Seasonal Influenza Vaccine During Pregnancy: Uptake, Knowledge, Attitudes and Perceptions in Al-Karak Governorate, Jordan using HBM.
Mahmoud
A
Jaafreh
1
Munir
Abu-Helalah
2
Mohammad
Ahmad
Abu-Lubad
3
Ro’ya
ALSaalan
4
Eliza
Dumour
5
1A
A
A
master of public health administration
Ministry of Health
Jordan
2
Department of Family and Community Medicine, School of Medicine, Director of Public Health Institute
University of Jordan, University of Jordan
11942
Amman
Jordan
3
Assistant Prof. of Microbiology, Faculty of Medicines
Mutah University
Jordan
4
Resident of Gynecology Karak Teaching Hospital
Ministry of Health
Karak
Jordan
5
Interns in Prince Ali Army Hospital
Karak
Jordan
Mahmoud A Jaafreh1, Munir Abu-Helalah2, Mohammad Ahmad Abu-Lubad3, Ro’ya ALSaalan4, Eliza Dumour5.
1 master of public health administration, Ministry of Health, Jordan.
2 Associate Professor of Epidemiology and Preventive Medicine Department of Family and Community Medicine, School of Medicine University of Jordan, Director of Public Health Institute
University of Jordan, Amman 11942, Jordan.
3 Assistant Prof. of Microbiology, Faculty of Medicines at Mutah University, Jordan.
4 Resident of Gynecology Karak Teaching Hospital, Ministry of Health, Karak, Jordan.
5 Interns in Prince Ali Army Hospital, Karak, Jordan.
Abstract
Background
A
Pregnant women are at an increased risk of developing severe flu and suffering its complications.
A
Many countries recommend annual flu immunization during pregnancy, but in Jordan, it has not been routinely recommended or adopted through local guidelines. Moreover, there is limited data on the influenza vaccine uptake, knowledge, attitudes, and barriers for flu virus vaccinnation during pregnancy. Therefore, this study was proposed to assess flu vaccination rates and associated factors among pregnant women in Al-Karak governorate, south of Jordan, during the 2021–2022 flu season. This study applied the Health Belief Model to investigate factors affecting receiving the influenza vaccine during pregnancy.
Methods
A cross-sectional study conducted using a reliable questionnaire on a representative sample of pregnant women who had been pregnant between September and November 2021 (N = 382). The Survey consisted of 5 parts to assess pregnant women socio-demographics, knowledge, uptake rate, attitude and perception as well as factors affecting influenza vaccine uptake.
Results
The Influenza vaccine coverage among pregnant women was (8.1%). An intermediate level of knowledge of influenza and its vaccine was reported among the study participants. There was a statistically significant difference between pregnant women in the vaccinated and non-vaccinated groups in terms of place of residence (p < .001), educational level (p < .001) and past vaccination history (p < .044). Predictors of vaccination revealed by logistic regression analysis included urban residence (P013.> OR 5.792), university and high educational level (p < .005 OR 1.35), in addition to previous vaccination (p < .022 OR 2.6). Other predictors revealed by the Health Belief Model (HBM) were the perceived severity of influenza, perceived benefits of vaccinations, perceived barriers to vaccinations, cues to action and attitudes toward influenza vaccine.
Conclusions
This study provides baseline data necessary to develop strategies for increasing flu vaccination rates aiming to reduce flu burden during pregnancy in the south of Jordan.
Keywords:
Flu
flu vaccine
knowledge
Uptake
Pregnancy
Health Belief Model
Jordan
A
A
A
A
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Introduction
Seasonal Influenza (SI) is caused by a virus that spread through droplets or fomites affecting the respiratory system seasonally. In pregnant women, Influenza infection leads to severe symptoms and complications compared to nonpregnant women and other populations1. It significantly impacts pregnant women's respiratory, immune and cardiovascular systems, leading to a high risk for cardiopulmonary hospitalization during the influenza season. Cardiopulmonary hospitalization rates due to influenza were close to 3, 6, and 10 per 10,000 women-months among pregnant women in their first, second, and third trimesters, respectively, as compared with approximately 2 per 10,000 women-months among nonpregnant women during the influenza season2.
The effect of influenza infection is not limited to the pregnant mother, but it also poses a threat to the fetus, although the transmission of the virus to the fetus through the placenta is rare3. Exposure to influenza during the first trimester of pregnancy increases the risk of any congenital abnormality two times more than the unexposed pregnant4. The influenza vaccine is routinely recommended in the northern hemisphere between September and November. It can protect pregnant women and their newborns from influenza-related morbidity and mortality leading to outpatient emergency visits and hospitalization. The protection extends to infants under six months of age by transmitting antibodies from mother to fetus through the placenta5.
