Abstract

Background

Coronavirus Disease 2019 (COVID鈥�19) has been associated with adverse effects and death among people with low immunity, including pregnant women. Despite introducing the vaccine as the proper means to curb the spread of the pandemic, vaccine uptake is still low. This study assessed the influence of perception, attitude, and trust toward COVID-19 vaccine uptake among pregnant women attending Antenatal Care Clinics.

Methods

A cross-sectional study design was used, utilizing a quantitative approach with a cross-sectional analytical design conducted in Mbeya urban, distribution of sample size during data collection based on client鈥檚 volume at three government health facilities (one tertiary health facility, one secondary health facility, and one primary health facility) in Mbeya Urban, Tanzania. Data were collected from 333 pregnant women who attended ANC during the data collection period using a questionnaire with closed-ended questions administered to respondents face-to-face. Data cleaning and analysis were done using Excel and Stata/SE 14.1 software for bivariate and multivariate data; Pearson鈥檚 chi-squire and Fisher鈥檚 test were used to analyze the independent determinants of COVID-19 vaccine uptake.

Results

The proportion of pregnant women vaccinated with the COVID-19 vaccine was 27%. There was a statistically significant association between the respondents鈥� vaccine uptake with primary education and <鈥�5 work experience to vaccine uptake P鈥�=鈥�0.015 (AOR鈥�=鈥�6.58; 95% CI; 1.45鈥�29.85), and P鈥�=鈥�0.046 (AOR鈥�=鈥�2.45; 95% CI; 1.02鈥�5.89) respectively. The association of attitude influence to COVID-19 vaccine uptake was statistically significant (acceptance of vaccine due to its availability, vaccine acceptance for protection against COVID-19 pandemic to respondent and her baby, experience from other vaccines) was statistically significant at P鈥�=鈥�0.011 (AOR鈥�=鈥�4.43; 95% CI; 1.41鈥�13.93), P鈥�=鈥�0.001 (AOR鈥�=鈥�45.83; 95% CI; 18.6-112.89) respectively. The level of trust in the COVID-19 vaccine influenced respondents鈥� association with vaccine uptake in the 2nd and 3rd trimesters of pregnancy (P鈥�=鈥�0.633 (AOR鈥�=鈥�1.23; 95% CI; 0.53鈥�2.48), respectively.

Conclusion

Pregnant women鈥檚 positive attitude and trust in the COVID-19 vaccine influenced them to uptake it; our conclusion supports the WHO guidelines that the COVID-19 vaccine should be administered to pregnant women since it is a safer means to curb COVID-19 pregnancy-related complications.

Introduction

Coronavirus disease 2019 (COVID鈥�19) is a respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 is a highly infectious pandemic that, if not managed, can cause severe illness in humans and death, especially in vulnerable groups, including pregnant women. This is because, for every contagious disease outbreak, pregnant women are especially susceptible because of their impaired physiological condition, hence making them vulnerable to infection. [1,2,3]

COVID-19 pregnancy-related complications include preterm births, undergoing cesarean section during delivery, intensive care unit (ICU) admission, mechanical ventilation, and death [4]. This study suggests that many countries, including the government of Tanzania among others, enhance, advocate, and implement preventive measures of adherence to infection prevention control (IPC) like social distancing, face masks, hand hygiene, and now COVID-19 vaccination as recommended by WHO [5] To curb the spread of COVID-19 and prevent, to a large extent, its pregnancy-related complications.

Even though the COVID-19 vaccine is being proven as an effective measure to curb the pandemic in pregnant women and a notable impact has been observed in reducing symptomatic infection, disease severity, hospitalization, and deaths among vaccinated individuals, even in settings with emerging variants compared to the unvaccinated population. [6, 7]; as reported from various studies, there is still a low uptake of the COVID-19 vaccine in the general population and specifically among pregnant women due to multiple factors. These factors include misconceptions about the COVID-19 vaccine, social media factors that influence perception towards the vaccine, health system factors, and psychological factors. Since there is still inadequate knowledge on the factors that influence low COVID-19 vaccine uptake, this study was designed to add knowledge towards vaccine uptake through understanding the influence of perception, attitude, and level of trust on COVID-19 vaccine uptake among pregnant women in Mbeya urban, Tanzania.

