Socio-Demographic and Economic Factors Associated with Uptake of COVID-19 Vaccine among Pregnant Women at Pumwani Maternity Hospital in Nairobi County, Kenya ()
1. Introduction
The Coronavirus Disease 2019 (COVID-19) is caused by novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This pandemic disease had a major impact on humans in terms of life loss, loss of economic benefits, and increased poverty [1] . Although vaccines were introduced to fight against the pandemic, acceptance has been a challenge [2] . The vaccination coverage at the global level has been estimated at 60.04% and 5.9% for fully and partially vaccinated populations respectively. In contrast, the African region had covered 17 % and 5.3% fully and partially vaccinated (ourworldindata.org).
In Kenya, there have been growing efforts to increase the uptake of COVID-19 even among pregnant women. The vaccination coverage for the country was 31% for those that are fully vaccinated and 9.2% being partially vaccinated, while in Nairobi County as of the end of May 2022, it was 48.9% for fully vaccinated [3] . Pregnant women are at high risk for severe illness and death from COVID-19 unlike non-pregnant ones [4] and also are at a higher risk of delivering a premature baby [5] . In mid-August 2021, the Kenya Obstetrical and Gynecological Society (KOGS) recommended access to the vaccines for pregnant and breastfeeding women noting that there is no evidence of adverse maternal or fetal effects from vaccinating pregnant women [6] . Pregnant women are at an expanded chance of risk of severe illness and passing on from COVID-19 unlike non-pregnant as the rates of admission to intensive care are three times greater in pregnant women compared to non-pregnant women, with a 25% greater likelihood of death [7] . In addition, women who contract COVID-19 during pregnancy have a higher risk of pre-eclampsia, preterm birth, stillbirth, and early neonatal death [8] . Despite Nairobi County having the highest prevalence of COVID-19 and a continuous supply of vaccines, vaccination coverage remains very low at 48%. Therefore, this study aimed to determine the level of uptake and socio-demographic and economic factors associated with the uptake of the COVID-19 vaccine among pregnant women utilizing antenatal care services at Pumwani Maternity Hospital in Nairobi County, Kenya.
2. Materials and Methods
2.1. Study Site
This study was carried out in Pumwani Maternity Hospital (PMH) which is located in Kamukunji Sub-county in Nairobi County, Kenya. PMH was purposely selected since it is a reference maternity hospital in the East African region, and the largest referral maternity hospital specializing in Obstetrics. This county covers an area of 703.9 Km2 and a target population of 4,397 people [9] .
2.2. Type and Period of Study
This was a facility-based cross-sectional study that was conducted from 15 June to 23 July 2023 and employed mixed methods approaches.
2.3. Study Population
The study population was pregnant women who were utilizing antenatal care services at PMH in Nairobi County.
2.3.1. Inclusion Criteria
Pregnant women written informed consent to participate in the study.
2.3.2. Exclusion Criteria
Pregnant women who were severely sick and those who had hearing difficulties or were mentally challenged were excluded.
2.4. Sample Size
The sample size for the study was determined using the Cochran, [10] Formula, 95% confidence, 5% margin of error, and 48.9% prevalence of COVID-19 vaccine uptake in the general population in Nairobi County as of May 2022. Since the average monthly ANC attendance at PMH was 900, the finite population correction factor was used to adjust the sample.
The Adjusted sample size is estimated in the following equation
Adjusted sample size:
Minimum sample size = 270
2.5. Study Variables
The independent variables studied included individual characteristics (age, marital status, educational level, occupation, personal income risk perception, fear of injection & and side effects, trust & and confidence, concern about baby & and future pregnancy) and facility-level characteristics (availability of vaccination section, vaccine stock out, long queues at the vaccination site, vaccinator is not available and long distance to the facility). Knowledge and attitudes toward the COVID-19 vaccine were also studied. The dependent variable was COVID-19 vaccine uptake among pregnant utilizing antenatal care services.
2.6. Data Collection Tools, Training of Research Assistants and Pre-Testing of the Questionnaire
Quantitative data was collected using a semi-structured interviewer-administered questionnaire using the Kobo Toolbox application and a Key Informant Interview (KII) guide. Five students pursuing health-related courses were involved as research assistants after being trained on data collection by the researcher for two days. The questionnaire was pretested at Mama Lucy Kibaki Hospital in Nairobi County to evaluate the clarity of the questions. The questions that were not clearly understood during the pretest were revised before collecting data for the study.
