Acceptability and Uptake of COVID-19 Vaccines among Pregnant and Lactating Women seeking services at a Tertiary Public Hospital in Kampala, Uganda

doi:10.21203/rs.3.rs-4844708/v1

Background

Globally, several vaccines, including COVID-19 vaccines, have been routinely recommended during pregnancy and lactation. However, data on COVID-19 vaccine acceptability and uptake among pregnant and lactating women are limited in Sub-Saharan Africa. While COVID-19 is no longer a public health emergency it is important to take stock of lessons learnt to prepare for future health threats including those that disproportionately affect pregnant/lactating women. We aimed to assess acceptability and uptake of COVID-19 vaccines among pregnant and lactating women in Uganda.

Methods

This was a cross-sectional study conducted among 424 pregnant and lactating women, who were seeking maternal and child health care at Kawempe National Referral Hospital in Kampala. We obtained data on vaccine acceptability defined as willingness to accept vaccines using interviewer-administered questionnaires. In addition, we assessed vaccination status. Factors associated with COVID-19 vaccine acceptability and uptake were evaluated using modified Poisson regression.

Results

The mean age of the respondents was 26.9 years (SD = 5.7), ranging from 14–45 years. Among 424 respondents, 51.7% had received at least one dose of COVID-19 vaccine, 94.1% had received tetanus toxoid vaccine, and 48.3% regardless of their vaccination status, were willing to receive COVID-19 vaccines. Only 5/212(2.4%) had received COVID-19 vaccines while lactating with none having been received during pregnancy. Factors associated with COVID-19 vaccine uptake included history of testing for COVID-19 (aPR = 1.92, CI:1.46–2.54) and having a vaccinated household member (aPR = 1.34, CI:1.03–1.84). COVID-19 vaccine willingness was significantly associated with being a household head (aPR = 2.2, CI:1.12–4.27) and having a vaccinated household member (aPR = 1.33, CI:1.04–1.76).

Conclusion

The uptake and willingness to receive COVID-19 vaccines among pregnant and lactating women were generally low, with no participants receiving COVID-19 vaccines during pregnancy and very few during lactation. In contrast, the majority had received tetanus toxoid vaccines, indicating a disparity in vaccine acceptance. Factors such as undergoing COVID-19 testing and having a vaccinated household member positively influenced COVID-19 vaccine uptake and willingness. These findings highlight the need for targeted interventions to improve the acceptance and uptake of COVID-19 vaccines, during pregnancy and lactation.

Pregnant women

Lactating women

Vaccination

Vaccine acceptability

Vaccine uptake

COVID-19 vaccines

Vulnerable population

Tertiary public hospital

Pregnant and lactating women represent a population with unique healthcare needs, particularly concerning the prevention of infectious diseases through vaccination. Vaccination during pregnancy has the potential to confer protection not only to the pregnant woman herself but also to her newborn child, offering a crucial opportunity to safeguard maternal and infant health thus reducing infectious disease-related morbidity and mortality in pregnant women and their infants(1).

Certain vaccines are safe and recommended for women before, during, and after pregnancy to help keep them and their babies healthy (2). The World Health Organization (WHO) recommends maternal vaccination against tetanus toxoid, pertussis, and influenza, as well as other vaccines including Coronavirus disease 2019 (COVID-19) and pneumococcus(2). However, despite the established benefits of COVID-19 vaccination in this population, uptake and acceptability of COVID-19 vaccines among pregnant and lactating women remain variable across different settings.

Studies have shown that pregnant women with COVID-19 are at a higher risk of developing severe disease and are more likely to suffer adverse outcomes including mortality, preterm births, and preeclampsia when compared with other women of reproductive age(3, 4). At the start of the COVID-19 pandemic in 2020, most deaths were among older persons and those with co-morbidities, but in 2021, the global increase in COVID-19 deaths among pregnant women became a concern(4).

Based on phase III clinical trials, several vaccines including Pfizer-BioNTech, Moderna and Oxford-AstraZeneca, were proved to be highly efficacious in preventing symptomatic COVID-19 infection in the general population excluding pregnant or lactating women during 2020–2021(5). Safety was a main concern for not including pregnant and lactating women in the COVID-19 clinical trials during 2020–2021. By mid-2022, all pregnant women after their first trimester and those who are breastfeeding were eligible for COVID-19 vaccination, as accumulating real-world evidence by April 2021 demonstrated no increased risk of adverse maternal and neonatal outcomes, leading to clear recommendations for vaccination during pregnancy as the risk-benefit ratio changed with more information(6, 7).

In Uganda, there is a lack of comprehensive data and studies on the uptake and acceptability of COVID-19 vaccines among pregnant and lactating women. To address these knowledge gaps, we conducted a study to assess the acceptability and uptake of COVID-19 vaccines among pregnant and lactating women visiting a tertiary public hospital in Kampala between May and July 2023.

Understanding uptake and acceptability to be vaccinated against COVID-19 among pregnant and lactating women will establish what proportion could intentionally not receive the vaccine; this is a potential threat to increased poor disease outcomes. We also compared uptake between COVID-19 vaccine and other routine vaccines to explore potential disease-specific differences in uptake. By exploring factors influencing vaccine decision-making and identifying barriers to COVID-19 vaccination uptake, our study aims to inform targeted interventions and strategies to improve COVID-19 vaccination coverage among this population. This information will also provide insights into plans for future pandemics especially in planning for those that disproportionately result in poor outcomes for pregnant women.

Study design and setting

We conducted a cross-sectional study among pregnant and lactating women visiting Kawempe national referral hospital (KNRH), specialized in provision of maternal and neonatal care services as well as serving as a teaching hospital for Makerere University College of Health Sciences in Kampala, Uganda. It has a 170-bed capacity and offers services to all patients referred from all regions of the country. with an average of 57 births daily(8).

We enrolled 212 pregnant and 212 lactating women through a systematic sampling approach. Pregnant women were enrolled at the antenatal unit and lactating women from the postnatal unit.

Data collection procedure and study questionnaire

The data was collected using a structured questionnaire based on survey questions designed to assess determinants of vaccine hesitancy by the SAGE Working group on vaccine hesitancy(9). These questions were adapted to suit the setting (Ugandan population), respondents (pregnant and lactating women), the disease (COVID-19) and the study objectives. Data was collected electronically using Kobo Toolbox software. Trained research assistants obtained clinical data from the patient’s files and hospital registers from participants who gave informed consent. Participants were then interviewed to obtain information on demographics and other determinants of vaccine hesitancy. Data collection tools were pretested before deployment in 10 participants.

Study variables

Socio-demographic characteristics included age, sex, education, tribe, religion, marital status, employment, residence, occupation, biological children, household head, household size, health insurance and income.

Clinical factors included pregnancy and lactation related such as gravidity, parity, chronic illness related including type and duration, duration of lactation or pregnancy (weeks of amenorrhea), twin or multiple pregnancy and number of pregnancies since 2020.

COVID-19 disease-related factors included history of testing, confirmed positive test, disease severity, hospitalization, and history of COVID-19 cases or deaths in the household. For COVID-19 vaccination status, the participants were asked about the doses, type of vaccine and when they received the vaccine.

