1
Cas o-SánchezE, e al. BMJ Open 2018;8:e022132. doi:10.1136/bmjopen-2018-022132
Open access
In luence o heal h li e acy on
accep ance o in luenza and pe ussis
accina ions: a c oss-sec ional s udy
among Spanish p egnan women
En ique Cas o-Sánchez,1 Ra ael Vila-Candel,2,3 F ancisco J So iano-Vidal,3,4,5,6
Es he Na a o-Illana,3 Ja ie Díez-Domingo3,5
To ci e: Cas o-SánchezE,
Vila-CandelR, So iano-VidalFJ,
e al. In luence o heal h li e acy
on accep ance o in luenza and
pe ussis accina ions: a c oss-
sec ional s udy among Spanish
p egnan women. BMJ Open
2018;8:e022132. doi:10.1136/
bmjopen-2018-022132
EC-S and RV-C con ibu ed
equally.
Recei ed 2 Feb ua y 2018
Re ised 17 Ap il 2018
Accep ed 7 June 2018
1NIHR Heal h P o ec ion
Resea ch Uni (HPRU) in
Heal hca e Associa ed In ec ions
(HCAI) and An imic obial
Resis ance (AMR), Impe ial
College London, London, UK
2Depa men o Obs e ics
and Gynaecology, Hospi al
Uni e si a io de la Ribe a,
Valencia, Spain
3Facul y o Nu sing, Uni e sidad
Ca ólica de Valencia ‘San
Vicen e Má i ’, Valencia, Spain
4Xà i a-On inyen Heal h
Depa men , Xà i a, Spain
5Founda ion o he P omo ion o
Heal h and Biomedical Resea ch
in he Valencian Region
(FISABIO), Valencia, Spain
6Depa men o Nu sing,
Uni e si y o Alican e. San
Vicen e del Raspeig, Alican e,
Spain
Co espondence o
D En ique Cas o-Sánchez;
e. cas o- sanchez@ impe ial.
ac. uk
Resea ch
© Au ho (s) (o hei
employe (s)) 2018. Re-use
pe mi ed unde CC BY.
Published by BMJ.
Abs AC
Objec i es Immunisa ions agains in luenza and
Bo de ella pe ussis in ec ion a e ecommended o
p egnan women in Valencia (Spain), ye accina ion a es
emain low. Heal h li e acy (HL) appea s as a c ucial ac o
in accina ion decision-making. We explo ed he ela ion
be ween HL o p egnan women and decisions o ecei e
in luenza and pe ussis immunisa ions.
se ing Uni e si y hospi al in Valencia (Spain).
Pa icipan s 119 women who ga e bi h a a hospi al
in Valencia (Spain) be ween No embe 2015 and May
2016. Women in he immedia e pos pa um pe iod
(mo e han 27 weeks o ges a ion), be ween No embe
2015 and May 2016 we e included in he s udy. Women
wi h impai men s, language ba ie s o illi e acy which
p e en ed comple ion o he ques ionnai es, o hose who
we e unde 18 yea s we e excluded om en olmen .
P ima y and seconda y ou come measu es HL le el;
in luenza and pe ussis immunisa ion a e; easons o
ejec ion o accina ion.
esul s 119 pa icipan s we e included (mean age
32.3±5.5 yea s, 52% p imipa ous, 95% ull- e m
deli e ies). A highe educa ion le el was associa ed wi h
Sho Assessmen o Heal h Li e acy o Spanish Adul s
_50 (adjus ed R2=0.22, p=0.014) and Newes Vi al Sign
(adjus ed R2=0.258, p=0.001) sco es. Depending on he
scale, 56%–85% o pa icipan s had adequa e HL. 52%
(62/119) and 94% (112/119) o women ecei ed in luenza
and pe ussis immunisa ion, espec i ely. Women ejec ing
in luenza accine had a highe HL le el (measu ed by
SALHSA_50 ool) han hose accep ing i (K uskal-Wallis
es p=0.022). 24% o women who declined in luenza
accina ion el he accine was unnecessa y, and 23%
claimed o ha e insu icien in o ma ion.
