Knowledge, Attitudes, and Subjective Norms Associated with COVID-19 Vaccination among Pregnant Women in Kenya: An Online Cross-Sectional Pilot Study Using WhatsApp

Vaccination is an established public health tool for preventing many infectious diseases and associated mortalities [1,2]. This is because inoculation processes are relatively safe, do not require frequent user intervention, and can ensure that large populations are protected from diseases [2]. Vaccination against the coronavirus disease 2019 (COVID-19) has prevented thousands of deaths and minimized hospitalizations due to severe COVID-19 infections [3,4].

The literature suggests that pregnant women were more susceptible to severe morbidities and mortality from COVID-19 compared with non-pregnant women of reproductive age [5,6]. A longitudinal study conducted in Western Kenya in 2020 revealed that 6% of pregnant women were diagnosed with COVID-19, compared to 4% of postpartum women [7]. Despite the risk, there are limited data on COVID-19 vaccination coverage and uptake during pregnancy in lower-middle-income countries [1], with vaccination rates ranging from 14.4% in Ethiopia [8] to 37.7% in Turkey [9]. Some possible explanations related to the lower rates of COVID-19 vaccination uptake include the lack of information on the safety of COVID-19 vaccines during pregnancy [10], vaccine hesitancy among healthcare providers [11], low susceptibility to COVID-19 [12], and concerns about rapid vaccine development [13].

GeoPoll’s study found that about 61% of Kenyans believed the COVID-19 vaccine was safe and effective [14]. Kenya participated in the COVID-19 Vaccine Global Access (COVAX) partnership program [15] with the goal of vaccinating the entire adult Kenyan population by June 2022 [16]. By May 2022, about 30% of the entire population in Kenya had received full vaccination [16]. Empirical evidence suggests minimal COVID-19 uptake can be attributed to environmental influences such as the unavailability of vaccines [10], weak health systems [17], and lack of trained personnel [1]. Societal influences such as misinformation and reduced community engagement have also been reported as reasons behind the low rollout of COVID-19 vaccination [6,13]. Policy changes and recommendations for COVID-19 vaccination during pregnancy [18,19,20] did not translate to higher uptake among pregnant women due to conflicting messages and limited information [21].

While a few studies have investigated attitudes of acceptance and hesitancy around COVID-19 vaccination among pregnant women [22,23], research suggests that comparatively few studies have assessed the role of psychosocial and behavioral determinants on COVID-19 vaccination in Sub-Saharan Africa [24,25]. To develop more effective intervention protocols, an in-depth understanding of the beliefs that guide vaccination is necessary to optimize public health efforts. This study used the Theory of Reasoned Action (TRA) as the theoretical framework [26]. The TRA’s constructs of attitudes and subjective norms (exposures) were examined to understand how they are associated with COVID-19 vaccination uptake (outcome variable). Attitudes are identified as the best predictors of intentions to perform a behavior and are significant in designing TRA-based interventions [27]. Subjective norms are operationalized as the vaccination beliefs of friends, family, or health providers influencing COVID-19 vaccination behavior.

Understanding the psychosocial influences of COVID-19 uptake in Kenya offers potential insight into targeted interventions to reduce vaccine hesitancy among women in Kenya. This pilot online cross-sectional study aimed to explore how knowledge and perceptions (attitudes and subjective norms) influenced COVID-19 vaccine uptake among pregnant women in Kenya using WhatsApp mobile app technology [28] as a recruitment tool.

As a pilot study, we aimed to investigate WhatsApp use in recruitment and research among pregnant women in Kenya. The study personnel reported data collection challenges, probably because not all pregnant women had smartphone access to WhatsApp. Approximately one-third of the 174 people who attempted the survey were ineligible, with about 21 (12%) eligible participants not consenting. An estimated 18 million people in Kenya use the internet, with 41% utilizing the WhatsApp platform as their favorite social media channel [28], suggesting that not all pregnant women felt comfortable using the messaging application. Other studies have reported negative psychological associations among WhatsApp users exposed to COVID-19-related information [34,35]. While some clinical staff encouraged pregnant women to participate in the study, using an online survey reduced any coercion likely to occur in public hospitals if women perceived that they could receive inferior services if they declined to participate. In the past, data in Kenya have been collected by researchers who engaged women in person and input the data directly on paper or iPads [36]. A study by Jacaranda Health also indicated the feasibility of using WhatsApp to communicate with pregnant women in Nairobi [37]. With the increasing use of WhatsApp messenger as an official channel of information [34] and other recent innovations, such as polls included in the application, health programs could utilize WhatsApp for advanced mechanisms for research and data collection in the future.