Participants were asked about their willingness to receive the COVID-19 vaccine or additional doses for those who had been vaccinated and if any of their household members were vaccinated against COVID-19. They were also asked about previous uptake since 2020 and their willingness to receive other vaccines, including Tetanus Toxoid (TT) vaccines, which are specifically re-offered during pregnancy in Uganda. Regardless of childhood vaccination status, all women aged 15–49 in Uganda are offered a schedule of five separate tetanus vaccine doses, starting at age 15, with two doses given per pregnancy(10).

Health system factors included distance from the home to health facility, health education program on vaccination and receiving any information on COVID-19 vaccination from health facilities. Other determinants based on SAGE questionnaire included contextual influences (arising due to historic, socio-cultural, environmental, health system/institutional, economic or political factors), individual and group influences (arising from personal perception of the vaccine or influences of the social/peer environment), and vaccine/vaccination (specific issues directly related to vaccine or vaccination). The SAGE questionnaire is a structured questionnaire based on survey questions designed to assess determinants of vaccine hesitancy by the SAGE Working group on vaccine hesitancy.

Two outcome variables were considered. 1) level of uptake of COVID-19 vaccine (received at least one dose), and 2) acceptability/willingness to receive the COVID-19 vaccine. All the two outcome variables were considered on a binary scale.

Statistical analysis

All study variables were summarized in forms of frequencies and percentages for categorical variables and means or medians for the continuous variables. The open-ended questions (in free text format) were analysed with a content analysis approach. Modified Poisson regression analysis was used to determine the factors associated with i) the level of uptake of the COVID-19 vaccine, and ii) willingness to receive the COVID-19 vaccine. The Prevalence Ratio (PR) was used as the measure of association and p values of less than 0.05 for statistical significance. Bivariate and multivariate analyses were performed. Only independent factors with p values less than 0.2 were considered for the multivariate analyses. The final adjusted models were checked for goodness of fit. STATA 15 was used for all the analyses.

Socio-demographic characteristics of the study participants

Among 424 study participants (212-pregnant and 212-lactating mothers), with mean age of 26.9, ranging from 14–45 years, 383 (90.6%) were married/cohabiting, 246 (58%) had achieved secondary level education, 41(9.7%) were heads of their households, 355 (83.7%) had 1–5 live occupants in their households, and 142 (33.5%) had a job, business or were working somewhere. Other participant characteristics are summarized in Table 1.

Table 1

Socio-demographic characteristics of the study participants
Variable/Question	Frequency (n = 424)	Percentage
Age categories (years)
≤ 26	218	51.4
> 26	206	48.6
District of residence
Kampala	179	42.2
Wakiso	220	51.9
Mukono	7	1.6
Others (Kayunga, Kiboga, Luwero, Masaka, Mityana, Mpigi, and Nakasongola)	18	4.2
Distance from home to the nearest public health facility that offers COVID-19 vaccination
≤ 5km	185	43.6
> 5km	239	56.4
Tribe
Acholi	6	1.4
Alur	4	0.9
Baganda	246	58.0
Bagisu	8	1.9
Bakiga	9	2.1
Banyankore	66	15.6
Banyole	4	0.9
Banyoro	9	2.1
Basoga	25	5.9
Batoro	6	1.4
Lango	2	0.5
Lugbara	2	0.5
Others (Bafumbira, Bakonjo, Bamba, Banyarwanda, Banubi, Basamia, Banyoro, Congolose, Japhadola, Kakwa, Sudanese)	37	8.7
Marital status
Married/cohabiting	383	90.3
Separated/widowed/divorced	7	1.6
Single/never married	34	8.0
Highest Education level achieved
None	5	1.2
Primary	110	25.9
Secondary	246	58.0
Tertiary/vocational	34	8.0
University	29	6.8
Religion
Adventist	10	2.4
Anglican	68	16.0
born-again	95	22.4
Catholic	154	36.3
Muslim	96	22.6
Faith of Unity	1	0.2
House hold head
No	383	90.3
Yes	41	9.7
Number of biological children (Alive only)
0	64	15.1
1–2	220	51.9
3–5	124	29.3
≥ 6	16	3.8
House hold size (number of live in occupants)
1–5	355	83.7
≥ 6	69	16.3
Employment status of respondent (Has a job or business or works somewhere)
No	282	66.5
Yes	142	33.5
Type/nature of occupation, n = 142
Business owner	35	24.6
Teacher	17	12.0
Health worker (nurse, midwife)	4	2.8
Vendor	8	5.6
Tailor	8	5.6
Business operator/attendant	45	31.7
Casual labour	1	0.7
Farming	1	0.7
Chef	2	1.4
Cleaners/house keepers	2	1.4
Waitress	6	4.2
Security	2	1.4
Secretary/administration	2	1.4
Accounts/Finance	5	3.5
Sales agent	4	2.8
Monthly income in USD, n = 112
> 50	56	50.0
≤ 50	56	50.0
Heard about health insurance
No	323	76.2
Yes	101	23.8
Had any health insurance since 2020, n = 101
No	97	96.0
Yes	4	4.0
If yes, details of insurance plan, n = 4
Group	0	0
Individual	3	75.0
Work	1	25.0

Clinical factors (pregnancy or lactation related) and COVID-19 disease related factors among study participants

Among 212 pregnant women, 101(47.6%) had a history of 1–2 pregnancies regardless of the outcomes, and 128 (60.4%) were 7–9 months pregnant. Among 212 lactating women, 185(87.3%) were at < 2 months of post child delivery. Among all 424 study respondents, 34 (8.0%) had a chronic illness; of these 10 (29.4%) had gestational hypertension, 7 (20.6%) Asthma, and 5 (14.7%) HIV/AIDS.

Only 130(30.7%) participants had ever tested for COVID-19. 10/130 (7.7%) had a confirmed positive test. Of these, 4/10 (40.0%) had a history of hospitalisation with COVID-19. Only 21 (4.1%) reported having household members who had ever tested positive for COVID-19 and 5 (1.2%) reported having had household deaths due to COVID-19. 220(51.9%) reported having household members who had been vaccinated against COVID-19. Other clinical and COVID-19 disease related factors are summarized in Table 2.

