Exploring patients' awareness and healthcare professionals' knowledge and attitude to pertussis and influenza vaccination during the antenatal periods in Cavan Monaghan general hospital

ABSTRACT

Infection with Pertussis or with Influenza during the antenatal period usually results in complications leading to severe morbidity and mortality.

Influenza virus outbreak usually occurs almost every year during the winter periods with profound burden on the entire healthcare system. Both disease conditions are preventable with adequate health education and vaccination. Healthcare professionals have a role to play in the communication and provision of this all important health programme.

Objective: We aimed to assess patients' awareness of pertussis and influenza vaccination as well as healthcare professionals' knowledge and attitude to pertussis and influenza vaccination during the antenatal periods in Cavan Monaghan General Hospital.

Design: We performed a prospective cohort study in the antenatal clinics among patients, Non- consultant hospital doctors (NCHDs) and midwives in the maternity unit.

Setting: Our setting was a regional hospital in the North East of the Republic of Ireland with approximately 2000 deliveries per annum.

Participants: These were randomly recruited from those attending routine antenatal clinic during the study period and healthcare professional working in the maternity unit.

Results: Of the 113 antenatal women who completed the questionnaire,. more than 75% have heard of both vaccinations in pregnancy. Interestingly, 51.3% of women heard of the vaccination from their General practitioner (GP) while 1.8% heard of it from their hospital doctor. Despite this awareness, 57.6% and 31.9% of women knew that influenza and pertussis vaccine respectively is safe in pregnancy. The uptake of both vaccines is quite low with 31% for pertussis and 42.5% for influenza vaccine respectively. Despite more than 95% of healthcare professionals being aware of the health service executive (HSE) guidelines on immunisation, more than 75% of healthcare professionals did not receive the influenza vaccinations themselves and had no plans to receive it. More so, only 18% of healthcare professionals always discuss immunisation with antenatal women during their consultations.

Conclusion: Our study identified low pertussis and influenza vaccine uptake among pregnant women and their HCPs. Inadequate knowledge of immunization guidelines among HCPs, lack of insight on the need to get the vaccines among HCPs and poor communication are the probable cause of the low uptake. Hence, the need for more health educational programs to improve health professionals' knowledge and vaccine confidence and also vaccine uptake by patients.

Introduction

Pertussis (whooping cough) is a highly contagious bacterial infection of the respiratory tract caused by Bordetella Pertussis. It affects all ages. However, in newborns of unimmunised women its course could be very severe with complications leading to severe morbidity and mortality. Influenza (Flu) is an infectious respiratory illness caused by the influenza virus with outbreak occurring almost every year during the winter periods with very profound burden on the entire healthcare system.¹

Pregnant women have an increased risk of severe morbidity and mortality when infected with influenza virus while pregnant. More so, infants who are under six months of age are more prone to contracting pertussis. The main rationale for pertussis vaccination is generation of protective immunity in the new born while the rationale for Influenza vaccination is protecting the mother during the vulnerable periods of pregnancy and preventing her from getting sick and infecting the new baby or leading to other complications like, miscarriages, preterm delivery, low birth weight and still birth.² Both infections can be prevented by vaccinating pregnant women during the antenatal period with inactivated influenza virus and pertussis vaccine which are safe in pregnancy and also protects the neonates against pertussis for the first few months of life until the neonate is immunised.

According to HSE guideline on immunisation, whooping cough vaccine is currently given in Ireland as part of the 6-in-1 vaccines. So, apart from whooping cough, this vaccine also protects against diphtheria, tetanus, Heamophilus influenza type b, hepatitis B and polio. Pregnant women should be offered tetanus (T), diphtheria (d) and acellular pertussis (ap) Tdap as early as possible after 16 weeks and up to 36 weeks gestation in each pregnancy, to protect themselves and their infant. Tdap can be given at any time in pregnancy after 36 weeks gestation although it may be less effective in providing passive protection to the infant. Tdap should be offered in the week after delivery to those women who were not vaccinated during their pregnancy. All pregnant women at any stage of pregnancy should receive inactivated influenza vaccine only.^3,13

It is the responsibility of the attending health care professionals (GP or family doctors and Hospital doctors) to discuss and administer these vaccines to their clients.

Pregnant women who were immunised during the antenatal period with pertussis and influenza vaccines produce antibodies which are passed unto their baby through the placenta.^12,14 Hence protecting the unborn baby in the first few weeks of life as the immunity is passed from the mother to the baby. This immunisation could prevent 1–2 hospital admissions per 1000 pregnant women.