The second aim of our study was to determine COVID-19 vaccination coverage among pregnant women in Kenya. Our study indicated that over 73% of pregnant women had already received at least one dose of the COVID-19 vaccine, which was much higher than the 28% previously reported in Kenya [38] and even in the general Kenyan population [16]. The higher vaccination rates in this study sample could be due to shifts in policy recommendations for COVID-19 vaccination [18,19,20], more availability of coronavirus disease 2019 vaccines through the COVAX initiative [15,16], and the sample characteristics—higher education levels, pregnant women seeking prenatal care in health facilities, and the setting (participants from referral hospitals). In the United States, about 55.4% of pregnant persons had received the COVID-19 vaccine by July 2021, despite the availability of COVID-19 vaccination and recommendations from the Centers for Disease Control and Prevention (CDC) [22,39]. Besides vaccine access, political, historical, and cultural factors could influence vaccination among pregnant populations besides the availability of vaccines [40].

The opinion that COVID-19 vaccination is not safe during pregnancy was held by 16.2% of our study participants, although a higher proportion (68.7%) of the women believed that COVID-19 vaccination could protect them from COVID-19. Similar to a study in Ethiopia [8], our study showed that most pregnant women had positive attitudes towards COVID-19 vaccination, and attitudes were significantly associated with COVID-19 vaccination. The scarcity of data on the safety of the COVID-19 vaccine during pregnancy [5], especially earlier in the pandemic, may have contributed to higher vaccination hesitancy. Reviews on COVID-19 vaccination during pregnancy also reported attitudes as factors influencing vaccine acceptance [21,24].

To our knowledge, this is among the few studies that examined subjective norms as a possible factor related to COVID-19 vaccination in pregnancy [41]. Other studies in the general population that have reported an association between vaccination and subjective norms [42] suggested the role of family members’ support in immunization. While our study did not indicate the association between norms and COVID-19 vaccination, descriptive data showed that proximal networks (family members, friends, and healthcare providers) strongly encouraged pregnant women to get vaccinated against COVID-19, which is similar to prior research [43]. With pregnant women reporting greater proximal influences compared to distal social influences (government officials, religious leaders, or celebrities), interventions should equip families and healthcare providers with timely and accurate information to assist women in decision-making.

Consistent with our findings, other authors have reported good knowledge of COVID-19 vaccination among pregnant women [38]. Contrary to previous studies that showed a relationship between knowledge and COVID-19 vaccination acceptance [44], our study did not show a significant association between the two, as nearly all participants believed that COVID-19 vaccination could help control the spread of COVID-19 infections. Given that COVID-19 was an emerging disease, in 2020, scientists across the globe utilized the information available at the time to inform populations about the best ways to help control and prevent severe COVID-19 infections [11,45,46]. As more research is conducted on COVID-19 and related vaccinations, some public health prevention practices such as wearing face protection, hand washing, and vaccination may still be recommended as other treatment options become available. During the pandemic, public health agencies, governments, and international organizations disseminated substantial information about COVID-19 [11,45,46]. However, a plethora of misinformation circulating via social media impacted public health interventions [47]. Some scholars argue that the ‘balkanization’ of COVID-19 information during the pandemic and dis/misinformation likely contributed to vaccine hesitancy [40]. As such, there is a need for vaccination programs to shift from just targeting knowledge through awareness campaigns to deploying innovative approaches that influence other psychological processes among pregnant women.

Vaccine intention, sometimes defined as the willingness to get a COVID-19 vaccine, was 58.6% among pregnant women in this study who were not already vaccinated, which was higher than what has been previously reported in Kenya (49.2%) [48], Nigeria (8.4%) [49], and Ethiopia [50]. Since the unvaccinated group in our sample was small, we did not conduct any analysis with this sub-sample. A longitudinal study among pregnant and postpartum women in Kenya reported changes in vaccination willingness (38% to 71%, p 36], suggesting that various factors could influence vaccine hesitancy among populations. Despite data showing COVID-19 vaccine safety and efficacy during pregnancy [5], there have been only slight changes in vaccination intention rates [21], necessitating thorough and systematic investigative research on vaccine hesitancy.

In summary, our study demonstrated that while vaccine coverage in this sample was much higher than in the general population in Kenya, health programs should consider interventions that address attitudes around preventative maternal behaviors, including vaccinations. In terms of research, the authors acknowledge the need to include additional questions, such as the intentions for full vaccination dosage among partially vaccinated pregnant women, for a more comprehensive outlook on vaccination behaviors. Public health action plans should also expand health communication campaigns that equip healthcare providers and the community with timely and accurate information. The most recent data show that about 30% of the general population in Kenya have received complete COVID-19 vaccine doses [16,51]. As such, the government and the Ministry of Health in Kenya must implement strategies to protect pregnant women, their families, and the general population in future pandemics.