Assessment of COVID-19 vaccine hesitancy among the pregnant women: a mixed-method study from field practice area of Sagar, Madhya Pradesh

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, reached pandemic status on March 11^th, 2020.¹ The SARS CoV2 pandemic has disrupted the life of people globally.² Unlike other medicines, vaccines work at both the individual and community level. While no vaccine is 100% effective, when used broadly in communities, several vaccine preventable diseases could be eliminated and some may be eradicated. High vaccine uptake rates, specific to each vaccine preventable disease, are needed for community-level immunity to be achieved and sustained in order that disease risk can lowered beyond what would be predicted by vaccine coverage alone.³

It is one of the most successful and cost-effective interventions to improve health outcomes. Vaccines have saved countless lives and improved health and well-being around the globe. However, to prevent the morbidity and mortality associated with vaccine preventable diseases and their complications, and optimize control of vaccine preventable diseases in communities, high uptake rates must be achieved. As the complacency, convenience and confidence (“3Cs”) model of vaccine hesitancy determinants succinctly categorized many factors it was embedded in the definition. Concerns about vaccine safety may be associated with vaccine hesitancy. However, it is important not to equate vaccine hesitancy and vaccine safety. Safety is only one driver of vaccine hesitancy. Nevertheless, in situations where vaccine safety is one of the underlying causes of vaccine hesitancy, using appropriate best practices to address concerns over adverse events following immunization, can minimize the potential negative impact that may result. Communication is a key tool for success of any immunization program but is not a specific determinant in vaccine hesitancy. However, inadequate or poor communication about vaccines (e.g., why they are recommended and their safety and effectiveness) can contribute to vaccine hesitancy.³ Vaccination is the one of the prime weapons against the COVID pandemic. But the overall challenge is to vaccinate the large population and to regulate the demand and supply of vaccine to fulfil the requirement. And it becomes imperative that there should be judicious use and equitable distribution of vaccine. Pregnancy does not increase the risk to COVID-19 infection, but current evidence indicate that pregnant women are at an increased risk for severe illness from COVID-19 compared to non-pregnant women in case they get infected.^4-6 Mass vaccination is the need of the hour to abstain the third wave. Hence it is important to immunize all the high-risk group including pregnant women. As the ANC period is crucial period of motherhood, there are some obscure notions which led to vaccine hesitancy. Vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services, has been recognized by the World Health Organization (WHO) as one of the biggest current threats to global public health.^7-8 Vaccine hesitancy is complex and multifaceted. Many factors influence vaccine-decision making, including cultural norms, social and peer influences, political views, and other factors that are specific to an individual or group, as well as concerns regarding specific vaccines.⁹ Vaccine hesitancy may also be related to misinformation and conspiracy theories which are often spread online, including through social media.¹⁰ Vaccine hesitancy occurs on the continuum between high vaccine demand and complete vaccine refusal i.e. one who is not demanding available and offered vaccines, but rather is equivocal about ever receiving some or all vaccines in accordance with the recommended schedule. Vaccine-hesitant individuals are a heterogeneous group who hold varying degrees of indecision about specific vaccines or vaccination in general. Vaccine-hesitant individuals may accept all vaccines but remain concerned about vaccines, some may refuse or delay some vaccines but accept others; some individuals may refuse all vaccines.¹¹ Vaccine hesitancy is widely recognised as one of the most serious threats to current global health.¹² Negative attitudes towards vaccines and an uncertainty or unwillingness to receive vaccinations are major barriers to managing the COVID-19 pandemic in the long-term.¹³ Vaccine acceptance among the general public and healthcare workers appears to have a decisive role in the successful control of the pandemic.¹⁴ Vaccine hesitancy is waning, yet inequities in receipt remain. There is a clear public health opportunity to convert higher vaccine willingness into successfully delivered vaccinations.¹⁵ The aim of the study was to assess the vaccine hesitancy in pregnant women of Sagar. And by this study we will recommend measures to reduce it so, that the mass immunization will be completed as early as possible and we combat this situation without delay.

