Health and Social Development, Faculty of (Okanagan)
Nursing, School of (Okanagan)
DSpace
UBCO
Dorn, Karyann
Master of Arts - MA
University of British Columbia
An active pandemic is a global crisis, COVID-19 began in the winter of 2019 and is responsible for over 6.9 million deaths worldwide (WHO, 2023). The most effective option for preventing hospitalization and mortality due to the global pandemic is the new COVID-19 vaccine. Pregnant persons at high risk for COVID-19 were given conflicting advice during the early vaccine roll-out due to a lack of data from the original trials. Limited vaccine safety data for pregnancy made them more vulnerable to misinformation on social media. This qualitative descriptive study aimed to clarify the perceptions and concerns of pregnant individuals residing in British Columbia who received or were hesitant towards a COVID-19 vaccine during pregnancy, and to situate their responses in relation to the broader challenges of the global health crisis. By describing their perceptions, beliefs, and concerns, the participants in this study contributed to understanding the influences that deter or encourage receiving the COVID-19 vaccine during pregnancy. In the fall of 2021, 25 pregnant British Columbians were interviewed using a semi-structured interview guide. The health belief model was used to analyze the data, which focused on participants' perceptions of COVID-19 susceptibility and severity, benefits and barriers to vaccines, and cues to action. Similar to pregnant people worldwide, they faced difficulty in deciding to receive the new COVID-19 during an active pandemic. Participants described it as a “very difficult decision,” and their “biggest fear is the effects on the unborn baby.” Their responses showed they recognized their susceptibility to COVID-19, even if they disagreed with its severity. Traditional constructs of the health belief model, such as cues from family and friends, were less influential on participants’ vaccine choices, and disinformation from social media influencers has created a modern barrier to receiving vaccines during pregnancy. Another influential factor was “the health practitioner who took time to validate their concerns” and “were invested and did not laugh at their fears.” COVID-19 vaccines will become seasonal, and promotional materials should emphasize the risks of the virus and that the vaccine is safe during pregnancy. The clinical recommendation is to advocate for patient-centered care: a maternity healthcare practitioner who will make time to listen and answer questions on the vaccine using transparency.
Perception Of COVID-19 Vaccines Among Pregnant People in BC: A Qualitative Study by Karyann Dorn B.A., University of Lethbridge, 2007 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE COLLEGE OF GRADUATE STUDIES (Interdisciplinary Studies) (Global Studies) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) August, 2023 © Karyann Dorn, 2023 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis/dissertation entitled: Perceptions Of COVID-19 Vaccines Among Pregnant People in BC: A Qualitative Study submitted by Karyann Dorn in partial fulfillment of the requirements of the degree of Master of Arts . Dr. Marie Tarrant – School of Nursing, FHSD Supervisor Dr. James Rochlin – Department of Economics, Philosophy and Political Science, FASS Supervisory Committee Member Dr. Elizabeth Keys – School of Nursing, FHSD Supervisory Committee Member Dr. Laura A. Meek – Department of Community, Culture and Global Studies University Examiner Click or tap here to enter text. iii Abstract An active pandemic is a global crisis, COVID-19 began in the winter of 2019 and is responsible for over 6.9 million deaths worldwide (WHO, 2023). The most effective option for preventing hospitalization and mortality due to the global pandemic is the new COVID-19 vaccine. Pregnant persons at high risk for Covid-19 were given conflicting advice during the early vaccine roll-out due to a lack of data from the original trials. Limited vaccine safety data for pregnancy made them more vulnerable to misinformation on social media. This qualitative descriptive study aimed to clarify the perceptions and concerns of pregnant individuals residing in British Columbia who received or were hesitant towards a COVID-19 vaccine during pregnancy, and to situate their responses in relation to the broader challenges of the global health crisis. By describing their perceptions, beliefs, and concerns, the participants in this study contributed to understanding the influences that deter or encourage receiving the COVID-19 vaccine during pregnancy. In the fall of 2021, 25 pregnant British Columbians were interviewed using a semi-structured interview guide. The health belief model was used to analyze the data, which focused on participants' perceptions of COVID-19 susceptibility and severity, benefits and barriers to vaccines, and cues to action. Similar to pregnant people worldwide, they faced difficulty in deciding to receive the new COVID-19 during an active pandemic. Participants described it as a “very difficult decision,” and their “biggest fear is the effects on the unborn baby.” Their responses showed they recognized their susceptibility to COVID-19, even if they disagreed with its severity. Traditional constructs of the health belief model, such as cues from family and friends, were less influential on participants’ vaccine choices, and disinformation from social media influencers has created a modern barrier to receiving vaccines during pregnancy. Another influential factor was “the health practitioner who took time to validate their concerns” and iv “were invested and did not laugh at their