VACCINE HESITANCY IN PREGNANT MOTHERS

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Addressing Vaccine Hesitancy in the Prenatal Population

Carly M. Wolsey
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Carly M. Wolsey

https://orcid.org/0000-0001-8475-5838

I have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to Carly M. Wolsey, 2538 S.
Canfield, Mesa, AZ 85209. Email: cbenshoo@asu.edu

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Abstract
False accusations concerning the development of autism and other hazardous side effects have
triggered parental vaccine hesitancy, leading to outbreaks of vaccine-preventable diseases. This
opposition to vaccination risks the health of both individuals and entire communities. The
purpose of this project was to determine the effectiveness of prenatal education on maternal
vaccine hesitancy and infant immunization rates. In a pretest posttest design, pregnant mothers
greater than or equal to 30 weeks gestation were recruited by The Arizona Partnership for
Immunization (TAPI) and virtually educated about infant immunization. A voice-over
PowerPoint presentation was delivered to the participants virtually and focused on vaccine
knowledge, intention to vaccinate, and vaccine hesitancy. These outcomes were evaluated
virtually pre- and post-intervention with the Parent Attitudes about Childhood Vaccines (PACV)
survey (⍺ = 0.84), and the infants’ vaccination records were compared against the recommended
immunization schedule at two months of age. Using the Wilcoxon Signed-Ranks test, data
analysis revealed vaccine hesitancy was significantly reduced between pre- and post-intervention
(Z = 27.70, p = .000), and 100% of the 2-month-old infants were fully immunized with the
recommended vaccines. The effect size (d = 12.807) also indicated a strong relationship between
pre- and post-intervention vaccine hesitancy. Vaccine hesitancy remains a threat to public health.
With prenatal education, pregnant mothers will likely become more knowledgeable of vaccine
benefits and better prepared to make informed decisions. Confident vaccination will decrease
vaccine hesitancy and improve immunization rates, while promoting individual and societal
health.
.

Keywords: Vaccine hesitancy, pregnant mothers, vaccine education, infant immunization

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Addressing Vaccine Hesitancy in the Prenatal Population
Vaccination of children continues to be a widely debated topic in parenting culture.
Uncorroborated claims of dangerous side effects and links to autism have led to vaccine
hesitancy. As vaccine apprehension grows, it threatens children’s wellbeing and the societal
benefit of herd immunity. Although concern of a potential link between autism and vaccines has
generated hesitancy, education can expose the falsity of these claims. When educated parents
confidently vaccinate their children, both individual and societal health will be achieved.
Background/Significance
With the controversial nature of vaccination in today’s parenting culture, a hesitancy to
vaccinate children has been observed. Salmon et al. (2015) define vaccine hesitancy as the
reluctance or refusal to vaccinate based on the understanding of alleged risks versus benefits.
Because vaccines have successfully prevented infectious diseases for several decades, young
parents are often unfamiliar with once-common childhood illnesses. Vaccine hesitancy not only
endangers individual health, but societal health as well by affecting herd immunity. Herd
immunity refers to a high proportion of vaccinated individuals, enabling protection for both
vaccinated and unvaccinated individuals (Logan et al., 2018). Additionally, outbreaks of
vaccine-preventable diseases warrant an increased need for healthcare and its subsequent costs.
Thus, patients, providers, communities, and entire healthcare systems are negatively impacted.
With vaccination rates decreasing and outbreaks of vaccine-preventable diseases
increasing, it is crucial that parental hesitancy be addressed to achieve vaccine benefits. Recent
literary sources have demonstrated the relevance of vaccine hesitancy, and the need for vaccine
education (Opel et al., 2016). With prenatal education, pregnant mothers become knowledgeable
of vaccine benefits and are consequently able to make informed decisions. Confident vaccination

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will decrease vaccine hesitancy and occurrence of vaccine-preventable diseases, while increasing
individual and societal health. This paper will serve to establish significance of vaccine
education in the prenatal period, synthesize current evidence, describe theoretical and
implementation frameworks, and describe methods and results.
In review of recent literature, parental vaccine hesitancy remains prevalent and
problematic for worldwide health. Unfortunately, vaccines have become victims of their own
success, as many parents are unfamiliar with vaccine-preventable diseases. As a national health
initiative, the Centers for Disease Control and Prevention (CDC) (2019) have declared the fight
against vaccine preventable diseases as a winnable battle. To increase vaccination coverage,
several studies have examined the etiology of vaccine hesitancy and its contributing factors;
however, substandard immunization rates and outbreaks of vaccine-preventable diseases persist
(Logan et al., 2018; Opel et al., 2016; Salmon et al., 2015).
Education remains a popular and consistent response to vaccine hesitancy. However,
recent studies revealed that pregnant women are often seeking vaccine information late in the
gestational period and/or 0-2 weeks following the child’s birth. This is problematic as the
standard of care typically involves childhood immunization education provided by the
pediatrician at well-child visits (Corben & Leask, 2018; Danchin et al., 2018; O’Leary et al.,
2018). Consequently, recent literature examined the effect of prenatal vaccine education on
decreasing vaccine hesitancy and improving infant immunization.
An immunization-focused nonprofit organization in the southwest noticed the local
increase in outbreaks of vaccine-preventable diseases correlating with decreasing childhood
immunization rates and increasing nonmedical vaccine exemptions. Objective data reveals that
80-84% of North Scottsdale Arizona Kindergarten students are immunized against the measles;

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ninety-five to 100% is the target rate to establish herd immunity. Furthermore, Arizona
experienced 7,129 confirmed cases of vaccine-preventable diseases in 2019 (Arizona
Department of Health Services, 2020). Nationally, 70.4% of children ages 19-35 months are
receiving the seven recommended vaccination series (CDC, 2017).
Concerned for individual and public safety, the organization contemplated an educational
intervention that had not yet been attempted. With the belief that pregnant women form their
position on infant immunization by late gestation, the organization focused on pregnant women
as a target population. A preliminary interest of this topic has led to the clinically relevant
PICOT question: In pregnant women (P), how does prenatal vaccine education (I) compared to
standard of care (C) influence vaccine hesitancy or predict infant immunization rates (O)?
Evidence Synthesis
To best answer the PICOT question, an exhaustive search and review of current literature
was performed. Three literature databases were thoroughly searched—PubMed, Cumulative
Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Library. These three
databases were selected for medical credibility, peer review, and quantity and relevance of
information available related to pregnant women, vaccine hesitancy, and infant immunization.
Additionally, grey literature from the ASU DNP Final Projects Collection was reviewed. Within
the digital repository, there are four projects related to vaccination and vaccine hesitancy but
none target pregnant women. Consequently, none of these studies were included for evaluation.
Database search keywords included: pregnant, vaccine education, vaccine hesitancy, and
infant immunization. Inclusion criteria included primary research published in English, peerreviewed articles or systematic reviews, and publication date within the past five years.
Additionally, MeSH and Boolean terms were utilized to expand the search results. Exclusion

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criteria included secondary research and the focus of pregnant women to vaccine themselves,
opposed to infant vaccination.
An initial PubMed search yielded 17 results. Thus, MeSH terms were utilized to broaden
the search and the following search yielded 11,801 results. Additional terms to specify keywords,
such as infant immunization, were added to the narrow search. However, utilizing the term
vaccine hesitancy severely limited results, so vaccine education OR vaccine compliance were
used as alternatives. First or second authors of high-quality articles were also searched for other
relevant studies. Studies from various countries were also considered. The final search yielded
142 results. Utilizing rapid critical appraisal (RCA), seven studies were included in the final
work.
Similar to the PubMed search, the initial CINAHL search with Boolean phrases included
pregnant women OR expectant mothers, vaccine education, and vaccine hesitancy within the
past five years, which yielded one result. Adding Boolean phrases, such as infant vaccination
yielded 478 results. Including the term vaccine education severely limited search results, so only
education was searched instead. The final search yielded 13 results, and through RCA, two new
studies were included.
The Cochrane Library was the final database searched. First, trials were searched and the
initial search included keywords, such as: pregnant, education, vaccine hesitancy, and
immunization, which resulted in 6,340 trials. In this database, utilizing the term vaccine
education rather than education limited the final yield to 18 results. Nine studies were
appropriate for inclusion but had been previously discovered through PubMed and CINAHL.
The Cochrane systematic reviews (SR) were also searched with the same key terms and yielded
one result, which was included. In summary, 10 total studies were included for final review and