Table 2

Clinical factors (pregnancy or lactation related) and COVID-19 disease related factors among study participants
Characteristic, n = 424	Frequency	Percentage
Gravidity, n = 212
1–2	101	47.6
3–4	80	37.7
5–6	25	11.8
≥ 7	6	2.8
Parity
0	56	13.2
1–3	298	70.3
4–5	53	12.5
≥ 6	17	4.0
How many pregnancies between January 2020 and now? including miscarriages
1	340	80.2
2	66	15.6
≥ 3	18	4.3
Duration of current pregnancy (months of amenorrhea), n = 212
1–3 months	6	2.8
4–6 months	78	36.8
7–9 months	128	60.4
Twin or multiple pregnancy, n = 212
No	202	95.3
Yes	10	4.7
Duration of current lactation (months post-delivery), n = 212
< 2 months	185	87.3
2–4 months	5	2.4
> 4–6 months	22	10.4
Chronic illness(es)
No	390	91.9
Yes	34	8.0
Type of chronic illness, n = 34
Chronic Hypertension	5	14.7
Chronic Diabetes Mellitus	1	2.9
HIV/AIDS	5	14.7
Asthma	7	20.6
Hepatitis B	2	5.9
Allergies	2	5.9
Gestational diabetes	2	5.9
Gestational hypertension	10	29.4
Year of chronic illness diagnosis, n = 34
2020–2023	8	44.1
2017–2019	8	23.5
2010–2016	4	11.8
< 2010	7	20.6
COVID-19 disease related
Ever tested for COVID-19
No	294	69.3
Yes	130	30.7
History of a confirmed Positive COVID-19 test, n = 130
No	120	92.3
Yes	10	7.7
History of hospitalisation with COVID-19, n = 10
Home based care	4	40.0
No	2	20.0
Yes	4	40.0
Disease severity (if had history of confirmed COVID-19, n = 10
Asymptomatic/mild	1	10.0
Moderate disease	8	80.0
Severe disease (Difficulty in Breathing)	1	10.0
Any household members tested positive for COVID-19
No	403	95.1
Yes	21	4.9
Any household deaths due to COVID-19 (Only people they lived with: Excluding non-resident friends, relatives and neighbours)
No	419	98.8
Yes	5	1.2
Any household members been vaccinated against COVID-19
Don’t know	78	18.4
No	126	29.7
Yes	220	51.9
How the vaccinated household members are related to respondent, n = 220
Husband/wife/spouse/partner	205	93.2
Children	8	3.6
Sister/brother	23	10.5
Parents	27	12.3
Other relatives including aunties, uncles, in-laws	4	1.8
Grand parents	1	0.5
Live in-house workers	2	0.9
Grand children	0	0

Level of uptake and COVID-19 vaccination acceptability among study participants

Among 424 study participants, 219 (51.6%) had received at least one dose of COVID-19 vaccine; of these, 77 (35.2%) had received only one dose, 122 (55.7%) two doses, and 20 (9.1%) had received boosters. Many of the vaccinated participants, 99/219 (45.2%) were not aware of the type of COVID-19 vaccine they had received while 54 (24.7%) had received AstraZeneca COVID-19 vaccine.

Most participants, 148/219 (67.6%) received their first dose of COVID-19 vaccine in 2021. Only 4/212(1.9%) had been vaccinated for COVID-19 while lactating and, none received COVID-19 vaccines when pregnant.

Among the 205 unvaccinated, 67 (32.7%) were willing to receive the COVID-19 vaccine. Only 43/77 (55.8%) of those who received one dose and 75/122 (61.5%) of those who received two doses expressed willingness to receive additional COVID-19 vaccines doses. All those who got boosters were willing to get additional doses. The most common reasons for unwillingness to receive COVID-19 vaccines included fear of side effects and safety concerns during pregnancy and lactation. Overall, the willingness to receive the COVID-19 vaccine among all participants, regardless of vaccination status, was 205 out of 424 (48.3%).

In the past three years, 399 (94.1%) participants reported having received Tetanus Toxoid vaccines. Nearly half of the participants 207 (48.8%) were not willing to have any other vaccines while pregnant or lactating. Other vaccination related factors are summarized in Table 3.

Table 3

Level of uptake and vaccination acceptability among study participants
Characteristic, n = 424	Frequency	Percentage (95% CI)
COVID-19 vaccination status (at least one dose)
Yes	219	51.6 (43.6–53.1)
No	205	48.4 (46.9–56.4)
	Frequency (Percentage)
COVID-19 vaccine doses received, n = 219
Booster dose	20	9.1
One dose	77	35.2
Two doses	122	55.7
COVID-19 vaccine received, n = 219	AstraZeneca 54 (24.7)	Johnson 33 (15.1)	Moderna 6 (2.7)	Pfizer 31 (14.2)	Don’t know 99 (45.2)	Sinovac 1 (0.5)
Dose1 only	17 (31.5)	27 (81.8)	-	8 (25.8)	29 (29.3)	-
Dose2 only	5 (9.3)	-	-	2 (6.5)	11 (11.1)	-
Booster only	-	1 (3.0)	-	-	-	-
Dose1 & dose2	29 (53.7)	3 (9.1)	5 (83.3)	17 (54.8)	46 (46.5)	1
Dose1 &dose2 &booster	3 (5.6)	2 (6.1)	1 (16.7)	4 (12.9)	9 (9.1)	-
	Vaccination year
Vaccination dose	2021	2022	2023
First dose, n = 219	148 (67.6)	67 (30.6)	4 (1.8)
Second dose, n = 142	88 (62.0)	52 (36.6)	2 (1.4)
Booster dose, n = 20	12 (60.0)	8 (40.0)	-
Willingness to receive COVID-19 vaccine
If received COVID-19 one dose, willingness to receive the second dose, n = 77
Not sure	16	20.8
Not willing	18	23.4
Willing	43	55.8
If not willing, reasons why, n = 18
COVID-19 ended	1	5.6
Got side effects/Fear of side effects	6	33.3
Due to my condition (pregnant/lactating)	3	16.7
Believes one dose is enough	2	11.1
Got single dose vaccine (Johnson&Johnson), does not think they need another dose	6	33.3
If received two COVID-19 doses, willingness to receive additional shots (boosters), n = 122
Not sure	19	15.6
Not willing	28	22.9
Willing	75	61.5
If not sure/not willing, reasons why, n = 28
COVID-19 ended	1	3.6
Fear of side effects	4	14.3
Due to my condition, still (pregnant/lactating)	5	17.9
Two doses are enough, I completed	11	39.3
Tired	2	7.1
Don’t know where to get it from	3	10.7
I never got COVID-19	2	7.1
If received booster doses, willingness to receive additional shots, n = 20
Not sure	0	0
Not willing	0	0
Willing	20	100
If has never received any doses, currently willing to receive the COVID-19 vaccine, n = 205
Not sure	49	23.9
Not willing	89	43.4
Willing	67	32.7
When they are willing to get the COVID-19 vaccine, n = 67
After birth	5	7.5
After lactation	19	28.4
Anytime including now	20	29.8
Not sure	22	32.8
If fully given information	1	1.5
How many Weeks after birth they are willing to get the COVID-19 vaccine, n = 5
2	4	80.0
3	1	20.0
How many Weeks after lactation they are willing to get the COVID-19 vaccine, n = 19
< 12	9	47.4
12–20	4	21.1
> 20	6	31.6
If no, why are you not willing to get the COVID-19 vaccine, n = 89
COVID-19 ended	15	16.9
Fear of side effects	19	21.3
Fear of injections	12	13.5
I never got COVID-19	5	5.6
Vaccine not safe/I am pregnant/lactating	21	23.6
Too many myths about the vaccines	13	14.6
Don’t have a national ID	4	4.5
Overall willingness to currently receive a COVID-19 vaccine regardless of COVID-19 vaccination status
	Frequency	Percentage (95% CI)
Not sure/Not willing	219	51.6 (46.8–56.4)
Willing	205	48.4 (43.6–53.1)
In 2020/2021, when we had many cases and deaths due to COVID-19 and implemented lockdowns and restrictions, were you willing to receive the vaccine then, n = 205 (never vaccinated with any dose COVID-19)
	Frequency	Percentage
Not sure	38	18.5
Not willing	102	49.8
Willing	65	31.7
Other vaccines
What other vaccines have you received since January 2020?
None	19	4.5
Tetanus toxoid	399	94.1
Rabies	3	0.7
Typhoid	6	1.4
Yellow fever	11	2.6
Hepatitis B	27	6.4
Regardless of COVID-19 vaccine willingness, what vaccines are they willing to receive currently (Now)
None	207	48.8
Tetanus toxoid	112	26.4
Rabies	13	3.1
Typhoid	25	5.9
Yellow fever	33	7.8
Meningitis	10	2.4
Hepatitis B	80	18.9