fears.” COVID-19 vaccines will become seasonal, and promotional materials should emphasize the risks of the virus and that the vaccine is safe during pregnancy. The clinical recommendation is to advocate for patient-centered care: a maternity healthcare practitioner who will make time to listen and answer questions on the vaccine using transparency. v Lay Summary This study surveyed British Columbians about their COVID-19 experiences and vaccine perceptions during pregnancy. Pregnant people had to consider the risk of exposure each time they left the house, as well as the risk to their baby's health. In fall 2021, participants noted that, like many pregnant people worldwide, they recognized COVID-19 as a health risk when making their vaccine decision, but that the vaccines were new and had limited information. Deciding to get the vaccine or remain at risk was difficult, as they had to decide for their baby as well. With so much COVID-19 info online, it was difficult to tell fact from fiction. Honest conversations with medical professionals were the most influential factor in understanding the virus' risks and the vaccine's safety during pregnancy. This study highlighted the need for educational materials to explain vaccine safety during pregnancy. vi Preface This Thesis is original work but has been made possible with assistance from the UBC project “Vaccine Hesitancy in BC: Understanding COVID-19 Vaccine Perceptions During Pregnancy, Breastfeeding, and Parenthood.” For this larger project I conducted research that focused on pregnancy through 25 semi-structured interviews between September and October 2021. This research has been approved by the University of British Columbia’s Behavioural Research Ethics Board (#H21-01543). Preliminary research was shared in May of 2022 at the national community health nursing conference (CHCN2022). Advertisements seen in this thesis was created by the knowledge mobilization coordinator Winona Phillips. vii Table of Contents Abstract .................................................................................................................................... iii Lay Summary ............................................................................................................................ v Preface ...................................................................................................................................... vi Table of Contents .................................................................................................................... vii List of Figures ......................................................................................................................... xii Acknowledgements ............................................................................................................... xiii Dedication .............................................................................................................................. xiv Chapter 1: Background, Problem and Significance ................................................................ 1 1.1 Introduction ............................................................................................................... 1 1.2 Background .............................................................................................................. 6 1.2.1 COVID-19 Vaccine Development ........................................................................ 7 1.2.1.1 Concerns and Fears about COVID-19 Vaccine ........................................... 9 1.2.1.2 COVID-19 Vaccine Efficacy ........................................................................10 1.3 Pregnancy and COVID-19 Infection .........................................................................11 1.3.1 COVID-19 Vaccines in Pregnancy .....................................................................12 1.3.2 Disinformation and Misinformation .....................................................................14 1.3.3 The Importance of HCPs ....................................................................................17 1.4 Research Problem ...................................................................................................19 1.4.1 Significance of the Problem ...............................................................................19 1.4.2 The Purpose Statement .....................................................................................21 1.5 Theoretical Framework ............................................................................................22 1.5.1 The Health Belief Model .....................................................................................22 1.5.1.1 The HBM within the research design ..........................................................24 1.6 Overview of this Thesis ............................................................................................24 Chapter 2: Methodology ........................................................................................................26 viii 2.1 Qualitative descriptive healthcare research..............................................................26 2.2 Research design ......................................................................................................28 2.2.1 Participants and Sampling .................................................................................28 2.2.2 Data Collection ..................................................................................................29 2.2.2.1 Audio recordings ........................................................................................30 2.2.2.2 Transcription ..............................................................................................31 2.2.2.3 Data management ......................................................................................31 2.2.3 Data analysis .....................................................................................................32 2.2.3.1 Directed Content Analysis ..........................................................................32 2.2.3.2 Creating findings ........................................................................................35 2.3 Ethical Considerations .............................................................................................35 2.4 Rigour and Reflexivity ..............................................................................................36 2.5 Plans for Results .....................................................................................................38 Chapter 3: Results ................................................................................................................39 3.1 Demographics .........................................................................................................39 3.2 Research Question 1: What are the concerns of pregnant people regarding the risks and outcomes of COVID-19 infection during pregnancy? ..................................................42 3.2.1 Perceived Susceptibility .....................................................................................43 3.2.1.1 COVID-19 Exposure Risks .........................................................................44 3.2.1.1.1 Increased case numbers and new variants ...........................................44 3.2.1.1.2 Exposure from outside factors beyond control ......................................45 3.2.2 Perceived Severity .............................................................................................46 3.2.2.1 Worry and anxiety about contracting COVID-19 .........................................46 3.2.2.2 Perceptions on age and natural immunity ...................................................49 3.3 Research Question 2: What beliefs do pregnant people hold regarding the benefits and barriers of being vaccinated for COVID-19 during pregnancy? ...................................50 ix 3.3.1 Perceived Benefits .............................................................................................51 3.3.1.1 COVID-19 Vaccines are safer than the COVID-19 virus .............................51 3.3.1.2 Vaccines and returning to normalcy ...........................................................52 3.3.1.3 Confidence and trust in the science of vaccines .........................................52 3.3.2 Perceived Barriers .............................................................................................53 3.3.2.1 The COVID-19 vaccines were developed quickly .......................................54 3.3.2.2 Unknown risks caused by the vaccine ........................................................55 3.3.2.3 Indecisive feelings about the COVID-19 vaccines ......................................56 3.4 Question 3: What are the major influences on a pregnant individual's health beliefs and behaviours regarding the COVID-19 virus and vaccinations? .....................................57 3.4.1 Cues to action ....................................................................................................58 3.4.1.1 Interactions and discussion with HCPs .......................................................59 3.4.1.1.1 Information from a knowledgeable HCP ...............................................60 3.4.1.1.2 Hesitancy from the HCP .......................................................................63 3.4.1.2 Information Sources on COVID-19 .............................................................64 3.4.1.2.1 Information from social media ...............................................................65 3.4.1.2.2 Information from Traditional Media .......................................................67 3.4.1.3 Discussing vaccines with friends and family ...............................................68 3.4.1.3.1 Taboo Topic .........................................................................................68 Chapter 4: Chapter 4: Discussion and Conclusion ................................................................69 4.1 Summary of the results ............................................................................................69 4.2 Discussion: ..............................................................................................................70 4.2.1 Risks of COVID-19 infection during pregnancy ..................................................71 4.2.2 Benefits and barriers of being Vaccinated for COVID-19 during pregnancy .......75 4.2.3 The influences on Health behaviours during COVID-19 and Vaccine decisions .78 4.2.3.1 Influence of conversations with HCPs ........................................................78 x 4.2.3.2 The Influences of social media ...................................................................80 4.2.3.3 Influences from friends and family ..............................................................84 4.3 Recommendations ...................................................................................................87 4.4 Limitations ...............................................................................................................88 4.5 Reflexivity ................................................................................................................90 4.5.1 The interview process ........................................................................................90 4.5.2 Analysis process ................................................................................................91 4.6 Conclusions .............................................................................................................92 Appendix A Advertisements ............................................................................. 