As pregnancy increases the risk of complications from influenza and pertussis due to changes in the pregnant woman's immunological functions, lung capacity and heart rate, routine vaccination during the antenatal period is recommended. Numerous studies have been done to ascertain healthcare professional's knowledge and attitude to influenza or pertussis vaccination.^4-9 However, none has been done to explore both patients awareness and healthcare workers knowledge attitude and practice to both influenza and pertussis vaccination during the antenatal period working in the same setting.

There is thus a gap in the literature on patient's perception and healthcare professionals' knowledge, attitude and practice to pertussis and influenza vaccination in an Irish Obstetric population.

Despite the HSE recommendation that women should get Pertussis and Influenza vaccination during each pregnancy even if they have been vaccinated in previous pregnancy, and that healthcare professionals working with susceptible patients should receive the vaccinations as an obligation to their patients unless contraindicated, the uptake for both vaccination during the antenatal period and among healthcare professionals remains low.^10,11

With the rising incidence of pertussis in babies and influenza, we therefore explored patients' awareness and healthcare professionals' knowledge and attitude to pertussis and influenza vaccination during the antenatal periods in Cavan Monaghan General Hospital.

Statistical method

Data was analysed using Statistical Package for Social Science software (SPSS, Chicago, IL. USA) version 23.0. Pearson Chi-square and Fisher's Test was used to compare categorical variables. Unpaired student's t-test was used to compare continuous variables. P values <0.05 were considered statistically significant.

Results

During the study period, 120 antenatal women were administered with the questionnaire out of which 113 women completed and returned the questionnaire. Sixty-seven (67) questionnaires was administered to healthcare professionals (HCPs) in the unit out of which fifty (50) were completed and returned. Baseline characteristics showed that Primiparae and multiparae comprised 43.4% and 56.6% respectively of the study group. From the demographics of the respondents as shown in Table 1, 86% of healthcare professionals had >5 years of clinical experience and 81% of patients were of Irish ethnicity.

Patients
	Frequency				Percentage
	Yes	No	Not sure		Yes		No		Not sure
Have you heard of pertussis vaccination?	87	26	0		76.9		23.1		0
Have you heard of Influenza vaccination?	96	17	0		84.9		15.1		0
Do you know if flu vaccine is safe in pregnancy	65	9	39		57.6		7.9		34.5
Do you know if pertussis vaccine is safe in pregnancy	36	11	66		31.9		9.7		58.4
Have you received whooping cough vaccination in this pregnancy or planning to	35	78	0		31		69		0
if No, Is it due to
Safety concern	32				41
Inadequate information	46				59
Have you received FLU vaccination in this pregnancy or planning to	48	65	0		42.5		57.5		0
if No, Is it due to
Safety concern	31				47.7
Inadequate information	34				52.3
Will you receive both vaccination if they were discussed and offered to you in this pregnancy	33	28	52		29.2		24.8		46
Patient's Source of information
	Frequency					Percentage
Antenatal Classes	12					10.6
Friends	17					15.0
GP	58					51.3
Internet	7					6.0
Pregnancy books	18					15.9
Midwives	23					20.4
Hospital Doctor	2					1.8
	Healthcare Professionals
	Yes	No		Not sure		Yes		No		Not sure
Have you heard of Pertussis and Influenza vaccination	48	2		0		96		4		0
Are you aware of the HSE Guidelines on vaccination in pregnancy	47	3		0		94		6		0
Are you aware of the HSE Guidelines on pertussis and influenza vaccination during the Antenatal period	38	12		0		76		24		0
Should pregnant women be offered pertussis vaccination as early as possible after 16 wks and up to 36 wks gestation in each pregnancy, to protect themselves and their infant	33	3		14		66		6		28
Is the effectiveness of pertussis vaccine in providing passive protection to the infant reduced if given after 36 wks gestation	15	7		28		30		14		56
Should pertussis vaccine be offered in the week after delivery to those women who were not vaccinated during pregnancy	18	10		22		36		20		44
Should all pregnant women at any stage of pregnancy receive influenza vaccination	26	15		9		52		30		18
Should all Health care professionals' who are in contact with infants and pregnant women receive both Vaccination	35	10		5		70		20		10
Pertussis Vaccination is recommended more to protect the baby	40	10		0		80		20		0
Influenza vaccination is recommended to protect the baby	12	38		0		24		76		0
Have you received your seasonal influenza vaccination	12	38		0		24		76		0
If No, Any plans to receive it	8	24		6		16		48		12
Have you ever discussed both vaccination with antenatal patients during your consultations	26	24		0		52		48		0
	Always	Often		Never
How often do you have this discussion	9	17		24		18		34		48

Baseline characteristics of study subjects and their response to questionnaire are shown in the table 1 above.

Table 1.

Baseline characteristics of the study subjects and their questionnaire response.