Broad objective

to assess the influence of perception, attitude, and level of trust on the uptake of COVID-19 vaccination among pregnant women attending ANC clinics in Mbeya Urban.

At the time of this study, no medicines or cures were officially established for COVID-19, apart from preventive measures and the COVID-19 vaccine. Therefore, this study aimed to fill the knowledge void by promoting a tailored approach towards raising awareness among the general population on the significance of the COVID-19 vaccine and developing policies and guidelines to foster vaccine uptake among pregnant women in Tanzania and the Eastern African region.

Furthermore, since studies on COVID-19 and vaccination are still very limited in Tanzania, the current research is significant, especially for pregnant women with COVID-19 vaccination. As explained before in this study, based on the cited previous studies, the vaccine has been proven to be the best approach to date to curb the illness and death rates caused by the pandemic. Thus, the findings of this study might add a new direction/component to the nation鈥檚 health policies to support COVID-19 vaccination among pregnant women at all levels of health facilities in Tanzania.

Materials and methods

This study aimed to assess the influence of perception, attitude, and level of trust on the uptake of COVID-19 vaccination among pregnant women attending an ANC clinic in Mbeya Urban.

Study design and setting

The study used a cross-sectional analytical design, employing a quantitative approach in data collection to assess the influence of perception, attitude, and level of trust on the uptake of COVID-19 vaccination among pregnant women attending ANC at the primary level (Kiwanja Mpaka Health Centre), secondary level (Mbeya Regional Referral Hospital (MRRH)) and tertiary level (Mbeya Zonal Referral Hospital (MZRH)) in Mbeya urban in Tanzania.

Study population

The study was conducted in Mbeya Urban in the health center, one regional referral hospital, and one zonal referral hospital. All these facilities had antenatal care clinics on weekdays. The population of this study was all pregnant women of reproductive age (15鈥�49 years) attending ANC clinics in Mbeya Urban.

Sample size calculation and sampling procedure

The researcher鈥檚 sample size was obtained based on the formula for a single population proportion (Cochran, 1977).

$$n = {{{Z^2}\,pq} \over {{E^2}}}$$

Where:

n鈥�=鈥塵inimum sample size.

P鈥�=鈥塸roportion from the previous study on the prevalence of pregnant women who had received the COVID-19 vaccine, which was 27% [8, 9].

E Margin of Error. That is, 5% in the context of this study.

Z鈥�=鈥塩ritical value of a normal distribution of 95% Confidence Interval equal to 1.96.

Nonresponse rate 10%.

Thus:

$$\eqalign{{\rm{n}} & = {{{{\left( {1.65} \right)}^2} \times {\rm{ }}0.27 \times \left( {1 - 0.27} \right)} \over {{{\left( {0.05} \right)}^2}}} \cr & \quad = 303{\rm{ }} + {\rm{ }}\left( {303 \times 0.10} \right){\rm{ }} = {\rm{ }}333 \cr}$$

N鈥�=鈥�333 respondents

Therefore, the minimum sample size was 333 pregnant women who met the inclusion criteria.

Sampling procedure

A random sampling method was used in this study, and the researcher developed the sampling frame from the ANC register for each facility. The total population of the study from the selected facilities was about 2400 pregnant women, who were used to calculate the sampling interval needed to enable systematic sampling during data collection for the respondents who met the inclusion criteria. The study population from all three facilities identified from selected facilities was divided by 333 sample sizes to get a sampling interval.

i.e. (i鈥�=鈥塏/n鈥�=鈥�2400/333鈥�=鈥�7.2 approximately 7).

Therefore, the sampling interval was every 7th pregnant woman

Where: -.

