Health literacy: A crucial determinant of vaccination decision-making

  • Enrique Castro-Sánchez
    Correspondence
    Corresponding author.
    Affiliations
    NIHR Health Protection Research Unit in Healthcare-Associated Infection and Antimicrobial Resistance at Imperial College London, Du Cane Road, London, W12 0NN, UK
    Search for articles by this author
  • Desireé Mena-Tudela
    Affiliations
    Department of Nursing, Faculty of Health Sciences, Universitat Jaume I, Castellón de la Plana, Castellón, Spain
    Search for articles by this author
  • Francisco Javier Soriano-Vidal
    Affiliations
    Department of Obstetrics and Gynaecology, Hospital Luis Alcanyis, Avda. Ausiàs March, 46800 Xàtiva, Spain

    Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain

    Department of Nursing, Universitat de València, C/Jaume Roig, s/n, 46001 Valencia, Spain

    Department of Nursing, University of Alicante, Cta. San Vicente del Raspeig s/n 03690 San Vicente del Raspeig, Alicante, Spain
    Search for articles by this author
  • Rafael Vila-Candel
    Affiliations
    Department of Obstetrics and Gynaecology, Hospital Universitario de la Ribera, Crta. Corbera km 1, 46.600 Valencia, Spain

    Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain

    Department of Nursing, Universitat de València, C/Jaume Roig, s/n, 46001 Valencia, Spain
    Search for articles by this author
Open AccessPublished:June 03, 2020DOI:https://doi.org/10.1016/j.ijid.2020.05.081
      Dear Editor,
      We read with interest the Review by
      • Buchy P.
      • Badur S.
      • Kassianos G.
      • Preiss S.
      • Tam J.S.
      Vaccinating pregnant women against influenza needs to be a priority for all countries: an expert commentary.
      summarizing the evidence on the micro (patients, healthcare workers), meso (vaccine manufacturers), and macro (wider society) determinants of influenza vaccination in pregnant women worldwide.
      We agree with the authors that improvements in vaccination coverage could be gained with better training for healthcare workers about communicating the benefits of vaccination and the risks associated with influenza infection, as well as education about such benefits to pregnant women. However, education per se may be insufficient unless it is underpinned by health literacy principles. Health literacy has been defined primarily as the capacity that citizens have to access and make use of health information to make decisions about their health and care (
      • Nutbeam D.
      The evolving concept of health literacy.
      ).
      Decisions to vaccinate are complex, requiring an understanding of the immune system and the pathogenesis of each microorganism, the variety of immunization schedules, the adverse events which occur at different rates and the influence of several health professionals involved in the decision-making process at different time points (
      • Vila-Candel R.
      • Soriano-Vidal F.J.
      • Castro-Sánchez E.
      Midwives, vaccines and health literacy: an underexplored relationship?.
      ).
      Our study exploring the influence of health literacy on influenza vaccination among pregnant women in Spain reflected how women with high health literacy were more likely to reject influenza vaccination than those with lower health literacy (
      • Castro-Sánchez E.
      • Vila-Candel R.
      • Soriano-Vidal F.J.
      • Navarro-Illana E.
      • Díez-Domingo J.
      Influence of health literacy on acceptance of influenza and pertussis vaccinations: a cross-sectional study among Spanish pregnant women.
      ). Among the reasons for these women to reject the vaccine were feelings about its need, in isolation and compared with other immunizations, and claims of having received insufficient information. To mitigate such a gap, women with high health literacy would access a greater variety of information sources, including those promoting outlier or fringe opinions (
      • Danchin M.H.
      • Costa-Pinto J.
      • Attwell K.
      • Willaby H.
      • Wiley K.
      • Hoq M.
      • et al.
      Vaccine decision-making begins in pregnancy: correlation between vaccine concerns, intentions and maternal vaccination with subsequent childhood vaccine uptake.
      ,
      • Vila-Candel R.
      • Navarro-Illana P.
      • Navarro-Illana E.
      • Castro-Sánchez E.
      • Duke K.
      • Soriano-Vidal F.J.
      • et al.
      Determinants of seasonal influenza vaccination in pregnant women in Valencia, Spain.
      ).
      The implications of this study are clear – a full understanding by healthcare professionals of how pregnant women make decisions about vaccinations is required, including the crucial topics of women’s interest and concern, which information sources they prefer to meet their needs, how they combine and integrate the evidence obtained into explanatory frameworks, and when these frameworks are shaped by emotions and influenced by social and personal networks.
      Interventions solely interested in providing evidence-focused vaccination messages to mitigate assumed information gaps, and without acting upon the determinants shared by vaccination and health literacy such as education level, self-efficacy, and empowerment, are unlikely to sustainably dent existing suboptimal vaccination rates among pregnant women, precluding them from the clinical, public health and social gains afforded by vaccination.

