A Childhood Immunization Education Program for Parents Delivered during Late Pregnancy and One-month Postpartum: A Randomized Controlled Trial

"Given that improved health literacy leads to healthier behavior..., our results about health literacy suggest that educational intervention leads to future vaccination."

In Japan, the decision as to whether a child will receive a vaccine depends on the parents, who typically receive information on vaccinations through pamphlets that are distributed by local governments within 2 months of childbirth. In addition to cost, insufficient information may be a factor contributing to low immunisation rates, particularly for optional vaccines, in this country. The present randomised controlled trial (RCT) evaluated the effectiveness of individual education sessions involving pregnant women and the children's fathers in shared decision-making on whether or not to immunise their child.

The development of the immunisation education programme was informed by focus group discussions and individual interviews with mothers of small children. It was based around 4 elements: engaging, through a participatory approach, fathers or family members, using a guidebook as a communication tool to share information and aid in promoting discussions regarding vaccinations; encouraging parents to seek a paediatrician or primary-care physician through both conversation and handouts before delivery to vaccinate their child; communicating the concept of vaccine-preventable diseases (VPDs), timing of initial vaccinations, and the importance of vaccination timeliness; and providing each expectant parent with easy access to up-to-date information regarding immunisation (via URLs, inquiries based on information provided by their local government through their website or public relations magazines, and home visits by public health workers to observe new babies).

In addition to the group guidance regarding immunisation provided by the private hospital outside Tokyo, participants in the intervention group received two individual immunisation education sessions, one (10 minutes) during late pregnancy and the second (3-5 minutes) at the one-month postpartum check-up. The first session used the guidebook with an infant immunisation schedule. The second session consisted of a check-up to determine whether parents had sought a paediatrician or primary care physician to vaccinate their child and confirmation of the date of initial vaccination using the checklist. When possible, the children's fathers and the women's partners or family members also attended the two sessions, which were conducted in an outpatient setting by a single investigator.

One hundred and seventy-five pregnant women participated, and 171 replied to the post-survey. Attitudes and beliefs regarding VPDs and childhood vaccination were evaluated based on the Health Belief Model (HBM) and the Integrated Behavioral Model. (IBM) Key findings:

• At age 3 months, intervention infants had higher self-reported immunisation rates for hepatitis B virus vaccine, or HBV (76% vs. 49%; P<0.001) and rotavirus vaccine (84% vs. 68%; P=0.019) than control group infants.
• The percentage of parents intending to vaccinate their infants was higher in the intervention group (77% vs. 52%; P<0.01).
• Improvements in scores for basic knowledge (mean [standard deviation, or SD]: 5.5 [3.6] vs. 3.0 [3.8], range: 10-30; P<0.001), advanced knowledge (mean [SD]: 5.1 [2.4] vs. 2.8 [2.5], range: 5-15; P<0.001), and health literacy regarding immunisation (mean [SD]: 0.5 [0.8] vs. 0.2 [0.6], range: 1-5; P<0.01) were higher in the intervention group.
• The rate of decision making by both parents (68% vs. 52%; P<0.05) was higher in the intervention group.

The researchers reflect on the degree of the fathers' involvement in intervention and decision-making, noting that both parents usually shared the decision-making process, even when they could not participate in the intervention during late pregnancy. This suggests a beneficial effect of indirect support provided by the guidebook, which functioned as a communication tool. In cases where the partner does not attend, medical professionals can encourage the mother to share information with the partner to aid in promoting discussions regarding vaccinations.

In conclusion, although cost remains a major barrier, "this intervention helped parents to obtain knowledge (visualize the burden of vaccination when suffering from a VPD, the benefit and burden of vaccination), and helped both parents to discuss, make decisions and take concrete actions." Thus, educational interventions that directly and indirectly involve fathers in shared decision-making on whether to immunise their child, as well as individualised interventions that provide parents with access to up-to-date information, may be effective in increasing vaccine uptake.