Age	Frequency	Percentage	Cumulative Percentage
Patients
<20	2	1.8	1.8
20–24	20	17.7	19.5
25–29	24	21.2	40.7
30–34	45	39.8	80.5
>35	22	19.5	100
Total	113	100
Nationality
Irish	92	81.4	81.4
Other EU	18	15.9	97.3
Non-EU	3	2.7	100
Total	113	100
Parity
Primip	49	43.4	43.4
Multip	64	56.6	100
Total	113	100
GA
20–27 wks+6 days	16	14.2	14.2
28–31 wks+6 days	54	47.8	61.9
32–35 wks+6 days	43	38.1	100
Total	113	100
Healthcare Professionals
Age (years)
20–30	10	20	20
>30	40	80	100
Total	50
Number of years of clinical experience
<5	5	10	10
5–10	24	48	58
>10	21	42	100
Total	50	100
Designation
SHO	8	16	16
Midwife	35	70	86
Registrar	7	14	100
Total	50	100

More than 75% of antenatal women have heard of both vaccinations in pregnancy. Interestingly, 51.3% of women heard of the vaccination from their GP while 1.8% heard of it from their hospital doctor. Despite this awareness, 57.6% and 31.9% of women knew that influenza and pertussis vaccine respectively is safe in pregnancy and the uptake of both vaccine was low with 31% for pertussis and 42.5% for influenza vaccine respectively. The reasons given for the poor uptake were safety concerns (41%) and inadequate information (59%) from healthcare professional. Only 29.2% of antenatal women who have not received both vaccines will receive them if they were discussed and offered. The Pearson's r correlation between having heard of influenza vaccine and receiving vaccine is -0.239 and the correlation between knowing flu vaccine is safe and receiving flu vaccine is 0.556. Additionally, while there is no statistically significant relationship between having heard of flu vaccine and receiving, there is however a statistically significant relationship between knowing flu vaccine is safe and receiving it (p<0.001) Just like is the case with flu vaccine, there is a statistically significant relationship between knowing whooping cough vaccine is safe and receiving the vaccine (P<0.005). This is coupled with a strong correlation of 0.761.

We also examined the knowledge, attitude and practices of healthcare practitioners to pertussis and influenza vaccination during the antenatal periods. Of the 50 HCPs that completed and returned their questionnaire, 70% (n = 35) were midwives and 30% (n = 15) were Non Consultant Hospital Doctors.

The overall response rate among HCPs was 75% (50/67) and 44% of respondents had more than 10 years of clinical experience. More than 95% of the respondents were aware of the HSE guideline on influenza and pertussis vaccination during the antenatal periods. However, only 66% (two-third) of respondents knew that pregnant women should be offered pertussis vaccination as early as possible after 16 weeks and up to 36 weeks gestation in each pregnancy to protect themselves and their infants.

Although the majority of healthcare professionals agreed that both vaccinations are useful in protecting susceptible infants, 70% of respondents do not know if the effectiveness of the vaccines in providing passive protection to the infant is reduced if given after 36 weeks gestation. More so, 64% do not know if the vaccinations should be offered in the week after delivery to those women who were not vaccinated during pregnancy. Despite 70% (n = 35) of respondents agreeing that all healthcare professionals who are in contact with infants and pregnant women should receive both vaccinations, 76% (n = 38) have not yet received the seasonal influenza vaccination and have no plans to receive it. 48% of respondents have never discussed it with patients while 34% and 18% of healthcare professionals often and always discuss it respectively. There was a statistically significant relationship between discussion and offering the vaccination and uptake (p<0.001).

There was a weak correlation of 0.17 between HCPs attitude, namely the practice of communicating the need for vaccination to patients and their knowledge of the guideline or their willingness to get vaccinated themselves. As a matter of fact, there is no statistically significant relationship to suggest such relationship. (p = 0.472).

Discussion

Our study setting was a regional hospital in the North East of the Republic of Ireland covering four counties bordering Northern Ireland with approximately 2000 deliveries per annum and an estimated population of about 176,000 according to 2016 census.

This study was unique in that we explored health providers' knowledge and attitude to vaccination and its relationship to patients immunisation uptake during the antenatal period. More so, both study participants are from the same setting.

