with a follow-up telephone interview at 8-10 weeks post-delivery. Factors associated with uptake of pertussis vaccination within the previous 5 y or postnatally and influenza vaccination during pregnancy were explored using log binomial regression models. A total of 297 pregnant women completed the questionnaire. For influenza vaccine, 20.3% were immunized during pregnancy and 3.0% postnatally. For pertussis vaccine, 13.1% were vaccinated within 5 y prior to pregnancy and 31 women received the vaccine postnatally, 16 (51.6%) received the vaccine >4 weeks after delivery. Receiving a recommendation from a healthcare provider (HCP) was an independent predictor for receipt of both pertussis (RR 2.07, p < 0.001) and influenza vaccine (RR 2.26, p = 0.001). Non-English speaking mothers were significantly less likely to have received pertussis vaccination prior to pregnancy or postnatally (RR 0.24, p = 0.011). Multiparous pregnant women were less likely to have received an influenza vaccine during their current pregnancy (p = 0.015). Uptake of pregnancy related immunization is low and likely due to poor knowledge of availability, language barriers and lack of recommendations from HCPs. Strategies to improve maternal vaccine uptake should include education about recommended vaccines for both HCPs and parents and written information in a variety of languages.

Perceptions of Hong Kong Chinese women toward influenza vaccination during pregnancy

INTRODUCTION

Pregnant women are the highest priority group for seasonal influenza vaccination. However, their vaccination uptake remains suboptimal. The purpose of this study is to explore Hong Kong women's perceptions of the threat of influenza infection during pregnancy, the risks and benefits of influenza vaccination, and their decision-making processes.

METHODS

We used a qualitative descriptive design and recruited women who had just given births to a live infant from April to June 2011. Participants were recruited from a large teaching hospital in Hong Kong and were interviewed in the immediate postpartum period.

RESULTS

A total of 32 postpartum women were interviewed, and two had been vaccinated during pregnancy. Following thematic analysis, three themes emerged: perceived risk of influenza infection, perceived risk of influenza vaccine, and decision-making cues. Overall, participants held negative impressions about influenza vaccination during pregnancy, and they underestimated the threat of influenza to themselves and their fetus. They were also confused about the safety and efficacy of the influenza vaccine and the differences between preventive strategies and treatment for influenza. Most participants reported that their health care providers (HCPs) did not offer or recommend vaccination. Because of negative media reports about vaccination, participants were hesitant to receive the vaccine. Motivating forces for vaccine acceptance were a perceived high prevalence of circulating influenza during their pregnancy and HCP recommendations and reassurances that the vaccination was safe, effective, and beneficial for the fetus.

CONCLUSION

Vaccination promotion strategies need to focus on encouraging HCPs to take the initiative to discuss vaccination with their pregnant clients and provide accurate and unbiased information about the risks of influenza and the benefits of vaccination.

Interventions to increase the uptake of seasonal influenza vaccination among pregnant women: A systematic review

BACKGROUND

Pregnant women and their infants under 6 months of age infected with influenza have a high risk of serious morbidity and mortality. Influenza vaccine during pregnancy offers 3-for-1 benefits to pregnant women, fetuses and newborn infants. Current vaccination uptake rates during pregnancy, however, are often lower than other high-risk groups and the general population.

METHODS

We systematically reviewed evidence on the effectiveness of interventions to improve influenza vaccination coverage in pregnant women. Risk differences (RDs) were calculated from the included studies.

RESULTS

Eleven studies were included in the review, of which four were randomized controlled trials (RCTs). Three cohort studies assessed provider-focused interventions while four RCTs and one cohort study evaluated pregnant women-focused interventions. Two cohort studies and a prospective intervention study assessed the effectiveness of bundled interventions. No study solely assessed the effectiveness of interventions to enhance access to influenza vaccination. One moderate quality RCT showed that an influenza pamphlet, with or without a verbalized benefit statement, improved the vaccination rate (RD=0.26; RD=0.39). The other reviewed RCTs showed discordant results, with RDs ranging from -0.15 to 0.03. Although all observational studies significantly improved vaccination rates (RDs ranged from 0.03 to 0.44), the quality of the evidence varied.

CONCLUSIONS

There is a lack of effective interventions to increase the influenza vaccination rate in pregnant women. Based on the existing research, we recommend that clinicians provide influenza pamphlets to pregnant women with a verbalized statement about the benefits of influenza vaccine to newborns. Further high-quality RCTs are needed to develop successful maternal influenza vaccination programs. Increased clarity in reporting the content of interventions would help to improve the comparability and generalizability of the published studies.

