What do pregnant women think about influenza disease and vaccination practices in selected countries

Figures & data

Table 1. Influenza vaccination policies for pregnant women at study sites during the study period

	Recommendation	Year recommendation began	Vaccine financing	Strategy for vaccine distribution
Nagpur	Recommended for pregnant women starting at 13 weeks gestation^a	2015	Provided by government free of charge	Vaccine was introduced by government in 2015. It is given in ANC clinics on optional basis irrespective of Influenza season
Lima	Recommended for pregnant women starting at 20 weeks gestation	2010	Provided by government free of charge	Vaccine campaigns (May-December)
Bangkok	Recommended for pregnant women starting at 13 weeks gestation	2009	Provided by government free of charge	Vaccine campaigns (June-August)

^aThird trimester (≥28 weeks gestation) only during 2015 and 2016. Recommendation expanded to include the second trimester

(13–27 weeks gestation) in 2017.

Table 2. Characteristics of participants by site (n = 4,648)

	Overall	Nagpur	Lima	Bangkok
	Total n (%)	All n (%)	All n (%)	All n (%)	p-Value
All	4,648	1,967 (42)	1,548 (33)	1,133 (24)
Age-group (years)
18–34	4,127 (89)	1,925 (98)	1,297 (84)	905 (80)	<0.01
≥35	521 (11)	42 (2)	251 (16)	228 (20)
Education
None	79 (2)	37 (2)	4 (0.3)	38 (3)	<0.01
Primary	927 (20)	343 (18)	121 (8)	463 (41)
Secondary	2,349 (51)	1,174 (60)	899 (58)	276 (24)
Post-secondary/University	1,278 (27)	406 (21)	522 (34)	350 (31)
Marital status
Married/living together	4,355 (94)	1,962 (100)	1,283 (83)	1,110 (98)	<0.01
Single/Widowed/Divorced/Separated	287 (6)	3 (0)	262 (17)	22 (2)
Occupation
Does not work outside home	3,297 (71)	1,888 (97)	1,085 (70)	324 (29)	<0.01
Works outside home	1,338 (29)	68 (3)	462 (30)	808 (71)
Has health insurance	2,360 (51)	167 (9)	1,136 (74)	1,057 (94)	<0.01
Monthly per capita income^a
Below poverty line	1,222 (46)	-	909 (59)	313 (28)	<0.01
Above poverty line	1,459 (54)	-	639 (41)	820 (72)
Number of people living in the household, excluding the mother
0–2	2,254 (48)	718 (37)	759 (49)	777 (69)	<0.01
3–4	1,349 (29)	625 (32)	505 (33)	219 (19)
5+	1,033 (22)	621 (32)	278 (18)	134 (12)
Number of ANC visits during pregnancy
0–4	1,144 (25)	679 (36)	429 (29)	36 (3)	<0.01
5–7	1,655 (36)	1,019 (54)	475 (32)	161 (15)
8+	1,671 (36)	196 (10)	578 (39)	897 (82)
Number of children
0	2,220 (48)	969 (49)	765 (50)	486 (43)	<0.01
1	1,711 (37)	807 (41)	477 (31)	427 (38)
2+	704 (15)	183 (9)	301 (20)	220 (19)
Gestational diabetes	162 (3)	3 (0)	40 (3)	119 (11)	<0.01
Gestational hypertension	318 (7)	162 (8)	86 (6)	70 (6)	<0.01
Any chronic condition^b	175 (4)	88 (4)	33 (2)	54 (5)	<0.01
Received influenza vaccination in current season (verified)	785 (17)	10 (1)	770 (50)	5 (0)	<0.01
Received influenza vaccination in current season (self-report/verified)	945 (20)	14 (1)	900 (58)	31 (3)	<0.01
Ever previously vaccinated against influenza	636/2330 (27)	0/70 (0)	439/1,305 (34)	197/955 (21)	<0.01
Received influenza vaccination in a previous pregnancy^c	229/1433 (16)	0/40 (0)	203/785 (23)	26/608 (4)	<0.01
Receipt of influenza vaccination recommendation by healthcare provider	1,096 (24)	13 (1)	894 (60)	189 (17)	<0.01
Self-perceived health score
Median (interquartile range: 0.25, 0.75)	90 (80,99)	99 (90,100)	70 (50,80)	90 (80,100)	<0.01*
Heard of influenza prior to enrollment	2651 (57)	167 (8)	1,399 (90)	1,085 (96)	<0.01