114 Appendix B Qualitative Interview Guide – Pregnant People ............................. 117 Appendix C Directed content analysis. ............................................................. 121 xi List of Tables Table 1 Health Belief Model .........................................................................................................23 Table 2 Demographics .................................................................................................................42 xii List of Figures Figure 1 Sample of Code Categories ........................................................................................34 Figure 2 Susceptibility and severity ...........................................................................................43 Figure 3 Benefits and Barriers ...................................................................................................51 Figure 4 Cues to Action .............................................................................................................58 Figure 5 Advertisement 1 ........................................................................................................ 114 Figure 6 Advertisement 2 ........................................................................................................ 115 Figure 7 Advertisement 3 ........................................................................................................ 116 Figure 8 Full content analysis .................................................................................................. 121 xiii Acknowledgements I wish to take this opportunity to thank my thesis committee members, Dr. Marie Tarrant, Dr. James Rochlin, and Dr. Elizabeth Keys, for sharing their knowledge and experience throughout the many phases of this process. Special thanks to Dr. Marie Tarrant, my supervisor, for her continual encouragement, support and inspiration that kept this project going. I want to thank Stephanie Masina and Noni Philips for their incredible assistance and hard work overseeing the Study team. It is important to acknowledge that the work in this thesis reflects a small portion of the larger project conducted on COVID-19 vaccine research; the promotional materials and assistance came from Noni, and Stephanie Masina oversaw lab management. The results and final thesis write-up are my own work, but I am thankful for the support and encouragement from the project team. Lastly, I would like to acknowledge the participants for discussing COVID-19. The pandemic was emotional, and everything we knew about the virus was evolving daily. Their vulnerable descriptions are a snapshot from when cases were high and hospitals in the province were over capacity. Thank You! xiv Dedication For my muses, Morgan King and Cheniese Bender! Starbucks for making their triple shot lattes a little too strong; I may never have finished without them. In loving memory of my dad, who suggested I return to school, and my mom and brother for supporting this dream. A massive shout out to the OKRD roller derby team, specifically Riot, for her coaching experience and offence plays for the thesis defense. To my ex-husband, who made space for research insanity. Thanks for remaining friends; Best of luck to your future. Finally, to Andrew Wakefield, you got it wrong. I was not vaccinated for whooping cough, I almost died on my 25th birthday because I became infected. I have autism and ulcerative colitis, and I am amazing. Stop spreading lies and demonizing neurodivergent people! 1 Chapter 1: Background, Problem and Significance 1.1 Introduction Coronavirus infection during pregnancy increases the risk of severe disease and mortality (WHO, 2022), and the best option to prevent severe outcomes is to promote vaccination. While COVID -19 vaccines are safe to receive during pregnancy (Male, 2021), pregnant individuals are concerned about the safety of COVID-19 vaccines and have been reluctant to get vaccinated (Skjefte, et al., 2021). Furthermore, early in the pandemic, pregnant people received conflicting information from public health officials because of the limited data on vaccines and misinformation online suggesting that the COVID-19 vaccines caused miscarriage, infertility, and other complications (Lu-Culligan & Iwasaki, 2021) This qualitative descriptive study aimed to clarify the perceptions and concerns of pregnant individuals residing in British Columbia who received or were hesitant towards a COVID-19 vaccine during pregnancy, and to situate their responses in relation to the broader challenges of the global health crisis. There was an immediate need to ask pregnant people to describe their healthcare experiences and allow them to discuss the gaps they have faced or the reasons contributing to their COVID-19 vaccine hesitancy. COVID-19 was a global pandemic, and mRNA COVID-19 vaccines were and continue to be the most effective methods for preventing hospitalizations and mortality from the virus. Vaccines were key to ending lockdowns, quarantines, and strict public health regulations during a period of global uncertainty. As of May 2023, the virus is responsible for an estimated 6,927,378 deaths (WHO, 2023). Although the world is no longer in a state of emergency, the virus continues to mutate and spread (WHO, 2023), and pregnant people still remain at risk for contracting the virus during their pregnancy. 