Immunization of pregnant women: Future of early infant protection

Children in early infancy do not mount effective antibody responses to many vaccines against commons infectious pathogens, which results in a window of increased susceptibility or severity infections. In addition, vaccine-preventable infections are among the leading causes of morbidity in pregnant women. Immunization during pregnancy can generate maternal immune protection as well as elicit the production and transfer of antibodies cross the placenta and via breastfeeding to provide early infant protection. Several successful vaccines are now recommended to all pregnant women worldwide. However, significant gaps exist in our understanding of the efficacy and safety of other vaccines and in women with conditions associated with increased susceptible to high-risk pregnancies. Public acceptance of maternal immunization remained to be improved. Broader success of maternal immunization will rely on the integration of advances in basic science in vaccine design and evaluation and carefully planned clinical trials that are inclusive to pregnant women.

Helping mothers to get the message about influenza: are texts the future for increased immunization?

Pregnant women and children are at increased risk of severe influenza infections. Despite existing recommendations, uptake of influenza vaccine in these vulnerable groups remains low. Text message reminder-recalls are a feasible and scalable method for promoting influenza vaccination. In randomized controlled trials, text message interventions have demonstrated small but significant increases in influenza vaccine coverage. They should be considered one of many tools available for increasing vaccination and thus improving maternal and child health.

Text4baby program: an opportunity to reach underserved pregnant and postpartum women?

Text4baby was launched in 2010 to promote healthy pregnancies and babies by the use of text messaging. The primary objective of this study was to assess factors related to the enrollment process and reception of text4baby. A prospective cohort study was conducted in two Women, Infant and Children clinics in Atlanta (April 2010-July 2011). Randomly selected pregnant and postpartum women (n = 468) were queried on cell phone use and instructed on text4baby enrollment. Self-enrollment issues were assessed at one-week follow-up (n = 351, 75.0 %), and message reception and reading patterns at two-month follow-up (n = 209, 44.7 %). Forty-two percent of the women had some college education and 82 % had household income <=$20,000. About half attempted text4baby self-enrollment (162/351), with enrollment success more likely among women with more education (80 % with some college vs. 62 % with less education), with household income above $10,000 (61 % < $10,000 vs. 83 % $10,001-$20,000 and 76 % > $20,000), and among women living in smaller households (77 % 1-3 members vs. 58 % > 3 members) (all p < 0.001). Among the 209 participants in the final follow-up contact, >90 % reported uninterrupted reception and regular reading of messages, and 88 % planned to continue using text4baby. Results also suggested that respondents who were younger (<26 year), less educated and had lower health literacy skills were more likely to have interrupted messages. Despite substantial interest in the text4baby program in an underserved population, innovative ways to help women with significant disadvantages enroll and receive uninterrupted messages are needed.

Attitudes, Intentions, and Barriers Toward Influenza Vaccination Among Pregnant Korean Women

Following our study of attitudes, barriers, and intentions concerning the influenza vaccination among pregnant women in South Korea, we discovered that women displaying a more positive attitude toward the influenza vaccination were more likely to receive it during their pregnancy. We also found that attitudes toward vaccination were more positive among vaccinated pregnant women than among those who were unvaccinated. Furthermore, women showed a greater intention to get vaccinated if a clinician, rather than friends, recommended it. The major perceived barriers to receiving an influenza vaccination were being pregnant, fearing harm to the baby, feeling healthy, and thinking it is unnecessary.

Influenza vaccine text message reminders for urban, low-income pregnant women: a randomized controlled trial

OBJECTIVES

We evaluated the impact of influenza vaccine text message reminders in a low-income obstetric population.

METHODS

We conducted a randomized controlled trial that enrolled 1187 obstetric patients from 5 community-based clinics in New York City. The intervention group received 5 weekly text messages regarding influenza vaccination starting mid-September 2011 and 2 text message appointment reminders. Both groups received standard automated telephone appointment reminders. The prespecified endpoints were receipt of either pre- or postpartum influenza vaccination calculated cumulatively at the end of each month (September-December 2011).

RESULTS

After adjusting for gestational age and number of clinic visits, women who received the intervention were 30% more likely to be vaccinated as of December 2011 (adjusted odds ratio [AOR] = 1.30; 95% confidence interval [CI] = 1.003, 1.69 end of September: AOR = 1.34; 95% CI = 0.98, 1.85; October: AOR = 1.35; 95% CI = 1.05, 1.75; November: AOR = 1.27; 95% CI = 0.98, 1.65). The subgroup of women early in the third trimester at randomization showed the greatest intervention effect (December 31: 61.9% intervention vs 49.0% control; AOR = 1.88; 95% CI = 1.12, 3.15).

CONCLUSIONS

In this low-income obstetric population, text messaging was associated with increased influenza vaccination, especially in those who received messages early in their third trimester.