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evaluation, which included: four RCTs, one SR, two correlational studies, two cross-sectional
surveys, and one observational cohort study.
After an exhaustive literature search, 10 studies were selected for rapid critical appraisal.
Half of the studies are high-level, including four RCTs and one SR. The remaining five studies
consist of nonexperimental cross-sectional surveys or correlational studies. The literature review
included international sampling, with only one study conducted in the U.S. All studies are recent
(2017-2019), and the majority utilized the Health Belief Model (HBM) as theoretical framework.
Eight out of 10 studies disclosed funding sources and limited bias was evident throughout.
Significant homogeneity was apparent in demographics, with all participants consisting of
pregnant women. The average age amongst studies was approximately 30 years. Only one study
also included expectant fathers (Otsuka-Ono et al., 2019). Slightly more than half of the
participants were multiparous, and the majority were educated (high school or college
graduates). Heterogeneity existed in number of participants amongst studies, ranging from 175 to
6182 (see Appendix A, Table 1).
The majority of experimental studies utilized face-to-face vaccine education (FTFVE) as
an intervention with commonalities among variables of interest, including: intention to vaccinate
(ITV), infant immunization rates, vaccine knowledge and decision making, and vaccine
hesitancy. Heterogeneity existed among study setting, with approximately half of the studies
conducted in a hospital setting and half in an obstetrician office clinic, with three studies
performed in both settings (see Appendix A, Table 2). Only one study conducted virtual FTFVE
(Veerasingam et al., 2017). Significant heterogeneity was also observed among measurement
tools, with several studies comparing immunization rates to the national immunization
requirements and/or utilizing Likert scales (self-developed by authors; validity and reliability not

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discussed). This finding suggests a gap in current literature. Measuring parental vaccine
hesitancy and efficacy of FTFVE is not yet well-researched or supported, and a valid, reliable
tool would greatly benefit current and future practice. Homogeneity was observed among
primary outcomes, with the majority of studies focusing on identification of vaccine hesitancy,
increased maternal vaccine knowledge, and increased infant immunization rates and intention to
vaccinate. Lastly, common themes were also evident among studies, including: prevalence of
vaccine hesitancy among pregnant women, FTFVE and decreased vaccine hesitancy, and
FTFVE and increased ITV and infant immunization rates. All study results were communicated
in confidence intervals, odds ratios, means, standard deviations, and/or level of evidence (see
Appendix A, Table 1).
Current literature confirms the significance of vaccine hesitancy in pregnant women and
suggests FTFVE delivered in the antenatal period can significantly improve maternal vaccine
knowledge, ITV and decision making, and infant immunization rates (see Appendix A, Table 2).
Additionally, primiparous mothers are significantly more vaccine hesitant than multiparous
mothers. The literature review also demonstrates the indirect relationship between vaccine
hesitancy and trust in healthcare providers. Lastly, pregnant mothers willing to receive influenza
or pertussis vaccinations during pregnancy for themselves were significantly less vaccine
hesitant toward infant immunization. Establishing a trusting provider-patient relationship during
pregnancy, especially with first-time mothers, and providing FTFVE during the antenatal period
can positively impact infant health and societal wellbeing by supporting herd immunity.
Addressing vaccine hesitancy prior to final decision-making of infants’ immunization status can
significantly decrease the occurrence of VPD, thus decreasing disease-related treatment costs and
positively impacting medical providers and entire healthcare systems.

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Theoretical Framework and Implementation Framework
Theory is essential in development of evidence-based practice, as it provides an
organized view of complex phenomena. In short, theory helps to explain what is known and
inspires what is yet to be learned (Moran et al. 2020). For this project, the Health Belief Model
(HBM) was chosen for the theoretical framework due to its prevalence in relevant studies and its
ease of application. Originally developed in the 1950s by Dr. Hochman and social scientist
colleagues, HBM was utilized to explain health-related behaviors (as cited in Larsen, 2019).
HBM was updated in the 1980s and currently consists of four foundational components: 1)
perceived benefits versus perceived barriers, 2) perceived threat (based on perceived seriousness
and susceptibility), 3) self-efficacy, and 4) cues to action (see Appendix B, Figure 1). These
components determine the likelihood of engagement in the health behavior. HBM continues to
be utilized today and is particularly helpful in exploration of attitudes and beliefs related to
adherence behaviors (Larsen, 2019).
When applied to pregnant mothers and vaccine hesitancy related to infants, HBM
suggests that pregnant mothers will not decide to vaccinate unless they believe the infant is at
risk and understand how severe that risk may be. Benefits and barriers to infant immunization
must also be assessed. Lastly, HBM suggests that pregnant mothers may want to make a change
but are unable to follow through. Thus, self-efficacy and cues to action are imperative. Cues to
action may include external or internal events that motivate an individual to change. In this
particular project, it may include positive infant vaccination marketing (i.e. health fair, billboard,
social media) and/or personal or relative experience with vaccine-preventable illnesses. Lastly,
empowering pregnant mothers to confidently vaccinate their children will contribute to selfefficacy. This may be most successful when applied to the foundation of a trusting patient-

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provider relationship. Improving patients’ self-efficacy may include setting attainable goals,
reframing perceived obstacles, and visualizing the long-term, “big picture” benefits.
In addition to HBM, Rosswurm and Larabee’s (1999) model for evidence-based practice
was selected to guide the implementation process. This framework was chosen not only for its
applicable stepwise process, but also for the incorporation of planned change during the
implementation phase. Utilizing data from a variety of sources is also an advantageous
component of this framework. Rosswurm and Larabee’s (1999) model includes six necessary
steps to generate evidence-based change: 1) assess need for change in practice, 2) link problem
intervention and outcomes, 3) synthesize best evidence, 4) design practice change, 5) implement
and evaluate change in practice, and 6) integrate and maintain change in practice (see Appendix
B, Figure 2). Additionally, utilizing HBM as theoretical underpinning fits well within the
Rosswurm and Larabee model.
Specifically, Rosswurm and Larrabee’s model is appropriate for use in this project,
evident by the feasible completion of the models’ initial steps. A need for change was identified
with the increasing occurrence of VPDs, decreasing infant/childhood immunization rates, and
increasing prevalence of parental vaccine hesitancy. Comparing the internal and external data
lead to the identification of a problem. Using standardized classification systems, potential
interventions, such as education, and desired outcomes, such as increased infant immunization
rates and decreased occurrence of VPDs, were identified. Through RCA, high-quality evidence
was synthesized for common themes (i.e. effectiveness of prenatal FTFVE) and assessed for
feasibility (see Appendix A, Tables 1 and 2). The next step involves designing a practice change,
including the proposed change of educating pregnant women on infant immunization as the
standard of care. Necessary resources, such as access to/willingness of pregnant women and

