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research-article2014
QHRXXX10.1177/1049732314551061Qualitative Health ResearchWiley et al.
Article
Understanding Pregnant Women’s Attitudes and Behavior Toward Influenza and Pertussis Vaccination
Qualitative Health Research 2015, Vol. 25(3) 360–370 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314551061 qhr.sagepub.com
Kerrie E. Wiley1, Spring C. Cooper2, Nicholas Wood1, and Julie Leask2
Abstract Internationally, pregnant and postpartum women have been the focus of influenza and pertussis immunization campaigns, with differing levels of vaccine acceptance. We used semistructured interviews to explore pregnant women’s perspectives on influenza vaccination during pregnancy and postpartum pertussis vaccination. Many women saw pregnancy as a busy time filled with advice on what they “should” and “should not” do to ensure the health of their fetus, and vaccinating themselves was regarded as just one of these tasks needing consideration. Women were more concerned about potential risks to their infants’ health before their own. They saw influenza as a disease affecting the mother, whereas they viewed pertussis as a threat to the baby and therefore comparatively more risky. They were thus more likely to intend to vaccinate against pertussis to protect their infant. Framing of vaccination information toward protection of the baby might help increase vaccine uptake among pregnant women. Keywords decision making; health seeking; immunization; infants; interviews, semistructured; perinatal health; pregnancy; risk, perceptions Influenza and pertussis cause significant morbidity and mortality during pregnancy and early infancy. Influenza infection during pregnancy is associated with increased risk of respiratory hospitalization, preterm delivery, and, in severe cases, admission to intensive care or maternal death (ANZIC Influenza Investigators et al., 2010; Jamieson et al., 2009; McNeil et al., 2011; Rasmussen, Jamieson, & Uyeki, 2012; Tamma, Steinhoff, & Omer, 2010). Pertussis infection in young infants is often severe and potentially fatal, with evidence suggesting that many infants are infected by their mothers (McIntyre & Wood, 2009; Wiley, Zuo, Macartney, & McIntyre, 2013). Vaccinating pregnant women against influenza and pertussis is an emerging public health strategy to prevent these outcomes (Australian Technical Advisory Group on Immunisation [ATAGI], 2008; Centers for Disease Control and Prevention [CDC], 2013; Mosby, Rasmussen, & Jamieson, 2011; National Health Service [UK], 2011). Currently in Australia, influenza vaccination is recommended for all pregnant women, regardless of pregnancy stage (ATAGI, 2013). Influenza vaccine has been shown to be safe to administer during pregnancy and effective in reducing febrile respiratory illness among pregnant women and among their infants during the first 6 months of life (Tamma et al., 2009; Tamma et al., 2010; Zaman et al., 2008).
Under the Australian childhood immunization schedule, infants receive their first pertussis immunization at 6 weeks of age and prior to this are vulnerable to infection. Postnatal pertussis vaccination of new mothers and other close household contacts (i.e., cocooning) is recommended to protect infants from pertussis infection (ATAGI, 2013). Vaccination against pertussis during the later stages of pregnancy, although offered as an alternative to cocooning in Australia, is now the favored approach in some countries (CDC, 2012; National Health Service [UK], 2012; New Zealand Ministry of Health, 2013). There is no evidence that vaccination against pertussis during pregnancy presents a risk to the pregnant woman or her fetus, and it offers the added advantage of protecting the newborn infant through maternal antibody transfer across the placenta (CDC, 2011). 1
The Children’s Hospital at Westmead, Westmead, New South Wales, Australia 2 The University of Sydney, Sydney, New South Wales, Australia Corresponding Author: Kerrie E. Wiley, National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales, 2145, Australia. Email: [email protected]
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Wiley et al. Historically, influenza vaccine uptake has been relatively low among pregnant women, with estimates in Australia ranging from 7% to 40% (McCarthy, Pollock, Nolan, Hay, & McDonald, 2012; White, Petersen, & Quinliven, 2010). There are no published Australian figures for uptake of postnatal pertussis vaccine, but uptake of between 53% and 86% has been shown internationally, which is consistently higher than that for influenza vaccine during pregnancy (Cheng et al., 2010; Healy, Rench, & Baker, 2011). Preliminary data suggest this is also the case with uptake of pertussis vaccine during pregnancy, now recommended in the United Kingdom, with 56% uptake as of January 2014 (United Kingdom Department of Health, 2013). The current focus among public health policy makers is understanding what drives pregnant women to accept vaccination, particularly in light of changing vaccination recommendations, and women’s perception of their susceptibility to specific diseases.
Health Behavior Models The barriers and facilitators to vaccine uptake by pregnant women have been explored in several international studies; the majority of these have been quantitative surveys specific to influenza vaccination. These studies commonly showed that health care provider recommendation and women’s perceived susceptibility to infection were associated with vaccine acceptance during pregnancy (Fridman et al., 2011; Gorman, Brewer, Wang, & Chambers, 2012; Lau, Cai, Tsui, & Choi, 2010; Lu et al., 2012; Naleway, Smith, & Mullooly, 2006). The most commonly cited theoretical approach used to develop these surveys was the health belief model (Armitage & Conner, 2000). This is a motivational model of health behavior which puts forward six determinants of health behavior in an individual: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, motivation, and cues to action. A qualitative study of pregnant women’s willingness to take up a vaccine for Group B Streptococcus showed that women felt there was inadequate information available detailing the risks associated with Group B Streptococcus infection. In agreement with the health belief model, this resulted in a low perception of susceptibility and thus low motivation to accept a vaccine, unless they or someone they knew had experience of the disease. The authors also reported that women do not necessarily base their vaccination decision on “a rational process of weighing risks, or upon scientific evidence” (Patten et al., 2006). Another model that has been used in previous studies is the systems model of clinical preventive care (Walsh & McPhee, 1992). This model incorporates a set of three factors: “pre-disposing” factors such as beliefs, “enabling” factors such as ability to afford a
vaccine, and “reinforcing” factors such as reward. Both patients and physicians are influenced by factors which fall into these three groups and also by organizational factors such as the health care system and cues to action. Interaction between the patient and the physician is a key element in this model. Naleway et al. (2006) examined influenza vaccine uptake during pregnancy—using this model to focus on the interaction between patient and physician—and the barriers and enabling factors affecting vaccination. The authors concluded that interventions to increase influenza vaccine uptake among pregnant women should focus on enabling factors, such as provision of information, and organizational measures, such as easily accessible vaccine. In our study, health behavior models such as the health belief model (Armitage & Conner, 2000) and the systems model of clinical preventive care (Walsh & McPhee, 1992) provided a useful framework to examine pregnant women’s attitudes and risk perception of vaccines and diseases. However, in these models, the preventive measure in question (in this case vaccination) is often examined in isolation. The models therefore fail to capture how the issue of vaccination is situated within the lived pregnancy experience and how that situation might affect vaccination’s relative importance for pregnant women. Sociological literature provided an alternative framework, the construct of “reproductive citizenship” (Lupton, 2012; Salmon, 2010), which enabled us to include vaccination as part of the complexity of the lived pregnancy experience and account for this complexity in ways the health belief model (Armitage & Conner, 2000) and the systems model of clinical preventive care (Walsh & McPhee, 1992) did not. In modern Western societies, a neoliberal approach dominates health care and health promotion. The individual is encouraged to voluntarily comply with accepted “best health care practice” and conform to notions of the responsible, self-interested citizen, rather than being coerced to do so (Lupton, 1995). This is particularly evident during pregnancy. Pregnant women are expected to practice self-regulation and monitoring of their bodies to protect their fetus, which is portrayed as vulnerable to risk, and are encouraged to do everything necessary to ensure optimum fetal development. They are presented with an often contradictory array of information from sources such as the mass media, expert opinions, government, and family or friends (Beck & Beck-Gernsheim, 1995; Lupton, 1999, 2011, 2012, 2013). Ideal mothers-tobe place the highest priority on the needs of their fetuses before their own, and those seen as not conforming to this ideal are admonished and frequently shamed and stigmatized, both by medical professionals and personal contacts (Beck & Beck-Gernsheim, 1995; Lupton, 2013; Salmon, 2010).
