NURS 3044: Vaccine Discussions in Pregnancy: Interviews with Midwives to Inform the Design: Research Methodology, UniSA, Australia

Part 1:

Question 1: Study Purpose/Question

• Did the study have a clearly stated purpose/research question? Yes / No

Research question: Vaccine discussions in pregnancy: interviews with midwives to inform the design of an intervention to promote uptake of maternal and childhood vaccines

• Explain your response below:

The research question above is clear and specific. This is because it utilizes the mnemonic PICo which is useful when formulating a qualitative research question. The table below displays what PICo represents.

Population- Midwives who have been interviewed

Elements of PICo used in the research questions are:

Interest- to inform the design of an intervention to promote uptake of maternal and childhood vaccines

Context- Vaccine discussion in pregnancy OR Public antenatal hospital settings in AUSTRALIA

An effective qualitative research question needs to convey sufficient information about essential aspects of a research question which include; the topic of the study, the participants, and the context of the stud. The utilization of PICo elevates the clarity and specificity of a research question as it helps organize and focus the question allowing it to be more researchable. The lack of PICo limits the specificity and hinders the researchable qualities of a research question.

Purpose: Interview midwives and collect qualitative data in order to inform the design of an intervention to promote the uptake of maternal and childhood vaccination

This study aims to understand the views, attitudes, thoughts, and feelings of midwives regarding maternal and childhood vaccination. It will explore midwives’ perceived roles in vaccine advocacy and delivery as well as barriers and enablers to device the implementation of practical and acceptable communication intervention.

Vaccination is a safe and effective way of protecting children and adults. It also an integral aspect of safeguarding the health of other people, now and for future generations.

Pregnancy is a critical time when expecting parents to start making decisions about vaccines. Currently in Australia, the coverage for maternal vaccination is reported between 65% and 80% for pertussis and 45-60% for the flu vaccine. Moreover, there is a lack of knowledge regarding effective communication approaches utilized during pregnancy to promote maternal and childhood vaccination. There is also a lack of evidence-based communication strategies and other resources for midwives to incorporate in their practice by discussing vaccination to parents. Hence the findings of this study would be a significant aspect of promoting maternal and childhood vaccines which ultimately helps increase and sustain high levels of vaccination rates.

Question 2: Relevance to nursing/midwifery practice

• Explain how this question was relevant to midwifery practice.

In Australia, three-quarters of all mothers birth in public hospitals (Kaufman J et al, 2019). This is where a large proportion of antenatal care is provided by midwives making them easily accessible and highly trusted to provide credible vaccine information to parents (Kaufman J et al, 2019).  Although midwives are expected to provide vaccine information and recommend maternal pertussis, influenza, and infant hepatitis B vaccination, it is not in the midwifery scope of practice to provide information about and discuss later childhood vaccination. To support this Kaufman J et al, (2019) highlights that recent studies have concluded that is limited education and training are provided to midwives regarding vaccination and vaccine communication. There also appears to be a disconnect as midwives support vaccination by some have varying views on whether it was central to their role.

This presents the lack of understanding of how midwives think, discuss, and advocate for maternal and childhood vaccination and what training and resources they desire to support these conversations in Australia. Thus the intervention designed from this study will equip midwives with knowledge and skills to promote maternal and childhood vaccines when engaging in discussions with women and their families about the topic.

Question 3: Ethics

• What were the possible risks of participating in the study?

There are no possible risks found in the study

• Were these risks clearly identified by the authors?                                                 Yes / No

The author did not identify any risks in the study

• If risks were identified by the authors, how did they propose to minimize risk?

There was no proposal to minimize risks in the study as there were no risks identified

• Did the authors state that they had approval from an ethics committee to undertake the study?

The authors did obtain ethics approval in Western Australia (RGS00000000736) and Victoria (HREC 37338A) to undertake the study.

Yes/No

• How did the authors obtain informed consent from the participants?

The study states that consent was obtained from all participating midwives (Kaufman J et al, 2019) however there is no explicit mention of informed consent. However, it can be assumed that informed consent was obtained as it is a key aspect of the ethical principles found in research (PPT WK 7).

• Did you identify and potential risks associated with the study that were not identified by the authors and if so, what were they?

Question 4: Study Methodology

• What is the chosen methodology for this study?

The study utilized a qualitative research methodology

• Was this choice suitable for the given research problem/question?                        Yes / No
• Explain your response to (b):

The research question is based upon interviewing midwives to gain a better understanding of their views and attitudes regarding vaccine discussion in pregnancy. Qualitative research is a broader term used to describe a specific approach of research that enables the examination of people’s personal experiences (Austin, Z et al 2014) This method utilizes in-depth interviews, observations, and discussions amongst others to analyze human experiences that are introspective and nuanced by nature. Regarding the questions, midwives can express their lived experiences and offer unique and complex perspectives. Yielding high-quality and in-depth data to help better understanding the topic and inspire further focused work in the future.

