Patient and Provider Perspectives on how Trust Influences Maternal Vaccine Acceptance among Pregnant Women in Kenya

"Our results highlight the importance of working towards respectful antenatal care as central to improving maternal vaccine uptake in Kenya."

Maternal immunisation is a strategy to protect pregnant women and their newborns. Many low- and middle-income countries (LMICs) have not implemented World Health Organization (WHO) Scientific Advisory Group of Experts (SAGE) recommendations - partially due to concerns about low demand and acceptance. This study explored how the patient-provider relationship - specifically, the role of trust - affects maternal vaccine uptake in Kenya, where limited research in this area exists. One factor that made Kenya a fitting study-site for this project is the recent re-emergence of anti-vaccine rhetoric against the tetanus vaccine.

The researchers conducted semi-structured, in-depth narrative interviews of 328 pregnant women and 112 health care providers (HCPs) from 4 sites in Kenya: Siaya, Nairobi, Mombasa, and Marsabit. Open-ended questions explored socio-cultural practices customs, values and beliefs.

Findings, in brief (illustrated in the article with quotations from research participants):

• HCPs' perspectives - Multiple providers reported that their patients would accept whatever they recommended because their patients completely trusted them; very few reported having ever had patients refuse to be vaccinated. 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. HCPs highlighted the negative impact of recent controversial remarks by religious and political groups about the tetanus vaccine; claims that the vaccine leads to infertility resulted in increased vaccine hesitancy. HCPs touted the importance of health education as a way to dispel these rumours and increase acceptance.
• Pregnant women's perspectives - Multiple women reported not knowing what was administered to them but accepting it anyways because it came from a doctor. Mirroring HCP views on provider attitudes, pregnant women shared that attitudes strongly influenced where and when they would choose to go seek medical care. Pregnant women also cited rude and intimidating behaviour from providers as factors hindering their willingness to ask questions. 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.

In short, the study found that patient trust in HCPs is integral to vaccine acceptance among pregnant women in Kenya. The HCP-patient relationship is a fiduciary one, whereby the patients' trust is primarily rooted in the provider's social position as a person who is highly educated in matters of health. A concern that was identified by both sides was that often, this trust in combination with time constraints leads to the use of "authoritative" or paternalistic approaches whereby vaccines are administered without information.

In this context, patient health education and provider attitudes are crucial for reinstating and fostering  trust, especially in cases where trust is impeded by community myths and misperceptions and/or religious and cultural factors. To maintain and increase immunsation trust, providers are advised to cultivate a positive environment that allows for favourable interactions and patient health education. This includes educating providers on maternal immunisations and enhancing knowledge of effective risk communication tactics in clinical encounters. Open communication promotes the patient's knowledge and self-efficacy, which, as evidenced by the health belief model, can improve health outcomes.