Pregnant women and newborns are at high risk for infectious diseases. Altered immunity status during pregnancy and challenges fully vaccinating newborns contribute to this medical reality. Maternal immunization is a strategy to protect pregnant women and their newborns. This study aimed to find out how patient-provider relationships affect maternal vaccine uptake, particularly in the context of a lower middle- income country where limited research in this area exists.
We conducted semi-structured, in-depth narrative interviews of both providers and pregnant women from four sites in Kenya: Siaya, Nairobi, Mombasa, and Marsabit. Interviews were conducted in either English or one of the local regional languages.
We found that patient trust in health care providers (HCPs) is integral to vaccine acceptance among pregnant women in Kenya. The HCP-patient relationship is a fiduciary one, whereby the patients’ trusts is primarily rooted in the provider’s social position as a person who is highly educated in matters of health. Furthermore, patient health education and provider attitudes are crucial for reinstating and fostering that trust, especially in cases where trust was impeded by rumors, community myths and misperceptions, and religious and cultural factors.
Patient trust in providers is a strong facilitator contributing to vaccine acceptance among pregnant women in Kenya. To maintain and increase immunization trust, providers have a critical role in cultivating a positive environment that allows for favorable interactions and patient health education. This includes educating providers on maternal immunizations and enhancing knowledge of effective risk communication tactics in clinical encounters.
Pregnant women and infants are highly susceptible to adverse outcomes stemming from infectious diseases. The fetal immune system does not fully develop until well after birth; meanwhile pregnancy leads to physiological and immunological changes that alter the mother’s immune system and lessen her ability to effectively respond to infections [1, 2]. According to WHO recommendations and based on the available evidence of safety and effectiveness, most vaccines (including against influenza, diphtheria, tetanus, and pertussis) are not administered until the child is at least 6 weeks old (with the exception of Hepatitis B, Polio and BCG); furthermore, vaccination schedules are not complete until the child is between 14 weeks and 6 months . This presents an immunity gap that can be addressed through the use of maternal vaccines which protect both the mother during pregnancy and the child during the prenatal and postnatal periods [1, 2]. However, low maternal vaccination coverage, particularly in low- and middle- income countries in Africa and Asia where often tetanus is the only recommended vaccination during pregnancy, continues to pose a threat to mothers and infants [4, 5].
There are promising and existing vaccines that have the potential to reduce neonatal and infant mortality rates, however, as mentioned before, the monovalent maternal tetanus vaccination is the only vaccine offered in most developing countries . Despite WHO’s Scientific Advisory Group of Experts (SAGE) recommendations emphasizing maternal influenza vaccination and supporting the continuation and expansion of immunization for pregnant women , many low- and middle- income countries have not implemented the recommendation - partially due to concerns about low demand and acceptance coupled with the issue of cost, availability and vaccine approval for inclusion into countries’ schedule .
Although some studies have largely attributed mother’s hesitancy to concerns about maternal and child safety that are often based off of misinformation, and also rooted on religious beliefs and cultural norms , there is limited information on the determinants of maternal vaccine acceptance in the context of low- and middle- income countries. Given the benefits of maternal immunization that have been observed with vaccines currently in use and the number of new vaccines currently being developed that have the potential to significantly contribute to address the high burden of disease in women and infants [10,11,12,13], (for example, a promising maternal vaccine to prevent respiratory syncytial virus (RSV) disease among infants is in advanced clinical trials [14, 15]), it is essential to achieve a better understanding of factors influencing demand and acceptance of current maternal vaccines. This will also facilitate a successful introduction of new vaccines as well as improved uptake of existing vaccines.
Thus, the objective of this study was to describe maternal trust within the patient - provider relationship in Kenya and how it shapes maternal immunization acceptance. Few studies have specifically looked at the role of providers in maternal vaccine acceptance, especially in the context of low- and middle- income countries. For this analysis, we used qualitative research methods to assess the role of patient trust in vaccine acceptance from the perspective of both pregnant women and health care providers in Kenya as an example of a LMIC.