The influenza vaccine uptake among pregnant women varies from country to country. A systematic review6 included 21 studies (from USA, Australia, UK, Canada, Netherlands, Hong-Kong, and Turkey) noted that the uptake rate of influenza vaccine during pregnancy ranged between 1.7% and 88.4%. Although the influenza vaccine is safe and effective to administer to pregnant women, published data on the uptake and acceptance of the influenza vaccine among pregnant women in the Middle East is limited. Few studies have shown that the rate of pregnant women receiving influenza vaccine during their current pregnancy ranges between 4.6% and 19.8%7, 8. This is in addition to poor awareness and knowledge about influenza and vaccines among pregnant women8, 9. Only few studies have identified barriers that may affect pregnant women knowledge of the influenza vaccine and their decision to receive it during pregnancy. These factors varied between demographic factors, medical history characteristics, level of knowledge and perceptions of pregnant women toward influenza and vaccines(10), 11.
A
Currently, there are no published studies that focus on seasonal influenza vaccine uptake during pregnancy in Jordan. Therefore, this study proposes assessing pregnant women uptake, knowledge, attitudes and perceptions in Al-Karak governorate, south of Jordan. Understanding these factors will help address the gaps in vaccine acceptance and guide future public health interventions.
Methods
Study setting and subjects.
The study was conducted at Al-Karak governorate in Jordan, which is divided into three regions (Northern, Central, and Southern), each has three or more comprehensive and primary health centres. Two health centers were selected randomly from each region, in addition to two public hospitals found in the governorate and selected private obstetrics clinics. The study was conducted in postnatal wards and Obstetrics and childhood out-patient clinics. Jordanian women who had been pregnant during the influenza season 2021–2022 in Al-Karak governorate during the study period were eligible to participate in the study, excluding those who are not permanent residents in Al-Karak governorate, those who refused to answer the questionnaire and those with a contra-indications to receiving the influenza vaccine.
Target Sample size.
Target sample size N was calculated using OpenEpi Version 3. The total study population is 7274 pregnant women based on the latest birth census over the city[12]. The prevalence rate = 50%; because no previous studies have measured the level of knowledge, attitudes and uptake rate of influenza vaccine among pregnant women in Jordan, the default prevalence used is 50%, with a confidence level of 95%, Z 0.95 = 1.96 (Normal Distribution Table). Therefore, the calculated sample size = 345. To consider for the non-response rate of the calculated sample size, 10% was added, therefore, a sample size of 380 pregnant women were required to reach the power of 95% with a 0.05 margin.
Data Collection.
Data collection period was conducted from June 2022 to September 2022, the obstetrics and childhood clinics were usually open for five days per week. Interviews were conducted by a team of female doctors and nurses trained to interview pregnant women. Training included the importance of the topic researched, the study objectives, ethical considerations and training on the questionnaires conduction and handling.
A
The first phase included selective hospitals and outpatient obstetric clinics during the month of June 2022. The second phase was in conducted in the Maternity and childhood clinics in the primary and comprehensive health centers as of July 2022. Participants were informed that the decision on participation or responses will not affect the standard of care they should be receiving. After approval was obtained from the participant, the interviews took place in a time not exceeding 10 minutes.
Questionnaire
A structured Arabic questionnaire was constructed through the combination of items from reliable and valid questionnaires7,12,13. Backward-forward translation of the questionnaire was done by medical and social experts, additionally, pilot-tested 20 pregnant women were interviewed to test the acceptability, length, clarity, and assess the questions /statements formats of the questionnaire. Pilot interviews were not included in the study sample. The final version is composed of 46 questions/statements other than the demographic data. All questions/statements were close-ended questions addressing five areas of interest; socio-demographic and medical history Information such as (age, level of education, residency, employment state, total monthly income, and health insurance, para and gravida status, miscarriage, medical history and history of influenza before and during the pregnancy), information related to influenza and influenza vaccine knowledge (10 multiple choice questions), perceptions and attitudes toward the influenza vaccine based on the Health Belief Model (HBM), uptake of influenza vaccine and, finally, factors affecting influenza vaccine uptake.
In this context, the theory of the Health Belief Model (HBM) contributed to explaining women's perceptions about their tendency to adopt healthy behavior that is determined by other factors: perception of disease susceptibility and perceived severity of the consequences of influenza, exposure to information that may prompt a pregnant woman to take the action of receiving the vaccine and the amount of benefit that she thinks she will get.
According to the HBM, a pregnant woman's readiness to take action (receive influenza vaccine) depends on the following beliefs or conditions: is she susceptible to this influenza? Is the threat of influenza serious to her health? Do the benefits of taking the vaccine outweigh the barriers? Is she confident she can carry out the vaccination successfully? Are there Cues to action present to motivate her to take the vaccine?
