Vaccinations are one of the greatest achievements of Public Health. Nevertheless, they are not exempt from criticism and speculation that increase, especially in developed countries, what is known as "vaccine hesitancy". Moreover, in recent years childhood vaccination coverages in Italy decreased well below the recommended thresholds mainly due to the increase of parents who decide to delay or even to decline vaccinations. To our knowledge, few studies have investigated factors that could influence decision-making of women in relation to their children's vaccination and have planned intervention strategies to fight this phenomenon.
This project aims to fulfill this gap and to search for new practices and interventions to modify the downward trend on immunization coverage. Pregnant women will be our target population since pregnancy is universally recognized as a strategic teachable moment to influence knowledge regarding childhood vaccinations, because attitudes and beliefs about this topic are often not yet fully structured and the level of information of parents becomes a key point to decide with consciousness. Antenatal classes appear to be the ideal setting to inform pregnant women also about vaccinations. Thus, to achieve this goal, a specific training for midwives will be organized to allow them to introduce accurate information on vaccinations in antenatal classes.
The project will consist of the following four steps: i) identification of level and determinants of knowledge and attitudes about vaccinations of a population of pregnant women; ii) identification of level and determinants of knowledge and attitudes about vaccinations of midwives; iii) identification and tailoring of strategies; iv) evaluation and monitoring of the impact of the intervention.
The final aim of this project is to empower populations and to improve health literacy of parents and finally to increase vaccination coverages through a spontaneous and conscious acceptance of vaccinations.
Despite the increasing awareness regarding vaccine hesitancy and its impact on immunization rates in most industrialized countries, to date there are few existing strategies that have been explicitly designed to address vaccine hesitancy, and even fewer strategies that have quantified the impact of the interventions proposed (6).
According to the WHO SAGE WG on vaccine hesitancy, dealing with vaccine hesitancy requires at first an understanding of the magnitude and setting of the problem and a diagnosis of its root causes. This should be followed by the identification and tailoring of evidence-based strategies to address the root causes, and a subsequent evaluation to determine the impact of the interventions and monitoring whether vaccine acceptance has improved (18). Our study will follow this recommended approach to dealing with vaccine hesitancy, with the aim to develop a strategy specifically targeted at pregnant women. As already stated, although the prenatal period is an ideal time for health education, often referred to as the "teachable moment", vaccine education during the antenatal period is under-utilized and has not been rigorously evaluated for efficacy (19).
To our knowledge, only one study has been published so far regarding knowledge and attitudes of pregnant women on vaccinations (10), and the few studies published on knowledge of midwives on vaccinations are not focused on pediatric vaccines. No study has ever been published to measure the impact of the training of midwives (and other HCWs involved in ANC) on immunization uptake, while, at the same time, the little evidence available on the role of midwives in promoting immunization among pregnant women suggests that the messages provided are linked with their own perceptions and attitudes on vaccinations (20, 21). We will therefore contribute to understanding the setting and the magnitude of the vaccine hesitancy in the specific context of ANC by investigating knowledge and attitudes among pregnant women and among HCWs involved in ANC, and we will tailor training and communication strategies on vaccines promotion based on our context analysis.
The specific setting explored in our study will be that of the antenatal classes conducted in family care centres in Italy, with the aim to develop a strategy that will be also replicable in similar settings in other countries. Introducing information on vaccinations in antenatal classes is coherent with the conclusions of a Cochrane systematic review on face to face interventions for informing or educating parents about early childhood vaccination: the authors concluded that such interventions have a limited effect and, therefore, it may be feasible and appropriate to incorporate communication about vaccination into a healthcare encounter, rather than conducting it as a separate activity (22).
We will then contribute to generate evidence regarding the impact of training of HCWs involved in ANC on vaccine hesitancy, by measuring a change in vaccination uptake as a primary outcome and a change in knowledge/awareness and/or attitudes (both among women and midwives and other HCWs involved in ANC) as a secondary outcome. The presence of immunization registries in each Local Health Unit, peculiar of the Italian context, will allow us monitoring immunization uptake at the local level in each Unit where the interventions will be conducted. Special attention will be posed to possible bias in the measurement of immunization uptake arising from the enforcement of the recently approved law decree on compulsory vaccinations in school pupils. However, since doubts have been raised about the effects of the compulsory vaccination on immunization rates, educational programs are a fundamental strategy to empower populations and to improve health literacy of parents for a spontaneous and conscious acceptance of vaccinations.