Question 5: Data Collection/Rigour

• Describe how the data was collected for this study (interview, observation, etc).

The data was collected using face to face and telephone semi-structural interviews constructed around scheduled availabilities and personal preferences of participants (Kaufman J et al, 2019). The study states that all interviews lasted between 20- 40 minutes and all audio was recorded and transcribes. Participants were asked a single open-ended question that focused on their perceived professional role which produces in-depth responses about experience, perceptions, opinions, feelings, and knowledge (Austin, Z et al 2014). Researchers put an effort to improve subsequent interviews by conducting meetings for interviewers to reflect compare their experience.

• Did the researchers provide the participants with the opportunity to check the collected data or research findings?   Yes / No
• Did the researchers continue recruiting people to the study until data saturation was reached?  Yes / No
• Did the study use multiple data collection methods (eg collect data from more than one source)?     Yes / No
• Explain how the points in (b), (c), and (d) contribute to the trustworthiness of the overall research findings.

Question 6: Participants

• How many participants were included in the study?

There were twelve participants in the study; seven midwives from the Royal Women’s Hospital in Melbourne, Victoria, and five from King Edward Memorial Hospital in Perth, Australia.

• What were the inclusion and exclusion criteria?

An explicit inclusion criterion was not stated in the study. However, researchers recruited midwives representing diverse roles, different levels of experience, and varied years of practice. There were no exclusion criteria stated in the study.

• Explain how the participants were recruited.

Midwives from Royal Women’s Hospital were recruited mainly through clinic managers who were asked to identify potential key midwives for the study. While midwives from King Edward Memorial Hospital were recruited by responding to flyers.

• Describe the setting in which the study took place (hospital, community, etc).

The study took place in public antenatal settings within two large tertiary hospitals: King Edward Memorial Hospital (KEMH) in Western Australia and the Royal Women’s Hospital (RWH) in Victoria

Question 7: Research Findings (outcomes)

• What were the main findings of this study? (provide a dot point summary)

Perceived role and professional value

• Some midwives perceived vaccination as minor aspects of their roles, one midwife form RWH is quoted saying “…I don’t consider [discussing vaccination] to be a huge part of my overall role” Kaufman J et al, 2019
• Other midwives believed it is an essential facet of their role for example “I think it’s a really important role for us…” Kaufman J et al, 2019

Professional role

• Numerous midwives communicated their reservations about advocating for vaccination too strongly or sharing their personal views. One midwife highlight that sharing personal stories could be harmless or detrimental: I don’t know whether I should use my personal feelings about it. Because also it works the other way.

Previous training

• There was little to no training provided about vaccination when the midwives were training “I think we did a bit at university on the afternoon”
• Some midwives sought out additional self-funded training and reported feeling more confident in their skills and ability to discuss vaccines

Making recommendations

• All midwives recommended maternal influenza and pertussis vaccines and infant hepatitis B
• There was a clear variation in the perceived origin of the recommendation. Such sources include the hospital, the State Health Department, doctors in the hospital, or “we”.
• Few midwives made personal recommendations.

Message content and framing

• Midwives all shared basic information about disease risks, side effects, vaccine benefits, and schedule when discussing vaccines
• Midwives explained that information presented could vary depending on the vaccine they were discussing one midwife supported by stating “we usually talk a little bit more about protecting the baby with whooping cough” while discussing influenza was centered around protecting the mother
• Discussion around childhood vaccines was less frequent and, in less detail

Descriptive and perceptions of vaccine delivery and related practices

• Some midwives at RWH perceived a potential barrier in the access of vaccine because pregnant women were referred back to their GPs to access vaccination due to the lack of maternal vaccine delivery and there is no designated immunization clinic at the hospital
• At KEMH, staffed immunization midwives often delivered the vaccines to an on-site vaccination clinic                                                                                                                               

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Timing and frequency

• The midwives at RWH highlighted that it was up to individual midwives to remember to have discussed maternal vaccines as there was no standardized point in pregnancy to bring it up: “We don’t really have a very good framework in terms of what education we should be providing at every antenatal appointment.” RWH4
• There did not appear to be a structured time to obtain parental consent for this vaccine at the RWH, and midwives described a reluctance to seek it during labor
• Midwives in both settings said that they discussed other childhood vaccines less frequently, for less time, and at less consistent time points.

Information quantity

• Midwives agreed that discussions around vaccines lasted 1-5 minutes
• Even less time was spent on childhood vaccines, which in many cases, were only discussed if the parents brought them up.