Conclusions In luenza accina ion a e was subop imal in
ou s udy. Women wi h high HL we e mo e likely o decline
immunisa ion. In o ma ion om p o essionals needs o
ma ch pa ien s' HL le els o educe nega i e pe cep ions
o accina ion.
bACkg Ound
Despi e i s bene i s, in luenza accine
co e age among p egnan women emains
low.1 Some de e minan s associa ed wi h
accina ion ejec ion include insu icien
in o ma ion by p o essionals and unde es i-
ma ion o in ec ion isks du ing p egnancy.2–4
Howe e , p egnancy is a isk ac o o
se e e in luenza, a main eason o hospi al
admission du ing ges a ion.5 The admin-
is a ion o in luenza accine o p egnan
women would p o ec immunised mo he s
and in an s. As he sa e y o he accine is
well es ablished, i s adminis a ion is ecom-
mended du ing any imes e o ges a ion.
Globally, in luenza accina ion co e age is
une en, anging om 15%–43% in Eu ope,6
o 50% in he USA.7 In Spain, he e a e no
published da a on na ional in luenza acci-
na ion co e age among p egnan women;
howe e , ou e iew in 2014–2015 epo ed
accina ion a es o 40.5% in p egnan
women in ou heal h depa men .8
Vaccina ion agains Bo de ella pe ussis is
equally ecommended o all p egnan women
in Valencia (Spain) since Janua y 2015 due o
ou b eaks o whooping cough.9 Women a e
o e ed immunisa ion on he hi d imes e ,
ideally be ween weeks 27 and 36 o ges a-
ion.6 As wi h in luenza, ma e nal immunisa-
ion also bene i s newbo ns.10 Acco ding o
WHO, 195 000 child en unde 5 yea s died in
2008 o whooping cough. Mo e han 80% o
dea hs occu ed in child en younge han 6
s eng hs and limi a ions o his s udy
►Valida ed heal h li e acy sc eening ools we e ad-
minis e ed o p egnan women o iden i y heal h li -
e acy le els. Immunisa ion s a us was ob ained om
o icial accina ion eco ds.
►Sc eening ools used in he s udy ha e been ali-
da ed in Spanish-speaking popula ions in he USA
bu no Spain.
►Fu he esea ch could ocus on he de elopmen
and use o p egnancy-speci ic scales.
on 8 July 2018 by gues . P o ec ed by copy igh .h p://bmjopen.bmj.com/BMJ Open: i s published as 10.1136/bmjopen-2018-022132 on 6 July 2018. Downloaded om
2Cas o-SánchezE, e al. BMJ Open 2018;8:e022132. doi:10.1136/bmjopen-2018-022132
Open access
mon hs o age. The numbe o whooping cough cases has
inc eased since 2011 wo ldwide, including he Eu opean
Union, and among child en and young adul s. In Spain,
he case incidence has shi ed om 739 cases in 2008 o
3088 cases in 2011, a global a e o 6.73/100 000 habi-
an s/yea o ha yea . Addi ionally, eigh dea hs in 2001
we e a ibu ed o whooping cough.11 O conce n, he e
a e cu en ly no published da a ega ding whooping
cough accina ion co e age among p egnan women in
Spain. Howe e , epo s on he incidence o whooping
cough in 2015 a e a ailable, indica ing 17.99 cases pe
100 000 people, wi h p o isional da a o 2016 sugges ing
a ma ked decline in epo ed cases.12
Among he ac o s de e mining accina ion accep-
ance, heal h li e acy (HL) e e s o he knowledge and
skills equi ed when making heal h decisions.13 Essen-
ial HL skills include eading, w i ing, nume acy and
sea ching o in o ma ion.14 15 Inadequa e HL has been
associa ed wi h poo heal h ou comes including inad-
equa e sel -ca ing and p e en i e beha iou s such as
accina ion.16 S anda dised ools o assessing HL a e
a ailable, ye mos ly in English17 and ocused on US
socie y. Eu opean esea che s ha e de eloped ques ion-
nai es,18 and some ools (Sho Assessmen o Heal h
Li e acy o Spanish Adul s; SAHLSA_50),19 20Newes
Vi al Sign (NVS)21–24 and Single I em Li e acy Sc eene
(SILS)25 ha e been alida ed in Spanish language bu no
o Spanish ci izens.
Al hough accina ion is especially ele an o p egnan
women and wide public heal h,26 no s udies ha e been
conduc ed in Spain explo ing he ela ionship be ween
HL and accine accep ance. We hypo hesise ha p eg-
nan women wi h limi ed HL may be less likely o accep
in luenza and pe ussis accina ions in Valencia (Spain).