The following components of HBM were used in the study: the pregnant woman’s perceived risk of getting influenza (perceived susceptibility), the belief of the resulting consequences for her and the health of the fetus (perceived severity), the potential positive benefits of influenza vaccine (perceived benefits), perceived barriers to influenza vaccine and the exposure to factors which prompt action (cues to action), as well as modifying variables (a person’s characteristics).
Statistical analyses:
To make the process of handling and analyzing the data more effective and easier, each variable and its respective items was coded with unique codes to ensure no duplication and ease of retrieval. This process helps to understand and manage these items for organizing purposes according to their unique codes 14. Statistical processing was carried out using the statistical package for the social sciences program (SPSS V.22). Data was checked to identify possible entry errors, missing values, incorrect or illogical answers and non-response to statements questions. Chi-square analysis was used to analyze the association between all baseline characteristics, knowledge level and vaccination status. Binary logistic regression was performed to find the predictors of vaccine uptake and Stepwise regression was performed to study the effect of selected baseline characteristics on each item of barrier measure. Multiple linear regression was performed to study the effect of all HBM variables on women’s attitude toward vaccination.
Ethics and Consent to Participate declarations
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The study was approved by the University of Mutah's ethics committee and the Jordanian Ministry of Health Central Ethics Committee.
Data Availability
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
Consent to Publish declaration
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All participants provided written informed consent for publication.
Research funding
The research did not receive any funding.
Results
Demographic Characteristics and Receiving of SIV Vaccination.
Four hundred fifteen (415) questionnaires were filled out, 33 were excluded because they were incomplete or did not match the inclusion criteria. Of the 382 interviewed pregnant women, 199 (52.1%) were from urban areas. Of the demographic characteristics, the place of residency and educational level were significantly different between pregnant women who received and did not receive influenza vaccine, 114 (29.8%) received influenza vaccine before, while the majority (70.2%) have remained unvaccinated. However, only 34 (8.9%) received the vaccine during previous pregnancies while 31 (8.1%) received the vaccine during the current pregnancy (Table 1).
Table 1
Descriptive demographic characteristics of pregnant women by receiving influenza vaccine.
|
Characteristics
|
Category
|
Have you received an influenza vaccine in the current pregnancy?
|
|
Yes
N = 31
|
No
N = 351
|
P value
|
|
N (%)
|
N (%)
|
|
Place of residency
|
Urban
|
20 (64.5)
|
179(51)
|
< .001 **
|
|
Rural
|
11(35.4)
|
172(49)
|
|
Education
|
School Education
|
13 (41.9)
|
127(36.1)
|
< .001 **
|
|
High Education*
|
18(58)
|
224(63.8)
|
|
Employment status
|
Full Time
|
19 (61.2)
|
116(34.4)
|
.997
|
|
Part-Time
|
5 (16.1)
|
21 (5.9)
|
|
Unemployed
|
7 (22.5)
|
214(59.7)
|
|
Monthly Income
|
less than 500 JD
|
10 (32.2)
|
218(62.1)
|
.612
|
|
from 500 to 1000 JD
|
20 (64.5)
|
125(35.6)
|
|
more than 1000 JD
|
1 (3.2)
|
8 (2.2)
|
|
Health Insurance
|
Ministry Of Health
|
20 (64.5)
|
197(56.1)
|
.779
|
|
Medical Services
|
3 (9.6)
|
98 (27.9)
|
|
Private Sector
|
1(3.2)
|
19(5.4)
|
|
University Hospitals
|
4(12.9)
|
5(1.4)
|
|
Relief Agency UNURWA
|
0(0.0)
|
2(0.5)
|
|
No Health insurance
|
3(9.6)
|
30(8.5)
|
|
Age (year)
|
18–25
|
21(67.7)
|
177(50.4)
|
.179
|
|
26–35
|
9 (29)
|
161(45.8)
|
|
36 or older
|
1 (3.0)
|
13 (3.7)
|
|
para-status
|
1
|
3 (9.6)
|
59 (16.8)
|
.422
|
|
2
|
9 (29.0)
|
74(21.08)
|
|
3 or more
|
19 (61.2)
|
218(62.1)
|
|
gravida status
|
0
|
2 (6.4)
|
20(5.7)
|
.303
|
|
1
|
5 (16.1)
|
85 (24.2)
|
|
2
|
12 (38.7)
|
84 (23.9)
|
|
3 or more
|
12 (38.7)
|
162(46.2)
|
|
miscarriage history
|
0
|
21 (67.7)
|
247(70.3)
|
.759
|
|
1 or more
|
10 (32.2)
|
104(29.6)
|
|
Regular Medications*
|
yes
|
5 (16.1)
|
82 (23.3)
|
.249
|
|
No
|
26 (83.8)
|
269(76.6)
|
|
Influenza Experience
|
Yes, During Pregnancy
|
7 (22.5)
|
51 (14.5)
|
.821
|
|
Yes, Before Pregnancy
|
4 (12.9)
|
59 (16.8)
|
|
Before and during pregnancy
|
1(3.0)
|
9 (2.5)
|
|
No
|
19 (61.2)
|
232(66.1)
|
|
Hospitalization due to Influenza complications
|
Yes, During Pregnancy
|
3 (9.6)
|
48 (13.5)
|
.821
|
|
Yes, Outside Pregnancy
|
2 (6.4)
|
21 (5.9)
|
|
No
|
26 (38.8)
|
282(80.3)
|
|
Perceived Severity of Influenza Vaccine.