Currently available resource

• Midwives used different resources to support their vaccination discussions with expectant parents
• Printed resources were used by most midwives to facilitate the discussion
• Midwives also sought out additional information over the phone from the Infection Control department at the hospital
• Online resources such as Better Health Channel were also utilized by midwives from both hospitals with one midwife saying I’d probably tell them to Google it to be honest” (KEMH5). However, she subsequently reflected that this might bring up misinformation

Suggested resources and training

• The midwives described that a single source of information would be helpful
• Several midwives from Victoria also agreed that printed fact sheets would be helpful
• the majority from both hospitals were strongly in favor of online resources, like an educational website or app for parents

Knowledge, gaps, and challenges

• Some midwives felt women were generally well informed about both maternal influenza and pertussis vaccines, but others thought there were gaps in women’s knowledge
• Interestingly, there was disagreement about the nature of these gaps – some thought influenza was more commonly understood than pertussis, while others thought the reverse. Despite acknowledging these gaps, several midwives felt that women are overloaded with information during pregnancy

Attitudes towards maternal and childhood vaccines

• The midwives agreed that most women seemed reasonably accepting of vaccinations and they had few questions or concerns.
• Pregnant women who asked more detailed questions or expressed uncertainty were generally more hesitant about the influenza vaccine, however, hesitancy around pertussis was less common

BARRIERS and ENABLERS to vaccination delivery and/or implementation of a vaccine promotion intervention

• Midwives expressed several potential barriers when discussing vaccines varying from lack of confidence in knowledge and communication skills to insufficient time for discussing and overloading women with information.
• There were also enablers displayed to each related barrier expressed. For example, midwives found that there was a lack of information or resources for vaccine discussions, and the related enabler to minimize this was that hospitals provide policies that prioritize vaccination

Question 8: Study limitations

• What were the limitations of this study stated by the author/s?

The author stated that the study has a small sample size of 12 midwives in total, however, it expressed that data saturation was quickly reached. Another limitation conveyed was the demographic differences across both settings. The midwives from KEMH were older and more experienced than the participants from RWH. The author highlighted that this may be due to minor differences in recruitment, with participants self-selecting at KEMH, and identified by a key informant (clinic manager) at RWH. Kaufman J et al, 2019 also suggests a deficiency in the study site as a limitation.

broader sample of study sites may have generated additional themes, though Frawley et al. identified similar themes despite interviewing participants in more varied locations.10

There were demographic differences across both sites, with KEMH midwives being older and more experienced than the RWH cohort. This may also be due to slight differences in recruitment, with participants self-selecting at KEMH, and identified by a key informant (clinic manager) at RWH. These features may have led to differences in views that may not necessarily reflect the organization more broadly.

• Explain why these are study limitations.

accounts characterizing particular perceptions and/or experiences that the researcher sees as relevant to the research question.

These features may have led to differences in views that may not necessarily reflect the organization more broadly

• Did the researchers disclose any personal ideas, experiences, or knowledge (bias) that might influence the conduct and outcomes of the study?                                                                    Yes / No
• Explain why personal ideas, experiences, or knowledge (bias) may reduce the validity of the study

Question 9: Applicability to clinical practice

• According to the Levels of Evidence pyramid, what level of evidence are the reported results from this paper?

According to the Levels of Evidence pyramid, this study is a Descriptive study (level III). Descriptive studies often report the views and experiences of participants selected from a specific setting (Daly J et al, 2007). In the of the chosen study; Midwives selected from two different hospitals were interviewed to gain a better understanding of their views and attitudes regarding vaccine discussion in pregnancy.

• Overall, should the outcomes of this study be used to inform evidence-based practice?   Yes / No

• Explain your rationale for your responses to questions (a) and (b).

This qualitative study filled an important research gap in Australia and internationally in considering the applicability of existing vaccine communication interventions to midwives’ discussions with expectant parents.

Part 2 Reflection (1000 words)

Write a reflection on the learning that you have undertaken in Research Methodology relating to the questions below. If you use supporting references you should reference as per the UniSA Harvard referencing system.

In your reflection, you should consider the following:

• Did you have prior ‘knowledge’ about immunization safety for children/pregnant women prior to undertaking this assessment? Describe your understanding of this.
• How did you acquire this knowledge (what way/s of knowing/where did the information come from)?
• Did you have an opinion (bias) or concerns about the safety of immunization for children/pregnant women prior to undertaking this assessment?
• Has anything that you have learned in the course changed your opinion (bias)/allayed you concerns/increased your concerns about the safety of immunization for children/pregnant women? If so, why?
• How has learned more about interpreting research and implementing evidence-based practice influenced your opinions about immunization for pregnant women/children?
• In this course, you have learned about how personal beliefs, experiences, and trust contribute to personal health choices and decisions. As a registered nurse and/or midwife, how will you balance a person’s health beliefs with evidence-based practice when assisting them with choices about health care?