Me hOds
s udy popula ion and sampling c i e ia
We conduc ed a c oss-sec ional s udy in women who had
gi en bi h a La Ribe a Uni e si y Hospi al (Hospi al
Uni e si a io de La Ribe a, HULR) in Valencia (Spain).
The HULR se es a popula ion o 250 000 ci izens and is
he only hospi al p o iding ma e ni y se ices o p egnan
women in he a ea, wi h an annual a e age o 1600 bi hs
in he yea when he s udy was ca ied ou . The in luenza
and pe ussis accine policy in he HULR mi o s he
na ional policy, whe e accines a e o e ed sys ema ically,
by communi y midwi es and amily doc o s, o all women
ee o cha ge. In 2015, he in luenza accina ion a e o
he whole Valencian Communi y was 34.4%.
Immunisa ion campaign in Spain s a s in Oc obe
and concludes in Ma ch. In o de o a oid seasonali y,
we included all women du ing he s udy pe iod. Women
in hei immedia e pos pa um pe iod (mo e han 27
weeks o ges a ion), be ween No embe 2015 and May
2016 we e included in he s udy. We excluded women
wi h impai men s, language ba ie s o illi e acy. Illi -
e a e women we e excluded om he s udy due o hei
inabili y o comple e he HL sc eening ools which we e
sel -adminis e ed. Any help om he esea che s would
likely in luence he esul s.27 Women younge han
18 yea s we e also excluded om aking pa . P io o
da a collec ion, w i en consen was ob ained om each
pa icipan .
Fo ec ui men , we sys ema ically app oached all
women admi ed o he ma e ni y wa d, e e y 4 days. To
calcula e he sample size, we used he SALHSA_50 ool
as a e e ence wi h a cu -o sco e o 0–37 o inadequa e
li e acy. Accep ing an alpha isk o 0.05 and a be a isk
o 0.2 in a bila e al con as , wi h a common SD o 7.028
and a loss o ollow-up a e o 10%, we es ima ed ha 102
pa icipan s would be equi ed.
Measu emen s
Du ing he immedia e pos pa um (24–48 hou s a e
deli e y), we collec ed sociodemog aphic, obs e ic a i-
ables and accina ion s a us h ough e iew o medical
eco ds, and HL om each woman h ough in e iew
wi h he esea che in cha ge.
Pa icipan s’ HL was de e mined using h ee sc eening
ools:
1. SALHSA_50: e alua es wo d ecogni ion and eading
comp ehension h ough a 50-i em ool. Quan i a i e
sco es classi y indi iduals wi h ‘adequa e’ (sco e: 38–50
poin s) o ‘inadequa e’ HL (sco e: 0–37 poin s). The
ool has been alida ed o Hispanics in he USA.
2. NVS: e alua es eading and nume acy h ough six
ques ions abou he label o an ice-c eam. The sum
sco e (0–6 poin s) ca ego ises indi iduals wi h high
likelihood o limi ed li e acy (sco e: 0–1 poin s), pos-
sibili y o limi ed li e acy (sco e: 2–3 poin s) and ade-
qua e li e acy (sco e: 4–6 poin s). I has been alida ed
o he Hispanic popula ion in he USA.23 I has high
sensi i i y, bu i can misclassi y people wi h adequa e
HL.29
3. SILS: i asks pa ien s how o en hey need help when
eading heal h ins uc ions. The esponse is eco d-
ed on a 5-poin Like - ype scale (1-ne e , 2- a ely,
3-some imes, 4-o en and 5-always) and ca ego ised as
adequa e o inadequa e. Sco es g ea e han 2 indica e
some di icul y wi h eading ma e ials.25
Rega ding accina ion, we analysed: (1) in luenza
o pe ussis accina ion s a us du ing p egnancy; (2) i
accina ed, heal h cen e whe e accina ed; (3) which
heal hca e p o ide ecommended i and (4) i accina-
ion ejec ion, easons o declining. Vaccina ion s a us
was co obo a ed using he egional accina ion egis y
which eco ds all accines ecei ed by pa ien s.8
O he a iables collec ed h ough e iew o medical
eco ds included: age, coun y o o igin, ci il s a us, occu-
pa ion, educa ion, ges a ional age, pa i y, ype o deli e y,
isk ac o s du ing p egnancy (wi hou isk o low isk,
p eges a ional o ges a ional diabe es, hy oid pa hology,
p e-eclampsia, win p egnancy and assis ed ep oduc ion
ea men ).