Contextual, Individual, Group and Vaccine-Specific Issues

Among 424 respondents, 99 (23.3%) had ever received some information from the health workers on COVID-19 vaccination among pregnant/lactating women, and 132 (31.1%) had ever attended health education programs or teachings on COVID-19 vaccination at the health facility. Most of the participants 360 (84.9%) reported ownership or regularly access to television, radio mobile phone (smart), internet or newspapers. 201 (47.4%) did not use social media platforms while 211 (49.8%) used WhatsApp, 164 (38.9%) Facebook, 88 (20.8%) Twitter, 55 (13.0%) Tik Tok, 41 (9.7%) YouTube and 24 (5.7%) used Snapchat. Among 223 participants who used social media, 149 (66.8%) obtained information related to COVID-19 vaccination from social media, and only 66 (29.6%) reported that they shared information related to COVID-19 vaccination on social media.

When asked about who they trust the most for information on COVID-19 vaccination, 380 (89.6%) trusted health workers including community health workers, 34 (8.0%) family, friends, relatives, and neighbours, 16 (3.8%) media such as radio, TV, and internet, 21 (4.9%) religious leaders and 6 (1.4%) leaders including politicians and local leaders. Few participants 108 (25.5%) reported they had believed some of the media reports on people dying following COVID-19 vaccination. Only 22 (5.2%) knew someone who hadn’t taken the COVID-19 vaccine due to religious reasons and only 11 (2.6%) knew someone who hadn’t taken the COVID-19 vaccine due to cultural/tribal/ethnicity reasons. Most participants 400 (94.3%) reported that their religion recommended vaccination, and 312 (73.6%) reported that their culture/tribe/ethnicity recommended vaccination. Only 53 (12.5%) reported that they would refuse the COVID-19 vaccine if the vaccinator was from another religion and only 25 (5.9%) would refuse if the vaccinator was from another culture/tribe/ethnicity.

Only 113 (26.6%) participants trusted that pharmaceutical companies are providing safe and effective COVID-19 vaccines for pregnant and lactating women. 146 (34.4%) believed there are other ways COVID-19 would be prevented instead of the vaccine. 44 (10.4%) felt that they had enough information about COVID-19 vaccines and their safety in pregnant or lactating women, 252 (59.4%) were very concerned that some of the COVID-19 vaccines may not be safe for pregnant or lactating women and only 122 (28.7%) thought that the COVID-19 vaccine will be needed even when the COVID-19 epidemic ends. Only 96 (22.6%) believed that vaccines in general were for them and their unborn/breastfeeding babies and 59 (13.9%) believed the COVID-19 vaccine was safe for them and their unborn/breastfeeding baby (supplementary material 1).

When asked about which mode of vaccination (injection or oral) they preferred for any vaccine, 227 (53.5%) preferred injections or oral, 142 (33.5%) injections only and 55 (13.0%) oral only. About where they preferred to receive the COVID-19 vaccine, 235 (55.4%) preferred a health centre, 122 (28.8%) from schools or institution-based programs, 68 (16.0%) mass campaign in community, 60 (14.2%) door to door and 26 (6.1%) personal doctor. Only 92 (21.7%) reported that they would follow the recommended schedule for COVID-19 vaccination (8 weeks after the first dose) while if the COVID-19 vaccine was offered at a cost, only 50 (11.8%) would still get it. Other participant responses are presented in Supplementary material 1.

Factors associated with uptake of COVID-19 vaccines among study participants

At the multivariate analysis, after adjusting for covariates, COVID-19 vaccine uptake was significantly associated with history of testing for COVID-19 disease regardless of negative or positive result (aPR = 1.92, CI: 1.46–2.54), and having a vaccinated household member (aPR = 1.38, CI: 1.03–1.84) (Table 4).