This research was part of a larger in-depth, mixed-methods, multi-tiered, national study on maternal vaccine acceptance in Kenya. A research question within this larger study was the role of healthcare providers on maternal vaccine acceptance. This paper focuses on the findings garnered from pregnant women and healthcare providers’ (HCPs) interviews; it specifically addresses how patient trust within the provider-patient relationship affects maternal vaccine acceptance among pregnant women.
Several factors made Kenya a fitting study-site for this project, the first being the recent re-emergence of anti-vaccine rhetoric against the tetanus vaccine. Secondly, Kenya has a large birth cohort (over 1.5 million births in 2012) and has a long standing history / partnership with the CDC that’s resulted in a strong, surveillance system. Lastly, there is considerable regional, cultural, religious, and tribal diversity in Kenya, which enabled our team to gather a variety of perspectives from those who work in the maternal/child health field. Thus, four field sites representing both urban and rural settings were selected, allowing for the examination of cultural, economic, and geographical differences within Kenya (Table 1). Clinics were selected based on their geographic location within the study areas and previous partnerships with the Kenya Medical Research Institute (KEMRI) – Centers for Disease Control (CDC) collaboration.
Both pregnant women and healthcare providers were selected through convenience sampling methods at clinical facilities (Table 2). Pregnant women were approached and consented at the clinics by study personnel. Healthcare workers were initially approached at the clinic; however, due to a nurses’ strike in 2017 when the data collection was ongoing, the protocol was adapted and most of the interviews were conducted at the homes of the healthcare providers.
Semi- structured, in-depth interview guides were developed using grounded theory  by the study’s lead anthropologist with input from the study team, in-country partners, and a scientific advisory committee. To understand the social determinants of maternal immunization acceptance among pregnant women in Kenya, open-ended questions explored socio-cultural practices customs, values and beliefs (Additional files 1 and 2).
During the initial pilot-testing phase, the guides were reviewed, revised, and updated as new themes emerged. An expert anthropologist trained in-country research team members in qualitative methods including protocol adherence, screening, consenting, qualitative interview methods, transcription and translation. The inclusion and exclusion criteria are described in Table 2. Interviews were conducted in either English, Swahili, Kikuyu, Luo, or Borana depending on site and preference of the interviewee. Interviews lasted approximately 30 to 60 min, depending on the extent of the discussion, and were audio recorded. Interviews were conducted in teams of two, allowing for an interviewer and note taker (Table 2). Both KEMRI IRB and Emory IRB approved the study protocol. CDC IRB reliance on Emory’s IRB was obtained.
Interviews were transcribed and translated (when necessary). The analysis was done using N-Vivo 11.0 qualitative data analysis software. Identifiable information such as names, dates, and addresses were removed from both the recordings to maintain participant confidentiality.
Prior to coding, the qualitative research team developed two codebooks including one for providers and one for pregnant women’s interviews. Once the codebooks were completed, codes were applied to the transcribed interviews; major thematic content emerged from this process. Intercoder reliability was performed among three coders participating in the coding and analysis. A kappa coefficient of ≥0.80 was considered a minimal cut-point for high intercoder agreement among coded content to maintain rigorous qualitative research standards. After 4 rounds of intercoder testing, the team achieved k ≥ 0.80 agreement on codes used in this analysis.
A total of 328 pregnant women and 112 HCPs, including nurses and clinical officers, were interviewed. Of the 112 HCPs, 42 HCPs worked in only public facilities while the rest worked also at private facilities. Our primary themes were patient trust, patient health education and provider attitudes towards patients. Additional quotes corresponding to the themes and subthemes are depicted in Tables 1, 2, 3, 4, 5 and 6.