on 8 July 2018 by gues . P o ec ed by copy igh .h p://bmjopen.bmj.com/BMJ Open: i s published as 10.1136/bmjopen-2018-022132 on 6 July 2018. Downloaded om
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Cas o-SánchezE, e al. BMJ Open 2018;8:e022132. doi:10.1136/bmjopen-2018-022132
Open access
s a is ical analysis
In he uni a ia e analysis, quan i a i e a iables we e
desc ibed wi h means and SD o median and IQR,
depending on he no mali y o hei dis ibu ion. The
Kolmogo o -Smi no goodness-o - i es was used o
de e mine he no mali y o dis ibu ions. In he bi a ia e
analysis, he χ2 es was used be ween he quali a i e a i-
ables and he accina ion s a us. To compa e he medical
isk ac o s du ing p egnancy ela ed o accina ion, OR
wi h a 95% CI was calcula ed.
The non-pa ame ic Mann-Whi ney U es was used
when he no mali y hypo hesis was ejec ed when
compa ing independen samples wi h he ca ego ised
alues o NVS and SAHLSA_50 and accina ion accep-
ance. To iden i y he a iables explaining he le el o
HL acco ding o each sc eening ool, a se ies o mul i-
a ia e analyses we e conduc ed. The mul i a ia e lineal
eg ession analysis (Wald s a is ic) was used ega ding he
explana o y co a ia es o he quan i a i e ools, NVS and
SALHSA_50, and a mul inomial model was cons uc ed
o he quali a i e scale SILS. The le el o s a is ical signi -
icance was se a 0.05. SPSS o Windows V.22.0 (IBM) was
used o da a analysis.
Pa ien and public in ol emen
Pa ien s we e no in ol ed in he de elopmen o he
esea ch ques ions, he design o he s udy o he ec ui -
men o pa icipan s. Agg ega ed s udy esul s will be
published on he websi e o he hospi al, in sui able
language.
esul s
Ou o a o al o 168 women who ini ially consen ed o
be included in he s udy, 49 we e excluded (29%) o
he ollowing easons: 10 (20%) we e b eas eeding, 16
(33%) had language ba ie s, 16 (33%) we e busy, 4 (8%)
we e absen om hei oom and 3 (6%) we e unwell.
The e o e, he s udy sample comp ised 119 pa icipan s
(71%).
Table 1 p esen s he sociodemog aphic cha ac e is ics
o pa icipan s. The mean age was 32.3±5.5 yea s, wi h
29.5±5.4 as mean age o he i s p egnancy. Fi y- wo pe
cen (62) we e p imipa ous. The mean ges a ional age a
deli e y was 39.1±1.5, wi h 95% (113) ull- e m deli e ies
(37–42 weeks).
The in o ma ion and ecommenda ion abou accina-
ion came mainly om hei midwi es (94%), in 4% om
he amily doc o and 2% o women did no p o ide any
in o ma ion. As we wan ed o be as su e as possible o he
accina ion s a us o each pa icipan , we alida ed he
accina ion s a us epo ed by he pa icipan s wi h he
immunisa ion s a us eco ded in he o icial elec onic
immunisa ion egis y. We co obo a ed ha all women
wi hou immunisa ion eco ded on he elec onic eco d
had no been accina ed.
Rega ding HL sc eening ools, he co ela ion
be ween SAHLSA_50 and SILS was mode a e, in e sely
p opo ional and signi ican ( =−0.251, p=0.007). The
co ela ion be ween NVS and SAHLSA_50 was mode a e
and signi ican ( =0.349, p<0.001). The co ela ion
be ween NVS and SILS was mode a e, in e sely p opo -
ional and also signi ican ( =−0.307, p=0.001).
We also analysed he in luence o pa icipan s’ educa-
ion on HL le el and he scales o assessmen . Highe
educa ion was di ec ly ela ed o highe SAHLSA_50
( =0.244, p<0.001) and NVS ( =0.366, p=0.002) sco es.
This ela ionship, howe e , was no p esen in he SILS
scale.