2.7. Selection of Study Participants and Data Collection
Systematic random sampling was used to select study participants from among pregnant women utilizing antenatal care services at PMH. The sampling interval “Kth” pregnant woman to be selected was computed each day before administering the questionnaire depending on the number of women who were present at the MCH clinic on the day of data collection. Ten to fifteen questionnaires were administered each day. Quantitative data were collected using face-to-face interviews which were conducted in a designated room at the MCH clinic to ensure privacy and confidentiality. Data was collected on the participants’ socio-demographic and cultural characteristics, knowledge, and attitudes toward the COVID-19 vaccine. The filled questionnaires were sent directly to the Kobo Toolbox server and checked daily by the researcher. Qualitative data was collected by conducting four KIIs with the MCH in charge, vaccinators, and midwives.
2.8. Data Management and Analysis
Data was downloaded from the Kobo toolbox server into an Excel sheet for cleaning and then exported to SPSS for analysis. The bi-variable Chi-square test and multivariable logistic regression models were applied to identify factors associated with the uptake COVID-19 vaccine among pregnant women utilizing antenatal care services. The difference was considered to be significant at p < 0.05. Thematic analysis was used to analyze the qualitative data.
2.9. Ethical Considerations
Ethical clearance was obtained from the Jomo Kenyatta University of Agriculture and Technology, Institutional Scientific and Ethics Review Committee and a research permit from the National Commission for Science and Innovation (NACOSTI). Administrative approval was obtained from the County Director of Health, Nairobi County, and the Medical Superintendent of PMH and Mama Lucy Kibaki Hospital. Written Informed consent was obtained from all the study participants after explaining to them the nature of the study. Confidentiality and privacy of the responses were ensured throughout the process. Participants who had not been vaccinated were referred to the vaccination center to receive the COVID-19 vaccine.
3. Results
3.1. Socio-Demographic and Socio-Economic Characteristics of Respondents
A total of 302 pregnant women participated in the study. Of these, 105 (34.8%) were aged between twenty-six (26) and thirty (30) years. The mean age was 28.60 ± (SD = 5.297). The majority 212 (70.2%) of the respondents were married and more than fifty percent 161 (53.3%) had attained the secondary level of education. About eighty-two percent 246 (81.5%) of the respondents were Christians. Most 122 (40.4%) of the respondents were housewives and five fifty-five percent 166 (55.0%) had no monthly income (Table 1).
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Table 1. Socio-demographic and socio-economic characteristics of respondents.
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Figure 1. Stage of gestation of the respondents.
3.2. Stage of Gestation of the Respondents
Most 146 (48.3%) of the respondents were in the second trimester of the pregnancy (Figure 2) followed by 93 (30.8%) in the third trimester. Followed by 63 (20.9%) having their first trimester (Figure 1).
3.3. Uptake of COVID-19 Vaccine and Reported Side Effects
The uptake of the COVID-19 vaccine was 41.1% (124/302). Of these, 75 (60.5%) had received two doses of the COVID-19 vaccine. Moreover, 14 (11.3%) received more than two doses. Forty-nine 49 (39.5%) of the respondents were vaccinated with Johnson & Johnson, 27 (21.8%) with AstraZeneca, 16 (12.9%) and 11 (8.9%) were vaccinated with Pfizer and Moderna, respectively, while a small group of 11 (8.87%), 3 (2.42%), 3 (2.42%), 3 (2.43%), 3 (2.42%), 5 (4.03%), 2 (1.61%), 1 (0.81%) and 1 (0.81%) of the pregnant women were vaccinated with moderna, AstraZeneca + moderna, Johnson & Johnson + Pfizer, moderna + Pfizer, Pfizer + moderna, Pfizer + Johnson & Johnson, Johnson & Johnson + moderna, Moderna + AstraZeneca, and Pfizer + AstraZeneca, respectively. Majority 101 (81.5%) of the respondents were vaccinated from public health facilities. Three quarters 94 (75.8%) of the vaccinated study participants reported having experienced side effects after vaccination, which included headache, joint pain, abscess at the injection site, vomiting and skin rash (Table 2).
3.4. Individual-Level Factors Associated with the Uptake of the COVID-19 Vaccine among Pregnant Women at Pumwani Maternity Hospital in Nairobi County, Kenya
At bivariate analysis, uptake of the COVID-19 vaccine was significantly associated with marriage (p ˂ 0.001), level of education (p < 0.001), average monthly income and religious affiliation (p < 0.001). There was no significant association with the other variable investigated in this study (Table 3).
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Table 2. Uptake of COVID-19 vaccine and reported side effects among the respondents.
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Table 3. Individual-level factors associated with the vaccine uptake.
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Table 4. Multi-variable logistic regression analysis.