|
More Severe
|
2 (6.4)
|
69 (19.6)
|
.064
|
|
Slightly more intense
|
15 (48.3)
|
99 (28.2)
|
|
same as in previous days
|
6 (19.35)
|
110 (31.3)
|
|
less severe
|
5 (16.1)
|
35 (9.9)
|
|
Have you heard of the influenza vaccine before?
|
Yes
|
26 (83.8)
|
277(64.6)
|
.514
|
|
No
|
5 (16.1)
|
74 (21.0)
|
|
Have you ever received the influenza vaccine before?
|
Yes
|
14 (45.1)
|
100 (28.4)
|
.044
|
|
No
|
17(54.8)
|
251(71.5)
|
|
Have you received an influenza vaccine in previous pregnancies?
|
Yes
|
4 (12.9)
|
27 (7.6)
|
.236
|
|
No
|
27(87.1%)
|
324(92.3)
|
|
Knowledge Score
|
Poor knowledge (< 5)
|
12 (38.7)
|
173 (49.3)
|
< .001 **
|
|
Good Knowledge ( > = 5)
|
19 (61.2)
|
178 (50.7)
|
|
Trust in healthcare provider advice about vaccine*
|
Low Trust
|
10(32.2)
|
162(46.1)
|
.563
|
|
High Trust
|
21(67.7)
|
189(53.8)
|
|
Total
|
|
31 (8.1)
|
351(91.8)
|
|
| * High Education = College, University, postgraduate. |
| * e.g., ( Antihypertension medication, Diabetic medications, Thyroid medication …) |
| * trust = How much do you trust your healthcare provider’s advice about influenza? Choose a rating from 0 to 10 |
| ** p < 0.001 |
Table 6 shows the likelihood of vaccination during the current pregnancy depending on HBM individual variables, knowledge score, attitude towards the vaccination, and other factors,
Table 6
Odds Ratios for Vaccination during current pregnancy: By HBM Individual variables, Knowledge score, attitude towards the vaccination, other factors
| |
B
|
Adjusted OR
|
95% CI
|
P value
|
| |
|
Lower
|
Upper
|
|
|
Residency (Urban)
|
1.756
|
5.792
|
1.454
|
23.078
|
.013*
|
|
Knowledge score (good Knowledge)
|
.302
|
1.352
|
1.097
|
1.666
|
.005*
|
|
Have you ever had the influenza vaccine before? () (yes)
|
.956
|
2.600
|
1.149
|
5.882
|
.022*
|
|
Taking the influenza vaccine during pregnancy will help me. (Benefits2)
|
.763
|
1.466
|
1.283
|
1.768
|
.003*
|
|
influenza vaccine can protect the baby during the first months of life (Benefit 4)
|
.510
|
1.665
|
1.022
|
2.712
|
.041*
|
|
The influenza vaccine can give me the flu (Barrier2)
|
− .375-
|
.687
|
.446
|
1.059
|
.039*
|
|
My doctor/nurse pharmacist's recommendation is important for making the right decision about getting the vaccine (cause to action 1)
|
.551
|
1.734
|
1.462
|
3.128
|
.047*
|
|
I trust the guidelines that recommend that all pregnant women get their annual influenza vaccine (cause to action 2)
|
.753
|
2.123
|
1.261
|
3.574
|
.005*
|
|
I feel like I have had all the information I need to decide if I should get the influenza vaccine (cause to action 3)
|
.584
|
1.794
|
1.080
|
2.978
|
.024*
|
|
I am against taking the flu vaccine during pregnancy (Attitude 1)
|
− .795-
|
.452
|
.225
|
.907
|
.026*
|
|
I recommend other women take the influenza vaccine during pregnancy. (Attitude 3)
|
.659
|
1.932
|
1.110
|
3.362
|
.020*
|
| P < 0.05 |
The result revealed that women from urban areas and those with good knowledge of influenza and vaccination were more likely to increase the likelihood of vaccination (OR = 5.792, 1.352) prospectively. Further, being previously vaccinated was significantly and positively predictive of vaccination during the current pregnancy (OR = 2.600).