Vaccina ion s a us
Se en een pe cen (20/62) o women had been acci-
na ed agains in luenza p io o p egnancy. Ges a ional
in luenza accina ion co e age was 52% (62/119). The
accine was adminis e ed o 5% (4/62) o women by
week 20, and o 16% (10/62) in he las weeks o ges a-
ion (mo e han 36 weeks). Conce ning pe ussis accine,
94% (112/119) o women had i du ing p egnancy, wi h
86% (96/112) accina ed be ween weeks 27 and 32 o
ges a ion. All women accina ed agains in luenza we e
simul aneously accina ed agains whooping cough.
The e we e no signi ican di e ences in sociodemo-
g aphic o obs e ic cha ac e is ics be ween p egnan
accina ion s a us o in luenza o pe ussis (p=0.15 and
p=0.35, espec i ely) (da a no shown).
The easons o ejec ion o women who we e no acci-
na ed agains in luenza du ing p egnancy (57) a e shown
in igu e 1. Twen y- i e pe cen (14/57) el ha he
accine was unnecessa y, 23% (13/57) claimed o ha e
ecei ed insu icien in o ma ion om heal h p o es-
sionals and 14% (8/57) claimed ha hey had ne e been
in ec ed. The easons epo ed by women declining acci-
na ion agains pe ussis we e lack o in o ma ion om
heal h p o essionals (4/7; 57%) and lack o any p ena al
ca e (3/7; 43%).
heal h li e acy
In he NVS scale, we ob ained an a e age sco e o 3.7±1.6
wi h alues be ween 0 and 6. These sco es we e ca ego ised
as inadequa e (13% (16/119)), limi ed (30% (36/119))
and adequa e HL (56% (67)). SAHLSA_50 sco es we e
44.1±4.4 ou o 50. Eigh y-six pe cen (102/119) o
women had adequa e HL le els (SAHLSA-50 sco e >37).
Acco ding o he SILS, 24% (29/119) women eplied
‘ne e ’ needing help when eading in o ma ion, 29%
(35/119) ‘ a ely’, 27% (32/119) ‘some imes’ and only
6% (7/119) eplied ‘o en’ and 13% (16/119) eplied
‘always’.
To iden i y a iables explaining HL le els acco ding
o each sc eening ool, mul i a ia e analyses we e
conduc ed. Mul i a ia e lineal eg ession was used
ega ding he explana o y co a ia es o quan i a i e
ools, NVS and SALHSA_50. Fo hese, he le el o educa-
ion was ound o be s a is ically signi ican (NVS (adjus ed
R2=0.258; p=0.001) and SALHSA_50 (adjus ed R2=0.220;
p=0.014)). A mul inomial model was cons uc ed o he
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Table 1 Sociodemog aphic, clinical and obs e ic cha ac e is ics o he sample by in luenza accine s a us (n=119)
To al ow Un accina ed, n=57 Vaccina ed, n=62
P alues*N N % N %
Ci il s a us
Wi h pa ne 48 20 35 28 45 0.458
Ma ied/ci il pa ne 67 35 61 32 52
Sepa a ed/di o ced 4 2 4 2 3
Le el o educa ion
P ima y school 40 20 36 20 32 0.296
Seconda y school 42 19 33 23 37
Uni e si y 37 18 44 19 31
Employmen s a us
I 13 9 16 4 6 0.083
II 66 35 61 31 50
III 2 0 0 2 3
IV 1 0 0 1 2
V 37 13 23 24 39
Coun y o O igin
Spain 104 51 89 53 85 0.261
Ano he EU coun y 8 5 9 3 5
Non-EU coun y 1 0 0 1 2
Cen al-Sou h Ame ica 6 1 2 5 8
Pe ussis accine
Un accina ed 7 7 12 0 0 0.269
Vaccina ed 112 50 88 62 100
Medical isk ac o s du ing p egnancy
None/low isk 92 45 79 47 76 0.570
P eges a ional/ges a ional
diabe es
7 2 3 5 8
Thy oid pa hology 7 5 9 2 3
P e-eclampsia 1 0 0 1 2
Twin p egnancy 3 1 2 2 3
ART 9 4 7 5 8
NVS ca ego ies
Inadequa e (0–1 poin s) 13 6 10 7 11 0.219
Limi ed (2–3 poin s) 38 14 25 24 39
Adequa e (4–6 poin s) 68 37 65 31 50
SAHLSA ca ego ies
Inadequa e (0–37 poin s) 17 6 10 11 18 0.261
Adequa e (38–50 poin s) 102 51 89 51 82
SILS ca ego ies
Ne e 29 13 23 16 26 0.947
Ra ely 34 17 30 17 27
Some imes 33 17 30 16 26
O en 8 4 7 4 6
Always 15 6 10 9 14
I, sel -employed, highe p o essional o manage ial employmen ; II, employee; III, s uden ; IV, s ay-a -home mo he ; V, unemployed.