^aIncome: (India: data not available; Thailand: Monthly income per capita ≥3,165 TBH; Peru: Monthly income per capita ≥338 soles). ^bDerived variable. ^cAmong those with a previous pregnancy and with self-response for vaccination (yes/no) (n = 1,433). * Kruskal–Wallis test (All other tested by Chi-square test).

Missing data: Education (n = 15), Marital status (n = 2), Occupation (n = 13), Have health insurance (n = 21), Monthly family income (n = 6), Number of people living in the household (n = 12), Number of ANC visits during pregnancy (n = 178), Number of children (n = 13), Proxy for vaccination (n = 9), Previously vaccinated (n = 2,318), Received vaccination in previous pregnancy (n = 1,442 of those who had a previous pregnancy: 2,874), Receipt of vaccination recommendation by a healthcare provider (n = 92), Self-perceived health score (n = 24), Heard of influenza prior to enrollment (n = 1).

Table 3. Attitudes about influenza illness among those who have heard of influenza prior to enrollment (n = 2,651)

		Sites
	Overall n = 2,651 n (%)	India n = 167 n (%)	Peru n = 1,399 n (%)	Thailand n = 1,085 n (%)	p-Value
How worried are you about getting sick with the flu?					<0.01
Very or somewhat worried	1,354 (51)	147 (88)	678 (48.5)	529 (49)
Not too worried or not worried at all	1,276 (48)	15 (9)	712 (51)	549 (51)
Unknown	18 (1)	5 (3)	7 (0.5)	6 (<1)
If a pregnant woman gets the flu, how likely is that the flu will harm her?					<0.01
Very or somewhat likely	2,258 (85)	153 (92)	1,104 (79)	1,001 (92)
Very or somewhat unlikely	211 (8)	8 (5)	162 (12)	41 (4)
Unknown	178 (7)	6 (3)	129 (9)	43 (4)
If a pregnant woman gets the flu, how likely is that the flu will harm her baby?					<0.01
Very or somewhat likely	2,282 (86)	157 (96)	1,097 (79)	1,028 (95)
Very or somewhat unlikely	160 (6)	3 (2)	129 (9)	28 (2)
Unknown	204 (8)	4 (2)	171 (12)	29 (3)

Note: Positive (“Very worried” and “Somewhat worried”; “Very likely” and “Somewhat likely”) and negative (“Not too worried” and “Not worried at all”; “Very unlikely” and “Somewhat unlikely”) answers have been collapsed.

Table 4. Attitudes about influenza vaccine among those who have heard of influenza and influenza vaccine prior to enrollment (n = 2,198)