3.5. Individual Factors Independently Associated with the Uptake of COVID-19 Vaccine among Pregnant Women at Pumwani Maternity Hospital in Nairobi County, Kenya
Married pregnant women were 3.65 times more likely to take up COVID-19 vaccine than unmarried (AOR = 3.65, 95% CI: 0.62 - 1.80, p = 0.001). Also, pregnant women who had a secondary education level had 3.78 times the likelihood of taking the COVID-19 vaccine than those without formal education (AOR = 3.78, 95% CI: 0.99 - 2.88, p = 0.001). Furthermore, pregnant women who had Jobs or were employed were more likely to take up the COVID-19 vaccine than those not employed (COR = 2.66, 95% CI: 1.31 - 3.06, p = 0.001) (Table 4).
The factors reported by all the Key Informants to be contributing to low uptake of COVID-19 vaccine were lack of knowledge about the COVID 19 vaccine, fear of injection, traditional and cultural beliefs and chronic illnesses within the population (Figure 2).
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Figure 2. Factors reported by KIs to influence the uptake of the COVID-19 vaccine.
4. Discussion
This study estimated the COVID-19 vaccine uptake among pregnant women as 41.1% of whom 60.5% had received two doses. Despite the well-defined maternal and neonatal COVID-19 risks and the vaccine’s proven benefits, the vaccine uptake among pregnant women was lower than among the Nairobi County population, which was 48% as of 2022. The fact that 48.3% of the respondents in the current study were in the second trimester of the pregnancy agrees with studies done in Wales [11] [12] and Saudi Arabia [13] which showed that pregnant women at later gestation are more likely to accept the vaccine. The most common side effects of COVID-19 vaccines experienced by respondents in our study which were headache, generalized pain and joint pain were similar to those reported by other researchers [14] [15] , and [16] . The findings contrast those reported by [17] and [18] who found the most common side effects for Pfizer, AstraZeneca and Sinopharm COVID-19 vaccines to be local effects, including pain, redness, and swelling at the injection site.
Uptake of the COVID-19 vaccine was significantly associated with marriage (p ˂ 0.001), level of education (p < 0.001), average monthly income and religious affiliation (p < 0.001). Those who were married were 3.65 times more likely to take up COVID-19 vaccine than the unmarried. Pregnant women who had a secondary education level had 3.78 times likelihood of taking the COVID-19 vaccine than those without formal education. Pregnant women who had a secondary education level had 3.78 times likelihood of taking the COVID-19 vaccine than those without formal education. The findings agree with reports from studies conducted in Ireland, Norway, Switzerland, the Netherland and United Kingdom which found that participants who were not married and those who low level of education (no formal education and primary education) were less likely to receive COVID-19 vaccine because of less income to cover the treatment of the side effects associated with the vaccinated [19] . Uptake of COVID-19 vaccine was found to be associated with higher levels of education in studies by [7] [20] [21] .
Our study showed that having a job was significantly (p = 0.001) associated with uptake of the COVID-19 vaccine. This finding is in line with results from studies on socioeconomic disparities and COVID-19, socio-economic gradients in COVID-19, association of race, ethnicity, other demographic, and socio-economic factors with vaccine conducted in Norway and United States [21] - [24] .
From the qualitative findings, the factors reported to contribute to low uptake of COVID-19 vaccine were lack of knowledge about the COVID-19 vaccine, fear of injection, traditional and cultural beliefs and chronic illnesses within the population. These results agree with findings by [25] [26] , and [27] who reported that level of knowledge about COVID-19, fear of needles or injection, as well as susceptibility to COVID-19 infection decreased the likelihood of accepting COVID-19 infection.
5. Conclusions
The study concluded that the uptake of the COVID-19 vaccine among pregnant women utilizing antenatal care services at Pumwani Maternity Hospital in Nairobi County was low compared to Kenya’s national COVID-19 vaccination target by the end of 2022. The socio-demographic and economic factors associated with the uptake of the COVID-19 vaccine among pregnant women in antenatal care services at Pumwani Maternity Hospital in Nairobi County were being married, having secondary level of education, or being employed.
Acknowledgements
The authors would like to thank the Second European and Developing Countries Clinical Trials Partnership (EDCTP2) Supported by the European Union (EU) for funding this research.
Authors’ contribution
All authors participated in the study’s design and the paper’s writing.
Limitations of the study
This study was conducted on participants attending ANC clinic at a referral hospital which limits generalizability of the findings. Therefore, community-based studies are needed to give a general picture of COVID-19 vaccine uptake among pregnant women in Nairobi county.
Appendix 1
Participant Questionnaire
Socio-demographic and Economic Factors Associated with Uptake of COVID-19 Vaccine Among Pregnant Women at Pumwani Maternity Hospital in Nairobi County, Kenya.