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agreeable setting accommodations, would be identified. Measurement outcomes would also be
defined. The following steps include implementation of the design, evaluation, integration into
standard of care, and maintenance with continuous monitoring for process improvement.
Methods
Arizona State University’s Institutional Review Board (IRB) approved the study
September 22nd, 2020. Participants were recruited by Women, Infant, and Children (WIC)
Maricopa Clinics and The Arizona Partnership for Immunization (TAPI). Inclusion criteria
included: pregnant women greater than or equal to 30 weeks of gestation, at least 18 years of
age, proficient in English, and planning to parent the infant after birth. Due to the pandemic and
social distancing recommendations, vaccine education was delivered virtually via PowerPoint
presentation. The educational presentation is approximately ten minutes in length with voice
recording and was emailed directly to the consenting participants. Ethical considerations were
contemplated, participants’ confidentiality was maintained throughout, and consent was obtained
from all participants.
The project’s online educational intervention focused on vaccine knowledge, intention to
vaccinate, and vaccine hesitancy. Through prenatal vaccine education, a decrease in vaccine
hesitancy and an increase in infant immunization was anticipated. If accomplished, prenatal
vaccine education has the potential to create a multi-tier impact: improvement in individual
health, fulfillment of herd immunity, and lessened costs and demands on healthcare providers
and healthcare organizations. The eligibility survey, which included the consent and inclusion
criteria, was distributed to potential participants in November and December 2020. Once
participants were identified through the eligibility survey, they were immediately sent the pretest.
Once the pretest survey was completed, the voice-over PowerPoint educational tool was

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distributed to project participants. When the participants finished viewing the PowerPoint, they
were directed to complete the post-intervention survey immediately afterward. The majority of
participants completed the viewing of the PowerPoint and post-intervention survey in December
2020, with a few participants completing the education and survey in January 2021. Lastly, the
participants completed a final, 2-month post-intervention survey and sent a picture of their
infant’s immunization record following the 2-month well-child visit. Two-month surveys and
infant immunization records were collected in March and April 2021.
To evaluate the outcomes of the vaccine education provided to pregnant mothers, two
different measurements were utilized. First, the Parent Attitudes about Childhood Vaccines
(PACV) survey was repeated pre-, immediate post-, and 2-months post-intervention to assess
changes in vaccine knowledge, intention to vaccinate, and vaccine hesitancy. The PACV’s three
subsections (safety and efficacy, general attitudes, and behavior) indicate good reliability with
Cronbach’s ⍺ of 0.74, 0.84, and 0.74, respectively (Opel et al., 2011). Lastly, the PACV is an

appropriate measurement tool for the project due to its strong alignment with the evaluation
questions. Secondly, infant immunization status (including adherence and timeliness) was

assessed when the infant reached two months of age. The immunization status of the following
vaccines was evaluated: Hib, PCV13, polio, DTaP, rotavirus, and completion of the hepatitis B
series. This information was accessed from the infant’s mother (project participant), who sent a
picture of the infant’s state immunization record booklet.
All data was collected and stored within the REDCap application. This application was
also utilized for survey creation and distribution. Data analysis included description statistics
(mean, standard deviation, percentages) to describe all variables. The Wilcoxon Signed-Ranks
test was conducted to compare the difference between pre-and post-intervention surveys. Finally,

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the effect size was calculated to estimate clinical significance and establish the presence of
relationship(s). Lastly, there was no outside funding available for this project, and the only cost
was the monetary reward disbursed to participants for completing all required surveys (see
Appendix B, Figure 3). This cost was covered by the survey’s author.
Results
Results were analyzed using the SPSS statistic software. Demographic results indicated
the mean age range of project participants was 25-34 years, the mean gestational age was 38-40
weeks, the majority were multiparous and had completed timely vaccination for their previous
children. All participants were Caucasian and married, and the majority had completed a
bachelor’s degree and were currently employed. The Wilcoxon Signed-Ranks test revealed a
mean PACV score of 34.2 (SD = 1.398) for pre-intervention and 6.5 (SD = 1.780) for postintervention and indicated that vaccine hesitancy was significantly reduced between the pre- and
post-intervention (Z = 27.70, p = .000). The effect size (d = 12.807) exceeded Cohen’s
convention for a large effect (d = .80), which indicates a strong relationship between pre- and
post-intervention vaccine hesitancy. Lastly, 100 percent of the infants were fully immunized
based on the CDC recommended 2-month vaccines.
The results indicate a statistically significant reduction in vaccine hesitancy after the
educational intervention and demonstrate a strong relationship between vaccine hesitancy and
vaccine education. The impact of this project allows for promotion of individual health through
routine vaccination and reduction in outbreaks of VPDs and promotion of community health
through herd immunity. Consequently, healthcare providers and systems are positively impacted
by reduction in time and costs associated with treatment of vaccine-preventable diseases. Based
on the results of this project, policymakers should strongly consider legislation that requires

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prenatal vaccine education as standard of care. Lastly, the project has a high likelihood of
sustainability due to the ease of application with various healthcare providers and low cost of
implementation.
Discussion
Virtual vaccine education was delivered to pregnant women to assess the influence of
education on infant immunization rates and maternal vaccine hesitancy. As evidenced by preand post-intervention surveys and assessment of 2-month infant immunization status, prenatal
vaccine education significantly reduced maternal vaccine hesitancy and increased infant
immunization rates. Thus, prenatal vaccine education has the potential to reduce outbreaks of
VPDs and decrease VPD-associated treatment and cost, which will positively impact entire
healthcare systems. Due to the pandemic, the project’s intervention was conducted virtually and
may have been more effective if the education had been delivered in person. The project is
limited by its single setting and small sample size (N = 10). Additionally, the maternal self-report
of infant immunization status may reveal potential bias. Overall, the project’s findings are
consistent with the literature supporting FTFVE as an effective way to reduce vaccine hesitancy
and increase immunization rates (Hu et al., 2017; Kaufman et al., 2018; Otsuka-Ono et al., 2019;
Saitoh et al., 2017). Future recommendations include conduction of a similar project or study
with a larger sample size, diverse demographics, and various settings.

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Appendix A

Evaluation and Synthesis Tables
Table A1
Evaluation Table Quantitative Studies
Citation

Bechini et al.,
(2019).
Impact
assessment of
an education
course on
vaccinations in
a population of
pregnant
women: A
pilot study.
Funding:
None
explicitly
disclosed; no
grants received
Bias: None
listed

Theory/
Conceptual
Framework

HBM inferred

Design/
Method

Design:
Correlation
al pilot
study
Purpose:
Evaluate
PG
women’s
VK and
attitudes
towards
vaccination
, ITV, and
impact of
educational
interventio

Sample/ Setting

Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

Findings/
Results

N: 201

IV: FTFVE

Demographics:
Gender (%):
100% PG females
Race (%): 94%
Italian
Age (mean): 34 yr
Education (%):
45% graduates

DV1: ITV
DV2: VK, ATV

3-point
Likert
scale
(selfdeveloped
by
authors;
validity
and
reliability
not
discussed)

Stata 12,
pairedsample tTest

DV1: 42.57
95%CI: 41.3143.82
t = 7.36
p < 0.00
DV2: 22.47
95%CI: 21.6323.32
t = 10.61
p < 0.001

Setting: OB
Department of
University of
Florence, Italy
Inclusion
criteria:
1) PG women

Definition: ITV
in this study
included both
intent to
vaccine
themselves
during
pregnancy and
their infants

Level/Quality of Evidence;
Decision for practice/
application to practice

LOE: IIIa
Strengths: Small attrition,
significant results, feasible and
cost-efficient intervention
Weaknesses: Small N, no
funding disclosed, low
hierarchy of evidence, Likert
scales lacked reliability and
validity due to authors’ selfdevelopment
Conclusions: FTFVE
significantly increased ITV,
VK, and ATV. FTFVE also
increased ITV for both mother
and infant—imperative to

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Theory/
Conceptual
Framework

Country: Italy

Design/
Method

Sample/ Setting

n on
vaccination

2) Referred to OB
Department at
University of
Florence

20
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

Findings/
Results

deliver FTFVE in antenatal
period.
Applicability: Likely
applicable, but may not be
generalizable—immunization
policies and practices differ
between countries.