		Sites
	Overall n = 2,198 n (%)	India n = 43 n (%)	Peru n = 1,240 n (%)	Thailand n = 915 n (%)	p-Value
How well do you think the flu vaccine works in protecting pregnant women from getting the flu?					<0.01
Very or somewhat well	1,735 (79)	43 (100)	853 (69)	839 (92)
Not too well or not at all	89 (4)	0 (0)	66 (5)	23 (2)
Unknown	370 (17)	0 (0)	317 (26)	53 (6)
How safe do you think flu vaccines are for pregnant women?					<0.01
Completely, very or somewhat safe	1,721 (78)	42 (98)	882 (71)	797 (87)
Completely, very or somewhat unsafe	118 (5)	1 (2)	53 (4)	64 (7)
Unknown	357 (16)	0 (0)	303 (24)	54 (6)
When a pregnant woman receives the flu vaccine, how well do you think the flu vaccine works in protecting her baby from the flu after her baby is born?					<0.01
Very or somewhat well	1,579 (72)	42 (98)	745 (60)	792 (87)
Not too well or not at all	180 (8)	1 (2)	120 (10)	59 (6)
Unknown	436 (20)	0 (0)	372 (30)	64 (7)
When a pregnant woman receives the flu vaccine, how safe do you think that the vaccine is for her baby?					<0.01
Completely, very or somewhat safe	1,638 (75)	43 (100)	835 (67)	760 (83)
Completely, very or somewhat unsafe	135 (6)	0 (0)	50 (4)	85 (9)
Unknown	423 (19)	0 (0)	353 (29)	70 (8)
Please indicate how much you agree or disagree with the following statement: Pregnant women should get the flu vaccine					<0.01
Agree	1,858 (85)	43 (100)	994 (80)	821 (90)
Disagree	136 (6)	0 (0)	81 (7)	55 (6)
Unknown	203 (9)	0 (0)	164 (13)	39 (4)
Do you think that a breastfeeding mother should get the flu vaccine if she did not receive it already while pregnant?					<0.01
Yes, she SHOULD	1,096 (50)	43 (100)	642 (52)	411 (45)
No, she should NOT	604 (28)	0 (0)	223 (18)	381 (42)
Unknown	496 (22)	0 (0)	373 (30)	123 (13)

Note: Positive (“Very well” and “Somewhat well”; “Completely safe”, “Very safe” and “Somewhat safe”; “Strongly agree” and “Agree”) and negative (“Not too well” and “Not at all”; “Completely unsafe”, “Very unsafe” and “Somewhat unsafe”; “Disagree” and “Strongly disagree”) answers have been collapsed.

Table 5. Predictors for influenza vaccination among pregnant women, crude OR, adjusted OR (using Peru data only (n = 1,240), with self-reported or verified vaccination variable as dependent variable)