Aims and objectives

To assess the various factors causing COVID-19 vaccine hesitancy in pregnant women. To give the appropriate recommendation for reduction of vaccine hesitancy.

METHODS

This was a mixed-method type of study.

Study population

In this study we have included 17 participants (1 nodal vaccination officer, 1 vaccination officer and HCWs (13 ASHA, 1 ANM and 1 counsellor) and, 70 unvaccinated pregnant women were also included who were willing to participate and were well oriented and had no medical contraindicated condition for COVID vaccine

Sampling procedure

For quantitative component we had used multistage random sampling. From field practice area (Chameli chowk) 7 Anganwadi centers were selected randomly through lottery system and from each Anganwadi center a random selection of 10 unvaccinated pregnant women was done and those 10 pregnant women (those were registered for ANC but haven’t taken COVID-19 vaccine were interviewed by visiting them door-to-door with the help of ASHA

For qualitative component in-depth interviews were conducted and we had interviewed nodal vaccination officers, vaccination officers and health care workers working in field practice area. All the study subjects were explained about the nature and reason for the study and they can withdraw from the study anytime.

Inclusion criteria

Pregnant females aged less than 50 years, who were willing to participate in the study and giving written consent. Participant should be well oriented for person, place and time.

Exclusion criteria

Pregnant women having contraindicated condition for COVID vaccination.

Sample size

17 participants [1 nodal vaccination officer, 1 vaccination officer and HCWs (13 ASHA, 1 ANM and 1 counsellor)]. 70 Unvaccinated pregnant women.

Data collection tool

For quantitative components a semi-structured questionnaire was used. For qualitative components a question guide was used.

Data analysis

Quantitative data analysis was done using MS Excel software which presents the descriptive analysis of percentages and proportion while the qualitative data was analyzed using NVivo 14 version.

Ethical consideration

Ethical approval on 28/10/2021, IECBMC/2021/49 and data collection has been done for 28/10/21 to 28/01/22 period after the ethical approval.

RESULTS

The study involved 70 pregnant women. The majority were aged 20-25 years (65.71%) and had completed middle school (31.43%). Most were unemployed or homemakers (81.43%). There was no significant association between age, education, occupation, or parity with vaccine hesitancy, suggesting that these factors did not differentially influence vaccine acceptance among the study population. Of the 70 pregnant women included in the study, 66 (94.2%) exhibited vaccine hesitancy, while 4 (5.7%) were resistant to vaccination (Table 1).

Factors shaping vaccine hesitancy

Quantitative findings revealed high levels of vaccine hesitancy among the study participants. A significant proportion expressed concerns about the pharmaceutical industry (30%), politicians and policymakers (60%), and rumors (80%). Additionally, many women perceived higher risks than benefits associated with the vaccine (75.7%) and were influenced by family and community members’ experiences (64.3%) (Table. 2).

Qualitative data provided deeper insights into these quantitative findings. The themes of avoidance, behavior, and cognition and sub-theme for avoidance as convenience, confidence, complacency emerged as key determinants of vaccine hesitancy (Table 3).

Avoidance was primarily related to logistical challenges like vaccine shortages and cumbersome registration processes. This aligns with the high percentage of women influenced by rumors and talk of the town, suggesting a lack of accessible and reliable information.

Confidence issues centered on fears of adverse events like pain, fever, and miscarriage, reflecting the high proportion of women perceiving higher risks associated with the vaccine. Trust issues with the pharmaceutical industry and healthcare providers further compounded these concerns.

Complacency was evident in the belief that previous COVID-19 infections or vaccinations among others offered sufficient protection. This perception, coupled with the influence of social norms and peer pressure (behavior theme), contributed to vaccine hesitancy.

Cognition highlighted the presence of knowledge about COVID-19 and vaccination but also the impact of misinformation and rumors in creating indecision. This aligns with the significant number of women influenced by rumors and talk of the town.

Key findings and implications

The integrated analysis underscores the complex interplay of factors contributing to vaccine hesitancy among pregnant women. While sociodemographic factors did not significantly influence hesitancy, a combination of logistical challenges, safety concerns, misinformation, and social pressures emerged as key determinants.