Exclusion
criteria:
None explicitly
listed

Utility to PICO: Applies to
PICO—consistent with all
elements. Recommended for
use in practice due to the
effectiveness of interventions.

Attrition: 4%
(lost to followup/incompletion
of post survey)
Corben, &
Leask, (2018).
Vaccination
hesitancy in
the antenatal
period: A
cross-sectional
survey
Funding:
University of
Sydney and
Mid North

HBM inferred

Design:
Crosssectional
survey
Purpose:
Assess
ITV, DM,
social
influences,
and
concerns
toward
vaccines

N: 221
Demographics:
Gender (%):
100% PG female
Age (%): 33% 3034yr
# PG (%): 64.9%
multipara
Trimester (%):
61% 3rd trimester
Education
(highest year of

Level/Quality of Evidence;
Decision for practice/
application to practice

IV1: PMP
women
IV2: PG
women support
for infant
vaccination
IV3: PG
women trust in
HCP
IV4: PG
women
vaccinating
themselves

42question
survey,
based on
Decisional
Conflict
Scale,
(α=0.87)
and
PACV
(α=0.84)

Fisher’s
exact
test, Chisquared,
Wilcoxo
n ranksum

DV1:
IV1: more
likely to be VH
OR = 3.40
95%CI: 1.348.60
IV2: less likely
to be VH
p < 0.005
IV3: Decreased
trust =
increased VH
p < 0.0001

LOE: IIIb
Strengths: Significant results
r/t vaccine DM, adequate N
for survey, measurement tools
thoroughly discussed and
based on valid/reliable scales
Weaknesses: Lower level of
evidence, large attrition (r/t
lack of consent to access
immunization records),
possible selection bias (provaccination mothers may have

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Coast Local
Health District
Bias: Possible
selection bias
Country:
Australia

Theory/
Conceptual
Framework

Design/
Method

and infant
immunizati
on rates
among
pregnant
mothers

Sample/ Setting

schooling, %):
73.1% Year 12
Setting: Antenatal
clinics across six
hospitals on the
NSW north coast
Inclusion
criteria:
1) PG
2) At least 18 yr
Exclusion
criteria:
None explicitly
listed
Attrition: 56%
(did not consent
to access infant
immunization
records)
0% for post
survey completion

21
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

DV1: VH
DV2: Perceived
vaccine risks
DV3: Decisionmaking
DV4: Infant
immunization*

Comparis
on to the
AIR

*Based on
accordance with
Australian
Immunization
Register (AIR)
at 8 mo

Data
Analysis

Findings/
Results

DV2:
IV1: Less sure
of balance of
vaccine risks
OR = 4.84
95%CI: 1.4416.29
DV3:
IV1: less likely
to have decided
about
vaccination by
end of 2nd tri
p = 0.0015
and higher
decisional
conflict
p = 0.0033
DV4:
IV1:
p = 0.242
IV4:
OR = 1.78
95%CI: 0.634.99

Level/Quality of Evidence;
Decision for practice/
application to practice

been more inclined to
complete survey)
Conclusions: PMP women =
more VH and undecided about
infant immunization. Results
indicate a strong justification
to screen for hesitancy in the
antenatal period and offer
assistance in this decisionmaking.
Applicability: FTFVE may
benefit mothers in the
antenatal period, but mothers’
attitudes/beliefs may also
differ between
countries/cultures.
Utility to PICO: Applies to
PICO—consistent with all
elements. Recommend
antenatal screening for vaccine
hesitancy—ideal timing in
antenatal period remains
unknown.

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Cunningham
et al., (2018).
Prevalence of
vaccine
hesitancy
among
expectant
mothers in
Houston,
Texas.
Funding:
None
disclosed
Bias: None
disclosed
Country: U.S.
(Houston, TX)

Theory/
Conceptual
Framework

HBM inferred

Design/
Method

Design:
Crosssectional
survey
Purpose:
Assess the
prevalence
of vaccine
hesitancy
among
pregnant
mothers in
Houston,
TX

Sample/ Setting

N: 648
Demographics:
Gender (%):
100% PG female
# PG (%): 51%
FTM
Maternal age (%):
66% > 30yr
Marital status
(%): 89% married
Education (%):
43% more than 4yr college degree
Household
income (%): 75%
>$50K/yr
# of children in
household (%):
46% 0 children
Race (%): 54%
White
High-risk PG (%):
78% not high-risk
Setting: Baylor
College of
Medicine

22
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

Findings/
Results

IV1: PG
women

PACV
(α=0.84)

Fisher’s
exact,
multivari
able
logistic
regressio
n, BlandAltman
plots

DV:
IV1: 8.2% VH
95%CI: 6.110.7
IV2: Decreased
VH
p < 0.001
Maternal
decline of
annual
influenza
vaccine = 7.4x
more likely VH
95%CI: 3.914.0
IV3:
Higher
education =
decreased VH
p = 0.003

IV2: PG
women receipt
of annual
influenza
vaccine
IV3: PG
women
education level
DV: VH

Level/Quality of Evidence;
Decision for practice/
application to practice

LOE: IIIb
Strengths: Large N, very
small attrition, detailed
description of data collection
and analysis, valid/reliable
measurement
Weaknesses: Lower level of
evidence, no funding
disclosed, single variable
measured, single setting,
majority participants =
Caucasian, high income,
higher level education
Conclusions: VH is prevalent
among PG mothers, especially
those with lower education.
Screening for VH in PG is
feasible and may be beneficial
in improving parental vaccine
education and infant
immunizations.
Applicability: Identify VH
prior to infant birth. Educating

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

OBGYN practice
at Texas
Children’s
Pavilion for
Women, Houston,
TX

23
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

Findings/
Results

Level/Quality of Evidence;
Decision for practice/
application to practice

PG mothers may positively
influence vaccine DM.
Utility to PICO: Applies to
PICO—consistent with all
elements.

Inclusion
criteria:
1) Englishspeaking
2) At least 18 yr
3) PG, 12-31 wks
gestation (fathers
could also be
included)
4) No prior
participation in
previous vaccine
study at study
institution
Exclusion
criteria:
None explicitly
listed

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

24
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

Findings/
Results

IV1: PMP
mothers
DV1: Vaccine
DM
DV2: VH r/t
vaccine safety

Paternal
Immunisat
ion Needs
and
AttitudesAntenatal
survey
(validity/r
eliability
not
discussed)

Chisquare
tests,
binary
regressio
n,
logistic
regressio
n

DV1: More
undecided than
MP;
15% difference
in proportion
95%CI: 10-21%
p < 0.001
DV2: More VH
than MP
mothers
p = 0.002
DV3: 56%
discussed
vaccines during
PG;
Midwives
(66%) and GP
(58%) = most
popular sources
DV4: 66% felt
they received
adequate VK
during PG
95% CI: 60-72;

Level/Quality of Evidence;
Decision for practice/
application to practice

Attrition: 1.5%
(unable to link
father to PG
mother)
Danchin et al.,
(2018).
Vaccine
decisionmaking begins
in pregnancy:
Correlation
between
vaccine
concerns,
intentions and
maternal
vaccination
with
subsequent
childhood
vaccine uptake
Funding:
Grants from
Murdoch
Childrens
Research
Institute and

HBM

Design:
Correlation
al study
Purpose:
To
determine
correlation
between 1)
intentions
and
concerns
regarding
childhood
vaccination
, 2)
concerns
about
pregnancy
vaccination
, 3) SES,
and 4)
update of
influenza

N: 975
Demographics:
Gender (%):
100% PG female
Gest. (mean):
31wk
Education (%):
60% University
degree
Birth country (%):
62% Australia
# children (%):
49% 0 (first child)
Setting: 4 public
hospitals across
Australia
Inclusion
criteria:
1) PG female
2) English
proficiency