	Vaccinated n (%)	Unvaccinated n (%)	Crude OR (95% CI)	Adjusted OR (95% CI)
All	733 (59)	507 (41)
Age-group
18–34	605 (83)	419 (83)	Ref	Ref
≥35	128 (17)	88 (17)	1.04 (0.75,1.45)	1.34 (0.89,2.01)
Education
None/Primary	45 (6)	30 (6)	Ref	Ref
Secondary	412 (56)	296 (58)	0.81 (0.46,1.44)	0.74 (0.37,1.46)
Post-secondary/University	276 (38)	180 (36)	0.85 (0.48,1.52)	0.75 (0.36,1.54)
Marital status
Married/living together	622 (85)	426 (84)	Ref	Ref
Single/Divorced/Separated/Widow	109 (15)	81 (16)	0.93 (0.65,1.32)	0.85 (0.55,1.31)
Occupation
Does not work outside home	510 (70)	360 (71)	Ref	Ref
Works outside home	222 (30)	147 (29)	0.97 (0.73,1.27)	0.79 (0.57,1.09)
Has health insurance	556 (76)	358 (71)	1.24 (0.93,1.64)	1.23 (0.88,1.73)
Monthly per capita income
Below poverty line	409 (56)	305 (60)	Ref	Ref
Above poverty line	324 (44)	202 (40)	1.25 (0.97,1.62)	1.38 (1.01,1.88)
Number of people living in the household
0–2	355 (48)	252 (50)	Ref	Ref
3–4	223 (30)	170 (34)	0.97 (0.74,1.29)	1.19 (0.82,1.73)
5+	153 (21)	81 (16)	1.25 (0.88,1.77)	1.27 (0.84,1.92)
Number of ANC visits during pregnancy
0–4	183 (25)	167 (33)	Ref	Ref
5–7	237 (32)	140 (28)	1.69 (1.23,2.32)	1.43 (0.99,2.07)
8+	301 (41)	157 (31)	1.75 (1.29,2.38)	2.41 (1.39,2.87)
Number of children
0	346 (47)	214 (42)	1.47 (1.06,2.04)	1.96 (1.23,3.12)
1	250 (34)	170 (34)	1.28 (0.91,1.8)	1.61 (1,2.58)
2+	134 (18)	122 (24)	Ref	Ref
Gestational diabetes	16 (2)	15 (3)	0.64 (0.31,1.32)	0.56 (0.23,1.34)
Gestational hypertension	41 (6)	30 (6)	0.95 (0.58, 1.58)	1.22 (0.68, 2.22)
Any chronic condition	20 (3)	9 (2)	1.96 (0.77,4.99)	2.16 (0.71,6.64)
Previously vaccinated against influenza	261 (36)	170 (34)	1.07 (0.82,1.38)	1.02 (0.75,1.38)
Receipt of influenza vaccination recommendation	568 (77)	161 (32)	7.55 (5.69,10.0)	8.25 (6.11,11.14)
Self-perceived health score, Median (interquartile range: 0.25, 0.75)	70 (50,80)	70 (60,85)	0.99 (0.99,1.00)	0.99 (0.99,1.00)
Worried about getting sick with influenza
Very or somewhat worried	360 (49)	246 (49)	0.98 (0.77,1.26)	0.8 (0.59,1.09)
Not worried	369 (50)	258 (51)	Ref	Ref
Unknown	4 (0.55)	2 (0.4)	2.57 (0.29,23.1)	5.5 (0.46,65.9)
Perception that influenza could harm a pregnant woman
Very or somewhat likely	582 (79)	397 (78)	1.09 (0.74,1.6)	1.04 (0.62,1.74)
Very or somewhat unlikely	85 (12)	61 (12)	Ref	Ref
Unknown	63 (9)	48 (9)	0.99 (0.57,1.71)	0.89 (0.42,1.89)
Perception that influenza could harm her baby
Very or somewhat likely	581 (79)	398 (79)	0.96 (0.62,1.47)	1.17 (0.65,2.09)
Very or somewhat unlikely	65 (9)	48 (9)	Ref	Ref
Unknown	86 (12)	61 (12)	0.98 (0.57,1.69)	1.2 (0.57,2.53)
Perception of protection provided by influenza vaccine for pregnant women
Very or somewhat well	508 (69)	345 (68)	1.32 (0.74,2.34)	1.13 (0.53,2.41)
Not too well or not at all	31 (4)	35 (7)	Ref	Ref
Unknown	193 (26)	124 (24)	1.41 (0.76,2.59)	1.52 (0.66,3.5)
Perception of protection provided by maternal receipt of influenza vaccine for baby
Very or somewhat well	444 (61)	301 (59)	1.46 (0.95,2.24)	1.18 (0.67,2.08)
Not too well or not at all	58 (8)	62 (12)	Ref	Ref
Unknown	229 (31)	143 (28)	1.53 (0.96,2.42)	1.33 (0.69,2.58)
Perception of influenza vaccination safety for pregnant women
Completely, very or somewhat safe	526 (72)	356 (70)	0.93 (0.48,1.79)	0.72 (0.3,1.71)
Completely, very or somewhat unsafe	28 (4)	25 (5)	Ref	Ref
Unknown	178 (24)	125 (25)	0.93 (0.46,1.84)	0.53 (0.21,1.36)
Perception of maternal influenza vaccination safety for baby
Completely, very or somewhat safe	497 (68)	338 (67)	1.46 (0.75,2.83)	2.23 (0.95,5.25)
Completely, very or somewhat unsafe	25 (3)	25 (5)	Ref	Ref
Unknown	210 (29)	143 (28)	1.56 (0.79,3.11)	2.29 (0.91,5.74)