Health care providers’ perspective
Patient trust in providers and resulting ethos
Multiple providers reported that their patients would accept whatever they recommended because their patients completely trusted them (Table 3). Providers believed that this trust was primarily rooted in the providers’ social position as a learned professional holding a great deal of knowledge about health. Additionally, providers believed that patients trusted that providers would always do what was right for them (Table 3). This perception of trust manifested in two different clinical approaches: providers who were presumptive and administered the vaccine to their patient without communicating what it was; and those who thought it still important to inform their patients what vaccine they were receiving prior to administration.
“They have no choice, we just tell them it is mandatory and it is good for them.”
“I think, when women come to the health care provider they have trust in them. Since they trust us, they will also trust what we tell them. It is now our work as the health care providers to give convenient information to these women so that they can go back to their homes satisfied.”
In both examples, providers explicitly or implicitly expressed perceived trust from their patients. However, the first provider had a more paternalistic view while the latter expressed the need to inform their patients. Ultimately, regardless of their personal belief systems, all providers recognized the amount of power this trust bestowed upon them and believed patients would not typically refuse to adhere to their recommendations (Table 3).
Provider attitudes towards patients (respect and approachability)
Although patient trust was implicit and very few providers reported having ever had patients refuse to be vaccinated, providers generally acknowledged the importance of their own personal attitudes for patient trust and vaccine acceptance when addressing pregnant women (Table 4). While some providers still practiced authoritative approaches, particularly in the rural areas, others heeded that the expectation of patient deference was no longer universal.
Nowadays, people do not harass mothers like in the previous years … In the past, people used to be blasted by the nurses or whoever was giving the services whenever they asked questions. Those days are long gone. It is always good to ask why you are being injected.
Some providers noted a shift in the evolution of the patient-provider relationship to one that needed open communication and respect for continued trust and acceptance of vaccines (Table 4). Many providers said that patients would prefer to be consulted and informed prior to receiving the vaccines (Table 4). However, even while acknowledging the need for positive attitudes and educating their patients on what they were receiving, many reported not being able to always brief their patients in practice; largely due to heavy workloads and time constraints.
“Maybe when a health care provider is in a hurry or is being overworked. You may find a long queue at the ANC waiting for vaccination. The nurse there may not have time to discuss much with every client about the vaccines. Sometimes they issue orders for the mothers to queue and get vaccinated. These are situation which may happen when there are several mothers at the clinic. This can cripple vaccine uptake since there is no time for explanations.”
Patient health education
Providers reported various religious and cultural barriers to vaccine uptake. However, providers highlighted the negative impact of recent controversial remarks by religious and political groups about the tetanus vaccine. They claimed that the vaccine led to infertility. These allegations resulted in increased vaccine hesitancy (Table 5). When asked how to mitigate these effects, providers touted the importance of health education as a way through which they could dispel these rumors and increase acceptance.
“But with continuous education given, the posters, you find that the number that come to access vaccination is high. For example, if you forget to give they will ask you for the vaccine.”
Although anti-vaccine rumors reduced patient trust in both providers and vaccines, provider responses suggested that there was still enough trust left among pregnant women to allow for the use of health education as a reinforcement tool.
“They always appreciate as long as the information that is being given to them is from somebody from a medical profession and whom [they] trust.”
According to the providers, educating the patients about the importance of vaccines would not only increase vaccine acceptance but it would also reinforce patient trust in providers and reinstate it in situations where it had dissipated. Additionally, providers reported that health education reduced default for subsequent vaccination and could also promote communal buy-in in cases where these women became vaccine advocates within their community (Table 5).
Pregnant Women’s perspective
1. Expressed patient trust
Pregnant women supported HCP views on trust. They explicitly said that they would accept whatever is recommended by HCPs, even if they didn’t know what it was. There were multiple women who reported not knowing what was administered to them but accepting it anyways because it came from a “doctor.”
It is us who need it, and we don’t know why we need it, so there is no way we can refuse. In addition, you cannot dispute what a doctor tells you, especially on something that he has taken years to train for. Even if they inject you with poisons or any other substance other than the vaccine, you wouldn’t know and you won’t have any say.”