IV2: PMP +
MP PG women
DV3: Vaccine
information
sources
DV4: VK
provided in PG
DV5: Vaccine
receipt in PG
DV6: HCP
recommendatio
n for vaccines
during PG
IV3: VH PG
women

Maternal
self-report
ACIR
records
compared
to survey

LOE: IIIb
Strengths: Large N, solid
theoretical framework,
significant results
Weaknesses: Very high
attrition, lower level of
evidence, non-English
proficient women were
excluded from study, funding
by grant from a vaccine
organization (possible bias),
validity/reliability of
measurement scale not
discussed
Conclusions: Maternal DM r/t
infant/childhood immunization
begins in prenatal period. PMP
are significantly more hesitant
than MP. All PG mothers
should be provided VK by
HCP and advised to receive

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Wesfarmers
Centre of
Vaccines and
Infectious
Diseases,
Telethon Kids
Institute
Bias: None
disclosed
Country:
Australia

Theory/
Conceptual
Framework

Design/
Method

and
pertussis
vaccines
during
pregnancy
and routine
childhood
vaccines

Sample/ Setting

Exclusion
criteria: None
explicitly listed
Attrition: 58%
(lost to follow-up
survey)

25
Major Variables
& Definitions

DV7: Timely
infant
immunization
IV4: Perceived
vaccine safety
DV8: Vaccine
uptake

Measurem
ent/
Instrumen
tation

Data
Analysis

Findings/
Results

DV5: 46%
received
influenza
vaccine; 82%
received
pertussis
vaccine
DV6: HCP
recommendatio
n = more likely
to receive
Pertussis:
OR 3.5
95%CI: 1.9-5.0
p = 0.002
Influenza:
OR 3.1
95%CI: 1.9-5.0
p = 0.000
DV7: VH
mothers = less
likely to have
their infants upto-date on
vaccines
95% CI: 1-41%
p = 0.035

Level/Quality of Evidence;
Decision for practice/
application to practice

pertussis and influenza
vaccines during PG.
Applicability: Although
Australia’s NIP differs from
the U.S., the results are likely
still applicable. Providing
vaccine education in the
prenatal period is also feasible.
Utility to PICO: Applies to
PICO—consistent with all
elements, especially that the
antenatal period is crucial to
address vaccine hesitancy.
This article also contained
extra information about the
correlation between maternal
vaccine uptake and its effect
on infant immunization.

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Hu et al.,
(2017).
Prenatal
vaccination
education
intervention
improves both
the mothers’
knowledge and
children’s
vaccination
coverage:
Evidence from
randomized
controlled trial
from eastern
China
Funding:
Funded by the
general
medical

Theory/
Conceptual
Framework

HBM inferred

Design/
Method

Design:
RCT
Purpose:
Examine
and verify
effectivene
ss of PVE,
specifically
on the
improveme
nts of
mother’s
vaccine
knowledge
and
improveme
nt of
completene
ss and

Sample/ Setting

N: 1252
n: 626 (IG)
n: 626 (CG)
Demographics:
Gender: 100% PG
female
Age (range): 2030 yr
Gest. wk (range):
29-36 wks
Educational level
(mean): college or
above
Occupation
(mean): farmer,
worker, or
businessman
SES: similarly
divided among
high, middle, and

26
Major Variables
& Definitions

IV: FTFVE
DV1: VK
DV2:
Vaccination
coverage*
DV3:
Completeness
and timeliness
of vaccine
doses*
Definition:
FTFVE
included oneon-one 15minute
interactive
FTFVE
sessions

Measurem
ent/
Instrumen
tation

Pre- and
post-test
(selfdeveloped
by
authors;
validity
and
reliability
not
discussed)
Comparis
on with
China’s
NIP
requireme
nts and
China’s
public
immunizat

Data
Analysis

Chisquare
analysis,
Wilcoxo
n ranksum test,
logistic
regressio
n,
MANOV
A

Findings/
Results

DV8: Increased
acceptance of
vaccine safety =
increased
vaccine uptake
95% CI: 14-79
p = 0.005
DV1:
Knowledge of
required
vaccines:
IG: 16.7%
p < 0.001
Knowledge of
vaccination
policy:
IG: 84.2%
p < 0.001
OR: 5.2
95%CI: 2.6-8.8
DV2:
IG: 90.0%
p < 0.01
OR: 3.4
95%CI: 2.1-4.8
DV3:
IG: 51.9%
p < 0.01

Level/Quality of Evidence;
Decision for practice/
application to practice

LOE: II
Strengths: RCT design, large
N, significant results, SES
diverse participants,
homogeneity between IG and
CG, no apparent author bias
Weaknesses: Large attrition,
validity and reliability not
measured, no exclusion
criteria specifically listed, 3mo interval between
intervention may allow
participants to receive vaccine
information from other
sources (TV, Internet)
Conclusions: Prenatal FTFVE
can significantly improve VK
and timely and complete

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

research
program of
Zhejiang
province
Bias: None
recognized or
reported
Country:
China

Theory/
Conceptual
Framework

Design/
Method

timeliness
of infant
immunizati
on based
on the
China NIP
guidelines

Sample/ Setting

low for both IG
and CG.
Setting: 6 districts
within the
Zhejiang province
(Yinzhou,
Dinghai,
Dongyang,
Changxing,
Liandu, and
Kecheng); 4
obstetric hospitals
with >500
deliveries
annually were
chosen from each
district = 24
hospitals total.
Intervention took
place in
educational
classrooms.

27
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

*Vaccination
coverage and
timeliness was
based on
China’s NIP
schedule for a
child at 12 mo,
including:
BCG, HBV3,
OPV3, DTP3,
MR, and JEV.
“Fully
immunized”
indicates 1 dose
of BCG, 3
doses of HBV,
3 doses of OPV,
3 doses of DTP,
1 dose of MR,
and 1 dose of
JEV.

ion
records.

Data
Analysis

Findings/
Results

Level/Quality of Evidence;
Decision for practice/
application to practice

OR: 2.3
95%CI: 1.6-3.5

vaccination. HCPs involved in
prenatal care should develop
partnership with NIPs.
Applicability: China’s NIP
differs from US immunization
requirements. Unsure whether
results will be applicable in a
country or region with
differing immunization
requirements--questionable
generalizability.
Utility to PICO: Greatly
beneficial—consistent with all
PICO elements.

Inclusion
criteria: Female,
PG, residing
Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

28
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

N: 204
n: 68 (IV1)
n: 68 (IV1)
n: 68 (CG)

IV1: Video
VarV education
IV2: Booklet
VarV education

Demographics:
Gender (%):
100% PG female
Age (mean): 25.8
Education (%):
59% vocational or
college graduated
Job status (%):
75.5% employed
Immigration
status (%): 61.5%
resident

DV1: VarV
coverage*
DV2: VarV
timeliness*
DV3: VarV
ITV

Comparis
on to
Zhejiang
provincial
immunizat
ion
informatio
n system

Chisquared
tests, utests,
STATA

Findings/
Results

Level/Quality of Evidence;
Decision for practice/
application to practice

within Zhejiang
province
Exclusion
criteria: None
explicitly listed
Attrition: 32%
(lost to drop out)
Hu et al.,
(2018).
Evaluation of
two health
education
interventions
to improve the
varicella
vaccination: A
randomized
controlled trial
from a
province in the
east China.
Funding:
General
medical

ELM

Design:
RCT
Purpose:
Evaluate
the effect
of two
health
education
interventio
ns on VarV
coverage
and
timeliness
and
knowledge
and attitude