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It is from this perspective that the construct of reproductive citizenship arises (Lupton, 2012; Salmon, 2010). Pregnant women are seen as responsible for the well-being of their fetus through regulation of their own behaviors and are exhorted to act in a way which meets society’s expectations of a good “reproductive citizen.” Women are urged to abstain from smoking and alcohol, increase their intake of vitamins and folate, avoid becoming stressed, maintain good health and optimum body weight through diet and exercise, and avoid certain foods and medications (Bell, McNaughton, & Salmon, 2009; Kukla, 2010; Lupton, 1999, 2011, 2012; Lyerly et al., 2009; McNaughton, 2010). Many pregnant women have voluntarily taken up the ideal of the reproductive citizen as part of the practices of pregnancy. They are highly aware that others are judging their behaviors while they are pregnant, and they believe they are responsible for protecting the health of their unborn infant (Burton-Jeangros, 2011; Lupton, 2008).
Aims With this study we aimed to gain an understanding of risk perception of influenza and pertussis and vaccination against these diseases, through the eyes of the pregnant woman, using semistructured qualitative interviews within a grounded theory methodology. We also sought to understand how women constructed notions of risk to themselves and their fetus or infant. From this analysis, we aimed to provide suggestions for how information and vaccination services might be tailored to meet the needs of pregnant women.
Method Participants A total of 815 women took part in an anonymous quantitative survey about pregnant women’s attitudes and awareness toward influenza and pertussis vaccinations (Wiley, Massey, Cooper, Wood, Ho, et al., 2013; Wiley, Massey, Cooper, Wood, Quinn, & Leask, 2013). We also invited each woman to participate in a qualitative interview, and 132 provided contact details. We recruited women from the antenatal clinics of three hospitals in New South Wales, Australia. We sought these hospitals because of the demographic diversity among their combined obstetric population, which enabled us to purposively seek pregnant women with a broad range of perspectives regarding vaccination. We sampled all days of clinic operation and invited all women attending the clinic on those days to take part in the study. The hospitals included in our study were a large tertiary hospital located in the inner city of Sydney which facilitated approximately 5,300 births per year, servicing an area where
50% of residents were tertiary educated, 74% spoke only English at home, and 1.2% identified as Aboriginal or Torres Strait Islander (Australian Bureau of Statistics [ABS], 2013); a large tertiary hospital in the Western suburbs of Sydney which facilitated approximately 4,200 births per year, servicing an area where 14% of residents were tertiary educated, 35% spoke only English at home, and 0.7% identified as Aboriginal or Torres Strait Islander (ABS, 2013); and a rural referral hospital in regional New South Wales which facilitated approximately 800 births per year, through a main clinic and an Aboriginal Community Controlled Health Service, and provided antenatal care for women who lived in regional and remote areas. In the immediate area surrounding this rural hospital, 6.9% of people were tertiary educated, 71% spoke only English at home, and 9.1% identified as Aboriginal or Torres Strait Islander (ABS, 2013).
Interviews Using grounded theory methodology, our study involved a cycle of data collection (interviews) and analysis followed by subsequent interview and analysis cycles. The first author conducted 20 in-depth interviews—9 face-toface and 11 by telephone—between July and November 2011 using a semistructured interview schedule which evolved with each iteration of the grounded theory data collection or analysis cycle (Charmaz, 2006). All participants assumed a pseudonym for the interview, which was used for analysis and reporting purposes. We ceased recruitment when theoretical saturation was reached (Bryant & Charmaz, 2010; Charmaz, 2006). We asked the women about their perception of disease risk for influenza and pertussis, their information needs and sources, and their feelings about receiving the influenza vaccine while pregnant and the pertussis vaccine postpartum, in line with the Australian recommendations at the time (ATAGI, 2008). We recorded all the interviews, and a professional transcription service transcribed them. The first author checked the transcriptions for accuracy. The Human Research Ethics Committees associated with each of the study sites and the New South Wales Aboriginal Health and Medical Research Council provided ethical approval for the study. Each participant gave informed consent following a verbal explanation of the study purpose and requirements in conjunction with a printed patient information leaflet, as per national and institutional guidelines.
Analysis The qualitative arm of the study reported here was executed concurrently with the quantitative survey, the results of which informed qualitative data collection and analysis as the study progressed. Results from the quantitative
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Wiley et al. survey are reported elsewhere (Wiley, Massey, Cooper, Wood, Ho, et al., 2013; Wiley, Massey, Cooper, Wood, Quinn, & Leask, 2013). Grounded theory methodology (Charmaz, 2006) offered a well-established framework with which we could explore maternal vaccination to develop a theory to explain vaccination attitudes and behavior in pregnancy. This inductive approach allowed exploration of the subject at a depth not generally facilitated through quantitative surveys alone. Throughout the process, the first author kept a research journal detailing her experiences and thoughts in relation to the collection, analysis, and reporting of the data. This allowed her to remain aware of the role of her own experiences and viewpoints in the execution and interpretation of the research. We used line-by-line coding (close coding of the interview transcripts to elicit initial themes) followed by focused coding (the synthesis of the themes elicited from line-byline coding into broader categories or concepts) to capture emergent themes from the transcripts. We then used axial coding (the drawing of connections between the elicited themes) to deduce the relationships between the emergent themes (Charmaz, 2006). Throughout the process we remained alert for “divergent” cases that appeared to contradict the patterns emerging from the analysis. We used the appearance of negative cases in the data as an indication that the emergent themes required refinement, in agreement with the approach suggested by Charmaz (2006). Refinement of themes involved an iterative process of moving “in” and “out” of the data, based on the findings of additional interviews, until no new themes were identified and divergent cases were no longer found (theoretical saturation). As the coding cycles developed, the concept of reproductive citizenship provided an ideal conceptual lens for articulating the diversity of women’s positions and information needs around influenza and pertussis vaccination. Using the thematic findings, we then assigned the participants a “type” based on their answers to questions regarding disease risk, informationseeking behavior, and vaccination behavior, taking into account tone and language use. We organized and analyzed the data using NVivo 10 software (2012). We ensured analytical rigor using expert checking: The fourth author, a researcher with extensive experience in the field, independently coded a sample of transcripts from a cross-section of participants. We compared coding and emergent themes and found them to agree.
Findings Factors Influencing Pregnant Women’s Views on Vaccination Most women made mention of their health care provider, the hospital or clinic they were attending, or the government
when discussing influences on their attitudes and actions surrounding vaccination. We considered all these to be individual parts of the government or health care system and designated them an umbrella term, the system, during this analysis. Women reported a significant level of trust in the system. For example, “I’ve got a good [general practitioner], so I would also talk to her if I were unsure”; “ . . . and it’s obviously been researched, well, I believe it is, because it’s coming through the hospital and not just through some pamphlet sitting on the side, you know?”; and “I believe that they [the government] would, like, source the right information, and they would look into it a little bit more and tell me what’s right and what’s wrong.” Women also generally relied on the system to provide them with vaccines in some way, either through clinics, the hospital, or their general practitioner. Some women accessed vaccines through workplace vaccination programs. In this way, women’s trust in the system influenced the information they sought and thus the relative importance of vaccination in their lived experience as pregnant women. The system also influenced the relative priority of acting on vaccination through logistic factors such as access to information (e.g., pamphlets and websites) and, in some cases, access to vaccines themselves (see Figure 1). Women made sense of influenza and pertussis vaccination and disease through the lens of their own experience. A direct experience with either disease created a greater sense of importance and motivation for protection against it. Similarly, women drew on the experiences and opinions of other people, with many citing family and friends as important influences in how they viewed vaccination. For example, “Talking to friends who’ve had babies and that kind of thing had more of an influence on my pregnancy than the relationship I have with her [her general practitioner]”; “My mum is a nurse, she encouraged me to have a flu needle”; and “My husband feels quite strongly about the benefits of immunization and I tend to listen to what he wants as well.” Information sources were important, as were the types of information women sought and how they accessed it. Most women accessed information online, with almost all of them reporting they would use Google to search for influenza- and pertussis-related information. Many made a distinction between information arising from the system (such as government websites) and other sources such as social media, with a preference for information from the system: Only if it’s like a specific website . . . recommended by the government or something . . . not like a dodgy website . . . because I believe that they would, like, source the right information, and they would look into it a little bit more and tell me what’s right and what’s wrong.