These findings highlight the need for targeted interventions addressing specific concerns, such as improving vaccine accessibility, building trust in healthcare systems and pharmaceutical industries, and countering misinformation through effective communication strategies. Additionally, addressing social norms and peer influence through community-based initiatives may be crucial in promoting vaccine acceptance among pregnant women.

DISCUSSION

The findings of this study align with the broader body of research highlighting the prevalence and complexity of COVID-19 vaccine hesitancy among pregnant women. Concerns about vaccine safety and efficacy emerged as the most common reasons for hesitancy, echoing the findings of previous studies.^11,17,18 The rapid development of COVID-19 vaccines and the lack of comprehensive safety data during early stages of vaccination campaigns exacerbated these concerns.^19,20

Similar to other studies, this research underscores the role of misinformation and rumours in shaping vaccine hesitancy.^21-23 The influence of social media and informal information networks in disseminating inaccurate or misleading information about vaccine safety cannot be overstated.

Furthermore, the study’s findings reinforce the importance of addressing contextual factors influencing vaccine hesitancy. The impact of socio-cultural, economic, and healthcare system-related factors, as highlighted by Razai et al, is evident in the qualitative data on avoidance and accessibility issues.¹¹

The concept of the “five Cs” framework (confidence, complacency, constraints, calculation, and collective responsibility) proposed by Betsch et al provides a useful lens for understanding the multifaceted nature of vaccine hesitancy.²² The themes of avoidance, confidence, and complacency observed in the qualitative data align with these constructs, emphasizing the need for tailored interventions addressing different aspects of hesitancy.

While the present study did not find significant associations between sociodemographic factors and vaccine hesitancy, previous research has identified disparities in vaccine acceptance based on factors such as age, education, and socioeconomic status.^20,23 These findings highlight the importance of equity-focused approaches to vaccine promotion and addressing the specific needs of vulnerable populations.

In conclusion, this study contributes to the growing body of evidence on COVID-19 vaccine hesitancy among pregnant women. The findings underscore the need for comprehensive interventions addressing vaccine safety concerns, improving access to accurate information, and building trust in healthcare systems. Tailored strategies addressing specific subgroups and leveraging social networks can be effective in promoting vaccine uptake and mitigating the impact of misinformation.

This study has several limitations. The sample size was relatively small, with only 70 pregnant women included, which may limit the generalizability of the findings to broader populations. Additionally, the study focused on a specific geographic region (Sagar district), and local socio-cultural factors may not be representative of other regions. The reliance on self-reported data introduces the possibility of response bias, where participants may not have fully disclosed their true beliefs or behaviors regarding vaccination. Lastly, the study did not account for potential changes in attitudes over time, as vaccine hesitancy may evolve with new information or experiences.

CONCLUSION

This study highlighted the multifaceted nature of COVID-19 vaccine hesitancy among pregnant women in Sagar district, Madhya Pradesh. While sociodemographic factors played a limited role, concerns about vaccine safety, accessibility, and misinformation emerged as key determinants. To address these barriers and increase vaccine acceptance, targeted interventions are essential. These include improving vaccine accessibility, enhancing communication about vaccine safety, countering misinformation through effective public health campaigns, strengthening community-based initiatives, and providing comprehensive training for healthcare providers. Additionally, engaging religious leaders, celebrities, and mass media, integrating COVID-19 vaccination with regular maternal and child healthcare services, and mandating vaccinations with appropriate sanctions can further contribute to increasing vaccination rates. By addressing these factors, policymakers and healthcare providers can work towards protecting the health of pregnant women and their children.

ACKNOWLEDGEMENTS

The authors are deeply indebted to the pregnant women who participated in this study. The authors also acknowledge the support and cooperation of the staff of the Polyclinic Chameli Chowk, Sagar, and Bundelkhand Medical College, Sagar (MP). Finally, we extend our thanks to Dr. Shubhra Dubey for her valuable contribution in data collection or analysis.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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