N鈥�=鈥�2400 (total population for pregnant women attending ANC in Mbeya urban),

n 333 (sample size for the study, which is 333 pregnant women), and.

i鈥�=鈥�7 (interval during data collection).

Data collection procedure

The hospital director sought an approval letter for data collection in the Mbeya zonal referral hospital and the Regional Administrative Secretary for data collection at the Mbeya regional referral hospital and Kiwanja Mpaka Health Center. Permission was sought from the unit in charge at the ANC clinic, and the pregnant women were approached. The researcher explained to them the purpose of the study, which was to get their informed consent. Those who consented were asked to fill out the questionnaires. A systematic sampling technique was employed to prevent any bias during data collection. To achieve this, each facility had at least 40 pregnant women who attended the ANC clinic daily. The researcher took one month in each facility collecting data, and the sampling size in each facility was divided as follows: 100 respondents from Mbeya Zonal Referral Hospital, 100 respondents from Mbeya Regional Referral Hospital, and 133 respondents from the Kiwanja Mpaka Health Centre. The allocation is based on the fact that there is high ANC attendance at the primary level compared to secondary and tertiary levels, which have more referred cases that require more specialized service [10]. The reason for using only one month in each facility was mainly to prevent a repetition of data collection from the same respondents because pregnant women attend the ANC clinic once every month. Therefore, each week, the researcher could get a minimum of 25 respondents in each facility to participate in the study. The selection was made for every 7th pregnant woman who arrived from home for the ANC clinic that day and met the study鈥檚 inclusion criteria. The same was asked for her consent to participate in the study with the assistance from the ANC nurse. This was done after taking the vital information from the pregnant women in the queue waiting to enter the doctor鈥檚 consultation room.

Recruitment and training of research assistant

After developing data collection tools, two research assistants from the National Institute of Medical Research (NIMR) with backgrounds in research were identified. Both of them had a medical doctor (MD) qualification and background. After their identification, they were trained and oriented to the respective tools for a successful data collection process in the field.

Data management and data quality assurance methods

The researcher tested the reliability by pre-testing the questions on pregnant women attending the ANC clinic in the Muhimbili National Hospital to ensure the respondents鈥� straightforward questions were understood. The questions could respond and measure what the study wanted to achieve. Nevertheless, the researcher tested the study鈥檚 validity using face validity, using four people (1 professor, one medical doctor with an MPH working as an assistant lecturer, and two assistant lecturers with postgraduate degrees in Health Policy and Management). All of these were from MUHAS School of Public Health and Social Sciences. They knew the topic of the study. They read the questionnaire and ensured the researcher that it had captured the necessary questions to be asked and the data required to be collected effectively.

Many of the questions focused on the study, and things that changed were the questions to define the two dependent variables: perception and trust clearly. This is because some questions on perception measured belief towards the COVID-19 vaccine, and some questions on trust measured belief towards the COVID-19 vaccine. It should be noted that vaccination status did not use an average Likert scale of five levels of measurement because it had only two (vaccinated or not vaccinated). Finally, the gender question was removed since we were studying pregnant women. So, changes were made to increase focus during data collection, and the questionnaire was improved based on the review of the expert鈥檚 recommendations.

The questionnaire collected information about pregnant women鈥檚 perceptions, attitudes, and levels of trust in the COVID-19 vaccine. The principal researcher developed the questionnaire by collecting questions on measuring the variables collected from different studies written in English but translated into Kiswahili and then back to English.

Data analysis

The participants鈥� responses were entered into data collection software (Stata/SE 14.1), whereby all completed questionnaires were checked to see if they were error-free, i.e., their eligibility, range of values inconsistency, and missing identification numbers. Later, all the submitted questionnaires were double-entered into the Excel database and then exported to Stata for data checks and cleaning.

Data analysis corresponding to each specific objective

To determine the proportion of pregnant women attending ANC clinic who have been vaccinated, Socio-demographic factors associated with the uptake of the COVID-19 vaccine among pregnant women were measured by demographic questions about individual factors related to uptake/nonuptake of the COVID-19 vaccine among pregnant women. To effectively carry this out, frequency measure (n) and proportion (%) were calculated using Stata/SE 14.1, where software continued variables were conducted to describe the study population in terms of mean, median, range, and standard deviation.