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ACCESS TO VACCINE
THE SYSTEM
Experts Government
WORKPLACE
“Reproductive Citizenship”
Hospital
Risk perception in pregnancy
Health care professional
Managing competing priorities (including immunization)
INFORMATION • Internet • Media • Other people • Availabilit y
EXPERIENCE Personal experience of disease • Experiences of other people round them
•
OTHER PEOPLE AROUND PREGNANT WOMEN • Friends • Family • Work colleagues
Figure 1. Factors influencing pregnant women’s management of the competing priorities of pregnancy. Solid arrows indicate that a factor has a direct effect on prioritization during pregnancy; broken arrows indicate an indirect effect through interaction with other factors.
Some women, however, were interested in what other pregnant women thought and did, turning to social media such as blogs. They valued accounts of personal experiences as well as more official sources of knowledge. These women were in stark contrast to the woman quoted above who actively avoided social media sources: “If there’s something I’m really unsure about, I’ll go on the Internet. I’ll, I’ll read blogs about it. I’ll read questions that other people have asked about it.” Furthermore, there was wide variation in women’s reporting of the relative availability of information for pregnant women regarding vaccination, even among women attending the same clinic. For example, “And considering that for some aspects of pregnancy, you’re drowned in information. Flu vaccine is just not one of them,” compared with, I know it’s [influenza vaccination] been discussed numerous times, and there’s a lot of information, I guess, that is available around pamphlets. And I think of all the information the hospital’s given me, the doctor’s given me, it’s always been mentioned in there.
These themes were all intertwined as parts of women’s everyday lives. Axial coding through the reproductive citizenship lens provided a model of how these factors interact to influence how pregnant women construct disease risk. The relative impact of each of these factors varied for each individual and was reliant on that individual’s reproductive citizenship stance (see Figure 1).
Reproductive Citizenship Women’s discussion of disease risk and vaccines during pregnancy was embedded in their notions of their everyday lives as pregnant women. Everyday sources of information were influential in shaping their perceptions and actions. These factors collectively influenced how the women viewed health and risk in the context of pregnancy. As the complexity of the lived pregnancy experience emerged from the data, the construct of reproductive citizenship (Lupton, 2012; Salmon, 2010) was a useful theoretical approach in which to ground our analysis. All of the women interviewed were aware that there were things that they “should” and “should not” do during pregnancy and therefore adhered in some way to the ideal of reproductive citizenship. However, they appeared to fall along a spectrum of reproductive citizenship groups in terms of vaccination decision making: what we termed the “quiescent” reproductive citizen, the “reactive” reproductive citizen, and the “proactive” reproductive citizen (see Figure 2). Using this analysis, we assigned women to groups on this spectrum for both pertussis and influenza, based on their reported informationseeking and vaccination behavior and their tone and language used. Quiescent reproductive citizens passively gained information, usually relying on that given to them through sources in the system such as their health care professional. These women usually accepted a recommended vaccine without question and were not engaged with the subject of the disease being discussed (influenza or
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Spectrum of reproductive citizenship types QUIESCENT
REACTIVE
PROACTIVE
“If the doctor would have instructed me then I would have taken it” “Someone at work had it [pertussis] . . . that prompted me to look online” “I’m covered . . . and I’ve had everyone in my family covered” OR “I considered it . . . and I decided not to do it”
Information-seeking behavior Takes information given to them by health care professionals, does not actively seek information Seeks information only if prompted to do so (e.g. through experience) Proactively seeks information on what is recommended/required
Level of engagement with subject
Vaccination behavior Takes up the vaccine without question if recommended to them
Not engaged
Takes up the vaccine opportunistically, based on perceived need and availability Actively seeks or refuses vaccination for self and/ or family
Engaged with subject
Highly engaged and conversant in the subject
Figure 2. Pregnant women’s information-seeking and vaccination behaviors regarding influenza or pertussis.
pertussis). For example, “If the doctor said yes to take it [the influenza vaccine] then I would have taken it.” Reactive reproductive citizens were engaged with the disease being discussed and had only sought information after being prompted to do so. Like the women quoted below, they often opportunistically accepted recommended vaccines if they were offered at the time of a consultation, “There was actually a case at work a few months ago . . . that did prompt me to look online and see about the dangers of whooping cough during pregnancy”; “My daughter was getting her, um, vaccinations anyway, and I thought, ‘Well, while I’m here—’ [she received her whooping cough vaccine].” Proactive reproductive citizens had actively and independently sought out information on the disease in question and actively sought vaccination (or had refused it). These women were highly engaged and conversant on the subject. For example, I’ve talked to a lot of people about it [pertussis] and, uh, asked the doctor about it as well . . . my husband went and had one, and my parents and my siblings and close friends have gone and had them done, just from me having conversations.
Vaccination in Relation to the Competing Priorities of Pregnancy A recurring theme among the participants was the view that pregnancy is a time of competing priorities. These priorities were related to the list of self-monitoring and health-seeking activities which are routinely recommended as part of modern Western antenatal care. These included, but were not limited to, the necessary blood tests, ultrasounds, blood pressure monitoring, and medical examinations women are required to attend. They also
included the various recommendations around suitable foods (and those to avoid), the correct level of exercise, correct sleeping positions, dietary supplements, relaxation techniques, and so forth. For example, when asked whether she’d considered having an influenza vaccine, one woman replied, Because you’ve got so many other things going on that it’s not something that you’re thinking about, you know? They’re saying take this, take that, and make sure you do this, don’t do that, don’t eat this, don’t eat that, so there’s so many things that you’ve got to remember while you’re pregnant. That’s just another thing that is put to the side and not even thought of because you’re just so busy thinking about everything else.
Women in the quiescent reproductive citizen category tended to rely completely on their health care provider to prioritize for them by bringing what was required to their attention. A typical statement of these women was “As soon as I got told that it was something that you should have while you are pregnant, I got it straight away and I didn’t even think about it.” Some women went so far as to say that it was an expectation they had of their health care professional to tell them what was required “because that should be their job, and they should know what’s right and what’s wrong. And they should be able to give me the right advice.” Health care provider advice was also important in how proactive reproductive citizens prioritized vaccinations. However, for these women, providers acted more as an information source rather than prompting prioritization: I probably would’ve discussed it with my [general practitioner] . . . or I’d go to the Internet as well . . . I’d be
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looking for something that sounded reputable. Something to do with babies and midwifery, and um, yeah, or the medical association or something like that.
Disease Risk Perception Women varied in how actively they sought information about or vaccination against influenza and pertussis. Generally, women were more passive in their information-seeking and vaccination behavior regarding influenza and more active in their information-seeking and vaccination behavior regarding pertussis. This appeared to be related to perceived differences between the two diseases. For example, “It [pertussis] probably scares me more than the flu, as bad as the flu can be. I think whooping cough’s an absolutely terrible thing . . . I prefer to take the risk and get the immunization.” Many women saw influenza as a mild disease. Several spontaneously expressed a concern that they cannot take medication to relieve flu symptoms if they are pregnant, rather than worry about the severity of symptoms or the possibility of hospitalization. The small number of women who took a more active approach to influenza vaccination had personal experience with the disease and therefore a higher perception of disease risk. The following two quotes exemplify these differing perceptions: I guess, you just get it, and you just got to get over it. The only thing I was concerned about—just the relief for myself when I had the flu . . . no one seems to have the answers as to why I can’t take certain things as to relief for myself. Last pregnancy I had flu A, so yes I’ve never been so sick in my life . . . so I think given that I had the disease, the flu, before and I had [it] while I was pregnant and I knew that I was pregnant again made me want to get it [the vaccine] as soon as I could so that hopefully I would avoid getting sick again.