Pregnant women describe a broad range of providers including healthcare volunteers, doctors, nurses, chemists, and outreach healthcare workers as “doctors”. Pregnant women did not always differentiate one from the other but when they did, they would often use the hospital as an identifying marker between providers. They would either describe the provider as the doctor walking around the neighborhood (community health workers), or as the doctor in the hospital (physicians, nurses, chemists). For the pregnant women who made a distinction between the different types of providers, trust was sometimes expressed more towards those providers who worked at the hospital.
“I believe it is safe if it is from health centers but not out there because you may not know who sent them and their motives. I would rather come to the hospital to confirm if there is a vaccine being given”.
When asked why they trusted HCPs, most pregnant women replied that they trusted providers because 1) providers are learned about health and are the only ones who can decipher their illnesses and treat them accordingly, 2) providers have institutional authority from the government to guard their health and 3) providers are healers and caregivers with honest motives (Table 6). Most notably, in some of the cases where patients showed hesitancy towards vaccines, patient trust in the government, superseded that mistrust (Table 6).
2. Provider attitudes towards patients (respect and approachability)
Once again, though trust in providers was consistently expressed, pregnant women also spoke about the importance of provider attitudes on facilitating trust and vaccine acceptance. Mirroring HCP views on provider attitudes, pregnant women shared that attitudes greatly contributed to where and when they would choose to go seek medical care.
“Personally I would not have come back here if it were not for my condition because of my first experience here. Because when you come to the clinic, you expect to find friendly people who are ready to help you. But if you come and find somebody who is arrogant, one who has I do not care attitude and it is like you are bothering them, I will prefer to go somewhere else where I will find somebody who will understand my condition.”
It is however important to note that provider attitudes were mostly considered as a factor in vaccine decisions by participants living in urban areas where there is an abundance of facilities available. Most participants living in rural areas often reported having little choice in where to go and considered distance and cost much more than they did provider attitudes (Table 4).
3. Patient health education
Women also noted the importance of health education in their decisions to accept the vaccines. While there were many who did not know what was being administered and did not care about knowing more about the vaccine, many others reported that having more information about what was being administered increased trust in their provider as well as the vaccine.
“I come here because of the services they provide but mostly I like the guidance and counseling they provide.”
On the other hand, there were many pregnant women who wanted more information but stated that they were unable to receive it. When asked why they didn’t inquire about what they were receiving, patients report either being scared of being admonished for speaking up / asking questions, or not having an opportunity to ask questions due to time constraints (Table 5). The lack of information and hostile provider attitudes may have not always hindered vaccine acceptance for most women, but some did say that it lessened their trust in HCPs:
“Even if it were you, you would be scared. We believe that if you are a know-it-all, they may even harm you. It is like telling the doctor ‘you did this and it is not done like that.’ You are sure that is not how it is done but because he/she wants to show you that he/she is there for that job and knows more than you do people say that he/she can harm you because you do not know what you are being injected with.”
In this study, we assessed how pregnant women and antenatal care providers perceive patient trust in their relationship and how, from their perspectives, it affects maternal vaccination in diverse areas from Kenya. The central result from this study was that both pregnant women and providers recognize that high trust is placed on the health care providers to make decisions about maternal immunization. A concern that was identified by both sides was that often, this trust in combination with time constraints leads to the use of ‘authoritative’ approaches from the providers’ side who sometimes vaccinate without providing information to the women. While this could be compared to the presumptive approach that is recommended in the US and other high-income countries, failing to provide pregnant women enough information to make informed healthcare decisions could lead to a deterioration of this trust. In this sense, women reported not feeling empowered to request information, but still trusting the providers to make vaccination decisions. In turn, some providers acknowledged recent changes where women are now allowed to request information and stressed the importance of shifting towards a relation that allows better communication and respect for the patient. This could also help address other sources of misinformation that can increase maternal vaccine hesitation.