*Χ2.
ART,assis ed- ep oduc ion ea men ; EU, Eu opean Union; NVS, Newes Vi al Sign;SAHLSA, Sho Assessmen o Heal h Li e acy
o Spanish Adul s;SILS, Single I em Li e acy Sc eene .
on 8 July 2018 by gues . P o ec ed by copy igh .h p://bmjopen.bmj.com/BMJ Open: i s published as 10.1136/bmjopen-2018-022132 on 6 July 2018. Downloaded om
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quali a i e scale SILS, obse ing no s a is ically signi ican
di e ences.
The e we e no di e ences in NVS and SILS sco es
be ween women who declined and hose who accep ed
in luenza accina ion (Mann-Whi ney U es , p=0.320 and
p=0.942, espec i ely). Howe e , o SAHLSA_50
(median=44.5; IQR=5.0 s 45.0; IQR=5.5) he di e -
ences we e s a is ically signi ican (Mann-Whi ney U es ,
p=0.019) ( igu e 2).
La e , sco es om he quan i a i e HL sc eening
ools (NVS, SALHSA_50) we e dis ibu ed in qua iles
( igu e 3). Fo he NVS scale, we ound no s a is ically
signi ican di e en be ween women who had accep ed
o declined accina ion (p=0.532). Howe e , such di e -
ence was seen when using he SALHSA_50 ool (K us-
kal-Wallis es , p=0.022). The median numbe o women
accina ed in he bo om qua ile was 8 (95% CI 7.0 o
9.0) e sus 24 (95% CI 23.0 o 25.0) in he op qua ile.
We we e in e es ed in examining he cha ac e is ics o
he women who we e excluded om he s udy (49). We
conduc ed an analysis o missing alues o he h ee HL
sc eening ools using he mul iple impu a ion chained
equa ions me hod.30 Again, o he NVS scale, we ound
no s a is ically signi ican di e ence be ween women
who had accep ed o declined accina ion (p=0.372)
Figu e 2 Rela ionship be ween accep ance o in luenza
accina ion and SAHLSA_50 scale (n=119).SAHLSA,Sho
Assessmen o Heal h Li e acy o Spanish Adul s.
Figu e 3 Rela ionship be ween accep ance o in luenza
accina ion and SAHLSA_50 scale dis ibu ion by qua iles
(n=119).SAHLSA,Sho Assessmen o Heal h Li e acy o
Spanish Adul s.
Figu e 1 Reasons gi en by pa icipan s o decline in luenza accina ion.
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and, ins ead, such di e ence was seen when using he
SALHSA_50 ool (K uskal-Wallis es , p=0.003). The
median numbe o women accina ed in he bo om
qua ile was 11 (95% CI 9.0 o 12.0) s 28 (95% CI 27.0 o
29.0) in he op qua ile.
Rega ding he NVS, sco es be ween pe ussis- accina ed
and un accina ed women we e simila (median=4.0;
IQR=0.0 s median=4.0; IQR=2.75), like he SAHLSA_50
scale (median=45.0; IQR=0.0 s median=45.0; IQR=5.0).
We also did no ind any di e ence wi h he esul s om
he SILS ool.
disCussiOn
Vaccina ion is an essen ial public heal h in e en ion. We
ocused on p egnan women, an especially ulne able
popula ion, and s udied he accep ance o wo accines
unde used in ou communi y.8 Few s udies e alua ing HL
and accina ion ha e been conduc ed hus a and, up o
now, none had ocused on p egnan women.