Women also used more emotive and descriptive tone and language when discussing pertussis. For example, “I’ve heard that it’s very scary . . . while I was pregnant, someone at work had been sick and then finally took a few days off and said, ‘Oh yeah, I had whooping cough.’ And I was furious.” The reason for the apparent disparity between influenza and pertussis risk perception appeared to be based in the societal notion that good reproductive citizenship involves the mother protecting her fetus or infant by putting their needs before her own. When asked about their thoughts on the risks of influenza during pregnancy, most women framed their response in relation to their fetus’s health. Many saw influenza as something that would affect themselves only and had not considered whether it would affect their fetus. Women who did mention the risk
to the unborn either referred to their own bodies expending energy fighting an infection, thus taking away resources that would otherwise be used by the fetus, or the possible effects that resultant fevers or necessary medications might have on the fetus. It’s time to nurture a baby as well as fight whatever thing you’ve got . . . a lot of the medication would be frightening to think—a lot you can’t take, and then just the effects that it would have on the growing fetus.
Thus influenza during pregnancy was perceived as a disease of the mother rather than one which directly afflicts the fetus and, therefore, of comparatively lower consequence. By comparison, when asked about their thoughts on pertussis, women saw it as a disease which primarily presents a danger to infants. In answering this question, women’s language was more emotive and visual, with words such as “fragile” and “vulnerable” used when describing infants. Media coverage of pertussis outbreaks lingered in some women’s memories and contributed to their conceptualization of the risks of this illness on young infants: What I’ve seen on the news, and what stayed with me, is the footage of these tiny little babies, you know with the full on body, um, coughing, and it, it, I just think, oh how dreadful.
Women assigned risk according to the risk posed to their fetus or baby, before consideration of risk to themselves, and were more active reproductive citizens when the perceived risk to their fetus or baby increased. In this way, pertussis is seen as of more concern to pregnant women than influenza. A typical example of the differing risk perception is: My perception is that there is no negative effect on the baby if I got the flu. It’s more just the trauma on your own body, I guess, plus having it. Whereas I think, my perception of whooping cough is more that there can be a serious consequence for the baby.
Women did not spontaneously mention the perceived risks of vaccination during pregnancy, and when questioned about how they felt, the majority of women responded that it wasn’t something they’d considered: “I haven’t given it a lot of thought to be honest with you”; and “Um, well, I, I don’t know. I’ve never had the actual flu injection.”
Discussion We examined how pregnant women view influenza and pertussis and how they say they act on vaccinating themselves against these diseases in the context of pregnancy.
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Wiley et al. There are some limitations to this study. Our results cannot be taken as representative of all pregnant women. Theoretical saturation was reached with this sample of women recruited from sites specifically chosen for demographic diversity; however, the inclusion of women from other locations might have yielded themes not identified here. In addition, with this sample we did not seek to explicitly explore the needs of specific cultural groups. Further research is currently underway with Aboriginal and Torres Strait Islander women and their families. Our results agree with the findings of previous studies, including the quantitative arm of the present study. The role of health care professional advice, perceived susceptibility to disease, and social norms surrounding health care practice have all previously been identified as factors associated with vaccination in pregnancy (Fabry, Gagneur, & Pasquier, 2011; Gorman et al., 2012; Lau et al., 2010; Naleway et al., 2006). In the quantitative arm of this study, we found that pregnant women who had received a recommendation to have an influenza vaccine were 20 times more likely to receive the vaccine than those who received no such recommendation; women who had received a recommendation to have the pertussis vaccine postpartum were 7 times more likely to report intention to have the vaccine (Wiley, Massey, Cooper, Wood, Ho, et al., 2013; Wiley, Massey, Cooper, Wood, Quinn, & Leask, 2013). These results confirm our qualitative findings relating to the integral role of the health care provider in how pregnant women view and act on vaccination. Our novel identification of the spectrum of women’s information needs and the way in which they use their health care professional allows for inclusion of the diversity of the lived pregnancy experience. It also provides an understanding of not only the factors involved in vaccination decision making but also the place occupied by vaccination in relation to the other priorities of pregnancy. When viewed in light of the concept of reproductive citizenship, we found that women can be grouped into a spectrum of categories: quiescent, reactive, and proactive. The concepts of active/passive vaccination behavior have arisen in previous qualitative research to explain human papillomavirus vaccine uptake by adolescent girls (Cooper Robbins, Bernard, McCaffery, Brotherton, & Skinner, 2010). Our findings indicate that women’s categorization as quiescent, reactive, and proactive reproductive citizens is modified by whether the disease for prevention is influenza or pertussis. This appears to be related to how women assign risk during pregnancy. Risk was usually assigned according to the risk posed to the fetus or newborn infant, before risk to the women themselves, and also through personal experience of the disease. Thus, pertussis was seen as a more serious disease
than influenza because it directly affects the fetus or infant, whereas influenza was seen primarily as a disease affecting the mother, with only secondary effects on the baby. These perceptions might be one possible factor in the reported differences in the uptake of influenza and pertussis vaccines by pregnant women. Women saw vaccination as one of many things they had to consider during pregnancy. How women managed these competing priorities was also related to reproductive citizenship. Quiescent reproductive citizens relied on their health care provider to assign priority to vaccination for them, whereas more proactive reproductive citizens assigned priority to vaccination themselves, using their health care provider primarily as a source of information. The fact that women did not spontaneously mention the perceived risks of vaccination during pregnancy was notable. The general approach of abstaining from medications normally associated with modern Western antenatal care would suggest that women would be cautious about the possible effects of vaccination on the unborn baby; however, our findings indicate that most women had not thought about it previously and would refer to their health care provider for guidance if they were unsure. This further highlights the importance of the trust women place in their health care provider and the importance of provider recommendation of vaccines. The health system these pregnant women access is largely oriented toward women who actively seek information and vaccination. Vaccine availability is highly variable among institutions within the system, with onsite vaccination clinics available in some settings but not others (Wiley, Massey, Cooper, Wood, Ho, et al., 2013). Many women must actively pursue the vaccine through a separate general practitioner visit. Our data also indicate variations in the perceived availability of information. Systemic provision of vaccines and information would cater for women across the entire spectrum of reproductive citizenship, including those who are passive in their approach. Our data show that the participants were largely unaware of the risks posed by influenza to their own health or to that of their unborn infant, and these risks require greater acknowledgment in education resources for pregnant women. Our data also indicate that framing of this information toward protecting the fetus/baby would be key to encouraging pregnant women to take up vaccine. Furthermore, consistent recommendations from providers and greater vaccine availability would cater to women who were more passive in their seeking of information and vaccines. These measures would provide more equitable access for women to a measure which has the potential to prevent morbidity and mortality in themselves and their infants.
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Acknowledgments We gratefully acknowledge Professor Deborah Lupton for her guidance and thank the staff and patients at the participating study institutions.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research was funded by a grant from the Financial Markets Foundation for Children (Grant 2010-099). Julie Leask is supported by a NHMRC Career Development Fellowship (APP1053473).