Definition:
Coverage
measured at 24
mo of age,
timeliness
measured based

5-point
Likert
scale
(selfdeveloped
by
authors;
validity

DV1:
IV1: 86.4%
RR: 4.8
95%CI: 2.111.3
IV2: 76.1%
RR: 2.4
95%CI: 1.2-5.1
DV2:
IV1: 70.1%
IV2: 61.2%
DV3:
IV1: 93.9%
IV2: 82.1%
p < 0.05

LOE: II
Strengths: High-quality RCT
design, small attrition, good
theoretical framework
Weaknesses: Small N, no
blinding, limited to East China
province (possibly not
generalizable), validity and
reliability not measured,
control group could have
intentionally read/watched
VarV educational material
Conclusions: Vaccine
education through video or
booklet methods may improve

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

research
program of
Zhejiang
province
Bias: None
disclosed
Country:
China

Theory/
Conceptual
Framework

29

Design/
Method

Sample/ Setting

Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

toward
VarV
vaccination

# children (mean):
0
Gest. wk at
enrollment
(mean): 16.8wk

on Zhejiang
recommendatio
ns

and
reliability
not
discussed)

Setting: 4 OB
hospitals within
the Zhejiang
Province
Inclusion
criteria:
1) PG women
2) At least 12wk
gest.
3) Living within
Zhejiang Province

Data
Analysis

Findings/
Results

Level/Quality of Evidence;
Decision for practice/
application to practice

infant vaccination. Video
education > booklet education.
Applicability: Recommended
for use in practice due to the
significance of the
interventions. However, may
not be generalizable due to its
homogenous population in the
study.
Utility to PICO: Valuable—
only one vaccine examined
but consistent with all PICO
elements.

Exclusion
criteria: Not
explicitly
discussed
Attrition: 1.9%
(lost to follow-up)

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Kaufman et
al., (2018).
Face-to-face
interventions
for informing
or educating
parents about
early
childhood
vaccination
Funding: La
Trobe
University
grant,
NHMRC,
Sydney’s
Children
Hospital
Network
Bias: None
reported
Country: 10
RCTs
conducted in
various
countries:
Australia,

Theory/
Conceptual
Framework

Design/
Method

HBM, TRA,
TPB, IBM,
TTM, and
Social
Cognitive
Theory

Design: SR
of RCTs
and clusterRCTs
Purpose:
To assess
the effects
of face-toface
interventio
ns for
educating
parents
about early
childhood
vaccination
on
vaccination
status and
parental
knowledge,
attitudes,
and ITV

Sample/ Setting

N: 10
n: 4527
DS: Cochrane
Library, Medline,
Embase Ovid,
CINAHL,
PsycINFO
Inclusion
criteria:
1) RCT or clusterRCT
2) FTFVE
intervention
3) Intervention
targeted toward
parents and
relevant to
childhood
immunization
Exclusion
criteria:
1) Intervention
was based on
maternal outreach
or support

30
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

Findings/
Results

IV: FTFVE

RoR
and/or
parental
survey
Pre- and
post-tests

PRISMA
,
GRADE

DV1: Low QoE
Z = 2.53
p = 0.01
RR = 1.2
95%CI: 1.041.37
DV2: Moderate
QoE
Z = 1.99
p = 0.05
SMD = 0.19
95%CI: 0-0.38
DV3: Low QoE
Z = 0.28
p = 0.78
SMD = 0.03
95%CI: -0.20.27
DV4: Low QoE
Z = 3.5
p=0
SMD = 0.55
95%CI: 0.240.85
DV5: Low QoE
Z = 0.71
p = 0.48
SMD = -1.93

DV1:
Vaccination
status (at final
time point)
DV2: VK
DV3: ATV
DV4: ITV
DV5: Adverse
effects (anxiety
r/t intervention)
Definition:
Final time point
varied between
studies (3mo15mo)

Likert
scale
(based on
HBM,
IBM) and
questionn
aire based
on Beliefs
about Flu
Vaccinati
on
Questionn
aire
(α=0.82)
1-wk postand 3-mo
post
surveys

Level/Quality of Evidence;
Decision for practice/
application to practice

LOE: I
Strengths: High-quality
RCTs, use of standardized
GRADE tool for evaluation,
reputable theoretical
frameworks discussed
Weaknesses: Small sample
size with 10 articles, majority
(8/10) of articles > 5 yr old,
high levels of statistical
heterogeneity leading to
downgraded certainty of
evidence
Conclusions: FTFVE may
improve vaccination status,
VK, ATV, and slightly
increase ITV. Some
populations may be more
receptive to FTFVE than
others—important to address
specific barriers.
Applicability: Recommended
for use in practice, although
results are not moderate to

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Theory/
Conceptual
Framework

Design/
Method

Canada,
China,
England,
Japan, Nepal,
Pakistan

Otsuka-Ono et
al., (2019). A
childhood
immunization
education
program for
parents
delivered
during late
pregnancy and
one-month
postpartum: A
randomized
controlled
trial.
Funding:
Pfizer Health

Sample/ Setting

31
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

intervention—
immunization
content not
specified
2) FTFVE could
not be isolated
(i.e. mass media
campaign)
HBM, IBM

Design:
RCT
Purpose:
To assess
the effect
of
individual
education
sessions
including
both
mother and
father in
late
pregnancy
and PP on

N: 175
n: 88 (IG)
n: 87 (CG)
Demographics:
Age, mother
(mean):
IG: 32.8, CG:
33.0
Age, father
(mean):
IG: 34.8, CG:
35.1
Race (mother):
100% Japanese
(both IG & CG)
# of preg (%):
IG: 53% FTM

Findings/
Results

95%CI: -7.273.41

IV: FTFVE
DV1:
Immunization
status*
DV2: ITV
DV3: Vaccine
DM
Definition:
FTFVE
involved
mothers and
fathers
delivered in late
PG and early
PP

Parental
selfreports
5-point
Likert
scale
(based on
HBM,
IBM)
(α=0.80)

Fisher’s
exact
test,
MannWhitney
U test,
Spearma
n’s rank
correlatio
n
coefficie
nt

DV1:
HBV: 76%
p < 0.001
RV: 84%
p = 0.019
Hib: 95%
p > 0.999
PCV13: 97%
p = 0.491
Number of
completed
vaccinations (04): 3.5 (0.9%)
p < 0.001
Completed all
four
vaccinations:
72%

Level/Quality of Evidence;
Decision for practice/
application to practice

high. Several countries
evaluated in the SR—may not
be generalizable. Address
populations for specific
barriers and modify FTFVE
appropriately.
Utility to PICO: Valuable—
consistent with all PICO
elements.
LOE: II
Strengths: High-quality RCT
design, small attrition,
homogeneity between IG and
CG, detailed discussion of
intervention development and
contents utilized
Weaknesses: Small N, Pfizer
funding, intervention setting
had previously tried to
improve immunization rates,
educator and researcher had
the same role—possible
conflict of interest

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Research
Foundation
Bias: Possible
self-reporting
bias; no bias
disclosed from
authors
Country:
Japan

Theory/
Conceptual
Framework

32

Design/
Method

Sample/ Setting

Major Variables
& Definitions

immunizati
on rates,
ITV, and
vaccine
DM

CG: 55% FTM
Marital status
(%): 99% married
(both IG & CG)
Education level
(%):
IG: 40%
university
CG: 36%
university
Mothers’ job
status (%): IG:
44% unemployed
CG: 46%
unemployed
Fathers’ job status
(%):
IG: 97% FT
employment
CG: 96% FT
employment
Annual income
(thousands of
yen):
IG: 42% 40005999
CG: 37% 40005999

*Immunization
status based on
HBV, RV, Hib,
and PCV13
vaccines,
recommended
by Japan’s PVL

Measurem
ent/
Instrumen
tation

Data
Analysis

Findings/
Results

Level/Quality of Evidence;
Decision for practice/
application to practice

p < 0.001
DV2: Intention
to receive most
vaccines: 77%
p = 0.001
DV3: DM
regarding
vaccinations:
Father and
mother: 68%,
mother only:
32%
p = 0.043

Conclusions: Prenatal and PP
FTFVE = significant increase
in infant immunization rates
and parental ITV. Involving
fathers in the FTFVE sessions
may have contributed to the
findings.
Applicability: May be
applicable, but costeffectiveness was not
evaluated. May not be
generalizable—immunization
policies and practices differ
between countries.
Utility to PICO: Valuable—
consistent with all PICO
elements.