Health Belief Model HBM And Attitude Towards Vaccination
From each HBM domains except perceived susceptibility, at least one item was predictive of influenza vaccination during pregnancy. One of “Perceived Severity of Influenza” items predicted influenza vaccine uptake during current pregnancy: vaccinated women were more likely to perceive themselves at risk of severe complications from influenza (Table 2). Details of the attitudes according to the HBM are described in Table 3. Table 4 shows the participants' responses to selective factors that may predict vaccination rates.
Table 2
Association between HBM items and vaccination status.
| |
Have you received an influenza vaccine during the current pregnancy?
|
P value
|
|
Yes
N = 31
(%)
|
No
N = 351
(%)
|
|
Strongly Disagree
/Disagree
|
Neutral
|
Agree
/Strongly Agree
|
Strongly Disagree
/Disagree
|
Neutral
|
Agree
/Strongly Agree
|
|
|
Perceived Susceptibility to Influenza
|
8
(25.8)
|
10
(32.3)
|
13
(41.9)
|
83
(23.6)
|
105
(29.9)
|
163
(46.4)
|
.890
|
|
I get influenza more easily than other people my age.
|
|
Without the vaccination, I feel that I am vulnerable to a severe infection with the influenza
|
11
(35.5)
|
9
(29.0)
|
11
(35.5)
|
108
(30.8)
|
101
(28.8)
|
142
(40.5)
|
.827
|
|
I am worried about the fetus being affected by the influenza
|
6
(19.4)
|
10
(32.3)
|
15
(48.4)
|
53
(15.1)
|
109
(31.1)
|
189
(53.8)
|
.776
|
|
Perceived Severity of Influenza
|
8
(25.8)
|
8
(25.8)
|
15
(48.4)
|
161
(45.9)
|
80
(22.8)
|
110
(31.3)
|
.073
|
|
If I get influenza during pregnancy, I may develop severe symptoms
|
|
If I get influenza during pregnancy, I expose myself to serious complications.
|
9
(29.0)
|
10
(32.3)
|
12
(38.7)
|
151
(43.0)
|
85
(24.2)
|
115
(32.8)
|
.035 *
|
|
If I get influenza while pregnant, the disease may harm my unborn baby.
|
11
(35.5)
|
7
(22.6)
|
13
(41.9)
|
171
(48.7)
|
89
(25.4)
|
91
(25.9)
|
.148
|
|
Perceived Benefits of vaccination
|
8
(25.8)
|
6
(19.4)
|
17
(54.8)
|
78
(22.2)
|
91
(25.9)
|
82
(51.9)
|
.706
|
|
I would not have to worry about getting influenza if I received the vaccine
|
|
Receiving the influenza vaccine during pregnancy will help me.
|
10
(32.3)
|
6
(19.4)
|
15
(48.4)
|
124
(35.3)
|
96
(27.4)
|
131
(37.3)
|
.034 *
|
|
Receiving the influenza vaccine during pregnancy will benefit the fetus.
|
11
(35.5)
|
3
(9.7)
|
17
(54.8)
|
118
(33.6)
|
91
(25.9)
|
142
(40.5)
|
.105
|
|
Influenza vaccine can protect the baby during the first months of life
|
5
(16.1)
|
10
(32.3)
|
16
(51.6)
|
90
(25.6)
|
118
(33.6)
|
143
(40.7)
|
.039 *
|
|
Perceived Barriers To influenza vaccination
|
10
(32.3)
|
13
(41.9)
|
8
(25.8)
|
90
(25.6)
|
104
(29.6)
|
157
(44.7)
|
.120
|
|
I am concerned about the side effects of the vaccine
|
|
The influenza vaccine can give me the flu
|
14
(45.2)
|
9
(29.0)
|
8
(25.8)
|
105
(29.9)
|
103
(29.3)
|
143
(40.7)
|
.015 *
|
|
I am worried there might be something I do not know about the influenza vaccine
|
11
(35.5)
|
8
(25.8)
|
12
(38.7)
|
92
(26.2)
|
102
(29.1)
|
157
(44.7)
|
.536
|
|
My family, friends, or co-workers did not encourage me to get the vaccine.