References ANZIC Influenza Investigators, Webb, S. A., Pettila, V., Seppelt, I., Bellomo, R., Bailey, M., . . . Yung, M. (2010). Critical illness due to 2009 A/H1N1 influenza in pregnant and postpartum women: Population based cohort study. British Medical Journal, 340, Article 751. doi:10.1136/ bmj.c1279 Armitage, C. J., & Conner, M. (2000). Social cognition models and health behaviour: A structured review. Psychology & Health, 15, 173–189. doi:10.1080/08870440008400299 Australian Bureau of Statistics. (2013). Census, Quickstats, 2011. Retrieved from http://www.abs.gov.au/websitedbs/ censushome.nsf/home/quickstats Australian Technical Advisory Group on Immunisation. (2008). The Australian immunisation handbook (9th ed.). Canberra: Australian Government Department of Health and Ageing. Australian Technical Advisory Group on Immunisation. (2013). The Australian immunisation handbook (10th ed.). Canberra: Australian Government Department of Health and Ageing. Beck, U., & Beck-Gernsheim, E. (1995). The normal chaos of love. Cambridge, MA: Blackwell. Bell, K., McNaughton, D., & Salmon, A. (2009). Medicine, morality and mothering: Public health discourses on foetal alcohol exposure, smoking around children and childhood overnutrition. Critical Public Health, 19, 155–170. doi:10.1080/09581590802385664 Bryant, A., & Charmaz, K. (Eds.). (2010). The SAGE handbook of grounded theory. London: SAGE. Burton-Jeangros, C. (2011). Surveillance of risks in everyday life: The agency of pregnant women and its limitations. Social Theory & Health, 9, 419–436. doi:10.1057/ sth.2011.15 Centers for Disease Control and Prevention. (2011). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have or anticipate having close contact with an infant aged
research-article2014
QHRXXX10.1177/1049732314551061Qualitative Health ResearchWiley et al.
Article
Understanding Pregnant Women’s Attitudes and Behavior Toward Influenza and Pertussis Vaccination
Qualitative Health Research 2015, Vol. 25(3) 360–370 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314551061 qhr.sagepub.com
Kerrie E. Wiley1, Spring C. Cooper2, Nicholas Wood1, and Julie Leask2
Abstract Internationally, pregnant and postpartum women have been the focus of influenza and pertussis immunization campaigns, with differing levels of vaccine acceptance. We used semistructured interviews to explore pregnant women’s perspectives on influenza vaccination during pregnancy and postpartum pertussis vaccination. Many women saw pregnancy as a busy time filled with advice on what they “should” and “should not” do to ensure the health of their fetus, and vaccinating themselves was regarded as just one of these tasks needing consideration. Women were more concerned about potential risks to their infants’ health before their own. They saw influenza as a disease affecting the mother, whereas they viewed pertussis as a threat to the baby and therefore comparatively more risky. They were thus more likely to intend to vaccinate against pertussis to protect their infant. Framing of vaccination information toward protection of the baby might help increase vaccine uptake among pregnant women. Keywords decision making; health seeking; immunization; infants; interviews, semistructured; perinatal health; pregnancy; risk, perceptions Influenza and pertussis cause significant morbidity and mortality during pregnancy and early infancy. Influenza infection during pregnancy is associated with increased risk of respiratory hospitalization, preterm delivery, and, in severe cases, admission to intensive care or maternal death (ANZIC Influenza Investigators et al., 2010; Jamieson et al., 2009; McNeil et al., 2011; Rasmussen, Jamieson, & Uyeki, 2012; Tamma, Steinhoff, & Omer, 2010). Pertussis infection in young infants is often severe and potentially fatal, with evidence suggesting that many infants are infected by their mothers (McIntyre & Wood, 2009; Wiley, Zuo, Macartney, & McIntyre, 2013). Vaccinating pregnant women against influenza and pertussis is an emerging public health strategy to prevent these outcomes (Australian Technical Advisory Group on Immunisation [ATAGI], 2008; Centers for Disease Control and Prevention [CDC], 2013; Mosby, Rasmussen, & Jamieson, 2011; National Health Service [UK], 2011). Currently in Australia, influenza vaccination is recommended for all pregnant women, regardless of pregnancy stage (ATAGI, 2013). Influenza vaccine has been shown to be safe to administer during pregnancy and effective in reducing febrile respiratory illness among pregnant women and among their infants during the first 6 months of life (Tamma et al., 2009; Tamma et al., 2010; Zaman et al., 2008).
Under the Australian childhood immunization schedule, infants receive their first pertussis immunization at 6 weeks of age and prior to this are vulnerable to infection. Postnatal pertussis vaccination of new mothers and other close household contacts (i.e., cocooning) is recommended to protect infants from pertussis infection (ATAGI, 2013). Vaccination against pertussis during the later stages of pregnancy, although offered as an alternative to cocooning in Australia, is now the favored approach in some countries (CDC, 2012; National Health Service [UK], 2012; New Zealand Ministry of Health, 2013). There is no evidence that vaccination against pertussis during pregnancy presents a risk to the pregnant woman or her fetus, and it offers the added advantage of protecting the newborn infant through maternal antibody transfer across the placenta (CDC, 2011). 1
The Children’s Hospital at Westmead, Westmead, New South Wales, Australia 2 The University of Sydney, Sydney, New South Wales, Australia Corresponding Author: Kerrie E. Wiley, National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales, 2145, Australia. Email: [email protected]
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Wiley et al. Historically, influenza vaccine uptake has been relatively low among pregnant women, with estimates in Australia ranging from 7% to 40% (McCarthy, Pollock, Nolan, Hay, & McDonald, 2012; White, Petersen, & Quinliven, 2010). There are no published Australian figures for uptake of postnatal pertussis vaccine, but uptake of between 53% and 86% has been shown internationally, which is consistently higher than that for influenza vaccine during pregnancy (Cheng et al., 2010; Healy, Rench, & Baker, 2011). Preliminary data suggest this is also the case with uptake of pertussis vaccine during pregnancy, now recommended in the United Kingdom, with 56% uptake as of January 2014 (United Kingdom Department of Health, 2013). The current focus among public health policy makers is understanding what drives pregnant women to accept vaccination, particularly in light of changing vaccination recommendations, and women’s perception of their susceptibility to specific diseases.
Health Behavior Models The barriers and facilitators to vaccine uptake by pregnant women have been explored in several international studies; the majority of these have been quantitative surveys specific to influenza vaccination. These studies commonly showed that health care provider recommendation and women’s perceived susceptibility to infection were associated with vaccine acceptance during pregnancy (Fridman et al., 2011; Gorman, Brewer, Wang, & Chambers, 2012; Lau, Cai, Tsui, & Choi, 2010; Lu et al., 2012; Naleway, Smith, & Mullooly, 2006). The most commonly cited theoretical approach used to develop these surveys was the health belief model (Armitage & Conner, 2000). This is a motivational model of health behavior which puts forward six determinants of health behavior in an individual: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, motivation, and cues to action. A qualitative study of pregnant women’s willingness to take up a vaccine for Group B Streptococcus showed that women felt there was inadequate information available detailing the risks associated with Group B Streptococcus infection. In agreement with the health belief model, this resulted in a low perception of susceptibility and thus low motivation to accept a vaccine, unless they or someone they knew had experience of the disease. The authors also reported that women do not necessarily base their vaccination decision on “a rational process of weighing risks, or upon scientific evidence” (Patten et al., 2006). Another model that has been used in previous studies is the systems model of clinical preventive care (Walsh & McPhee, 1992). This model incorporates a set of three factors: “pre-disposing” factors such as beliefs, “enabling” factors such as ability to afford a
vaccine, and “reinforcing” factors such as reward. Both patients and physicians are influenced by factors which fall into these three groups and also by organizational factors such as the health care system and cues to action. Interaction between the patient and the physician is a key element in this model. Naleway et al. (2006) examined influenza vaccine uptake during pregnancy—using this model to focus on the interaction between patient and physician—and the barriers and enabling factors affecting vaccination. The authors concluded that interventions to increase influenza vaccine uptake among pregnant women should focus on enabling factors, such as provision of information, and organizational measures, such as easily accessible vaccine. In our study, health behavior models such as the health belief model (Armitage & Conner, 2000) and the systems model of clinical preventive care (Walsh & McPhee, 1992) provided a useful framework to examine pregnant women’s attitudes and risk perception of vaccines and diseases. However, in these models, the preventive measure in question (in this case vaccination) is often examined in isolation. The models therefore fail to capture how the issue of vaccination is situated within the lived pregnancy experience and how that situation might affect vaccination’s relative importance for pregnant women. Sociological literature provided an alternative framework, the construct of “reproductive citizenship” (Lupton, 2012; Salmon, 2010), which enabled us to include vaccination as part of the complexity of the lived pregnancy experience and account for this complexity in ways the health belief model (Armitage & Conner, 2000) and the systems model of clinical preventive care (Walsh & McPhee, 1992) did not. In modern Western societies, a neoliberal approach dominates health care and health promotion. The individual is encouraged to voluntarily comply with accepted “best health care practice” and conform to notions of the responsible, self-interested citizen, rather than being coerced to do so (Lupton, 1995). This is particularly evident during pregnancy. Pregnant women are expected to practice self-regulation and monitoring of their bodies to protect their fetus, which is portrayed as vulnerable to risk, and are encouraged to do everything necessary to ensure optimum fetal development. They are presented with an often contradictory array of information from sources such as the mass media, expert opinions, government, and family or friends (Beck & Beck-Gernsheim, 1995; Lupton, 1999, 2011, 2012, 2013). Ideal mothers-tobe place the highest priority on the needs of their fetuses before their own, and those seen as not conforming to this ideal are admonished and frequently shamed and stigmatized, both by medical professionals and personal contacts (Beck & Beck-Gernsheim, 1995; Lupton, 2013; Salmon, 2010).