2 In this thesis, I report the findings of a study conducted between September and October 2021 to describe the perceptions of pregnant people toward COVID-19 and COVID-19 vaccines during pregnancy. This qualitative descriptive study aimed to describe the perceptions, attitudes, beliefs, and concerns of pregnant persons who were navigating their daily lives during the global pandemic and their decisions to receive a COVID-19 vaccine during pregnancy. This qualitative health research study addresses the following central research question: What are the perceptions of pregnant persons toward COVID-19 which contributed to receiving or refusing the new COVID-19 vaccines? While focusing on participants from British Columbia, the goal was to understand the influences that contributed to encouraging confidence in receiving the COVID-19 vaccine during pregnancy. Before going further, I want to start with the research practice of reflexivity, and share my positionality. This important step provides a broader examination of power, bias and lived experiences that may influence the lens used throughout the research process (Lee, Collins, & Simon-Kumar, 2021). Within healthcare research, there is a need to acknowledge the fluid identity created by being a practitioner with both lived and working experiences (Rushton, 2022). As a health care professional with a background in pharmacy, my focus in this study was understanding the nuance of COVID-19 vaccine hesitancy among pregnant persons. While I was able to draw upon my clinical expertise and knowledge of pharmaceutical sciences and patient-centered care, I have to acknowledge that I came into this study as a strong supporter of all vaccines, especially the COVID-19 vaccines. While I recognized the critical importance of evidence-based decision-making, this study aimed to explore this vulnerable population's perspectives, concerns, and information-seeking behaviours toward COVID-19 vaccination. 3 I acknowledge that my positionality might introduce both biases and strengths to my research. While my background provided an informed lens through which I approached this study, I was committed to mitigating potential biases through reflexivity, reviewed again in chapters two and four. I also recognize that alternative healthcare practices and research disciplines may use different methods and data translations, and this was explored under limitations through a comprehensive exploration of diverse perspectives. By actively engaging with the perceptions and experiences of pregnant individuals from various backgrounds, I tried to foster an inclusive and culturally sensitive understanding of COVID-19 vaccine hesitancy. Hill Collins and Bilge (2016) have noted that large events are rarely shaped by one factor, and they suggest a praxis of inquiry should include intersectionality, that conditions of social, political, and self in life are diverse and mutually influencing. In this way, I acknowledge that I am also an interdisciplinary scholar, and this is like carrying every piece of knowledge you have gleaned and taking it forward into your next research project. I have had many diverse roles beyond pharmacy. Including anthropology field school in Ecuador, working for travel Alberta, civilian with command for the Canadian military and working on research for the Canadian government on topics of sexual violence. These equally have shaped my values and contribute to mutually overlapping influences on my research. An active pandemic is a global event, therefore examining the descriptions provided by the participants was only the first step, and in order to enrich the topic further I have considered the intersectional praxis of inquiry using an interdisciplinary approach. It is important within this project to go beyond simply applying two disciplines to address a complex problem (Augsburg, 2006). Rather, an interdisciplinary approach creates a more comprehensive perspective, in which two or more disciplines complement each other to address the research question (Newell, 2001). 4 The literature throughout this thesis study draws from many disciplines including social psychology, nursing, health informatics, history, and clinical practices. For this thesis study, I focused on examining how pregnant persons experienced COVID-19, but I also envision an idea of being pregnant during the pandemic that is not limited by borders. The experiences of participants from British Columbia may be compared and contrasted with the many maternal vaccine studies from around the world, with many diverse and mutually influencing perceptions. Nimako and Kruk (2021), noted that regardless of a country’s income level, the pandemic forced attention directly on the struggles and vital importance of health systems. There was a strong global or macro level of health experts’ responses to the pandemic, that was then passed down to a meso level where execution of pandemic action was reliant on a national/subnational response influenced by often ambitious politics and subject to policy, before being executed on a micro or local level, which was limited to local supply and available care. Contemporary health promotion is local in access directly affecting our primary health outcomes, but health promotion is also embedded in public health messaging, which is formalized using globalized knowledge (Labonte & Laverack, 2008). In the case of a pandemic, globalization came from the messaging developed by the World Health Organization (WHO), which set out manageable guidelines from health experts, but glocalization for guidelines were managed by national governments and regionalized health authorities, who