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

33
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

Findings/
Results

Fisher’s
exact
test,
MannWhitney
U test

DV1*: All 5
vaccines43.0%
95% CI: 0.5-1.6
p = 0.77
Hib85.0%
95% CI: 0.7-3.3
p = 0.26
PCV13-

Level/Quality of Evidence;
Decision for practice/
application to practice

Setting: Private
Tokyo hospital
Inclusion
criteria:
1) PG, gestational
wk: 29-33
2) At least 18 yr
Exclusion
criteria:
None explicitly
listed
Attrition: 2%
(lost to follow-up)
Saitoh et al.,
(2017). Effect
of stepwise
perinatal
immunization
education: A
clusterrandomized
controlled
trial.

HBM

Design:
ClusterRCT

N: 188
n: 100 (IG)
n: 88 (CG)

IV: FTFVE in
three separate
occasions

Parental
selfreports

Purpose:
To evaluate
the impact
of stepwise
FTFVE
interventio

Demographics:
Mean age (IG):
31.9
Mean age (CG):
31.5

DV1:
Completion of
recommended
vaccines*

5-point
Likert
scale
(selfdeveloped
by

LOE: II
Strengths: RCT design,
explicit details of stepwise
education intervention, small
attrition, homogeneity
between IG and CG
Weaknesses: Small N, lack of
confirmation of accuracy on

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Funding: St.
Luke’s Life
Science
Institute
Bias: None
reported
Country:
Japan

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

n on infant
immunizati
on status
and
maternal
knowledge

Education (mean):
Junior college
# PG (%): FTM
(48%, 40%)
Job status (%):
Unemployed
(73%, 60%).
Household
income (%):
3000-4999
(thousands of yen)
(38%, 32%)
Setting: Five
hospitals and four
private OB clinics
Inclusion
criteria:
1) PG, gestational
wk: 24-30
2) At least 18 yr
3) Able to
communicate in
Japanese
Exclusion
criteria:

34
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

DV2: Vaccine
schedule
adherence*
DV3: VK

authors;
validity
and
reliability
not
discussed)

Definition:
FTFVE
provided in
prenatal period
(34-36 wk),
postnatal period
(3-6 days postdelivery), and
1-mo PP at well
baby check-up
*Completion
and adherence
based on the 5
vaccine doses
required at 6mo
(Hib, PCV13,
DTaP-IPV,
HBV, and RV)

Data
Analysis

Findings/
Results

Level/Quality of Evidence;
Decision for practice/
application to practice

85.0%
95% CI: 0.7-3.5
p = 0.19
DTaP-IPV85.0%
95% CI: 1.0-4.3
p = 0.04
HBV54.0%
95% CI: 0.5-1.8
p = 1.00
RV66.0%
95% CI: 0.1-2.3
p = 0.45
DV2: Hib3Mean+/-SD:
129.3+/-14.8
p = 0.003
PCV133Mean+/-SD:
129.5+/-15.9
p = 0.006
DTaP-IPV3Mean+/-SD:
160.1+/-14.9
p = 0.03
HBV2-

parental self-reporting, Likert
scale utilized lacked reliability
and validity, potential for
exposure to other sources for
vaccine information (TV,
Internet)
Conclusions: FTFVE =
improvement in immunization
rates and maternal VK.
Repeating study in different
country and/or with larger N
may yield significant results.
Overall, may help with
development of standardized
prenatal FTFVE programs.
Applicability: May not be
generalizable—immunization
policies and practices differ
between countries.
Applicability is also
uncertain—cost-effectiveness
was not evaluated.

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

35
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

None explicitly
listed

Findings/
Results

Mean+/-SD:
112.2+/-35.2
p = 0.60
RV3Mean+/-SD:
130.9+/-15.9
p = 0.34
DV3**:
Mean+/-SD:
10.7+/-1.6
p = 0.70

Attrition: 9.6%
(lost to follow-up)

Level/Quality of Evidence;
Decision for practice/
application to practice

Utility to PICO: Consistent
with all PICO elements—may
be a valuable reference

*Based on ITT
analysis
**Knowledge
at 6-mo followup
Veerasingam
et al., (2017).
Vaccine
education
during
pregnancy and
timeliness of
infant
immunization.

HBM inferred

Design:
Observatio
nal cohort
study
Purpose:
Describe
the source
of
encouragin

N: 6182
Demographics:
Gender (%):
100% PG female
Ethnicity (%):
54% European
Age group (%):
52% 30-39yr

IV1: PG
women
DV1:
Characteristics
of VK
DV2: Sources
of VK

Survey
(selfdeveloped
by
authors;
validity
and
reliability
not
discussed)

Multivari
able
logistic
regressio
n

DV1:
IV1: 30%-only
encouraging
10%-both
encouraging
and
discouraging
4%-only
discouraging

LOE: IIIb
Strengths: large N, nationally
generalizable, no bias, very
low attrition rate
Weaknesses: Lower level of
evidence, no details on the
type of media used for VK,
self-developed survey

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Funding: New
Zealand
Ministries of
Social
Development,
Health,
Education,
Justice, and
Pacific Island
Affairs and
other various
government
departments
and ministries
Bias: None
disclosed
Country: New
Zealand

Theory/
Conceptual
Framework

Design/
Method

g and
discouragin
g
immunizati
on
information
received by
PG women
and its
association
with
timeliness
of infant
immunizati
on

Sample/ Setting

36
Major Variables
& Definitions

Parity (%): 58%
subsequent child
Planned PG (%):
60% planned
Education (%):
69% tertiary

IV2:
Characteristics
of VK
DV3: Infant
vaccination
timeliness

Setting:
Computer-assisted
face-to-face
interview, no
additional details
provided

Definition:
Timeliness
based on NZ’s
NIR and the NZ
Immunization
Schedule

Inclusion
criteria:
1) PG women
2) EDD between
4/25/20093/25/2010
3) Residents of
defined region of
NZ (chosen for its
population
diversity)
Exclusion
criteria: None

Measurem
ent/
Instrumen
tation

Comparis
on to NIR

Data
Analysis

Findings/
Results

56%-no
information
DV2:
14%-from
family/friends
35%-from HCP
14%-from
media
DV3:
IV2:
Discouraging
info only,
taking all
immunizations:
OR = 0.49
95%CI: 0.380.64
Timeliness:
OR = 2.61
95%CI: 1.873.59
Both
encouraging
and
discouraging,
taking all
immunizations:
OR: 0.51

Level/Quality of Evidence;
Decision for practice/
application to practice

Conclusions: PG women who
received discouraging VK =
increased VH, regardless of
receipt of encouraging VK.
Large amount of PG women
did not receive any VK during
PG—it is imperative that HCP
discuss vaccines in antenatal
period.
Applicability: Providing
truthful, encouraging VK to
PG mothers is recommended
in practice due to potential
benefits. May not be
generalizable due to differing
immunization policies and
practices between countries.
Utility to PICO: Consistent
with all PICO elements—
valuable to also know the
sources of VK

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Attrition: 1%
(lost to
incompletion of
interview)