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It is from this perspective that the construct of reproductive citizenship arises (Lupton, 2012; Salmon, 2010). Pregnant women are seen as responsible for the well-being of their fetus through regulation of their own behaviors and are exhorted to act in a way which meets society’s expectations of a good “reproductive citizen.” Women are urged to abstain from smoking and alcohol, increase their intake of vitamins and folate, avoid becoming stressed, maintain good health and optimum body weight through diet and exercise, and avoid certain foods and medications (Bell, McNaughton, & Salmon, 2009; Kukla, 2010; Lupton, 1999, 2011, 2012; Lyerly et al., 2009; McNaughton, 2010). Many pregnant women have voluntarily taken up the ideal of the reproductive citizen as part of the practices of pregnancy. They are highly aware that others are judging their behaviors while they are pregnant, and they believe they are responsible for protecting the health of their unborn infant (Burton-Jeangros, 2011; Lupton, 2008).
Aims With this study we aimed to gain an understanding of risk perception of influenza and pertussis and vaccination against these diseases, through the eyes of the pregnant woman, using semistructured qualitative interviews within a grounded theory methodology. We also sought to understand how women constructed notions of risk to themselves and their fetus or infant. From this analysis, we aimed to provide suggestions for how information and vaccination services might be tailored to meet the needs of pregnant women.
Method Participants A total of 815 women took part in an anonymous quantitative survey about pregnant women’s attitudes and awareness toward influenza and pertussis vaccinations (Wiley, Massey, Cooper, Wood, Ho, et al., 2013; Wiley, Massey, Cooper, Wood, Quinn, & Leask, 2013). We also invited each woman to participate in a qualitative interview, and 132 provided contact details. We recruited women from the antenatal clinics of three hospitals in New South Wales, Australia. We sought these hospitals because of the demographic diversity among their combined obstetric population, which enabled us to purposively seek pregnant women with a broad range of perspectives regarding vaccination. We sampled all days of clinic operation and invited all women attending the clinic on those days to take part in the study. The hospitals included in our study were a large tertiary hospital located in the inner city of Sydney which facilitated approximately 5,300 births per year, servicing an area where
50% of residents were tertiary educated, 74% spoke only English at home, and 1.2% identified as Aboriginal or Torres Strait Islander (Australian Bureau of Statistics [ABS], 2013); a large tertiary hospital in the Western suburbs of Sydney which facilitated approximately 4,200 births per year, servicing an area where 14% of residents were tertiary educated, 35% spoke only English at home, and 0.7% identified as Aboriginal or Torres Strait Islander (ABS, 2013); and a rural referral hospital in regional New South Wales which facilitated approximately 800 births per year, through a main clinic and an Aboriginal Community Controlled Health Service, and provided antenatal care for women who lived in regional and remote areas. In the immediate area surrounding this rural hospital, 6.9% of people were tertiary educated, 71% spoke only English at home, and 9.1% identified as Aboriginal or Torres Strait Islander (ABS, 2013).
Interviews Using grounded theory methodology, our study involved a cycle of data collection (interviews) and analysis followed by subsequent interview and analysis cycles. The first author conducted 20 in-depth interviews—9 face-toface and 11 by telephone—between July and November 2011 using a semistructured interview schedule which evolved with each iteration of the grounded theory data collection or analysis cycle (Charmaz, 2006). All participants assumed a pseudonym for the interview, which was used for analysis and reporting purposes. We ceased recruitment when theoretical saturation was reached (Bryant & Charmaz, 2010; Charmaz, 2006). We asked the women about their perception of disease risk for influenza and pertussis, their information needs and sources, and their feelings about receiving the influenza vaccine while pregnant and the pertussis vaccine postpartum, in line with the Australian recommendations at the time (ATAGI, 2008). We recorded all the interviews, and a professional transcription service transcribed them. The first author checked the transcriptions for accuracy. The Human Research Ethics Committees associated with each of the study sites and the New South Wales Aboriginal Health and Medical Research Council provided ethical approval for the study. Each participant gave informed consent following a verbal explanation of the study purpose and requirements in conjunction with a printed patient information leaflet, as per national and institutional guidelines.
Analysis The qualitative arm of the study reported here was executed concurrently with the quantitative survey, the results of which informed qualitative data collection and analysis as the study progressed. Results from the quantitative
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Wiley et al. survey are reported elsewhere (Wiley, Massey, Cooper, Wood, Ho, et al., 2013; Wiley, Massey, Cooper, Wood, Quinn, & Leask, 2013). Grounded theory methodology (Charmaz, 2006) offered a well-established framework with which we could explore maternal vaccination to develop a theory to explain vaccination attitudes and behavior in pregnancy. This inductive approach allowed exploration of the subject at a depth not generally facilitated through quantitative surveys alone. Throughout the process, the first author kept a research journal detailing her experiences and thoughts in relation to the collection, analysis, and reporting of the data. This allowed her to remain aware of the role of her own experiences and viewpoints in the execution and interpretation of the research. We used line-by-line coding (close coding of the interview transcripts to elicit initial themes) followed by focused coding (the synthesis of the themes elicited from line-byline coding into broader categories or concepts) to capture emergent themes from the transcripts. We then used axial coding (the drawing of connections between the elicited themes) to deduce the relationships between the emergent themes (Charmaz, 2006). Throughout the process we remained alert for “divergent” cases that appeared to contradict the patterns emerging from the analysis. We used the appearance of negative cases in the data as an indication that the emergent themes required refinement, in agreement with the approach suggested by Charmaz (2006). Refinement of themes involved an iterative process of moving “in” and “out” of the data, based on the findings of additional interviews, until no new themes were identified and divergent cases were no longer found (theoretical saturation). As the coding cycles developed, the concept of reproductive citizenship provided an ideal conceptual lens for articulating the diversity of women’s positions and information needs around influenza and pertussis vaccination. Using the thematic findings, we then assigned the participants a “type” based on their answers to questions regarding disease risk, informationseeking behavior, and vaccination behavior, taking into account tone and language use. We organized and analyzed the data using NVivo 10 software (2012). We ensured analytical rigor using expert checking: The fourth author, a researcher with extensive experience in the field, independently coded a sample of transcripts from a cross-section of participants. We compared coding and emergent themes and found them to agree.