In ou s udy, in luenza accina ion did no each
ecommended le els al hough co e age sligh ly exceeded
Aus alian31 bu no US a es.32 In Valencia, co e age
has p og essi ely imp o ed om 2011 (8.5%) o 2015
(34.4%).8 Rega ding pe ussis, he 97% accina ion a e
imp o es on Belgian (39%)33 o UK (70%)6 a es. The
dispa i y be ween pe ussis and in luenza immunisa ion
a es has no been p e iously add essed in de ail.6 We
belie e ha in ou se ing, ea o pe ussis—pe haps
in luenced by mass media34 and uelled by he inc easing
numbe o cases—could explain such high accina ion
p e alence. Indeed, he pe ussis accina ion p og amme
was commenced ollowing a su ge in he numbe o cases
and dea hs. Clinicians may ha e he e o e been keene o
ensu e ha p egnan women go accina ed and may ha e
amed hei ad ice mo e asse i ely. On he o he hand,
he disin e es om heal h p o essionals in p o iding
in o ma ion abou in luenza accina ion oge he wi h
ma e nal pe cep ions ha in luenza accine was unneces-
sa y we e he mos equen ly ci ed causes o accine ejec-
ion, in ag eemen wi h p io s udies.5–8 35 This posi ion
ob iously igno es he bene i s o acqui ed immuni y o
he newbo n which could educe pe ina al in ec ions.36
We ound ha NVS classi ied 58% o pa icipan s wi h
adequa e HL. Howe e , his igu e inc eased up o 89%
i SAHLSA_50 was used. Cu en ly, he e a e no publica-
ions compa ing bo h scales simul aneously in he same
popula ion. Such disc epancy be ween sc eening ools
could be o much ele ance as, o he ools p agma ically
chosen o ou esea ch, only SALHSA_50 was p edic-
i e o accina ion in p egnan women. Howe e , women
wi h high SALHSA_50 sco es we e mo e likely o decline
in luenza accina ion, pe haps due o p econcei ed
ideas; i migh also be ha women wi h high HL ha e
mo e abili ies o look o in o ma ion on he in e ne
o o he sou ces and cons uc a na a i e ha suppo s
such p econcep ions, leading o declining his accina-
ion.37 Such na a i es would also no be challenged i
p o essionals ail o adequa ely in o m hem o ocus hei
pe suasion solely on a ional, da a-based easons ins ead
o complemen ing such e idence wi h o he emo ional
and beha iou al aspec s.36 38 39 These esul s di e ge om
cu en e idence4 in his g oup o women possibly highly
in ol ed in hei heal hca e, as al eady explo ed.40
As pe haps expec ed, HL sc eening esul s we e di ec ly
ela ed o he educa ion o pa icipan s and hus, a highe
le el o educa ion was associa ed wi h highe HL. In e -
es ingly, o he au ho s ha e epo ed ha a highe le el
o educa ion is associa ed wi h highe a es o accine
ejec ion and hesi a ion.35 41 In ac , i would appea ha
he eme ging ela ionship be ween HL and accina ion
desc ibed by hose au ho s may be ep esen ed as an
‘in e ed U’ shape’ (ie, high and low HL le els equally
associa ed wi h low accina ion).
The analysis o missing alues would help esol e
some o he challenges o igina ed om he incomple e
esponses. I cases wi h missing da a we e o be sys ema -
ically di e en o cases wi h comple e in o ma ion, hen
esul s could be equi ocal.30 In ou case, howe e , he anal-
ysis o missing alues did no p oduce di e en esul s o
he o iginal analysis conduc ed wi hou impu ed alues.
Ou s udy p esen s limi a ions. Al hough he e a e
app oxima ely 51 HL ools a ailable,17 expe iences in
Spain wi h hese ins umen s ha e been ew and limi ed
o he Heal h Li e acy Su ey—Eu opean Union42 o he
eHeal h Li e acy43 ools. In addi ion, none o hese ools
ha e been alida ed in Spain, ye hey ha e been so in
Spanish-speaking US popula ions. Mo eo e , as he e a e
no scales speci ically ocused on p egnan women, ou
ques ionnai e selec ion was eminen ly p agma ic and
based on ease o use (SILS), obus ness (SAHLSA_50)
and eliabili y (NVS). Addi ionally, he ou ine use o HL
sc eening ools in clinical p ac ice emains ne e heless
con o e sial, as such ou ine sc eening has shown no
bene i s ye could ha e undesi able e ec s o pa ien s.44
Decisions ela ed o accina ion may be in luenced by
he in o ma ion p o ided, he communica ion app oaches
and a i udes o by heal h p o essionals.35 36 Since he e
is cu en ly no s anda dised app oach o de e mine he
abili ies ha p egnan women ha e o make e ec i e use
o he in o ma ion p o ided, we hypo hesise ha in o -
ma ion o e ed o each woman will be mo e o less simila
and, he e o e, women wi h low HL may be mo e likely o
make subop imal decisions because o such de ici . Logi-
cally, his does no conside e o s ha p o essionals may
make o compensa e o any di icul ies in unde s anding.