From our study, we found that majority of women received information on pertussis and influenza vaccination from their General practitioners (GP) and midwives. Despite this awareness, the uptake of both vaccinations during the antenatal period remained low which is consistent with the findings in several studies.^1,3,4,15

Furthermore, safety concerns and inadequate information from healthcare professionals was the main reasons given by pregnant women for not receiving the immunisations. This also was similar in several studies that looked at uptake of influenza vaccination in pregnancy.^5-9 The Pearson's r correlation between having heard of influenza vaccine and receiving vaccine is -0.239 and the correlation between knowing flu vaccine is safe and receiving flu vaccine is 0.556. This means that there is a strong relationship between knowing that flu vaccine is safe and receiving flu vaccine. Additionally, while there is no statistically significant relationship between having heard of flu vaccine and receiving, there is statistically significant relationship between knowing flu vaccine is safe and receiving it. This finding was consistent with other studies that looked at vaccine uptake and reasons for vaccine hesitancy.^4,6,9,10 This in essence implies that both patients and healthcare workers are more likely to have the vaccine if they know that it is safe, rather than merely having heard of it. Just like is the case with flu vaccine, there is a statistically significant relationship between knowing whooping cough vaccine is safe and receiving the vaccine. There exists a definite and statistically significant relationship between intention to comply and knowing that the vaccine is safe. In either case, the results suggests that knowing that the vaccine is safe, although not to a large extent, influences a patient's intention to comply.There was a statistically significant relationship between discussion and offering the vaccination and uptake which is consistent with other studies on vaccine uptake.^6,8,9

Correlation between HCP attitude, namely the practice of communicating the need for vaccination to patients and their knowledge of the guideline or their willingness to get vaccinated themselves suggests that the awareness of guideline has little impact on whether a HCP engages a patient on the need for vaccination or how often he does the same. However, there was a statistically significant relationship between discussion and offering the vaccination and uptake which is consistent with other studies on vaccine uptake.^2,8,9

HCPs knowledge of the recommendation, routine discussion of both vaccines and their administration were all factors strongly associated with improved vaccine uptake by eligible pregnant women.

Method

We performed a prospective cohort study in the antenatal clinics. Our study participants were healthcare professionals (Non- consultant hospital doctors (NCHDs) and Midwives) and pregnant women attending routine antenatal care in Cavan Monaghan General Hospital, a regional hospital in the North East during the study period.

Patients were randomly recruited from those attending routine antenatal clinic during the study period. Healthcare professionals in the department were also invited to participate in the study.

Following informed consent, two separate self-filled questionnaires were administered to the participants.

The following information were recorded from the questionnaire: Patients demographics, whether or not they have heard of the pertussis and influenza vaccination, their source of information, whether or not they knew if the vaccines are safe in pregnancy, whether or not they have received the vaccines, if not; their reason for not receiving it and if they would receive it if it was discussed and offered to them in this pregnancy.

To assess Healthcare professionals knowledge and attitude to pertussis and influenza vaccination during the antenatal periods, midwives and NCHDs working in the obstetric unit of Cavan general hospital were requested to complete a questionnaire.

The following information was gathered: Healthcare professionals demographics and number of years of clinical practice.

To assess their knowledge, we asked the following: Whether or not they have heard of both vaccinations in pregnancy, if they were aware of the HSE guidelines on vaccinations in pregnancy, if they were aware of the HSE guidelines on pertussis and influenza vaccinations during the antenatal periods, should Pregnant women be offered pertussis vaccination as early as possible after 16 weeks and up to 36 weeks gestation in each pregnancy, to protect themselves and their infant? Is the effectiveness of pertussis vaccine in providing passive protection to the infant reduced if given after 36 weeks gestation? Should pertussis vaccine be offered in the week after delivery to those women who were not vaccinated during pregnancy? Should All pregnant women at any stage of pregnancy receive influenza vaccination? Should All Health care professionals who are in contact with infants and pregnant women receive both vaccinations? Is Pertussis vaccination recommended more to protect the baby or mother? and is Influenza vaccination recommended more to protect the baby or mother?

To assess their attitude, we asked: If they have received their seasonal Influenza vaccination? If No, Any plans to receive it? If they have ever discussed both vaccinations with antenatal patients during their consultations with patients? and how often do they have this discussion with antenatal patients.

Conclusions

Our study identified low pertussis and influenza vaccine uptake among pregnant women and their HCPs. Inadequate knowledge of immunization protocols and guidelines among HCPs, lack of insight on the need to get the vaccines among HCPs and poor communication are the probable cause of the low uptake.

We therefore recommend more health educational programs to improve health professionals' knowledge, vaccine confidence and also target their reasons for hesitancy. This in turn will increase vaccine recommendation and uptake among pregnant women. Knowledgeable healthcare professionals need to recommend the vaccine and provide accurate and timely information to increase success of this important programme.

Disclosure of potential conflicts of interest

All authors report no conflicts of interest relevant to this article.

Acknowledgments

We would like to thank all the patients and staff that participated in the study for their time and efforts.

Financial support

No financial support was provided relevant to this article.