|
12
(38.7)
|
8
(25.8)
|
11
(35.5)
|
88
(25.1)
|
101
(28.8)
|
162
(46.2)
|
.243
|
|
Cues To Action
|
11
(35.5)
|
8
(25.8)
|
12
(38.7)
|
114
(32.5)
|
92
(26.2)
|
145
(41.3)
|
.038 *
|
|
My doctor /nurse pharmacist’s recommendation is important for making the right decision about getting the vaccine
|
|
I trust the guidelines that recommend that all pregnant women get their annual influenza vaccine
|
8
(25.8)
|
6 (19.4)
|
17
(54.8)
|
115
(32.8)
|
100
(28.5)
|
136
(38.7)
|
.020 *
|
|
I feel like I have had all the information I need to decide if I should get the influenza vaccine
|
9
(29.0)
|
6
(19.4)
|
16
(51.6)
|
127
(36.2)
|
104
(29.6)
|
120
(34.2)
|
.014 *
|
| *P < 0.05 |
Table 3
The Association Between Perceived Attitude and Vaccination Status. Total responce N( 382)
| |
Have you received an influenza vaccine during the current pregnancy?
|
P value
|
|
Yes
N = 31
(%)
|
No
N = 351
(%)
|
|
Strongly Disagree
/Disagree
|
Neutral
|
Agree
/Strongly Agree
|
Strongly Disagree
/Disagree
|
Neutral
|
Agree
/Strongly Agree
|
|
|
I am against receiving the flu vaccine during pregnancy.
|
15
(48.4)
|
8
(25.8)
|
8
(25.8)
|
35
(10.0)
|
100
(28.5)
|
216
(61.5)
|
< .001 *
|
|
I don't mind taking the influenza vaccine during pregnancies
|
7
(22.6)
|
12
(38.7)
|
12
(38.7)
|
233
(66.4)
|
76
(21.7)
|
42
(12.0)
|
< .001 *
|
|
I recommend other women take the influenza vaccine during pregnancy.
|
6
(19.4)
|
13
(41.9)
|
12
(38.7)
|
213
(60.7)
|
100
(28.5)
|
38
(10.8)
|
< .001 *
|
| *P < 0.001 |
Table 4
Participants' responses to other factors that may predict vaccination rate. Total responce N( 382)
|
Other Factors
|
Yes
|
No
|
|
N (%)
|
N (%)
|
|
Have you ever received advice from a doctor during pregnancy about the influenza vaccine?
|
170 (44.50)
|
212 (55.5)
|
|
Have you ever received advice from the nurse during pregnancy about the influenza vaccine?
|
153 (40.1)
|
229 (59.9)
|
|
Have you ever received advice from the pharmacist during pregnancy about the influenza vaccine?
|
148 (38.7)
|
234 (61.3)
|
|
Have you been advised by anyone (relative, colleague, friend) to receive the influenza vaccine during this pregnancy?
|
163 (42.7)
|
219 (57.3)
|
|
Did any person or source influence not receive influenza vaccination during this pregnancy?
|
139 (36.4)
|
243 (63.6)
|
|
Do you know anyone who has become severely ill with influenza?
|
180 (47.1)
|
202 (52.88)
|
|
Do you know anyone who has had a bad reaction to the influenza vaccine?
|
184 (48.2)
|
198 (51.8)
|
|
Do you have enough information about the safety and side effects of the influenza vaccine?
|
144 (37.7)
|
238 (62.3)
|
There were statistically significant predictors for influenza vaccine uptake during pregnancy through the stepwise regression analysis including urban residence (P < .013 OR 5.792), university and high educational level (p < .005 OR 1.35), in addition to previous vaccination (p < .022 OR 2.6). Other predictors revealed by the Health Belief Model were the perceived severity of influenza, perceived benefits of vaccinations, perceived barriers to vaccinations, cues to action and attitudes toward influenza vaccine (Table 4).
Discussion
The influenza vaccine uptake was observed in the study at a rate of (8.1%). In fact, in Jordan, influenza vaccine is provided free of charge only for the elderly with underlying chronic diseases (for example, renal failure) and for healthcare workers in public health provision services. Furthermore, national health insurance does not cover the cost of the vaccine.
However, Jordan is one of the 14 countries in the Eastern Mediterranean and Western Pacific region that has adopted a national immunization policy or guidelines against seasonal influenza (National Program for Surveillance and Control of Influenza since 1980 as well as Pandemic Influenza Preparedness and Response Plan since 2009)15. It seems that there are no practical steps to improve the uptake rates of the vaccine among the Jordanian community in general and pregnant women in particular. Similar findings of low uptake rates have been reported in other studies conducted in developing countries, which could be explained by the lack of an effective national policy regarding influenza vaccination among pregnant women.