Al hough explo ing such e o s was ou side he emi o
ou wo k, i would be in e es ing o in es iga e his aspec
in u u e s udies, oge he wi h any suppo ing ma e ials
used by p o essionals.
COnClusiOn
Vaccina ion is an essen ial public heal h measu e, and
p egnan women can pa icula ly bene i om his in e -
en ion. Iden i ying de e minan s o accina ion such
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7
Cas o-SánchezE, e al. BMJ Open 2018;8:e022132. doi:10.1136/bmjopen-2018-022132
Open access
as HL would acili a e an adequa e use o esou ces o
encou age sha ed decision-making, ul ima ely esul ing
in op imal accina ion a es. Ou indings sugges ing a
ela ion be ween high HL and ejec ion o accina ion
encou age u he esea ch o iden i y and desc ibe he
ac o s in ol ed in such ela ion and implemen mi i-
ga ing ini ia i es.
Acknowledgemen s The au ho s a e g a e ul o he Uni e sidad Ca ólica de
Valencia and o he HULR o hei suppo and pa icipa ion in his p ojec , and o
all he women who ha e also aken pa . The au ho s also hank P o esso Daniel
Lee o au ho ising he use o he SALHSA_50 ool in hei esea ch.
Con ibu o s EC-S and RV-C concep ualised and designed he s udy. RV-C and
FS-V collec ed da a. EC-S, RV-C and FS-V ca ied ou he da a analyses. EC-S,
RV-C, EN-I, JDD and FS-V d a ed he ini ial manusc ip . EC-S, RV-C, FS-V, EN-I and
JDD e iewed and e ised he manusc ip . All au ho s ead and app o ed he inal
manusc ip .
Funding This wo k was suppo ed by he Uni e sidad Ca ólica de Valencia “San
Vicen e Má i ” (Spain) h ough a compe i i e g an call [PRUCV/2015/639]. ECS is
a ilia ed wi h he Na ional Ins i u e o Heal h Resea ch (NIHR) Heal h P o ec ion
Resea ch Uni (HPRU) in Heal hca e Associa ed In ec ion and An imic obial
Resis ance a Impe ial College London in pa ne ship wi h Public Heal h England
(PHE), and he NIHR Impe ial Pa ien Sa e y T ansla ional Resea ch Cen e. ECS
has ecei ed a Wellcome ISSF Facul y Fellowship a Impe ial College London, an
Ea ly Ca ee Resea ch Fellowship om he An imic obial Resea ch Collabo a i e a
Impe ial College London, and acknowledges he suppo o he Flo ence Nigh ingale
Founda ion.
disclaime The iews exp essed a e hose o he au ho s and no necessa ily
hose o he NHS, he NIHR, he Depa men o Heal h, o Public Heal h England. The
unde s had no ole in s udy design; collec ion, analysis and in e p e a ion o da a;
w i ing he epo ; and he decision o submi he epo o publica ion.
Compe ing in e es s None decla ed.
Pa ien consen No equi ed.
e hics app o al The s udy was conduc ed in compliance wi h he Decla a ion o
Helsinki and i was app o ed by he Resea ch E hics and Resea ch Commi ee o
Hospi al Uni e si a io de La Ribe a on 10/07/15.
P o enance and pee e iew No commissioned; ex e nally pee e iewed.
da a sha ing s a emen No addi ional da a a e a ailable.
Open access This is an open access a icle dis ibu ed in acco dance wi h he
C ea i e Commons A ibu ion 4.0 Unpo ed (CC BY 4.0) license, which pe mi s
o he s o copy, edis ibu e, emix, ans o m and build upon his wo k o any
pu pose, p o ided he o iginal wo k is p ope ly ci ed, a link o he licence is gi en,
and indica ion o whe he changes we e made. See: h ps:// c ea i ecommons. o g/
licenses/ by/ 4. 0/.
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