To find out the perceptions, attitudes, and trust influencing COVID-19 vaccine uptake among pregnant women attending ANC clinic, the perceptions associated with uptake/nonuptake of COVID-19 were measured by a Likert scale from 1 to 5 responses whereby the respondent鈥檚 mean score of <鈥�2.5 was labeled as having positive perception, attitudes, and trust towards COVID 19 and the mean score of >鈥�2.5 was labeled as having negative perception, attitudes, and mistrust towards COVID 19 [11].

Category variables and proportional frequencies were calculated to examine the factors influencing COVID-19 uptake among pregnant women attending ANC clinics. The Pearson Chi-square statistics test compared group differences for categorical variables. The bivariate and multivariate logistic regression included all statistically significant variables using chi-square.

To find the association between the dependent variable and all four objectives/variables, socio-demographic, perception, attitude, and trust objectives were added to the software, and multivariate binary logistic regression was done. Crude Odds Ratios (OR) and Adjusted Odds Ratio (AOR) with 95% confidence intervals (CI) after adjusting for confounders were reported, and Fisher鈥檚 test was used to compare the mean difference between variables. Pie charts and bar charts were used for pictorial presentation of the results. Relationship, association, and variable differences were considered statistically significant at P鈥�&濒迟;鈥�0.05.

Results

Demographic characteristics of the participants about COVID-19 vaccine uptake

A total of 333 pregnant women attending antenatal clinics were recruited in this study. The Majority were aged between 25 and 35 years, 225(67.5%), with a mean age of 27.33鈥壜扁��4.56 years. It was revealed that the majority of them were married/cohabiting. These comprised 234 (70.3%) of all respondents, and more than half of the study population had secondary education as their highest level of education 181(54.4%). Half of them were self-employed, 175 (52.6%), in various informal and formal occupations such as petty business, food vending tailoring, and shopkeeping. It was revealed that the majority of the study population, 210 (63.1%), were reported to have experience of fewer than five years in occupations that were generating income for their living, as indicated in Table听1 below.

Table 1 Demographic characteristics of the study population (n鈥�=鈥�333)

COVID-19 vaccination status

As indicated in Fig.听1 below, 89 (27%) of the study population (n鈥�=鈥�333) were pregnant women vaccinated with the COVID-19 vaccine.

Fig. 1

COVID-19 vaccination status

Perception towards COVID-19 vaccine and vaccination status

Among those who positively perceived their susceptibility to COVID-19 infection, 57 (27.3%) were vaccinated with the COVID-19 vaccine. Also, among those who perceived severity in this case, how people interpret and respond to information about COVID-19 infection regarding illness and mortality rates, 63 (25.2%) were vaccinated with the COVID-19 vaccine. Of those who perceived barriers and challenges to uptake of the COVID-19 vaccine, 63 (26.7%) were vaccinated with the COVID-19 vaccine. Among those who perceived the benefit of the uptake of the COVID-19 vaccine to the community, 85 (27.0%) were vaccinated. Also, for those who perceived a cue to the action, which refers to a signal or reminder that informs individuals to initiate the action of uptake of uptake of the CIVID-19 vaccine, 86 (27.6%) were vaccinated. By using the chi-square test, it was found that all of the perceptions were not associated with COVID-19 vaccination status. Table听2 below illustrates the findings.

Table 2 Perception of the respondents towards COVID-19 vaccine by vaccination status

Attitude towards COVID-19 vaccination and vaccination status

Of those who were having positive attitude towards getting COVID-19 vaccine if it could be available 84 (25.9%) were vaccinated, more than quarter 79 (29.55) of those who had positive attitude towards accepting COVID-19 vaccine for themselves and children were vaccinated. Majority 58 (82.9%) of those who had received other vaccinations in the past five years, were vaccinated. Attitudes were associated with vaccination status at p-values 0.048, 0.021 and 0.001 respectively. Table听3 below illustrates the findings.