Table 4

Factors associated with uptake of COVID-19 vaccine (at least one dose) among study participants
Variable, (n = 424)	Not vaccinated, n = 205 (%)	Vaccinated, n = 219 (%)	Crude PR (95% CI), P value	Adjusted PR (95% CI), P value
Pregnant/lactating
Pregnant	99 (46.7)	113 (53.3)	1.00 (ref)
Lactating	106 (50.0)	106 (50.0)	0.94 (0.72–1.22), 0.636
Age categories (years)
< 18	6 (85.7)	1 (14.3)	0.25 (0.04–1.86), 0.178
18–25	91 (49.2)	94 (50.8)	0.91 (0.66–1.28), 0.599
26–30	64 (48.1)	69 (51.9)	0.93 (0.66–1.33), 0.705
31–49	44 (44.4)	55 (55.6)	1.00 (ref)
District of residence
Kampala	82 (45.8)	97 (54.2)	1.00 (ref)
Wakiso	108 (49.1)	112 (50.9)	0.94 (0.72–1.23), 0.653
Mukono	4 (57.1)	3 (42.9)	0.79 (0.25–2.49), 0.689
Others	11 (61.1)	7 (38.9)	0.72 (0.33–1.54), 0.397
Distance from home to the nearest public health facility that offers COVID-19 vaccination
≤ 5km	91 (49.2)	94 (50.8)	0.97 (0.74–1.26), 0.832
> 5km	114 (47.7)	125 (52.3)	1.00 (ref)
Tribe
Baganda	125 (50.8)	121 (49.2)	1.00 (ref)
Banyankore	32 (48.5)	34 (51.5)	1.05 (0.72–1.53), 0.812
Basoga	12 (48.0)	13 (52.0)	1.06 (0.59–1.87), 0.849
Others	36 (41.4)	51 (58.6)	1.19 (0.86–1.65), 0.293
Marital status
Married/cohabiting	185 (48.3)	198 (51.7)	1.00 (ref)
Separated/widowed/divorced	4 (57.1)	3 (42.9)	0.83 (0.26–2.59), 0.747
Single/never married	16 (47.1)	18 (52.9)	1.02 (0.63–1.66), 0.923
Highest Education level achieved
None/Primary	62 (53.9)	53 (46.1)	1.00 (ref)
Secondary	117 (47.6)	129 (52.4)	1.14 (0.83–1.56), 0.429
Tertiary/vocational/University	26 (41.3)	37 (58.7)	1.27 (0.84–1.94), 0.258
Religion
Adventist	6 (60.0)	4 (40.0)	0.68 (0.25–1.84), 0.445
Anglican	30 (44.1)	38 (55.9)	0.95 (0.65–1.38), 0.773
born-again	53 (55.8)	42 (44.2)	0.75 (0.52–1.08), 0.120
Catholic	63 (40.9)	91 (59.1)	1.00(ref)
Muslim	52 (54.2)	44 (45.8)	0.76 (0.54–1.11), 0.116
Faith of Unity	1 (100)	-	-
House hold head
No	181 (47.3)	202 (52.7)	1.00 (ref)
Yes	24 (58.5)	17 (41.5)	0.78 (0.48–0.61), 0.341
Number of biological children (Alive only)
0	29 (45.3)	35 (54.7)	1.00 (ref)
1–5	169 (49.1)	175 (50.9)	0.93 (0.65–1.34), 0.696
≥ 6	7 (43.7)	9 (56.3)	1.03 (0.49–2.14), 0.940
House hold size (number of live in occupants)
1–5	173 (48.7)	182 (51.3)	1.00 (ref)
≥ 6	32 (46.4)	37 (53.6)	1.05 (0.73–1.48), 0.803
Employment status of respondent (Has a job or business or works somewhere)
No	142 (50.4)	140 (49.6)	1.00 (ref)
Yes	63 (44.4)	79 (55.6)	1.12 (0.85–1.47), 0.418
Heard about health insurance
No	169 (52.3)	154 (47.7)	1.00 (ref)
Yes	36 (35.6)	65 (64.4)	1.35 (1.01–1.80), 0.043
Had any health insurance since 2020
No	203 (48.3)	217 (51.7)	1.00 (ref)
Yes	2 (50.0)	2 (50.0)	0.96 (0.24–0.59), 0.963
Parity
0	27 (48.2)	29 (51.8)	1.00 (ref)
1–3	150 (50.3)	148 (49.7)	0.96 (0.64–1.43), 0.837
4–5	22 (41.5)	31 (58.5)	1.13 (0.68–1.87), 0.637
≥ 6	6 (35.3)	11 (64.7)	1.25 (0.62–2.50), 0.529
How many pregnancies between January 2020 and now? including miscarriages
1	160 (47.1)	180 (52.9)	1.00 (ref)
2	35 (53.0)	31 (47.0)	0.88 (0.61–1.29), 0.538
≥ 3	10 (55.6)	8 (44.4)	0.84 (0.41–1.70), 0.628
Chronic illness(es)
Yes	17 (50.0)	17 (50.0)	1.04 (0.63–1.70), 0.889
No	188 (48.2)	202 (51.8)	1.00 (ref)
Ever tested for COVID-19
No	181 (61.6)	113 (38.4)	1.00 (ref)	1.00 (ref)
Yes	24 (18.5)	106 (81.5)	2.12 (1.63–2.77), 0.000	1.92 (1.45–2.54), 0.000
History of a confirmed Positive COVID-19 test
No	203 (49.0)	211 (51.0)	1.00 (ref)
Yes	2 (20.0)	8 (80.0)	1.57 (0.77–3.18), 0.211
Any household members tested positive for COVID-19
No	200 (49.6)	203 (50.4)	1.00 (ref)
Yes	5 (23.8)	16 (76.2)	1.51 (0.91–2.52), 0.111
Any household deaths due to COVID-19 (Only people they lived with: Excluding non-resident friends, relatives and neighbours)
No	204 (48.7)	215 (51.3)	1.00 (ref)
Yes	1 (20.0)	4 (80.0)	1.56 (0.58–4.19), 0.379
Received some other vaccines since January 2020
No other vaccines	201 (49.6)	204 (50.4)	1.00 (ref)
Yes	4 (21.1)	15 (78.9)	1.57 (0.93–2.65), 0.093
If there was an Ebola Virus Disease vaccine, would you currently be willing to receive it?
Not sure/Not willing	103 (59.9)	69 (40.1)	1.00(ref)
Willing	102 (40.5)	150 (59.5)	1.48 (1.12–1.97), 0.007
Have any household members been vaccinated against COVID-19?
Don’t know/No	126 (61.8)	78 (38.2)	1.00 (ref)	1.00 (ref)
Yes	79 (35.9)	141 (64.1)	1.67 (1.27–2.21), 0.000	1.38 (1.03–1.84), 0.030
While at the health facility, did you EVER receive any information from the health workers on COVID-19 vaccination?
No	152 (60.8)	98 (39.2)	1.00 (ref)
Yes	53 (30.5)	121 (69.5)	1.77 (1.36–2.32), 0.000
Did you EVER receive any information from the health workers on COVID-19 vaccination among pregnant/lactating women?
No	173 (53.2)	152 (46.8)	1.00 (ref)
Yes	32 (32.3)	67 (67.7)	1.45 (1.08–1.93), 0.012
Did you EVER attend any health education programs or teachings on COVID-19 vaccination at the health facility?
No	159 (54.5)	133 (45.5)	1.00 (ref)
Yes	46 (34.8)	86 (65.2)	1.43 (1.09–1.87), 0.010
Does participant own or regularly has access to any of these? Television Radio Mobile phone (smart) Internet Newspapers
No	41 (64.1)	23 (35.9)	1.00 (ref)
Yes	164 (45.6)	196 (54.4)	1.55 (0.98–2.33), 0.059
Do you obtain information related to COVID-19 vaccination on social media?
No	138 (50.2)	137 (49.8)	1.00 (ref)
Yes	67 (45.0)	82(55.0)	1.10 (0.84–1.45), 0.476
Have you EVER experienced any bad reaction after any immunization?
No/Unsure	196 (50.6)	191 (49.4)	1.00 (ref)
Yes	9(24.3)	28 (75.7)	1.53 (1.03–2.28), 0.035
Which mode of vaccination (injection or oral) do you PREFER? (For any vaccine)
Injections or oral	118 (52.0)	109 (48.0)	1.00 (ref)
Injections only	58 (40.9)	84 (59.1)	1.23 (0.93–1.63), 0.151
Oral only	29 (52.7)	26 (47.3)	0.98 (0.64–1.51), 0.943
PR = Prevalence Ratio

Factors associated with willingness to receive COVID-19 vaccines among study participants

At the multivariate analysis, after adjusting for covariates, willingness to receive the COVID-19 vaccine was significantly associated with being a household head (aPR = 0.46, CI: 0.24–0.89) and previous COVID-19 vaccine uptake (aPR = 1.88, CI: 1.41–2.52) (Table 5).