A common theme among both pregnant women and providers was the concern that increasing misconceptions disseminated by some religious and political leaders [17, 18] could have led to increased vaccine hesitancy and mistrust in Kenya. Some of this misinformation included warnings against vaccines being used as means for sterilizations. While it is hard to determine direct causality, these statements occurred in parallel with a 16% decrease in women who had booster doses between 2013 (77%) and 2016 (61%) based on data from the Kenya Demographic Health Surveys . In this context, our results showing the strong trust of pregnant women on their providers to make decisions about vaccination highlight an opportunity to preserve and leverage this relationship to improve to improve maternal vaccine acceptance for existing and new maternal vaccines (e.g. RSV).
We identified two main factors that could be utilized to improve this relationship through increasing trust: patient health education and improved patient- provider interactions. The association between patient trust, provider attitudes towards patients, and patient health education is cyclic. Both pregnant women and providers expressed that pregnant women wanted to know more about vaccines, and that patient health education can increase trust in both the provider and the vaccine itself. Conversely, pregnant women conveyed that they only trust vaccine information if it is relayed by providers. However, the amount of trust that is inherently present between patients and providers is reportedly being hampered by poor provider attitudes towards patients. Both providers and pregnant women stated that inherent patient trust was rooted in a fiduciary relationship: patients trust that providers know more about health and consequently transfer autonomy to the provider. A fiduciary relationship, as defined by James Marcum, is one where trust stems from the provider’s expert and technical knowledge .
Although patients were not opposed to providers making health decisions for them, they voiced their frustrations at how providers sometimes treated them. Many women shared that staff attitudes greatly contributed to if, when, and where they chose to go seek medical care. Similar findings were previously reported in a study that looked at patterns of childhood vaccine acceptance in Malawi, India, Ethiopia and the Philippines . Since maternal vaccination with TT is provided through antenatal care visits, if providers’ attitudes discourage women from attending the visits, decreased maternal vaccine coverage could be one of the many negative consequences of this miscommunication. Our results highlight the importance of working towards respectful antenatal care as central to improving maternal vaccine uptake in Kenya.
Aside from facility choice and impact on access to antenatal care, these attitudes also hampered effective health communication between patients and providers. Pregnant women cited rude and intimidating behavior from providers as factors hindering their willingness to ask questions or come back for subsequent treatment. Providers corroborated this view and attributed this behavior to historically paternalistic approaches and heavy workloads and time constraints.
These results suggest that patient education and provider attitudes towards patients are imperative for the growth of this trust and are interrelated in a cyclic fashion; patient health education reinforces patient trust in providers while providers’ attitudes towards their patients can either reinforce or hamper that trust. We recommend that, in addition to improving their attitudes towards their patients, providers should learn effective risk communication and how to facilitate open communication. This promotes the patient’s knowledge and self-efficacy which, as evidenced by the health belief model, improves health outcomes . Governments can facilitate these changes by including modules on patient health communication during continued medical education (CMEs) for providers. Additionally, given our data’s illustration of the impact of provider time constraints on patient- provider interactions and patient health education, facilities can mitigate these effects by using the community health volunteers to educate pregnant women on vaccines.
In addition to trusting the provider because they consider them highly knowledgeable, pregnant women said they trusted providers because they had governmental authority. Pregnant women believed that providers would not administer anything that was harmful because the government would not harm them. Sometimes this trust extended to the types of health facilities they chose to frequent: pregnant women showed more trust towards public health institutions than private health institutions. This is an important revelation given that low trust in governments is considered to contribute to the global hesitancy of vaccination .
