Keywords
Antenatal care providers, healthcare providers, vaccine acceptance, maternal vaccination, knowledge, attitudes and beliefs
Antenatal care providers, healthcare providers, vaccine acceptance, maternal vaccination, knowledge, attitudes and beliefs
Young infants remain highly vulnerable to infectious diseases1, partially because vaccination is not feasible or effective for most diseases during the first months of life1. Maternal immunization has the potential to yield protection for both the mother and their infant2. Clinical studies have demonstrated protection of infants against various infectious diseases such as pertussis and influenza through the placental transfer of antibodies from vaccinated mothers3,4. Hence, the importance of promoting maternal immunization, especially in settings where the risk of infection during pregnancy and early infancy is high.
Despite proven advantages and significant progress in maternal immunization worldwide, many countries in Africa, including Kenya, recommend only tetanus- diphtheria (Td) vaccination for pregnant women, and coverage remains suboptimal in some regions5. Some of the determinants of low vaccine uptake in the African region include living in urban or peri-urban areas; few dedicated economic and human resources; lack of sufficient vaccines due to demand and supply inconsistencies and barriers to vaccine acceptance by pregnant women and their communities5–7. Healthcare providers can play a key role in overcoming these barriers. Studies in the United States have shown that women who had discussions about vaccine benefits with their antenatal care providers were more likely to accept vaccine during pregnancy8.
Pregnant women have shown that they rely and trust healthcare providers for immunization related information2. A couple of studies in Asia and Africa have shown that healthcare provider recommendation not only improve vaccine acceptance in pregnant women but can also motivate their male-partners to accept maternal vaccination. This patient-provider relationship has been seen particularly important in low-to-middle income countries (LMIC)9,10. Providers’ attitudes and beliefs towards vaccination have also been shown to influence vaccine recommendations for pregnant women11. Despite high morbidity and mortality of vaccine preventable disease in LMIC such as Kenya12, most of the research assessing the knowledge, attitudes, and beliefs of health providers towards maternal immunization has been conducted in high- income settings. The objective of this study was to assess attitudes, beliefs and characteristics of antenatal care providers towards maternal vaccination in Kenya.
Data for this analysis are part of a larger study aimed at identifying determinants of maternal vaccine acceptance in Kenya, which was conducted between June 2016 and August 2018. The study was conducted by Emory University, in collaboration with the Centers for Disease Control and Prevention (CDC) and the Kenya Medical Research Institute (KEMRI). Approval for the study was obtained from Emory University’s [IRB00089673] and KEMRI’s Institutional Review Boards [SSC 3292]. Written informed consent was obtained from participants before enrolling in the study.
The study population included 150 antenatal care providers working in antenatal care clinics and hospitals, from primary care to referral settings, in four different areas in Kenya (Nairobi, Mombasa, Marsabit, and Siaya counties). The sample size was calculated in order to estimate correlations between predictors and ANC responses based on a conservative distribution of 50% for response variables, assuming 80% power and an alpha of 0.05. The inclusion criteria for participants were being employed in a clinic or hospital in the target sites as an ANC provider and providing services to pregnant women. The recruitment sites varied from small clinics to large hospitals with patient population ranges between tens to hundreds of women. The study sites were selected to represent the geographic diversity of Kenya and based on the study team ability to access them: Nairobi is the capital and largest city of Kenya; Mombasa is a coastal city with a majority Muslim population; Marsabit is a remote region with low population density and nomadic groups; and Siaya represents western Kenyan rural region.
The research staff visited the 150 clinics and hospitals and distributed a quantitative knowledge, attitude and behavior (KAB) survey to the antenatal care (ANC) providers (see extended data for questionnaire13). The survey was developed based on information collected in the qualitative phase of the study, which included 111 semi-structured interviews with ANC providers14 and pilot tested by the study team in all sites. Participants were recruited both as a convenience sample from study facilities and referral through the healthcare workers and colleagues. The self-administered KAB included questions on vaccine-preventable diseases (including burden and perceived risk), vaccine effectiveness, vaccine safety, vaccination norms, prior experience with vaccination (either for themselves, their children, their patients, etc.), positive and negative motivations to vaccinate, and values around vaccination. The survey also collected socio-demographic information. All the questionnaires were translated into the local languages, including Luo, Kikyo, Luhya, Kamba, Swahili, Mijikenda, Taita, Borana, Rendile, Burji and Somali. For the purpose of analysis, the questionnaires were translated back to English.
Demographic variables were categorized as follows: age, education and marital status were dichotomized (<30 vs. ≥30 years; college or less vs. more than college; and single vs. married/cohabitation) respectively. Religion was divided into four categories: catholic, protestant, Muslim and traditional African churches/traditional religion/others.
To get an aggregate of positive, neutral or negative responses, we collapsed the five item Likert scale into three. Strongly agree and agree were summarized as agree and strongly disagree and disagree were summarized as disagree.
Descriptive statistics (means and standard deviations, proportions) were summarized for all the variables and survey questions. using SAS, version 9.4 (SAS Institute, Cary, NC).
A total of 150 participants were included in this study (see underlying data13). Most of the participants were female (77.3%), nurses (89.3%) and over 30 years of age (67.3%) (Table 1).