Findings Factors Influencing Pregnant Women’s Views on Vaccination Most women made mention of their health care provider, the hospital or clinic they were attending, or the government
when discussing influences on their attitudes and actions surrounding vaccination. We considered all these to be individual parts of the government or health care system and designated them an umbrella term, the system, during this analysis. Women reported a significant level of trust in the system. For example, “I’ve got a good [general practitioner], so I would also talk to her if I were unsure”; “ . . . and it’s obviously been researched, well, I believe it is, because it’s coming through the hospital and not just through some pamphlet sitting on the side, you know?”; and “I believe that they [the government] would, like, source the right information, and they would look into it a little bit more and tell me what’s right and what’s wrong.” Women also generally relied on the system to provide them with vaccines in some way, either through clinics, the hospital, or their general practitioner. Some women accessed vaccines through workplace vaccination programs. In this way, women’s trust in the system influenced the information they sought and thus the relative importance of vaccination in their lived experience as pregnant women. The system also influenced the relative priority of acting on vaccination through logistic factors such as access to information (e.g., pamphlets and websites) and, in some cases, access to vaccines themselves (see Figure 1). Women made sense of influenza and pertussis vaccination and disease through the lens of their own experience. A direct experience with either disease created a greater sense of importance and motivation for protection against it. Similarly, women drew on the experiences and opinions of other people, with many citing family and friends as important influences in how they viewed vaccination. For example, “Talking to friends who’ve had babies and that kind of thing had more of an influence on my pregnancy than the relationship I have with her [her general practitioner]”; “My mum is a nurse, she encouraged me to have a flu needle”; and “My husband feels quite strongly about the benefits of immunization and I tend to listen to what he wants as well.” Information sources were important, as were the types of information women sought and how they accessed it. Most women accessed information online, with almost all of them reporting they would use Google to search for influenza- and pertussis-related information. Many made a distinction between information arising from the system (such as government websites) and other sources such as social media, with a preference for information from the system: Only if it’s like a specific website . . . recommended by the government or something . . . not like a dodgy website . . . because I believe that they would, like, source the right information, and they would look into it a little bit more and tell me what’s right and what’s wrong.
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ACCESS TO VACCINE
THE SYSTEM
Experts Government
WORKPLACE
“Reproductive Citizenship”
Hospital
Risk perception in pregnancy
Health care professional
Managing competing priorities (including immunization)
INFORMATION • Internet • Media • Other people • Availabilit y
EXPERIENCE Personal experience of disease • Experiences of other people round them
•
OTHER PEOPLE AROUND PREGNANT WOMEN • Friends • Family • Work colleagues
Figure 1. Factors influencing pregnant women’s management of the competing priorities of pregnancy. Solid arrows indicate that a factor has a direct effect on prioritization during pregnancy; broken arrows indicate an indirect effect through interaction with other factors.
Some women, however, were interested in what other pregnant women thought and did, turning to social media such as blogs. They valued accounts of personal experiences as well as more official sources of knowledge. These women were in stark contrast to the woman quoted above who actively avoided social media sources: “If there’s something I’m really unsure about, I’ll go on the Internet. I’ll, I’ll read blogs about it. I’ll read questions that other people have asked about it.” Furthermore, there was wide variation in women’s reporting of the relative availability of information for pregnant women regarding vaccination, even among women attending the same clinic. For example, “And considering that for some aspects of pregnancy, you’re drowned in information. Flu vaccine is just not one of them,” compared with, I know it’s [influenza vaccination] been discussed numerous times, and there’s a lot of information, I guess, that is available around pamphlets. And I think of all the information the hospital’s given me, the doctor’s given me, it’s always been mentioned in there.
These themes were all intertwined as parts of women’s everyday lives. Axial coding through the reproductive citizenship lens provided a model of how these factors interact to influence how pregnant women construct disease risk. The relative impact of each of these factors varied for each individual and was reliant on that individual’s reproductive citizenship stance (see Figure 1).
Reproductive Citizenship Women’s discussion of disease risk and vaccines during pregnancy was embedded in their notions of their everyday lives as pregnant women. Everyday sources of information were influential in shaping their perceptions and actions. These factors collectively influenced how the women viewed health and risk in the context of pregnancy. As the complexity of the lived pregnancy experience emerged from the data, the construct of reproductive citizenship (Lupton, 2012; Salmon, 2010) was a useful theoretical approach in which to ground our analysis. All of the women interviewed were aware that there were things that they “should” and “should not” do during pregnancy and therefore adhered in some way to the ideal of reproductive citizenship. However, they appeared to fall along a spectrum of reproductive citizenship groups in terms of vaccination decision making: what we termed the “quiescent” reproductive citizen, the “reactive” reproductive citizen, and the “proactive” reproductive citizen (see Figure 2). Using this analysis, we assigned women to groups on this spectrum for both pertussis and influenza, based on their reported informationseeking and vaccination behavior and their tone and language used. Quiescent reproductive citizens passively gained information, usually relying on that given to them through sources in the system such as their health care professional. These women usually accepted a recommended vaccine without question and were not engaged with the subject of the disease being discussed (influenza or
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Spectrum of reproductive citizenship types QUIESCENT
REACTIVE
PROACTIVE
“If the doctor would have instructed me then I would have taken it” “Someone at work had it [pertussis] . . . that prompted me to look online” “I’m covered . . . and I’ve had everyone in my family covered” OR “I considered it . . . and I decided not to do it”
Information-seeking behavior Takes information given to them by health care professionals, does not actively seek information Seeks information only if prompted to do so (e.g. through experience) Proactively seeks information on what is recommended/required
Level of engagement with subject
Vaccination behavior Takes up the vaccine without question if recommended to them
Not engaged
Takes up the vaccine opportunistically, based on perceived need and availability Actively seeks or refuses vaccination for self and/ or family
Engaged with subject
Highly engaged and conversant in the subject
Figure 2. Pregnant women’s information-seeking and vaccination behaviors regarding influenza or pertussis.
pertussis). For example, “If the doctor said yes to take it [the influenza vaccine] then I would have taken it.” Reactive reproductive citizens were engaged with the disease being discussed and had only sought information after being prompted to do so. Like the women quoted below, they often opportunistically accepted recommended vaccines if they were offered at the time of a consultation, “There was actually a case at work a few months ago . . . that did prompt me to look online and see about the dangers of whooping cough during pregnancy”; “My daughter was getting her, um, vaccinations anyway, and I thought, ‘Well, while I’m here—’ [she received her whooping cough vaccine].” Proactive reproductive citizens had actively and independently sought out information on the disease in question and actively sought vaccination (or had refused it). These women were highly engaged and conversant on the subject. For example, I’ve talked to a lot of people about it [pertussis] and, uh, asked the doctor about it as well . . . my husband went and had one, and my parents and my siblings and close friends have gone and had them done, just from me having conversations.
Vaccination in Relation to the Competing Priorities of Pregnancy A recurring theme among the participants was the view that pregnancy is a time of competing priorities. These priorities were related to the list of self-monitoring and health-seeking activities which are routinely recommended as part of modern Western antenatal care. These included, but were not limited to, the necessary blood tests, ultrasounds, blood pressure monitoring, and medical examinations women are required to attend. They also
included the various recommendations around suitable foods (and those to avoid), the correct level of exercise, correct sleeping positions, dietary supplements, relaxation techniques, and so forth. For example, when asked whether she’d considered having an influenza vaccine, one woman replied, Because you’ve got so many other things going on that it’s not something that you’re thinking about, you know? They’re saying take this, take that, and make sure you do this, don’t do that, don’t eat this, don’t eat that, so there’s so many things that you’ve got to remember while you’re pregnant. That’s just another thing that is put to the side and not even thought of because you’re just so busy thinking about everything else.
Women in the quiescent reproductive citizen category tended to rely completely on their health care provider to prioritize for them by bringing what was required to their attention. A typical statement of these women was “As soon as I got told that it was something that you should have while you are pregnant, I got it straight away and I didn’t even think about it.” Some women went so far as to say that it was an expectation they had of their health care professional to tell them what was required “because that should be their job, and they should know what’s right and what’s wrong. And they should be able to give me the right advice.” Health care provider advice was also important in how proactive reproductive citizens prioritized vaccinations. However, for these women, providers acted more as an information source rather than prompting prioritization: I probably would’ve discussed it with my [general practitioner] . . . or I’d go to the Internet as well . . . I’d be
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looking for something that sounded reputable. Something to do with babies and midwifery, and um, yeah, or the medical association or something like that.