Table 5

Factors associated with willingness to receive the COVID-19 vaccine among study participants
Variable, (n = 424)	Not willing, n = 219 (%)	Willing to receive, n = 205 (%)	Crude PR (95% CI), P value	Adjusted PR (95% CI), P value
Pregnant/lactating
Pregnant	112 (52.8)	100 (47.2)	1.00 (ref)
Lactating	107 (50.5)	105 (49.5)	1.05 (0.79–1.38), 0.727
Socio demographic factors
Age categories (years)
< 18	1 (14.3)	6 (85.7)	1.00 (ref)
18–25	106 (57.3)	79 (42.7)	0.49 (0.22–1.14), 0.100
26–30	66 (49.6)	67 (50.4)	0.58 (0.25–1.35), 0.212
31–49	46 (46.5)	53 (53.5)	0.62 (0.27–1.45), 0.275
District of residence
Kampala	97 (54.2)	82 (45.8)	1.00 (ref)
Wakiso	111 (50.5)	109 (49.5)	1.08 (0.81–1.44), 0.592
Mukono	1 (14.3)	6 (85.7)	1.87 (0.82–4.28), 0.138
Others	10 (55.6)	8 (44.4)	0.97 (0.46-2.00), 0.935
Distance from home to the nearest public health facility that offers COVID-19 vaccination
≤ 5km	98 (53.0)	87 (47.0)	1.00 (ref)
> 5km	121 (50.6)	118 (49.4)	0.95 (0.72–1.25), 0.731
Tribe
Baganda	125 (50.8)	121 (49.2)	1.00 (ref)
Banyankore	34 (51.5)	32 (48.5)	0.98 (0.67–1.45), 0.942
Basoga	12 (48.0)	13 (52.0)	1.06 (0.59–1.87), 0.849
Others	48 (55.2)	39 (44.8)	0.91 (0.64–1.31), 0.614
Marital status
Married/cohabiting	196 (51.2)	187 (48.8)	1.00 (ref)
Separated/widowed/divorced	6 (85.7)	1 (14.3)	0.29 (0.04–2.09), 0.220
Single/never married	17 (50.0)	17 (50.0)	1.02 (0.62–1.68), 0.925
Highest Education level achieved
None/Primary	60 (52.2)	55 (47.8)	1.00 (ref)
Secondary	126 (51.2)	120 (48.8)	1.02 (0.74–1.40), 0.903
Tertiary/vocational/University	33 (52.4)	30 (47.6)	0.99 (0.64–1.55), 0.985
Religion
Adventist	8 (80.0)	2 (20.0)	0.40 (0.09–1.65), 0.207
Anglican	32 (47.1)	36 (52.9)	1.07 (0.72–1.59), 0.729
born-again	52 (54.7)	43 (45.3)	0.92 (0.63–1.33), 0.651
Catholic	78 (50.6)	76 (49.4)	1.00 (ref)
Muslim	48 (50.0)	48 (50.0)	1.01 (0.71–1.45), 0.943
Faith of Unity	1 (100)	0	-
House hold head
No	187 (48.8)	196 (51.2)	1.00 (ref)	1.00 (ref)
Yes	32 (78.1)	9 (21.9)	0.43 (0.22–0.84), 0.013	0.46 (0.24–0.89), 0.023
Number of biological children (Alive only)
0	38 (59.4)	26 (40.6)	1.00 (ref)
1–5	172 (50.0)	172 (50.0)	1.23 (0.81–1.86), 0.324
≥ 6	9 (56.3)	7 (43.7)	1.07 (0.46–2.48), 0.862
House hold size (number of live in occupants)
1–5	188 (53.0)	167 (47.0)	1.00 (ref)
≥ 6	31 (44.9)	38 (55.1)	1.17 (0.82–1.66), 0.381
Employment status of respondent (Has a job or business or works somewhere)
No	139 (49.3)	143 (50.7)	1.00 (ref)
Yes	80 (56.3)	62 (43.7)	0.86 (0.64–1.16), 0.325
Heard about health insurance
No	172 (53.3)	151 (46.7)	1.00 (ref)
Yes	47 (46.5)	54 (53.5)	1.14 (0.83–1.56), 0.397
Had any health insurance since 2020
No	216 (51.4)	204 (48.6)	1.00 (ref)
Yes	3 (75.0)	1 (25.0)	0.51 (0.07–3.67), 0.508
Parity
0	33 (58.9)	23 (41.1)	1.00 (ref)
1–3	155 (52.0)	143 (48.0)	1.17 (0.75–1.81), 0.489
4–5	21 (39.6)	32 (60.4)	1.47 (0.86–2.51), 0.159
≥ 6	10 (58.8)	7 (41.2)	1.00 (0.43–2.34), 0.995
How many pregnancies between January 2020 and now? including miscarriages
1	170 (50.0)	170 (50.0)	1.00 (ref)
2	37 (56.1)	29 (43.9)	0.88 (0.59–1.30), 0.520
≥ 3	12 (66.7)	6 (33.3)	0.67 (0.29–1.50), 0.329
Chronic illness(es)
Yes	23 (67.6)	11 (32.4)	1.00 (ref)
No	196 (50.3)	194 (49.7)	1.54 (0.84–2.82), 0.165
Ever tested for COVID-19
No	161 (54.8)	133 (45.2)	1.00 (ref)
Yes	58 (44.6)	72 (55.4)	1.22 (0.92–1.63), 0.167
History of a confirmed Positive COVID-19 test
No	216 (52.2)	198 (47.8)	1.00 (ref)
Yes	3 (30.0)	7 (70.0)	1.46 (0.69–3.11), 0.322
Any household members tested positive for COVID-19
No	204 (50.6)	199 (49.4)	1.00 (ref)
Yes	15 (71.4)	6 (28.6)	0.58 (0.26–1.30), 0.187
Any household deaths due to COVID-19 (Only people they lived with: Excluding non-resident friends, relatives and neighbours)
No	216 (51.5)	203 (48.5)	1.00 (ref)
Yes	3 (60.0)	2 (40.0)	0.83 (0.21–3.32), 0.787
Received some other vaccines since January 2020
No other vaccines	212 (52.4)	193 (47.6)	1.00 (ref)
Yes	7 (36.8)	12 (63.2)	1.32 (0.74–2.37), 0.344
If there was an Ebola Virus Disease vaccine, would you currently be willing to receive it?
Not sure/Not willing	135 (78.5)	37 (21.5)	1.00 (ref)
Willing	84 (33.3)	168 (66.7)	3.10 (2.17–4.42), 0.000
Have any household members been vaccinated against COVID-19?
Don’t know/No	122 (59.8)	82 (40.2)	1.00 (ref)
Yes	97 (44.1)	123(55.9)	1.39 (1.05–1.84), 0.021
Previous COVID-19 vaccinated (uptake)
No	138 (67.3)	67 (32.7)	1.00 (ref)	1.00 (ref)
Yes	81 (37.0)	138 (63.0)	1.93 (1.44–2.58), 0.000	1.88 (1.41–2.52), 0.000
While at the health facility, did you EVER receive any information from the health workers on COVID-19 vaccination?
No	145 (58.0)	105 (42.0)	1.00 (ref)
Yes	74 (42.5)	100 (57.5)	1.37 (1.04–1.79), 0.025
Did you EVER receive any information from the health workers on COVID-19 vaccination among pregnant/lactating women?
No	175 (53.8)	150 (46.2)	1.00 (ref)
Yes	44 (44.4)	55 (55.6)	1.20 (0.88–1.64), 0.240
Did you EVER attend any health education programs or teachings on COVID-19 vaccination at the health facility?
No	167 (57.2)	125 (42.8)	1.00 (ref)
Yes	52 (39.4)	80 (60.6)	1.42 (1.07–1.87), 0.015
Does participant own or regularly has access to any of these? Television Radio Mobile phone (smart) Internet Newspapers
No	41 (64.1)	23 (35.9)	1.00 (ref)
Yes	178 (49.4)	182 (50.6)	1.41 (0.91–2.17), 0.123
Do you obtain information related to COVID-19 vaccination on social media?
No	143 (52.0)	132 (48.0)	1.00 (ref)
Yes	76 (51.0)	73 (49.0)	1.02 (0.77–1.36), 0.888
Have you EVER experienced any bad reaction after any immunization?
No/Unsure	205 (53.0)	182 (47.0)	1.00 (ref)
Yes	14 (37.8)	23 (62.2)	1.32 (0.86–2.04), 0.207
Did you get a bad reaction after the first COVID-19 dose?
No/Unsure	210 (52.1)	193 (47.9)	1.00 (ref)
Yes	9 (42.9)	12 (57.1)	1.19 (0.66–2.14), 0.553
Which mode of vaccination (injection or oral) do you PREFER? (For any vaccine)
Injections or oral	129 (56.8)	98 (43.2)	1.00 (ref)
Injections only	60 (42.3)	82 (57.7)	1.34 (0.99–1.79), 0.052
Oral only	30 (54.5)	25 (45.5)	1.05 (0.68–1.63), 0.818
PR = Prevalence Ratio