Nearly all of the ANC providers had positive attitudes towards maternal vaccination in general (when no vaccine was specified), agreeing that vaccines are one of the safest strategies to protect both mother and newborns from diseases, and can be administered even when they are suffering from chronic conditions such as HIV. Nearly 80% of the providers agreed that influenza is a matter of concern in pregnant women. Approximately 97% of the providers agreed that Td vaccine is effective and should be administered in pregnancy (Table 2).
Providers responded that myths and misconceptions about vaccines in the society did not affect their decisions related to maternal vaccination. A majority also expressed that political leaders do not influence provider’s decision to accept vaccines. Similarly, most participants disagreed that ethnic/cultural background or religious beliefs influenced their attitudes or beliefs towards vaccination. (Table 3).
Educational resources to guide women about vaccines (92.7%) and supply of vaccines by government sector (87.3%) were reported to be accessible in enough quantity (Table 4). However, logistical (66%) and human resources (52.7%) were reported to be less available for vaccine delivery. Furthermore, 78% believed that pregnant women take all the scheduled vaccines even when they migrate to new places. In addition, they feel that their patients trusted their suggestions and information about vaccine recommendation.
Results from this study of ANC providers in Kenya highlight important avenues to improve coverage with maternal vaccinations that are currently recommended in the country (currently, only TT), as well as opportunities for the introduction of additional vaccines for pregnant women. First, the providers had favorable attitudes towards vaccine administration and believed that a greater number of vaccines should be recommended to protect both mother and the child from preventable diseases and associated debilitating outcomes. Second, providers reported that religion, myths or political opinions do not influence their attitudes and recommendations around maternal vaccination. Third, almost all providers perceived that women consider them as a trustworthy source of information about vaccinations. Finally, it was reported that healthcare centers were well equipped with educational materials. There was also an uninterrupted supply of vaccines from the government sector.
Providers perception of having adequate vaccine supplies was contradictory to a report of 2011 –2015 from the Kenya Division of Vaccines and Immunization, that cited both demand and supply challenges in vaccine availability12. There have been incidents of depleted vaccine supply some African countries, including Kenya and Tanzania15. One of the reasons behind the divergent results might be that our study included mostly accessible clinics and hospitals located within or near urban areas with good infrastructure. It is also possible that efforts to improve vaccine supplies based on previous assessments have been noticed by the providers.
It is important to note that the perceptions of HCPs around maternal immunization are mostly based on the experience with tetanus vaccines (either TT or Td). Maternal immunization against tetanus has been implemented for decades in Kenya. Similarly, partly due to programs to improve coverage, the TT vaccine is regarded as a safe and effective to prevent childhood tetanus16. While the introduction of other maternal vaccines (e.g. influenza) can benefit from the experience with TT, each new vaccine that is introduced will need to be assessed individually and efforts to promote coverage need to be catered to their specific characteristics.
Efforts to introduce maternal immunization with influenza in Kenya are ongoing. Influenza virus infection was reported as one of the concerns during pregnancy in Kenya17. Since ANC providers are regarded as a main source of information, this is another opportunity where policymakers and immunization managers can partner with HCP to inform and motivate pregnant women to receive an influenza vaccine once the recommendation is enacted.
Globally, studies have shown the influence of ethnicity and cultural background on acceptance of different vaccines18–20. An encouraging finding from this study was that providers reported that religion, politics and ethnic background did not negatively impact their attitudes and beliefs towards maternal vaccination.
A limitation of this study is that we only included 4 out of 47 counties in Kenya, however the areas selected in our study represented a diversity of geographic areas (low and high population density, urban and rural). Similarly, most of those surveyed were female nurses of Luo ethnicity. Thus, these results may not be representative of the overall KAB among HCWs in Kenya. This might have contributed to the lack of variation in responses which precluded the analysis of predictors. Even though the questionnaire was especially developed based on qualitative work with our target population and it was piloted with practitioners and health workers from the sites of interest, we did not collect data on validity or reliability. Similarly, we did not collect information on the number of providers that were approached and declined to participate. Other limitations are the potential for socially desirable responses. Finally, as previously discussed, only one vaccine (TT) is currently recommended for pregnant women in Kenya.
Taking into account the positive attitudes of healthcare providers, and their recommendations of introduction of new vaccines, this study supports relying on ANC providers as partners to improve maternal vaccine acceptance in Kenya. Campaigns to improve vaccine acceptance in this setting should be implemented in coordination with providers and leverage their willingness to recommend maternal vaccines. It would also be important to identify the sources of training and information that have facilitated this widespread acceptance of maternal immunization among providers in Kenya, and potentially try to replicate these approaches in similar settings.
Harvard Dataverse: Replication Data for: Antenatal care providers’ attitudes and beliefs towards maternal vaccination in Kenya. https://doi.org/10.7910/DVN/43PPDD13
This project contains the following underlying data:
Harvard Dataverse: Replication Data for: Antenatal care providers’ attitudes and beliefs towards maternal vaccination in Kenya. https://doi.org/10.7910/DVN/43PPDD13
The project contains the following extended data:
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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Is the work clearly and accurately presented and does it cite the current literature?
Partly
Is the study design appropriate and is the work technically sound?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Not applicable
Are all the source data underlying the results available to ensure full reproducibility?
No
Are the conclusions drawn adequately supported by the results?
No
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Gynecologic-oncology
Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?
No source data required
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Qualitative research, acceptance of maternal vaccines in low and middle income countries, vaccine confidence and hesitancy.
Alongside their report, reviewers assign a status to the article:
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