Table 3 Attitude towards COVID-19 by vaccination status

Trust towards COVID-19 vaccine and vaccination status

Among those with confidence and trust to the safety of the vaccine 52 (25.9%) were vaccinated and this was associated with COVID-19 vaccination status at p-value 0.027. Accepted gestation age for vaccination 14鈥�28 weeks and more than 28 weeks were associated with COVID-19 vaccination status at p-value 0.001 and 0.009 respectively. Other trust factors such as worry about COVID-19, efficacy of vaccination during pregnancy and accepted gestation, age for vaccination of less than 14 weeks were not associated with COVID-19 vaccination status. Table听4 below illustrates the findings.

Table 4 Trust towards COVID-19 vaccine by vaccination status

Using chi-square test, multivariate logistic regression was done to determine the strength of the association between COVID-19 vaccination status and demographic, attitude and trust variables which had p-value鈥�<鈥�0.005. After adjusting for other variables in the model, those with primary education were 6.58 (95% CI (1.45鈥�29.85) more likely to be vaccinated compared to those with college/University education p-value 0.015. In terms of work experience, those with work experience of 5鈥�10 years were 2.45 (95% CI (1.02鈥�5.89) more like to be vaccinated with COVID-19 vaccine compared to those with less than five years of experience p-value 0. 046.

Using chi-square test all attitude factors were associated with COVID-19 vaccination status, in the multivariate analysis, the odds of those who accepted vaccines for themselves or for their children was 4.43 (95%CI (1.41鈥�13.93) higher compared to those who did not accept vaccine for themselves and their children p-value 0.011. Those who had received other vaccines over the last 5 years had odds of 45.83 (95% CI (18.60-112.89) higher than those who did get vaccinated with other vaccine in the past five years with p-value 0.001. Table听5 below illustrates the findings.

Table 5 Logistic regression for the association between demographic, attitude, trust variable and COVID-19 vaccination status

Discussion

The demographic characteristics that had a statistically significant association with vaccination status were: age group of 25鈥�35 years, as supported by previous studies, was statistically associated with COVID-19 vaccination among the respondents. [12], level of education, occupation, and work experience. Our findings that respondents with primary education level were more likely to uptake the COVID-19 vaccine (40.6%) as indicated in Table 6 which support other previous studies鈥� findings [13] and contradicts with some other previous studies which suggests that the respondents with tertiary/higher education level were more likely to uptake the vaccine [14]. This study suggests that the reason for highly educated people being hesitant to take vaccines might be due to access to myths and mistrust information regarding the effectiveness and safety of vaccines in pregnancy compared to their counterparts [13]. It was found that marital status had no statistical association with COVID-19 vaccine uptake among respondents as explained in Table听1 of this study results.

Table 6 Below indicates: COVID-19 vaccination status by demographic characteristics

The respondents鈥� occupation was not observed by other studies as an associated factor to COVID-19 vaccine uptake. Based on this, this study finding suggests that self-employed respondents (47.2%) were more ready to uptake the COVID-19 vaccine than their counterparts. Based on these findings, this study suggests that the reason might be that the self-employed pregnant women perceived the severity of the disease and, therefore, they did not want to risk their lives because most of them depended on their efforts to feed their families and protect them from the pandemic, they had access to proper information regarding the benefits of vaccine from the social media, posters, television. They perceived themselves to be susceptible to contracting COVID-19 at their working environment (a good example of susceptible environment are public spaces). They also perceived that the severity of disease could hamper their day-to-day activities and that lack of health insurance coverage might be an influencing factor for their readiness to uptake vaccination because they feared about the costs of medical services if they fell sick due to the pandemic.

The data in this study suggest that the proportion of pregnant women attending ANC clinics who had been vaccinated for COVID 19 vaccine was 27% lower compared to some other countries like the United States (40%), England (53.1%) and Saudi Arabia (57.1%)^13,14. Low vaccine uptake might be a result of late launch of COVID 19 vaccine usage among pregnant women in Tanzania compared to other countries.