One of our limitations is potential selection bias. The pregnant women in our study were recruited during their antenatal care visits at the health facilities. By virtue of them already being at the hospital, they may already have relatively high trust /little resistance to seeking care. Similarly, we only interviewed women seeking treatment in public facilities; those who attend private facilities may hold different views that were not captured by our study. However, most women in Kenya attend public facilities and the large sample size, especially for a qualitative study, could have offset some of this limitations. Additionally, most public health care providers were on strike during this phase of our research which could have also influenced their answers, since they were not practicing and perhaps had a particularly negative outlook. However, we were able to complete the data collection by meeting providers at their convenience, and capture the views of healthcare providers under real world conditions.
Our study highlights the importance of the patient- provider relationship as a facilitator for maternal vaccine acceptance in Kenya. Maintaining and improving trust within this partnership is extremely important for patient compliance. We argue that health care systems cannot rely on patient deference for treatment compliance, especially in a changing context where trust in the system might decrease over time (as seen in other countries like the United States ). Recommendations to foster maternal vaccination acceptance moving forward include motivating providers to allow open communication with pregnant women, and providing information to improve patients’ knowledge and understanding of the importance of vaccination during pregnancy. Important next steps are to provide this information to policymakers and healthcare managers to try to implement some of the recommendations written herein.
Availability of data and materials
This analysis was primarily based on qualitative data. Some data may be available upon request after reviewing for confidentiality. Please contact Dr. Gonzalez Casanova to request the data (email@example.com).
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The authors would like to acknowledge participants for taking the time to express their views surrounding maternal immunization as well as the field team for their hard work.
The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of [the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry].
This work was supported by the Bill and Melinda Gates Foundation under grant OPP1120377. The funding source collaborated with the study team in through periodic meetings to support the design and implementation of the study, however the final data collection, analysis and interpretation of the results was conducted by the study team independently from the funder.
Authors and Affiliations
Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
Stacy W. Nganga, Andrew Wilson, Irina Bergenfeld, Courtni Andrews, Vincent L. Fenimore, Ines Gonzalez-Casanova, Paula M. Frew, Saad B. Omer & Fauzia A. Malik
Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
Nancy A. Otieno, Maxwell Adero & Dominic Ouma
Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
Sandra S. Chaves, Jennifer R. Verani & Marc-Alain Widdowson
UNLV School of Public Health, University of Nevada, Las Vegas, NV, USA
Vincent L. Fenimore & Paula M. Frew
Department of Behavioral Science and Health Education, Emory University Rollins School of Public Health, Atlanta, GA, USA
Paula M. Frew
Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
Paula M. Frew
UNLV Population Health & Health Equity Initiative, University of Nevada, Las Vegas, NV, USA
Paula M. Frew
Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
Saad B. Omer
Division of Pediatrics, Atlanta, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
SWN participated in the data collection, conducted the analysis and drafted the manuscript. NAO, MA, DO, SSC, JV, and MAW, AW, IGC, PF, FAM contributed to the design and implementation of the data collection, and provided insights for the analysis and interpretation of the results, and supported the drafting of the manuscript. IB, CA, VLF supported the data analysis and interpretation of the results. SBO was the principal investigator from this study and contributed to the design, implementation, analysis, and interpretation of the results. All the authors reviewed and approved the final version of the manuscript.
The study was reviewed and approved by Emory’s Institutional Review Board (IRB00089673) and the Ethics Committee of the Kenya Medical Research Institute. All participants provided written informed consent before the interviews and information was de-identified before transcription and translation.
Consent for publication
Participants (healthcare workers and pregnant women) consented to de-identified results from the interviews to be used in dissemination materials and publication.
This study received research funding from the Bill and Melinda Gates Foundation. Dr. Omer serves as a consultant to the Bill and Melinda Gates Foundation and receives compensation for these services. The terms of this arrangement have been reviewed and approved by Emory University in accordance with its conflict of interest policies.
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Nganga, S.W., Otieno, N.A., Adero, M. et al. Patient and provider perspectives on how trust influences maternal vaccine acceptance among pregnant women in Kenya.
BMC Health Serv Res19, 747 (2019). https://doi.org/10.1186/s12913-019-4537-8