Our study provides valuable insights into the factors influencing COVID-19 vaccine uptake and acceptability among pregnant and lactating women attending a tertiary public hospital in Kampala, Uganda. Despite the established benefits of COVID-19 vaccination during pregnancy and lactation, our findings indicate suboptimal coverage of COVID-19 vaccines among study participants. Our findings are in agreement with a systematic review which showed that the prevalence of COVID-19 vaccine uptake during pregnancy was low in Sub-Saharan Africa at (14.4–28)%(11).

None of the women in our study received a COVID-19 vaccine during pregnancy whilst very few received it during lactation. This can be explained by the fact that there were no educational campaigns and communication strategies for COVID-19 vaccination tailored to pregnant and lactating women as part of Uganda’s COVID-19 vaccination program(12).

Our study found that only 32.7% of unvaccinated participants were willing to receive the COVID-19 vaccine. Acceptability was also suboptimal among those who had received one (55.8%) or two (61.5%) doses, but 100% of participants who received booster doses were willing to receive additional doses. This suggests that women who have taken up the vaccine could be involved as ‘expert patients’ in campaigns to help encourage their peers that the vaccination is helpful and safe, potentially enhancing vaccine acceptability and uptake among pregnant and lactating women.

Our findings show that COVID-19 vaccine uptake was associated with history of testing for COVID-19 and having a vaccinated household member. This highlights the influence of social networks and household dynamics on vaccine decision-making. Pregnant and lactating women with a history of COVID-19 testing or with vaccinated household members were more likely to accept COVID-19 vaccines, suggesting the importance of peer influence and social norms in shaping vaccine behaviors.

In Uganda, COVID-19 testing was challenging to access. A Polymerase chain reaction (PCR) test cost around 250,000 Ugandan shillings (approximately 68 USD), and most people had to pay for their tests, except in a few public health facilities that often-faced stockouts(13). Limited testing supplies, mostly imported, and high costs discouraged many Ugandans from getting tested. Free testing was available only to specific groups, such as health workers and individuals seeking care at public health facilities(13, 14). Consequently, even those with severe symptoms often faced barriers to testing. This context emphasizes the significant influence of testing accessibility on vaccine uptake behaviors.

Similar to our study findings, a study among health workers in Nigeria showed that those who had been tested for COVID-19 were more likely (aOR:7.64; p < 0.001) to accept the vaccine(15).

Interestingly, our study identified a significant association between being a household head and willingness to receive COVID-19 vaccines, further indicating the potential role of household dynamics in shaping vaccine attitudes. This finding may suggest that women who are household heads do not face the same barriers related to seeking permission from a husband or male partner. It may also reflect altered priorities due to being the sole parent, and understanding this area could be a future research priority. Our findings are in line with findings from a survey involving six countries in East and West Africa which reported that social ties and perceptions as well as intra-household power relations matter for COVID-19 vaccine take-up(16). Future research could delve deeper into how intra-household decision-making processes affect vaccine acceptance among pregnant/lactating women.

Our findings show that 94.1% of the women had received TT vaccines in the past three years. TT vaccines have been administered to pregnant women for many years with minimal safety and community concerns, making them more trusted than newer vaccines like COVID-19 vaccines. There was a low trust in the safety of vaccines in general and COVID-19 vaccines for women and their unborn /breastfeeding babies. However, nearly half of the women (48.8%) were not willing to receive any other vaccines while pregnant or lactating, possibly due to concerns about the safety of new vaccines, lack of information, or cultural beliefs. Understanding these reasons is crucial for developing strategies to improve vaccine acceptance in this population.

In addition, we established that while health workers were most trusted source of information on COVID-19, the reach of their education campaigns on COVID-19 including specific information for pregnant and breastfeeding women were poor. Only 16.5% of the study participants felt that COVID-19 vaccine side effects had been discussed openly by the public health authorities and 18.4% had received information on adverse events. Future health promotions should monitor the reach of health worker-led education campaigns.

COVID-19 health literacy campaigns in Uganda engaged a lot of political, religious leaders, however women reported that trust in these figures is low; future campaigns should strategically engage more health workers. There was also low trust in information from media outlets. While nearly half of the women did not use social media, the majority who had access had obtained information on COVID-19 from there. This is in line with the heightened role of social media in health literacy that COVID-19 exposed(17–19).

The low willingness to pay for the COVID-19 vaccine if it was offered at a cost could have implications for future strategies for public roll-out of vaccines. Willingness to pay for the COVID-19 vaccine has been found to differ depending on the setting and is increased with higher income and a higher perceived risk. In our setting where the employment rate was low with a median monthly income of 50 USD among the study participants, and where the perceived risk of COVID-19 was low, the low reported rate of willingness to pay for the vaccine may be easier to understand (20–22).

Limitations

The limitations of our study include its cross-sectional design, which prohibits causal inference, and the reliance on self-reported data, which may be subject to recall bias. Additionally, our study was conducted at a single tertiary public hospital in Kampala, limiting the generalizability of our findings to other settings in Uganda.

The uptake and willingness to receive COVID-19 vaccines among pregnant and lactating women were generally low, with no participants receiving COVID-19 vaccines during pregnancy and very few during lactation. In contrast, the majority had received Tetanus Toxoid vaccines, indicating a disparity in vaccine acceptance. Factors such as undergoing COVID-19 testing and having a vaccinated household member positively influenced COVID-19 vaccine uptake and willingness. These findings highlight the need for targeted interventions to improve the acceptance and uptake of COVID-19 vaccines during pregnancy and lactation.

AIDS: Acquired Immune Deficiency Syndrome; aPR: adjusted prevalence ratio; CI: Confidence Interval; COVID-19: Coronavirus disease 2019; HCWs: Health Care Workers; HIV: Human Immunodeficiency Virus; KNRH: Kawempe National Referral Hospital; LMICs: Low- and middle-income countries; MoH: Ministry of Health; PR: Prevalence Ratio; TT: Tetanus Toxoid; UNEPI: Uganda National Expanded Program on Immunization; WHO: World Health Organization

Ethics approval and consent to participate

Approval to carry out this research was sought from the Research and Ethics Committee of the Infectious Diseases Institute Kampala (IDI-REC-2022-31) and the Uganda National Council of Science and Technology (HS2929ES). Signed informed consent and assent were sought from the study participants. To ensure patient protection and confidentiality, any possible patient identifiers were eliminated by use of serial numbers.