37
Major Variables
& Definitions

Measurem
ent/
Instrumen
tation

Data
Analysis

Findings/
Results

Level/Quality of Evidence;
Decision for practice/
application to practice

95%CI: 0.420.63
Timeliness:
OR: 2.70
95%CI: 2.083.50
No information,
taking all
immunizations:
OR = 1.00
Timeliness:
OR = 1.00

Key: ACIR-Australian Childhood Immuisation Register; ATV-attitudes toward vaccination; BCG-bacillus calmette-guerin live attenuated vaccine; CG-control group; CI-confidence interval; DMdecision-making; DTaP-IPV-inactivated polio virus, diphtheria, tetanus, pertussis; DTP-diphtheria-tetanus combined vaccine; DS-databases searched; DV-dependent variable; ELM-Elaboration
Likelihood Model; FT-full-time; FTFVE-face-to-face vaccine education; FTM-first time mothers; Gest.-gestational; GP-general practitioner; HBM-Health Belief Model; HBV-hepatitis B virus; HCPhealth care providers; Hib-haemophilus influenzae type b; IBM-Integrated Behavioral Model; IG-intervention group; ITT-intention to treat; ITV-intention to vaccine; IV- independent variable; JEVJapanese encephalitis live attenuated vaccine; MANOVA-multivariate analysis of variance; MP-multiparous; MR-measles-rubella combined live attenuated vaccine; mo-month; N-number of studies (if
SR) or participants in study; n- number of participants (if SR) or number of participants in subset;; NIP-National Immunization Program; NIR-National Immunization Register; NR-not reported; NZNew Zealand; OB-obstetrician; OCS-observational cohort study; OPV-oral polio live attenuated virus; OR-odds ratio; PACV-Parental Attitudes About Childhood Vaccines; PCV13-conjugated 13valent pneumococcal; PG-pregnant/pregnancy; PMP-primiparous; PP-postpartum; PVE-prenatal vaccine education; PVL-Preventative Vaccination Law; QoE-quality of evidence; RCT-randomized
control trial; RoR-review of records; RV-rotavirus; r/t-related to; SES-socioeconomic status; SMD-standard mean difference; tri-trimester; TV-television; VarV-varicella vaccine; VH-vaccine
hesitant/hesitancy; VK-vaccine knowledge; wk-week; yr-year; #-number of

VACCINE HESITANCY IN PREGNANT MOTHERS

38

Table A2
Synthesis Table
Author

Bechini et al.

Corben &
Leask

Cunningham
et al.

Danchin et
al.

Hu et al.

Hu et al.

Kaufman
et al.

Otsuka-Ono
et al.

Saitoh et al.

Veerasingam
et al.

2019

2018

2018

2018

2017

2018

2018

2019

2017

2017

Study
Design
(LOE)

CRS (IIIa)

CSS (IIIb)

CSS (IIIb)

CRS (IIIb)

RCT (II)

RCT (II)

SR (I)

RCT (II)

RCT (II)

OCS (IIIb)

Theoretical
Framework

HBM
(inferred)

HBM
(inferred)

HBM
(inferred)

HBM

HBM
(inferred)

ELM

HBM

HBM, IBM

HBM

HBM
(inferred)

Age (% or
mean)

34yr

33%
30-34yr

66% > 30yr

NR

20-30yr

25.8

32.8yr (M)
34.8yr (F)

31.9yr

52% 30-39yr

%Females

100%

100%

100%

100%

100%

100%

100%

100%

ED level
(% or
mean)

45% college
graduates

73.1% high
school
graduates

43% more
than 4-yr
college
degree

60%
university
degree

College
or above

59%
vocational
or college
graduation

100%
(expectant
fathers also
included)
40%
university
graduates

Junior
college

69% tertiary

% # PG

NR

64.9%
multiparous

46%
primiparous

49%
primiparous

NR

NR

53%
primiparous

48%
primiparous

58%
multiparous

X

X

X

X

X

Year

Demographics

100%

Setting
Hospital
OB clinic
Virtual

X
X

X

X

X
X

X
X

Key: CRS-correlational study; CSS-cross-sectional survey; DM-decision making; ED-education; ELM-Elaboration Likelihood Model; FTFVE-face-to-face vaccine education; HBM-Health Belief
Model; IBM-Integrated Behavioral Model; II-infant immunization; LOE-level of evidence; NR-not reported; OB-obstetrician; OCS-observational cohort study; PG-pregnant/pregnancy; SR-systematic
review; RCT-randomized control trial; VH-vaccine hesitancy; VK-vaccine knowledge; U.S.-United States; yr-years; # -number of; *-statistically significant with p < 0.05; ~ - low/moderate evidence in
SR; + - strong evidence in SR; - increase

VACCINE HESITANCY IN PREGNANT MOTHERS

39

Independent Variables
FTFVE

X

X

X

Video
education

X

Booklet
education

X

PG women

X

X

X

VH

X

X

X

II &
Timeliness

X

X

X

X

Dependent Variables

ITV

X

VK/DM

X

X

X

X
X

X

X

X

X
X

X

X

X

X

X

X

X

Themes
FTFVE &
ITV or II

*

*

~

*

*

FTFVE &
VK

*

*

+

*

*

PG women
& VH
prevalence

*

*

*

Key: CRS-correlational study; CSS-cross-sectional survey; DM-decision making; ED-education; ELM-Elaboration Likelihood Model; FTFVE-face-to-face vaccine education; HBM-Health Belief
Model; IBM-Integrated Behavioral Model; II-infant immunization; LOE-level of evidence; NR-not reported; OB-obstetrician; OCS-observational cohort study; PG-pregnant/pregnancy; SR-systematic
review; RCT-randomized control trial; VH-vaccine hesitancy; VK-vaccine knowledge; U.S.-United States; yr-years; # -number of; *-statistically significant with p < 0.05; ~ - low/moderate evidence in
SR; + - strong evidence in SR; - increase

VACCINE HESITANCY IN PREGNANT MOTHERS
Appendix B
Models and Frameworks
Figure 1
Health Belief Model

as cited in Larsen (2019).

40

VACCINE HESITANCY IN PREGNANT MOTHERS
Figure 2
Rosswurm & Larrabee Evidence-Based Practice Model

Rosswurm & Larrabee (1999).

41

VACCINE HESITANCY IN PREGNANT MOTHERS

42

Figure 3
Budget for Addressing Vaccine Hesitancy in the Prenatal Population with Education

Phase

Activities

Cost

Subtotal

Total

Direct Costs
Preparation

Delivery
Evaluation

Design PowerPoint
presentation to be used during
virtual implementation
Design of pre- and postsurvey in virtual format (via
REDCap) and emailed to
participants
Voice-over PowerPoint

$0

Email remainders to complete
post-survey and inform of
infant’s immunization status

$0 $0

$0

$0

$0

$0

Indirect Costs
Delivery
Evaluation

Computer and Internet access
for virtual delivery
Small monetary participant
gift ($10/participant x 20)

$0

$0

$200

$200

$200

Funding
$0

None
Cost Savings
Providing vaccine education to pregnant mothers may significantly decrease vaccine hesitancy and

increase vaccine knowledge and infant immunization rates. Implementation of vaccine education in the
prenatal period can provide parents with confidence to vaccinate their infants, which proactively
improves both the infant’s health and societal health by contributing to herd immunity (Logan et al.,
2018; Salmon et al., 2015). Decreased vaccine hesitancy and increased infant immunization rates will
also lessen the outbreaks of vaccine-preventable diseases (VPDs). Although the project does not
provide direct revenue to TAPI or the WIC clinics, the cost savings have monumental potential. With
less treatment of VPDs, healthcare-related costs (time off work for patients/family, hospital stays,

VACCINE HESITANCY IN PREGNANT MOTHERS
medication prescribed, healthcare providers time/pay, etc.) and demands are lessened and entire
healthcare systems are positively impacted (Opel et al., 2016).

43