For instance, in a study conducted in Tunisia during the 2018–2019 influenza season, only (4.6%) of the surveyed pregnant women were vaccinated during their pregnancy(8). Likewise, in another study conducted in Saudi Arabia, only 19.8% of the surveyed pregnant women received the vaccine during their pregnancy(7). The lack of awareness of pregnant women regarding the importance of receiving vaccinated against influenza during pregnancy and the lack of physician recommendations of influenza vaccine are the main reasons for this low uptake.
The overall knowledge of pregnant women about influenza and its vaccine was intermediate (see Table 5). An intermediate level of knowledge of influenza and the vaccine could be explained by inadequate health education in health centers and maternity clinics, as well as the weak role of audio-visual media in spreading awareness about the importance of vaccination during pregnancy. Moreover, the study shows that women of university degree and high-education have statistically significant more disease and vaccine knowledge than school-educated women. Similar results were reported in an Italian study, in addition to other variables such as age and number of children7, 16, the study showed different results where the educational level was not significantly related to vaccine knowledge, but other variables such as employment status, monthly income, and the number of pregnancies were significantly related.
A
Table S1
|
Construct name
|
Items numbers
|
Reliability
|
Status
|
|
Perceived Susceptibility to Influenza Infection.
|
3
|
0.77
|
Reliable
|
|
Perceived Severity of Illness.
|
3
|
0.82
|
Reliable
|
|
Perceived Benefits of Vaccination.
|
4
|
0.79
|
Reliable
|
|
Perceived Barriers And Concerns About vaccination.
|
4
|
0.87
|
Reliable
|
|
Cause to action
|
3
|
0.79
|
Reliable
|
|
Attitude toward vaccination
|
3
|
0.83
|
Reliable
|
|
Other Barriers
|
3
|
0.76
|
Reliable
|
|
All measurements scale
|
25
|
0.82
|
Reliable
|
A
Table S2
Exploratory factor analysis of factors
|
Construct
|
Item
|
Item Description
|
Factor loading
|
Eigen value
|
Variance explained
|
|
Perceived Susceptibility
|
Susciptibility1
|
I get the flu more easily than other people my age.
|
.790
|
4.563
|
18.253
|
| |
Susciptibility2
|
Without the vaccination, I feel that I am vulnerable to a severe infection with the influenza. (Complications may occur)
|
.712
|
|
|
| |
Susciptibility3
|
I'm worried about the fetus being affected by the flu
|
.822
|
|
|
|
Perceived Severity
|
Severity1
|
If you get the flu during pregnancy, you may develop severe symptoms.
|
.769
|
3.163
|
12.654
|
| |
Severity2
|
If I catch the flu during pregnancy, I expose myself to serious complications.
|
.841
|
|
|
| |
Severity3
|
If you get the flu while pregnant, the disease may harm your unborn baby
|
.779
|
|
|
| |
benefits1
|
I wouldn't have to worry about getting the flu if I got the flu shot
|
.721
|
2.514
|
10.057
|
|
Perceived Benefits
|
benefits2
|
Taking the flu vaccine during pregnancy will help me.
|
.700
|
|
|
| |
benefits3
|
Taking the flu vaccine during pregnancy will benefit the fetus.
|
.789
|
|
|
| |
benefits4
|
The flu vaccine can protect the baby during the first months of life
|
.774
|
|
|
| |
Threat1
|
I am concerned about the side effects of the vaccine
|
.735
|
2.137
|
8.547
|
| |
Threat2
|
The influenza vaccine can give me the flu
|
.669
|
|
|
|
Perceived Threats
|
Threat3
|
I'm worried there might be something I don't know about the influenza vaccine
|
.745
|
|
|
| |
Threat4
|
My family, friends, or co-workers did not encourage me to get the vaccine
|
.764
|
|
|
|
Perceived Cues To Action
|
Cues_To_Action1
|
My doctor/nurse/pharmacist's recommendation is important for making the right decision about getting the vaccine
|
.616
|
1.750
|
7.000
|
| |
Cues_To_Action2
|
I trust the guidelines that recommend that all pregnant women get their annual influenza vaccine
|
.695
|
|
|
| |
Cues_To_Action3
|
I feel like I've had all the information I need to decide if I should get the influenza vaccine
|
.714
|
|
|
|
Attitude towards vaccination
|
Attitude1
|
I am against taking the flu vaccine during pregnancy.
|
.827
|
5.633
|
4.880
|
| |
Attitude 2
|
I don't mind taking influenza vaccine during pregnancies
|
.787
|
|
|
| |
Attitude 3
|
I recommend other women to take influenza vaccine.