Consent for publication

Not applicable

Competing interests

All authors declare that they have no competing interests

Authors Contributions

Conceived and designed the study: EBK and EALO. Supervision of research assistants and project implementation: EBK, EALO, BNS, EJN, JN, and ARA. Analyzed and interpreted the data and wrote the first draft of the manuscript: EBK, EALO, BNS, EJN, JN, and ARA. Contributed substantially to the analysis and interpretation of data: EBK, EALO, DK, RM, BC, and CW. Critically reviewed the paper for important intellectual content: DK, RM, ARA, BC and CW. All the authors have read and approved the manuscript.

Funding

This study was funded by an Early Career Grants programme award from the Royal Society of Tropical Medicine and Hygiene (RSTMH) in partnership with the National Institute for Health and Care Research (NIHR), received by the first author in 2022. CW is supported by Wellcome Clinical Research Career Development Fellowship 222075/Z/20/Z.

Availability of data and materials

The datasets upon which our findings are based belong to the project investigation team. For confidentiality reasons, the datasets are not publicly available. However, the datasets can be availed upon reasonable request from the corresponding author and with permission from the project team.

Acknowledgments

We thank the study participants who agreed to be interviewed. Appreciation also goes to the entire project team (investigators and research assistants).

Kochhar S, Edwards KM, Ropero Alvarez AM, Moro PL, Ortiz JR. Introduction of new vaccines for immunization in pregnancy - Programmatic, regulatory, safety and ethical considerations. Vaccine. 2019 May 31;37(25):3267–77.
Maertens K, Orije MRP, Van Damme P, Leuridan E. Vaccination during pregnancy: current and possible future recommendations. Eur J Pediatr. 2020;179(2):235–42.
August 2021 JLR// 05. Devex. 2021 [cited 2024 Apr 12]. Increasing calls to vaccinate pregnant women against COVID-19. Available from: https://www.devex.com/news/sponsored/increasing-calls-to-vaccinate-pregnant-women-against-covid-19-100542
Villar J, Ariff S, Gunier RB, Thiruvengadam R, Rauch S, Kholin A, et al. Maternal and Neonatal Morbidity and Mortality Among Pregnant Women With and Without COVID-19 Infection: The INTERCOVID Multinational Cohort Study. JAMA Pediatr. 2021 Aug 1;175(8):817–26.
Chirico F, da Silva JAT, Tsigaris P, Sharun K. Safety & effectiveness of COVID-19 vaccines: A narrative review. Indian J Med Res. 2022 Jan;155(1):91–104.
CDC. Centers for Disease Control and Prevention. 2024 [cited 2024 Apr 12]. Vaccination Considerations for People Pregnant or Breastfeeding. Available from: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html
Cole C, Tsakiroglou M, Waitt C. Communication is crucial: Lessons from COVID‐19 vaccination and pregnancy. Br J Clin Pharmacol. 2023 Feb;89(2):582–93.
Ainebyona H, Ayebare E, Nabisere A, Saftner MA. Prevalence of Maternal Fever and Associated Factors among Postnatal Women at Kawempe National Referral Hospital, Uganda: A Preliminary Study. Int J Environ Res Public Health. 2024 Mar 8;21(3):316.
The SAGE Working Group on Vaccine Hesitancy. The determinants of vaccine hesitancy: Sample survey questions [Internet]. Available from: https://www.who.int/immunization/sage/meetings/2013/april/4_survey_questionsRevised.pdf
Nalubega P, Karafillakis E, Atuhaire L, Akite P, Zalwango F, Chantler T, et al. Maternal Vaccination in Uganda: Exploring Pregnant Women, Community Leaders and Healthcare Workers’ Perceptions. Vaccines. 2021 May 25;9(6):552.
Ayieko S, Baker K, Messiah SE, Lewis B, Markham C. Determinants of COVID-19 Vaccination Decision-Making Behaviors among Pregnant Women in Sub-Saharan Africa: A Scoping Review. Vaccines. 2023 Jul;11(7):1233.
Zavala E, Krubiner CB, Jaffe EF, Nicklin A, Gur-Arie R, Wonodi C, et al. Global disparities in public health guidance for the use of COVID-19 vaccines in pregnancy. BMJ Glob Health. 2022 Feb 1;7(2):e007730.
Check On COVID-19 Laboratories-Experts | Uganda Virus Research Institute [Internet]. [cited 2024 Jul 16]. Available from: https://www.uvri.go.ug/news/check-covid-19-laboratories-experts
Exemplars in Global Health. TESTING & SURVEILLANCE: UGANDA [Internet]. [cited 2024 Jul 16]. Available from: https://www.exemplars.health/emerging-topics/epidemic-preparedness-and-response/testing-and-surveillance/uganda
Abubakar AT, Suleiman K, Ahmad SI, Yahaya SS, Bello UI, Suleiman BA, et al. Acceptance of COVID-19 vaccine and associated factors among healthcare workers in Katsina state: a cross-sectional study in Northwest Nigeria. BMJ Open. 2023 Dec 22;13(12):e063281.
Wollburg P, Markhof Y, Kanyanda S, Zezza A. Assessing COVID-19 vaccine hesitancy and barriers to uptake in Sub-Saharan Africa. Commun Med. 2023 Sep 11;3(1):1–11.
Gunasekeran DV, Chew A, Chandrasekar EK, Rajendram P, Kandarpa V, Rajendram M, et al. The Impact and Applications of Social Media Platforms for Public Health Responses Before and During the COVID-19 Pandemic: Systematic Literature Review. J Med Internet Res. 2022 Apr 11;24(4):e33680.
Liu PL. COVID-19 information on social media and preventive behaviors: Managing the pandemic through personal responsibility. Soc Sci Med 1982. 2021 May;277:113928.
Joseph AM, Fernandez V, Kritzman S, Eaddy I, Cook OM, Lambros S, et al. COVID-19 Misinformation on Social Media: A Scoping Review. Cureus. 14(4):e24601.
Soofi M, Kok G, Soltani S, Kazemi-Karyani A, Najafi F, Karamimatin B. Willingness to pay for a COVID-19 vaccine and its associated determinants in Iran. Front Public Health. 2023 Feb 16;11:1036110.
Tran BX, Do AL, Boyer L, Auquier P, Le HT, Le Vu MN, et al. Preference and Willingness to Pay for the Regular COVID-19 Booster Shot in the Vietnamese Population: Theory-Driven Discrete Choice Experiment. JMIR Public Health Surveill. 2023 Jan 31;9:e43055.
Harapan H, Wagner AL, Yufika A, Winardi W, Anwar S, Gan AK, et al. Willingness-to-pay for a COVID-19 vaccine and its associated determinants in Indonesia. Hum Vaccines Immunother. 2020 Dec 1;16(12):3074–80.

No competing interests reported.

Supplementarymaterial1.docx

Acceptability and Uptake of COVID-19 Vaccines among Pregnant and Lactating Women seeking services at a Tertiary Public Hospital in Kampala, Uganda

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Introduction

METHODS

Study design and setting

Data collection procedure and study questionnaire

Study variables

Statistical analysis

RESULTS

Socio-demographic characteristics of the study participants

Clinical factors (pregnancy or lactation related) and COVID-19 disease related factors among study participants

Level of uptake and COVID-19 vaccination acceptability among study participants

Contextual, Individual, Group and Vaccine-Specific Issues

Factors associated with uptake of COVID-19 vaccines among study participants

Factors associated with willingness to receive COVID-19 vaccines among study participants

Discussion

Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1