COVID-19 vaccination in pregnancy: ambiguity in decision-making

An exploration of women's decision-making processes around accepting or declining vaccinations in pregnancy: A qualitative descriptive study

OBJECTIVE

To explore women's perceptions and experiences of accepting or declining vaccinations in pregnancy, and to identify factors that influence vaccination uptake.

DESIGN

A qualitative descriptive interview-based study.

SETTING

The maternity unit of a rural hospital in the Republic of Ireland.

PARTICIPANTS

A purposive sample of eight women who were pregnant, aged 18 and over, who were receiving antenatal care through the public healthcare system. Half of the participants accepted vaccinations, while the other half declined, reflecting varying levels of vaccine hesitancy.

METHODS

Semi structured interviews (n=8) were conducted between July 2022 and August 2022 and analysed using thematic analysis.

FINDINGS

The study offers insight into women's decision-making processes on vaccinations in pregnancy. Five main themes were identified (1). Maternal Instincts in the Shadow of Uncertainty, (2). Lack of Balanced Information, (3). Misinformation: Difficult to Ignore, (4). Navigating Fear and Social Pressures, (5). Perceived Benefits Outweighing Risk.

KEY CONCLUSIONS

The decision-making process around vaccination in pregnancy is complex and multifaceted, influenced by various factors that can either hinder or promote uptake rates. Participants expressed complex emotions, associated fears and anxieties, and highlighted the necessity for more balanced and transparent dialogues with healthcare professionals. They emphasised the need for the dissemination of high-quality objective evidence from health authorities. This, they felt, would help facilitate genuine informed decision making, and ease the burden of feelings of uncertainty.

IMPLICATIONS FOR PRACTICE

The provision of balanced, reliable, evidence-based information made available through multiple sources, alongside open and non-judgemental conversations with healthcare professionals is essential to support women in making informed decisions. Consequently, healthcare professionals require education and training to effectively communicate vaccination information clearly, empathetically, and in a way that is tailored to individual needs.

DECIDE, A Pregnancy-specific Patient-provider Communication Approach: Multi-method and Codesign

BACKGROUND

Vaccination in pregnancy is recommended for preventing maternal and infant morbidity, but uptake is low. Existing presumptive and participatory vaccine communication approaches for childhood vaccinations may not encompass the nuanced decision-making during pregnancy.

METHODS

We employed a multi-method study using the double diamond design framework to codesign a pregnancy-specific, person-centered communication approach. Key activities of each double diamond phase are listed below:Discover: Conducted a scoping review, a survey assessing psychological antecedents of (n = 237) pregnant or lactating individuals, qualitative interviews with (n = 169) patients and (n = 47) healthcare providers (HCPs) and gathered insights through (n = 20) community outreach events to understand the problem.Define: Synthesized findings through thematic analysis and key informant interviews, to validate our understanding of the problem.Develop: Prototyped solutions through role-playing, iterative feedback with patient partners and HCPs, and qualitative inquiry into parental preferences.Deliver: Finalized the communication approach after iterative usability testing with (n = 15) HCPs and feedback-driven refinement with (n = 9) patient partners.

RESULTS

We confirmed the need for a pregnancy-specific communication approach and identified key gaps. We then built a prototype where perinatal HCPs could use either a presumptive if acceptant or participatory if hesitant approach but questioned the applicability of vaccine hesitancy to pregnancy. We abandoned a solely presumptive approach given parental insights: it is normal to "question" during pregnancy and developed a balanced approach. The final DECIDE (determine, elicit, consent, interactive discussion, deliver, empower) communication approach balances shared decision-making with a clear recommendation. It addresses pregnant individuals' desire for autonomy and support, and HCPs call for simple tools to improve their confidence and communication skills without alienating their patients.

CONCLUSION AND NEXT STEPS

DECIDE is a pregnancy-specific vaccine communication approach potentially applicable to other interventions beyond vaccination.

A critical review of the reporting of reflexive thematic analysis in Health Promotion International

Using the concept of methodological congruence-where the different elements of a study 'fit' together-we explore both problematic and good practice in (reflexive) thematic analysis (TA) as reported in Health Promotion International (HPI). Aligning with the importance we place on 'owning your perspectives' we situate this exploration in relation to our understanding of the variation in approaches to TA and qualitative research more broadly. This contextualization is necessary for highlighting why we judge practices to be in/congruent, and to facilitate more knowing congruence in future research. We critically reviewed a 'sample' of 31 papers published in HPI between 2010 and 2023 citing Braun and Clarke as reference for TA. We overview a range of problematic and good features of the use of TA in HPI, before focusing on two domains that seemed to present key challenges: theory and themes. Methodological incongruence can occur when postpositivist values and practices unwittingly creep into ostensibly non-positivist TA; we encourage thoughtfully and what we term 'knowing' consideration of theory, and quality practices and criteria. Methodological incongruence can also occur through mismatched conceptualizations of themes-notably, the use of 'topic summaries' as themes for reflexive TA (and fragmented thematic structures with 'thin' themes). We provide examples from the reviewed papers to demonstrate good practice in researcher reflexivity, articulation of theoretical and methodological frameworks and congruent themes. However, mindful of power dynamics, we only discuss problematic practice in general terms, to protect author anonymity. To facilitate thoughtful, quality TA-of all kinds-we provide eight pointers for researchers (and reviewers) to guide quality practice, and facilitate the use of concepts, procedures and criteria that promote knowing methodological congruence.