With regard to the association between the attitudes to the uptake of COVID-19 vaccine among pregnant women; the study findings reported that pregnant women had positive attitude to uptake COVID 19 vaccine as supported by other previous studies [15, 16]. These findings suggest that respondents had positive attitude that vaccine could provide protection against COVID 19 disease for themselves and their unborn babies/children. The readiness of vaccine uptake was also influenced by the previous experience on other vaccine uptake as supported by other previous studies [17, 18].

Regarding the association between levels of trust to COVID-19 vaccine uptake, the study findings suggest that the respondents/pregnant women had no fear, no anxiety, and no worry for the side effects of the vaccine in pregnancy and unborn babies hence they had trust towards COVID-19 vaccine among the respondents thus influencing them to uptake the vaccine as supported by the previous studies [19]. This study findings contradict with other previous studies which suggested that respondents had fear, anxiety and worry to vaccine side effects on pregnancy and the unborn babies which created negative attitude among the respondent鈥檚 decision to vaccine uptake [13, 14, 20]. In addition, respondents who had received vaccines like influenza (H1N1) previously had more trust to vaccine than their counterparts [21].

There was limited literature on previous studies on the proper gestation age of pregnancy where pregnant women were ready to uptake COVID-19 vaccine. This study findings suggest that there is strong association between pregnant women in the second and third trimester of pregnancy being ready to uptake vaccine (low hesitance) than in first trimesters as supported by few literatures from one of the previous studies [20, 22].

Limitations

This study was cross-sectional and conducted using quantitative approach which makes it difficult for its findings to be generalizable to a large population and might not be rich in information like if it were conducted using qualitative approach. However, this was mitigated by increasing the number of the sample size so to get generalizable results of the larger population.

After running logistic regression analysis, the study findings suggest that the score on perception, attitude and trust were high but vaccination was low, qualitative research approach could have been able to dig deep.

Recommendations

The permanent secretary, government chief medical officer and communicable disease department under the Minister of Health, healthcare workers (doctors, nurses, etc.) at facilities which provide COVID 19 vaccine together with stakeholders (NGOs, GAVI etc.) should promote a tailored approach [23] towards raising awareness on the benefits of vaccines, especially in pregnant women and their babies, without any fear of living abnormal lives after vaccination. It should be noted that the vaccine is safe and effective as a proper means of IPC to curb the COVID-19 pandemic.

The Government of Tanzania, through its MoH, should continue promoting the adherence to and uptake of COVID-19 vaccination to all recommended groups, including pregnant women; hence, HCWs and other stakeholders/media should practice health promotion and campaigns for the aim of providing adequate proper information for the aim of creating positive perception, attitude, and trust towards the utilization of vaccine since it is beneficial to curb the formation of virus variants that may make it even more difficult to curb the pandemic in the future.

Conclusion

COVID-19 vaccine uptake in this study was low among pregnant women, the reasons for the low proportion as described in this study (in Fig.听1 above) were:

Delays by the government of Tanzania (in comparison with other countries in the world) to accept the use of COVID-19 vaccination in the general population and specifically in pregnant women and late development of tailored approaches towards the benefits of vaccine had created improper perceptions, attitudes and mistrust among the population that vaccine usage can cause COVID 19 infection, the respondents being not sure of the effectiveness of vaccine in pregnancy, hence creating low vaccination demand. [12].

Another reason for the low uptake of the COVID-19 vaccine is that respondent cues鈥� actions were also influenced by the recommendations to use the vaccine by health workers or the Ministry of Health (MoH) guideline; thus, vaccine hesitancy was partly due to inadequate health promotion and the delay in developing the COVID-19 vaccine guideline and not being used effectively by healthcare workers in places where people get the vaccine.

Positive attitudes and trust towards COVID-19 should be promoted to increase COVID-19 vaccination uptake among pregnant women.