took into consideration local politics, social movements, cultural values, and current underlining health inequalities that already existed (WHO, 2023). This adds global studies to the research, and an opportunity to investigate both global and local decisions made during COVID-19 and to acknowledge the influences this may have had on pregnant people making the decision to 5 vaccinate. The end goal of this study was not to modify policies and procedures, or to devise a solution to the extensive global health issue of COVID-19. Rather, there is a need to simply listen to the experiences and perceptions of pregnant individuals to place their descriptions into the larger global context, as this may give us an understanding of their health beliefs and motivations and contribute to the global data on maternal vaccination. Although the COVID pandemic is no longer considered a global emergency, the virus is still present and spreading in our communities, and the results from this study may be useful for future campaigns to promote seasonal vaccines administered to pregnant people. I also need to acknowledge upfront the challenge of researching the perceptions of pregnant people regarding COVID-19 vaccines while the pandemic was unfolding. The initial literature review was conducted in April 2021, in-depth interviews were conducted in September and October 2021, and data analysis was completed between December 2021 and June 2022. During this period, new research has been published daily. One report noted that approximately 4% of all published research in 2020 was related to COVID-19, with upwards of 200,000 articles published before December 2020 (Else, 2020). Furthermore, information regarding public health measures and recommendations for vaccinations has changed rapidly. Therefore, in this thesis, I primarily focused on the literature on COVID-19 vaccines and vaccination during pregnancy. To assist in contextualizing this rapidly evolving body of research, I also reviewed studies that explored perceptions of more established vaccines administered during pregnancy, such as influenza and pertussis. After collecting and analyzing the data, I returned to review the studies published during the study period and continued adding new information. It is also important to acknowledge that, with the rapid and constant publication of new research, I may not have 6 reviewed all relevant studies on COVID-19 vaccines and pregnancy. However, I hope that I have provided a fair overview for the final version of my thesis. 1.2 Background Cases of pneumonia of unknown etiology were first reported in Wuhan, China, between December 19, 2019, and January 5, 2020 (WHO, 2020). The disease was quickly isolated and identified by Chinese scientists as a severe acute respiratory syndrome (SARs) caused by a novel coronavirus (COV) (Chan, et al., 2020), and has subsequently been named corona (CO) virus (VI) disease (D) 2019, but is referred to as COVID-19 (WHO, 2020; CDC, 2019-2021). In addition, early data collection and contact tracing in Wuhan indicated that most patients were zoonotically infected (animal-to-human contact) through interactions in the Huanan seafood market (WHO, 2020). On January 14, 2020, the WHO determined COVID-19 can be transmitted through person-to-person contact (WHO, 2020), and the Global Outbreak Alert and Response Network (GOARN) initiated the preparedness procedures for severe viral outbreaks. COVID-19 was declared a global pandemic on March 11, 2020 (WHO, 2020). A pandemic is defined as an "epidemic occurring over an extensive area, crossing international boundaries, and usually affecting a large number of people" (Porta & International Epidemiological Association, 2008;2014) On March 13 2020 the WHO reported early morbidity and mortality data from Europe, showing that global cases of COVID-19 had reached more than 132,000, with 5,000 deaths across 123 countries (WHO, 2020). The declaration of a global pandemic led to global lockdowns, the curtailment of international and domestic travel, and curfews. Nevertheless, the spread of the infection continued, and the global death toll rose exponentially. On June 26, 2021, there were 3,912,420 reported deaths worldwide (Dong, Hongru, & Gardner, 2019-2022), and the death toll has continued to rise with estimates putting it well over 6.9 million (WHO, 2023). 7 Without an effective treatment or vaccine, COVID-19 overwhelmed hospitals, substantially increased the stress on healthcare practitioners (HCP) and led to disastrous outcomes. For example, HCPs in Italy and Spain had record-high mortality rates and had to make ethical decisions around the rationing of care based on a lack of supplies and the high demand for limited beds within intensive care units (Faggioni, Gonzalez-Melado, & Di Pietro, 2021). Frontline HCPs were putting their lives at risk, and studies show that COVID-19 has caused them to suffer stress, anxiety, depression, insomnia, and burnout (Lai, et al., 2020; Hu, et al., 2020; Pappa, et al., 2020; Shreffler, Petrey, & Huecker, 2020). Vaccination against the virus has been identified as the best option to decrease hospitalizations and prevent excess deaths (WHO, 2020). 