Inactivated influenza vaccine during pregnancy and risks for adverse obstetric events

OBJECTIVE

To compare risks for adverse obstetric events between females who did and did not receive trivalent inactivated influenza vaccine during pregnancy.

METHOD

This retrospective, observational cohort study was conducted at seven Vaccine Safety Datalink sites. Pregnancies were identified from administrative and claims data using a validated algorithm. Females vaccinated while pregnant from 2002 to 2009 were matched one-to-two with replacement to unvaccinated pregnant females. Using a generalized estimating equation method with a Poisson distribution and log link, we evaluated the association of trivalent inactivated influenza vaccine with 13 outcomes. Given our large sample size and multiple comparisons (19 contrasts), a cutoff for significance of P<.005 was selected a priori.

RESULTS

Our cohort included 74,292 vaccinated females matched on age, site, and pregnancy start date with 144,597 unvaccinated females. We did not observe increased risks within 42 days of vaccination for hyperemesis, chronic hypertension, gestational hypertension, gestational diabetes, proteinuria, or urinary tract infection. Using a risk window from vaccination through pregnancy end, we did not observe increased risks after vaccination for proteinuria, urinary tract infection, gestational hypertension, preeclampsia or eclampsia, chorioamnionitis, puerperal infection, venous complications, pulmonary embolism, or peripartum cardiomyopathy. A reduced risk for gestational diabetes after vaccination was detected (adjusted hazard rate ratio 0.88, 95% confidence interval 0.83-0.93), likely as a result of healthy vaccine bias or earlier detection among vaccinees.

CONCLUSION

In this large cohort, influenza vaccination during pregnancy was not associated with increased risks for medically attended adverse obstetric events.

LEVEL OF EVIDENCE

II.

Using text messaging to assess adolescents' health information needs: an ecological momentary assessment

Background

Use of mobile technology has made a huge impact on communication, access, and information/resource delivery to adolescents. Mobile technology is frequently used by adolescents.

Objective

The purpose of this study was to understand the health information needs of adolescents in the context of their everyday lives and to assess how they meet their information needs.

Methods

We gave 60 adolescents smartphones with unlimited text messaging and data for 30 days. Each smartphone had applications related to asthma, obesity, human immunodeficiency virus, and diet preinstalled on the phone. We sent text messages 3 times per week and asked the following questions: (1) What questions did you have about your health today? (2) Where did you look for an answer (mobile device, mobile application, online, friend, book, or parent)? (3) Was your question answered and how? (4) Anything else?

Results

Our participants ranged from 13-18 years of age, 37 (62%) participants were male and 22 (37%) were female. Of the 60 participants, 71% (42/60) participants identified themselves as Hispanic and 77% (46/60) were frequent users of mobile devices. We had a 90% (1935/2150) response rate to our text messages. Participants sent a total of 1935 text messages in response to the ecological momentary assessment questions. Adolescents sent a total of 421 text messages related to a health information needs, and 516 text messages related to the source of information to the answers of their questions, which were related to parents, friends, online, mobile apps, teachers, or coaches.

Conclusions

Text messaging technology is a useful tool for assessing adolescents’ health behavior in real-time. Adolescents are willing to use text messaging to report their health information. Findings from this study contribute to the evidence base on addressing the health information needs of adolescents. In particular, attention should be paid to issues related to diet and exercise. These findings may be the harbinger for future obesity prevention programs for adolescents.

Standardized functions for smartphone applications: examples from maternal and child health

Millennium Development Goals (MDGs) are unlikely to be met in most low- and middle-income countries (LMIC). Smartphones and smartphone proxy systems using simpler phones, equipped with the capabilities to identify location/time and link to the web, are increasingly available and likely to provide an excellent platform to support healthcare self-management, delivery, quality, and supervision. Smart phones allow information to be delivered by voice, texts, pictures, and videos as well as be triggered by location and date. Prompts and reminders, as well as real-time monitoring, can improve quality of health care. We propose a three-tier model for designing platforms for both professional and paraprofessional health providers and families: (1) foundational functions (informing, training, monitoring, shaping, supporting, and linking to care); (2) content-specific targets (e.g., for MDG; developmentally related tasks); (3) local cultural adaptations (e.g., language). We utilize the Maternal and Child Health (MCH) MDG in order to demonstrate how the existing literature can be organized and leveraged on open-source platforms and provide examples using our own experience in Africa over the last 8 years.

Acceptance and rejection of influenza vaccination by pregnant women in southern Iran: physicians' role and barriers

OBJECTIVE

Vaccination provides the most effective protection against maternal, fetal and neonatal complications of influenza infection. This study aimed to determine the uptake rate of influenza vaccination including 2009 pandemic H1N1 influenza and seasonal influenza vaccination and the reasons for acceptance or rejection among pregnant women.