      Funding

      Enrique Castro-Sánchez is affiliated with the National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London (grant No. HPRU- 2012e10047) in collaboration with Public Health England and Imperial College Healthcare NHS Trust. He is also an NIHR Senior Nurse and Midwife Research Leader and recognizes the support of the NIHR Imperial Patient Safety Translational Research Centre and the BRC.

      References

        • Buchy P.
        • Badur S.
        • Kassianos G.
        • Preiss S.
        • Tam J.S.
        Vaccinating pregnant women against influenza needs to be a priority for all countries: an expert commentary.
        Int J Infect Dis. 2020; 92: 1-12https://doi.org/10.1016/j.ijid.2019.12.019
        • Castro-Sánchez E.
        • Vila-Candel R.
        • Soriano-Vidal F.J.
        • Navarro-Illana E.
        • Díez-Domingo J.
        Influence of health literacy on acceptance of influenza and pertussis vaccinations: a cross-sectional study among Spanish pregnant women.
        BMJ Open. 2018; 8e022132https://doi.org/10.1136/bmjopen-2018-022132
        • Danchin M.H.
        • Costa-Pinto J.
        • Attwell K.
        • Willaby H.
        • Wiley K.
        • Hoq M.
        • et al.
        Vaccine decision-making begins in pregnancy: correlation between vaccine concerns, intentions and maternal vaccination with subsequent childhood vaccine uptake.
        Vaccine. 2018; 36: 6473-6479https://doi.org/10.1016/j.vaccine.2017.08.003
        • Nutbeam D.
        The evolving concept of health literacy.
        Soc Sci Med. 2008; 67: 2072-2078
        • Vila-Candel R.
        • Soriano-Vidal F.J.
        • Castro-Sánchez E.
        Midwives, vaccines and health literacy: an underexplored relationship?.
        Gac Sanit. 2016; 30: 403https://doi.org/10.1016/j.gaceta.2016.05.004
        • Vila-Candel R.
        • Navarro-Illana P.
        • Navarro-Illana E.
        • Castro-Sánchez E.
        • Duke K.
        • Soriano-Vidal F.J.
        • et al.
        Determinants of seasonal influenza vaccination in pregnant women in Valencia, Spain.
        BMC Public Health. 2016; 16: 1173https://doi.org/10.1186/s12889-016-3823-1

      Linked Article

      • Vaccinating pregnant women against influenza needs to be a priority for all countries: An expert commentary
        International Journal of Infectious DiseasesVol. 92
        • Preview
          Pregnancy and early infancy are periods of increased vulnerability to some infections for both mother and child (Jones and Heath, 2014). Due to physiological and immunological changes, pregnancy may increase susceptibility to infection and increase the risk of serious outcomes of infections, such as hepatitis E, herpes simplex virus, influenza, listeriosis, and malaria (Kourtis et al., 2014; Sappenfield et al., 2013). Changes in the immune system during pregnancy are mediated by hormones, cytokines, and immune cells, as well as structural changes such as remodelling of the endometrium (Vojtek et al., 2018).
        • Full-Text
        • PDF
        Open Access
      • Reply to “Health literacy, a crucial determinant of vaccination decision-making among pregnant women” by Castro-Sánchez et al
        International Journal of Infectious DiseasesVol. 97
        • Preview
          In their correspondence entitled “Health literacy, a crucial determinant of vaccination decision-making among pregnant women”, Castro-Sánchez et al. rightly highlight the complexity of the considerations leading to the decision to vaccinate. In our recent review entitled “Vaccinating pregnant women against influenza needs to be a priority for all countries: An expert commentary” (Buchy et al., 2020), we dedicated a chapter to the description of the main obstacles to influenza vaccination in pregnancy and the lessons learned from countries that have succeeded in increasing vaccination coverage in pregnant women.
        • Full-Text
        • PDF
        Open Access