Disease Risk Perception Women varied in how actively they sought information about or vaccination against influenza and pertussis. Generally, women were more passive in their information-seeking and vaccination behavior regarding influenza and more active in their information-seeking and vaccination behavior regarding pertussis. This appeared to be related to perceived differences between the two diseases. For example, “It [pertussis] probably scares me more than the flu, as bad as the flu can be. I think whooping cough’s an absolutely terrible thing . . . I prefer to take the risk and get the immunization.” Many women saw influenza as a mild disease. Several spontaneously expressed a concern that they cannot take medication to relieve flu symptoms if they are pregnant, rather than worry about the severity of symptoms or the possibility of hospitalization. The small number of women who took a more active approach to influenza vaccination had personal experience with the disease and therefore a higher perception of disease risk. The following two quotes exemplify these differing perceptions: I guess, you just get it, and you just got to get over it. The only thing I was concerned about—just the relief for myself when I had the flu . . . no one seems to have the answers as to why I can’t take certain things as to relief for myself. Last pregnancy I had flu A, so yes I’ve never been so sick in my life . . . so I think given that I had the disease, the flu, before and I had [it] while I was pregnant and I knew that I was pregnant again made me want to get it [the vaccine] as soon as I could so that hopefully I would avoid getting sick again.
Women also used more emotive and descriptive tone and language when discussing pertussis. For example, “I’ve heard that it’s very scary . . . while I was pregnant, someone at work had been sick and then finally took a few days off and said, ‘Oh yeah, I had whooping cough.’ And I was furious.” The reason for the apparent disparity between influenza and pertussis risk perception appeared to be based in the societal notion that good reproductive citizenship involves the mother protecting her fetus or infant by putting their needs before her own. When asked about their thoughts on the risks of influenza during pregnancy, most women framed their response in relation to their fetus’s health. Many saw influenza as something that would affect themselves only and had not considered whether it would affect their fetus. Women who did mention the risk
to the unborn either referred to their own bodies expending energy fighting an infection, thus taking away resources that would otherwise be used by the fetus, or the possible effects that resultant fevers or necessary medications might have on the fetus. It’s time to nurture a baby as well as fight whatever thing you’ve got . . . a lot of the medication would be frightening to think—a lot you can’t take, and then just the effects that it would have on the growing fetus.
Thus influenza during pregnancy was perceived as a disease of the mother rather than one which directly afflicts the fetus and, therefore, of comparatively lower consequence. By comparison, when asked about their thoughts on pertussis, women saw it as a disease which primarily presents a danger to infants. In answering this question, women’s language was more emotive and visual, with words such as “fragile” and “vulnerable” used when describing infants. Media coverage of pertussis outbreaks lingered in some women’s memories and contributed to their conceptualization of the risks of this illness on young infants: What I’ve seen on the news, and what stayed with me, is the footage of these tiny little babies, you know with the full on body, um, coughing, and it, it, I just think, oh how dreadful.
Women assigned risk according to the risk posed to their fetus or baby, before consideration of risk to themselves, and were more active reproductive citizens when the perceived risk to their fetus or baby increased. In this way, pertussis is seen as of more concern to pregnant women than influenza. A typical example of the differing risk perception is: My perception is that there is no negative effect on the baby if I got the flu. It’s more just the trauma on your own body, I guess, plus having it. Whereas I think, my perception of whooping cough is more that there can be a serious consequence for the baby.
Women did not spontaneously mention the perceived risks of vaccination during pregnancy, and when questioned about how they felt, the majority of women responded that it wasn’t something they’d considered: “I haven’t given it a lot of thought to be honest with you”; and “Um, well, I, I don’t know. I’ve never had the actual flu injection.”
Discussion We examined how pregnant women view influenza and pertussis and how they say they act on vaccinating themselves against these diseases in the context of pregnancy.
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Wiley et al. There are some limitations to this study. Our results cannot be taken as representative of all pregnant women. Theoretical saturation was reached with this sample of women recruited from sites specifically chosen for demographic diversity; however, the inclusion of women from other locations might have yielded themes not identified here. In addition, with this sample we did not seek to explicitly explore the needs of specific cultural groups. Further research is currently underway with Aboriginal and Torres Strait Islander women and their families. Our results agree with the findings of previous studies, including the quantitative arm of the present study. The role of health care professional advice, perceived susceptibility to disease, and social norms surrounding health care practice have all previously been identified as factors associated with vaccination in pregnancy (Fabry, Gagneur, & Pasquier, 2011; Gorman et al., 2012; Lau et al., 2010; Naleway et al., 2006). In the quantitative arm of this study, we found that pregnant women who had received a recommendation to have an influenza vaccine were 20 times more likely to receive the vaccine than those who received no such recommendation; women who had received a recommendation to have the pertussis vaccine postpartum were 7 times more likely to report intention to have the vaccine (Wiley, Massey, Cooper, Wood, Ho, et al., 2013; Wiley, Massey, Cooper, Wood, Quinn, & Leask, 2013). These results confirm our qualitative findings relating to the integral role of the health care provider in how pregnant women view and act on vaccination. Our novel identification of the spectrum of women’s information needs and the way in which they use their health care professional allows for inclusion of the diversity of the lived pregnancy experience. It also provides an understanding of not only the factors involved in vaccination decision making but also the place occupied by vaccination in relation to the other priorities of pregnancy. When viewed in light of the concept of reproductive citizenship, we found that women can be grouped into a spectrum of categories: quiescent, reactive, and proactive. The concepts of active/passive vaccination behavior have arisen in previous qualitative research to explain human papillomavirus vaccine uptake by adolescent girls (Cooper Robbins, Bernard, McCaffery, Brotherton, & Skinner, 2010). Our findings indicate that women’s categorization as quiescent, reactive, and proactive reproductive citizens is modified by whether the disease for prevention is influenza or pertussis. This appears to be related to how women assign risk during pregnancy. Risk was usually assigned according to the risk posed to the fetus or newborn infant, before risk to the women themselves, and also through personal experience of the disease. Thus, pertussis was seen as a more serious disease
than influenza because it directly affects the fetus or infant, whereas influenza was seen primarily as a disease affecting the mother, with only secondary effects on the baby. These perceptions might be one possible factor in the reported differences in the uptake of influenza and pertussis vaccines by pregnant women. Women saw vaccination as one of many things they had to consider during pregnancy. How women managed these competing priorities was also related to reproductive citizenship. Quiescent reproductive citizens relied on their health care provider to assign priority to vaccination for them, whereas more proactive reproductive citizens assigned priority to vaccination themselves, using their health care provider primarily as a source of information. The fact that women did not spontaneously mention the perceived risks of vaccination during pregnancy was notable. The general approach of abstaining from medications normally associated with modern Western antenatal care would suggest that women would be cautious about the possible effects of vaccination on the unborn baby; however, our findings indicate that most women had not thought about it previously and would refer to their health care provider for guidance if they were unsure. This further highlights the importance of the trust women place in their health care provider and the importance of provider recommendation of vaccines. The health system these pregnant women access is largely oriented toward women who actively seek information and vaccination. Vaccine availability is highly variable among institutions within the system, with onsite vaccination clinics available in some settings but not others (Wiley, Massey, Cooper, Wood, Ho, et al., 2013). Many women must actively pursue the vaccine through a separate general practitioner visit. Our data also indicate variations in the perceived availability of information. Systemic provision of vaccines and information would cater for women across the entire spectrum of reproductive citizenship, including those who are passive in their approach. Our data show that the participants were largely unaware of the risks posed by influenza to their own health or to that of their unborn infant, and these risks require greater acknowledgment in education resources for pregnant women. Our data also indicate that framing of this information toward protecting the fetus/baby would be key to encouraging pregnant women to take up vaccine. Furthermore, consistent recommendations from providers and greater vaccine availability would cater to women who were more passive in their seeking of information and vaccines. These measures would provide more equitable access for women to a measure which has the potential to prevent morbidity and mortality in themselves and their infants.
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Qualitative Health Research 25(3)
Acknowledgments We gratefully acknowledge Professor Deborah Lupton for her guidance and thank the staff and patients at the participating study institutions.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research was funded by a grant from the Financial Markets Foundation for Children (Grant 2010-099). Julie Leask is supported by a NHMRC Career Development Fellowship (APP1053473).
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