|
.828
|
|
|
| |
Accumulative variance
|
|
|
|
67.023
|
Table 5
Knowledge Items Scale Analysis. Total responce N( 382)
|
Items
|
Correct
n (%)
|
Wrong
n (%)
|
|
1. Influenza is a …………. disease (Highly contagious)
|
143 (37%)
|
239 (63%)
|
|
2. Influenza may lead to (All of the above)
|
235 (61.5%)
|
147 (38.5%)
|
|
3. Risk of complications from influenza in pregnant women
(Greater than non-pregnant women)
|
203 (53.1%)
|
179 (46.9%)
|
|
4. Immunity during pregnancy ……. (Decreases)
|
235 (61.5%)
|
147 (38.5%)
|
|
5. Influenza vaccination during pregnancy
(Helps protect pregnant women from influenza)
|
204 (53.4%)
|
178 (46.6%)
|
|
6. Vaccination of pregnant women against influenza
(Helps protect the fetus and child after birth)
|
62 (16.2(%
|
320 (83.8%)
|
|
7. The influenza vaccine is given in (Winter season)
|
184 (48.2%)
|
198 (51.8%)
|
|
8. The best way to protect against influenza is.
(Taking the vaccine with adequate precautions)
|
223 (58.4%)
|
159 (41.6%)
|
|
9. Give the influenza vaccine during pregnancy.
(The vaccine should be given to all pregnant women)
|
152 (39.8%)
|
230 (60.2%)
|
|
10. Influenza vaccination during pregnancy
(Safe during pregnancy)
|
122 (31.9%)
|
260 (68.1%)
|
|
Knowledge categories n (%)
|
197 (51.6%)
|
185 (48.4%)
|
| (correct answer) |
HBM Predictors of Seasonal Influenza Vaccination During Pregnancy
Results of the multivariable analysis of the HBM items reveal that the significant predictors that are positively associated with influenza vaccine uptake during current pregnancy are their perception of influenza severity, perception of vaccination benefits and cues to act. In parallel, the perception of threats is negatively associated with women's vaccine uptake during pregnancy; pregnant women who feel that their influenza infection during pregnancy could lead to serious complications for their health and the health of the fetus are more likely to receive the influenza vaccine than those who didn’t feel that threat. Based on a similar study, all domains of HBM were found to have significant correlations with the vaccine uptake rates including the perception of disease severity, perception of susceptibility and perception of perceived benefits where they positively correlated with vaccine uptake, in contrast with perceived threats where they negatively correlated with vaccine uptake(12). Studies have shown that women’s awareness of threats predicts the acceptance and uptake of vaccinations (17), (18).
Regarding the aspect of perceived benefits, similar results were encountered in other studies; pregnant women who believed the vaccine would protect them, their fetuses and newborn babies from influenza complications had higher levels of acceptance than other pregnant women
17, 18. Pregnant women who believe that making the right decision about getting the vaccine depends on an HCPs recommendation are also more likely to accept the vaccine than other pregnant women. Similarly finding, in a Chinese study
(13).
A
Trusting guidelines that recommend that all pregnant women receive the annual influenza vaccine makes them more likely to accept the vaccine than other pregnant women. This finding is constant with
12, 17.
In addition to HBM barriers, the study identified several barriers that hindered pregnant women from receiving the vaccine; such as concern about mother and baby safety and belief that the vaccine is not effective. These results are consistent with a study conducted in Amman, the capital of Jordan, to understand factors affecting influenza vaccine uptake among Jordan's population, including 1107 adults 19.
Concerning barriers predictors, women in urban areas, having three or more para and having hospitalization experience due to influenza complications -whether during pregnancy or outside pregnancy-, are less likely to perceive barriers to vaccination and don’t believe that the flu vaccine can be dangerous for pregnant women or belief that the influenza vaccine can be dangerous to the fetus (Table 6).
Study Limitations.
This study has a few limitations. Firstly, it was conducted between June and September, which is after the flu season, limiting the number of participants. Secondly, it coincided with the coronavirus pandemic, requiring the research team to clarify the differences between the coronavirus and influenza vaccines. Thirdly, there is no documented information in the health records to verify the data obtained during the interviews.
Conclusion
A
Influenza vaccine should be provided as part of the protocol for management of pregnant women with monitoring of the uptake rate. The investigation revealed a significant relationship between HCPs recommendation and vaccine uptake. The low rate of influenza vaccine uptake among pregnant women in Al-Karak governorate supports the need to establish health education programs to improve awareness and knowledge about seasonal influenza and the efficacy and safety of vaccines among this population. Vaccination program strategies should primarily target prenatal health care providers because their opinion can significantly influence a woman’s vaccination decision.
A
Author Contribution
All authors contributed to the study design, supervision, data collection, data analysis, and the writing and revision of the final manuscript, and all authors take full responsibility for the content of this work
A
Data Availability
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
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