JOMO KENYATTA UNIVERSITY OF AGRICULTURE AND TECHNOLOGY
COLLEGE OF HEALTH SCIENCES
SCHOOL OF PUBLIC HEALTH (SoPH)
PO BOX 62000-00200 NAIROBI TEL. (067) 52711 EXT 2226.
The information obtained will be treated confidentially and it will be used anonymously.
Section 1: Sociodemographic Characteristics
1. Date: ______________
2. Hospital: ___________________
3. Age: _____
4. Marital status:
a. Married b. Not Married c. Divorce d. Cohabiting
5. Residential area __________________________
6. Highest Level of Education
a. No formal education b. Primary education
c. Secondary education d. Tertiary Education
7. Employment status
a. Employed b. Not employed c. Housewife
d. Other specify: ___________
8. Average monthly income
a. 10,000 – 50,000 ksh b. 60,000 – 100,000 ksh c. above 100,000 ksh
9. Religious Affiliation__________________________
10. Gestation:
a. First Trimester b. Second Trimester c. Third Trimester
Section 2: individual knowledge and attitude toward uptake of COVID-19 vaccine:
11. Have you heard about the COVID-19 vaccine?
a. Yes b. No
12. Do you think COVID-19 is safe for pregnant women?
a. Yes b. No
13. Do you think the COVID-19 vaccine is very important for pregnant women?
a. Yes b. No
14. From which Sources of information did you hear about the COVID-19 vaccine
a. Midwife
b. Health-related website (National Health Services)
c. TV
d. Radio
e. Newspaper
f. Friends and family
g. Social media e.g. (Facebook, Instagram, YouTube, WhatsApp).
h. Other specify_______________________
15. Which COVID-19 vaccine information source did you trust
a. Midwife
b. Health-related website (National Health Services)
c. TV
d. Radio
e. Newspaper
f. Friends and family
g. Social media (e.g., Facebook, Instagram, YouTube, WhatsApp)
h. Other specify____________________________
Section 2: uptake of COVID-19 vaccine:
16. Have you been vaccinated against COVID-19?
a. Yes b. No
17. If yes is Q11, when was vaccination date: _____________________
Unknown
18. If Q11 is Yes. The number of doses of the COVID-19 vaccine you received?
a. One dose b. Two doses c. More than two doses or a boost dose
19. If the answer is Yes in Q11 which type of COVID-19 vaccine, did you receive?
a. AstraZeneca b. Pfizer c. Moderna d. Johnson & Johnson
20. Where did you receive it?
a. Public facility b. Private facility c. Others specify: __________
21. Did you experience any side effects after vaccination:
a. Yes b. No
22. If the answer is yes in Q 16 what were the side effects:
a. Fever b. headache c. joint pain d. general body pain
23. If the answer is No in Q11 what is the reason for not being vaccinated?
a. Concern about baby/future pregnancies
b. Lack of data on vaccine
c. Concerns about breastfeeding
d. The midwife/doctor did not offer vaccines.
e. Planning to receive it later.
f. Vaccine stock out
g. Fearing of injection
h. Long queues at vaccination sites
i. Vaccinators are not available.
j. Other specify ________________________
24. How long does it take you to reach a health facility to get a vaccination:
a. Less the 30 minutes b. One hour
c. One hour and a half d. More the two hours
25. What means of transport do you use?
a. Matatu b. Boda boda
c. Foot d. other specify_________
Appendix 2
Key Informant Interview Guide
Socio-demographic and Economic Factors Associated with Uptake of COVID-19 Vaccine Among Pregnant Women at Pumwani Maternity Hospital in Nairobi County, Kenya
JOMO KENYATTA UNIVERSITY OF AGRICULTURE AND TECHNOLOGY
COLLEGE OF HEALTH SCIENCES
SCHOOL OF PUBLIC HEALTH (SoPH)
PO BOX 62000-00200 NAIROBI TEL. (067) 52711 EXT 2226.
The information obtained will be treated confidentially and it will be used anonymously.
Health facility key informant interview.
Staff interviewed Cadre/Qualification ………………………….
Position ………………. Years in the position ………………….
1. Explain whether this health facility provides COVID-19 vaccination services.
2. State the types of COVID-19 vaccines you are offering to your clients.
3. Describe some of the challenges you face during offering COVID-19
4. Can you tell us the population catchment area for this facility?
5. Does the facility have a defaulter’s tracking system, for the second dose vaccines, and what are mechanisms put in place to address this problem
6. What do think are factors that influence vaccine uptake among pregnant women?
(a) individuals (b) level facility-level factors
7. What should be done to improve COVID-19 vaccine uptake in pregnancy?