1.2.1 COVID-19 Vaccine Development Vaccine technology aims to prevent an individual from getting sick from a virus or other pathogen that may cause moderate to severe illness. Davidson and Gale (2017) define vaccines as "biological preparations that, when introduced to the body, cause an individual to acquire immunity to a specific disease" (p. 8). Most vaccines safely introduce weakened or dead virus material into the body's immune system to develop immunological memory that subsequently protects the person if they are exposed to the virus in the future. The COVID-19 pandemic had created a race to produce a safe and effective coronavirus vaccine that would help end the pandemic, save lives, and prevent further damage to the global economy. Many scientists and pharmaceutical companies from around the world began researching possible vaccines for covid. By March of 2020, there were 232 candidate vaccines proposed for development, but only nine vaccines were approved for human clinical trials (Kashte, Gulbake, El-Amin III, & Gupta, 2021; WHO, 2021; Zimmer, Corum, Wee, & Kristoffersen, 2022). The Emergency Use Authorization (EUA) system was activated, allowing 8 these nine vaccines to rapidly start conducting human-based clinical trials (Kashte, Gulbake, El-Amin III, & Gupta, 2021). The EUA is legislation that was enacted in the early 1990s by the government in the United Kingdom as part of a pandemic preparedness plan, which allows pharmaceutical companies to reduce the standard 10 to 15 year time frame for vaccine clinical trials to 12 to 24 months (Kashte, Gulbake, El-Amin III, & Gupta, 2021). Similarly, in the United States of America (USA), operation warp speed was designed to develop and deploy COVID-19 vaccines as quickly and safely as possible (AJMC Staff, 2021). Before the COVID-19 vaccines, the fastest vaccine developed was for the mumps virus, which required five years of research and clinical trials before gaining approval (Marlow, Haber, Hickman, & Patel, 2020). On December 2, 2020, the UK became the first country to approve a COVID-19 vaccine from Pfizer/BioNTech (GOV.UK, 2020). This approval was followed by an announcement from the WHO on December 31, 2020, proposing regulatory guidelines for emergency listing for the Pfizer/BioNTech COVID-19 vaccine and declarations to ensure equitable global access to COVID-19 vaccines (WHO, 2020). On December 12, 2020, COVID-19 vaccines were made available for use in Canada under the EUA approval process (Government of Canada, 2021). Canada has approved vaccines developed by pharmaceutical companies Pfizer, Moderna, Janssen (Johnson & Johnson), and AstraZeneca. The Janssen (J & J) and AstraZeneca vaccines use viral vector technology, which combines a harmless virus with weakened genetic material from the COVID-19 virus (Government of Canada, 2021). After injecting a viral vector COVID-19 vaccine, the individual is exposing their immune system to the weakened genetic material from the coronavirus, and their immune system begins to produce protective antibodies that will help prevent future infection (Government of Canada, 2021). Pfizer and Moderna developed COVID-19 vaccines using the messenger ribonucleic acid (mRNA) process (CDC, 2022). 9 Researchers have isolated the DNA and RNA sequences of the coronavirus and synthesized RNA to replicate only harmless genetic material from the virus that will create an immune response. After injecting an mRNA COVID-19 vaccine, the individual cells begin to replicate harmless spike proteins, similar to the spike proteins found on the virus, which activate their immune system and produce antibodies that protect them if exposed to the COVID-19 virus (CDC, 2022). 1.2.1.1 Concerns and Fears about COVID-19 Vaccine On March 12, 2021, Denmark and Austrian health authorities reported that a batch of AstraZeneca COVID-19 vaccines caused thrombosis and pulmonary embolism (Wise, 2021). Although the European Medicines Agency, a decentralized agency of the European Union responsible for scientific evaluation supervision and safety monitoring of medications in the EU (European Medicines Agency : Science Medicines Health, 2022), determined that the side effects of blood clots were rare, eight countries within the European Union suspended or halted the use of COVID-19 vaccines from AstraZeneca (Wise, 2021). Subsequently, many European news outlets started reporting on the rise of thromboembolic events caused by the COVID-19 AstraZeneca vaccine, bringing this information to the public's attention (Wise, 2021). Similarly, six individuals who had received Janssen (J & J) vaccines suffered a rare cerebral venous sinus thrombosis, which was reported to the Vaccine Adverse Event Reporting System (VAERS) in the United States (CDC, 2021). These reports led to recommendations to pause the use of the Janssen (J & J) vaccines on April 13, 2021 (MacNeil, et al., 2021). Currently, the Government of Canada does not recommend the Janssen (J & J) vaccine to people who are pregnant (Government of Canada, 2021). Pfizer and Modern COVID-19 vaccines were the first mRNA vaccines to be used in humans (Dolgin, 2021). Many studies on vaccine hesitancy toward COVID-19 vaccines have 10 reported participants’ concerns about novel vaccines and fear of potential long-term side effects (Alabdulla, Reagu, Al-Khal, Elzain, & Jones, 2021; Goldman, et al., 2020; Kreps, et al., 2020; Latkin, Dayton, Yi, Colon, & Kong, 2021; Schmelz, 2021; Sherman, et al., 2021; Symyd, et al., 2021; Borriello, Master, Pellegrini, & Rose, 2021). Fears and concerns about the safety of mRNA vaccines have been frequently discussed on social media shortly after Pfizer and Moderna vaccines were approved (Boucher, et al., 2022). Using a natural language programming analysis, Boucher et al. (2022) searched for global tweets published in English and French on the social media platform Twitter. They found that 23.4% (n=146,191) of the tweets on vaccines were hesitancy-based, and the primary narrative on mRNA vaccines was that the technology has never been tested and could be harmful (Boucher, et al., 2022). These online discussions increased mistrust of science and skepticism about vaccines and may have contributed to the