RESULT

Mean age of the 416 pregnant women enrolled in this study was 27.06 ± 5.27 y. Only 25 (6%) of 397 women had history of vaccination. Of 383 (92.06%) pregnant women who had rejected vaccination, 116 (30.28%) declared that they lacked information about influenza vaccination and 44 (11.48%) felt that they did not need vaccination. Concerns about the safety of influenza vaccination were reported by only 2 women (0.52%). Of the 25 (6%) pregnant women who were vaccinated against influenza, 15 (60%) accepted because of advice they received from persons other than physicians, 5 (20%) believed that influenza vaccination is necessary for everyone, and 3 (12%) accepted because of a history of frequent influenza virus infections in previous years.

METHOD

This questionnaire based study was conducted at obstetrics and maternity hospitals affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. Pregnant women were interviewed individually and privately. SPSS was used for data analysis.

CONCLUSION

Most of the unvaccinated and vaccinated pregnant women lacked sufficient knowledge about influenza. Education of pregnant women about influenza vaccination and encouragement from physicians may have a remarkable effect on turning poor compliance into high flu vaccination uptake among pregnant women.

Assessing the safety of influenza immunization during pregnancy: the Vaccine Safety Datalink

The influenza vaccine can reduce maternal and neonatal morbidity and mortality and thus is recommended for all pregnant women. However, concerns regarding safety of influenza vaccine remain a barrier to vaccination. We describe ongoing analyses of influenza vaccine safety during pregnancy within the Vaccine Safety Datalink that includes the evaluation of acute events, adverse pregnancy and birth outcomes, and congenital anomalies. In addition, we highlight unique challenges and strategies for the study of vaccine safety among pregnant women with the use of large linked databases.

Improving influenza vaccination coverage in pregnancy in Melbourne 2010-2011

BACKGROUND

Seasonal influenza vaccination during pregnancy is effective in preventing serious maternal and infant respiratory illness, but published Australian audits are sparse concerning practice.

AIMS

Guided by information gained from new mothers about obstacles to influenza vaccination in July 2010, an educational program for maternity staff and pregnant women was developed with the aim of improving vaccine uptake in 2011.

METHODS

One hundred and ninety-nine new mothers in July 2010 and 240 new mothers in July 2011 on postnatal wards of a tertiary obstetric hospital were interviewed about whether influenza vaccine had been offered or given and about reasons why women chose for or against vaccination during pregnancy.

RESULTS

Influenza vaccination increased from 30% in 2010 to 40% in 2011 (P = 0.03). Fewer women cited safety concerns for themselves or their babies after the 2011 educational campaign. Comments from 90 women in 2011 give grounds for speculation that the vaccination rate could have been as high as 78% if influenza vaccination had been integrated as part of hospital-based antenatal care.

CONCLUSIONS

Influenza vaccine coverage during pregnancy is increasing but obstacles persist, especially absent or inconsistent advice from healthcare workers and lack of ready access during routine antenatal care.

Text4baby in the United States and Russia: an opportunity for understanding how mHealth affects maternal and child health

Text4baby uses new technology to deliver health messages and engage pregnant women and new mothers in healthy behaviors. The authors describe the need for carefully conducted early adopter epidemiologic evaluation and describe one such evaluation in a women, infant, and children clinic population in the United States and its proposed adaptation for use among early users of Text4baby in Russia. Collaborative efforts among countries can guide international understanding and use of best practices of this emerging technology.

Text4Health: impact of text message reminder-recalls for pediatric and adolescent immunizations

OBJECTIVES

We conducted 2 studies to determine the impact of text message immunization reminder-recalls in an urban, low-income population.

METHODS

In 1 study, text message immunization reminders were sent to a random sample of parents (n = 195) whose children aged 11 to 18 years needed either or both meningococcal (MCV4) and tetanus-diphtheria-acellular pertussis (Tdap) immunizations. We compared receipt of MCV4 or Tdap at 4, 12, and 24 weeks with age- and gender-matched controls. In the other study, we compared attendance at a postshortage Haemophilus influenzae B (Hib) immunization recall session between parents who received text message and paper-mailed reminders (n = 87) and those who only received paper-mailed reminders (n = 87).

RESULTS

Significantly more adolescents with intervention parents received either or both MCV4 and Tdap at weeks 4 (15.4% vs 4.2%; P < .001), 12 (26.7% vs 13.9%; P < .005), and 24 (36.4% vs 18.1%; P < .001). Significantly more parents who received both Hib reminders attended a recall session compared with parents who only received a mailed reminder (21.8% vs 9.2%; P < .05). After controlling for age, gender, race/ethnicity, insurance status, and language, text messaging was still significantly associated with both studies' outcomes.

CONCLUSIONS

Text messaging for reminder-recalls improved immunization coverage in a low-income, urban population.