low rates of COVID-19 vaccine uptake globally. Despite the narrative around mRNA vaccines, this technology is not new, and researchers have been experimenting with mRNA since 1978, when scientists used liposomes to transport RNA from a rabbit into a mouse, successfully showing RNA replication (Dimitriadis, 1978). Since the early 2000s, several pharmaceutical companies have proposed mRNA processes for medical use, and mRNA vaccines are currently approved and available for veterinary markets (Dolgin, 2021). The mRNA COVID-19 vaccine's rapid development can be attributed to past research on the process of creating mRNA vaccines and the speed at which researchers isolated the novel coronavirus DNA. 1.2.1.2 COVID-19 Vaccine Efficacy Vaccination has been shown to be effective against COVID-19, especially against severe diseases, hospitalization, and death. As of December 14, 2020 there have been well over 98 million vaccine doses received by Canadians (Public Health Agency of Canada, 2022), with 11 91.128% of the population reporting at least one dose (Little, 2020-2023). Early data from the United Kingdom showed that the first dose of COVID-19 vaccine was 80% effective against hospitalization and death (Bernal, et al., 2021). While early studies from Pfizer/BioNTech suggested that the effectiveness of their vaccine in preventing covid infection was up to 95% after the second dose (Chagla, 2021), newer evidence clearly showed that COVID-19 vaccine effectiveness wanes over time (Nordstrom, Ballin, & Nordstrom, 2021; Skowronski, et al., 2022). In the first month after the second dose of a COVID-19 vaccine, an individual has 70-90% protection against the virus (Skowronski, et al., 2022). However, vaccine efficacy against infection declines to around 65% percent after 121 days (Nordstrom, Ballin, & Nordstrom, 2021). Newer mutated variants of the COVID-19 virus have also decreased vaccine efficacy, especially against infection. However, the original vaccines continue to provide substantial protection against hospitalization and death even with newer variants. Data from the British Columbia Centre for Disease Control (BCCDC) in February 2022 show that booster doses of COVID-19 vaccines increase protection against severe infection and hospitalization to 95% against the Delta variant and 90% against the Omicron variant (BC CDC, 2022). 1.3 Pregnancy and COVID-19 Infection The WHO states that while pregnant individuals are equally susceptible to covid infection as the general population, infection during pregnancy increases the risk of severe infection and the likelihood of preterm birth (WHO, 2022). Data from the first wave of the pandemic showed that approximately one-third (31.5%) of pregnant individuals were hospitalized with covid infection as compared to (5.8%) of non-pregnant individuals (Ellington, et al., 2020). Further information from the COVID-NET study tracking hospitalizations in the United States showed that 16.2 % of pregnant persons displaying covid symptoms had been admitted to the ICU with severe COVID-19 disease complications (Delahoy, et al., 2020).In addition, CANCOVID-Preg 12 (2022), a national system developed for tracking COVID-19 in pregnancy in Canada, showed 9879 reported cases of coronavirus infection during pregnancy up to January 1, 2022. However, they have not updated past this date because most testing for the virus is now conducted using rapid home tests and individuals are no longer required to report their health status. 1.3.1 COVID-19 Vaccines in Pregnancy Pregnant individuals were excluded from phase three clinical trials conducted by pharmaceutical companies seeking approval for their COVID-19 vaccines (Rasmussen, Kelly, Horton, & Jamieson, 2021; U.S FDA, 2020). This was not the first time pregnant people have been omitted from vaccine trials (Rubin, 2021), as exclusion from clinical trials for new medications and vaccines has historically been due to safety concerns for the foetus (Rasmussen, Kelly, Horton, & Jamieson, 2021). Thus, without evidence confirming that COVID-19 vaccines were safe during pregnancy, the medical and scientific community was cautious about making strong recommendations for vaccination (Rasmussen & Jamieson, 2020). However, having no evidence of safety is not the same as suggesting that the vaccines are unsafe; rather, it indicates that the vaccine cannot be recommended because the safety is unknown. Researchers and maternal medicine specialists worldwide have worked rapidly to develop necessary evidence to support recommendations for providing COVID-19 vaccines during pregnancy (Rasmussen & Jamieson, 2020). Two studies conducted before the new COVID-19 vaccines were available by researchers were interested in the possible vaccine hesitancy noted that pregnant participants were worried about receiving a vaccine because there were no human trials explicitly conducted with pregnant people (Mohan, Reagu, Lindow, & Alabdulla, 2021; Levy, Singh, Laura, & Malavika, 2021). One study from Qatar conducted between October and November 2020 with participants recommended delaying the rollout of the vaccine to the public and continuing with vaccine trials 13 that included pregnant people (Mohan, Reagu, Lindow, & Alabdulla, 2021). In their study conducted as the vaccines received approval in December 2020, Levy et al. (2021) identified a need for ongoing COVID-19 vaccine trials that included people with the capacity for pregnancy or trials that were pregnancy-specific to create short- and long-term safety data which they suggested could improve vaccine education and information (Levy, Singh, Laura, & Malavika, 2021). Pfizer and Moderna researchers also reported that pregnant people were inadvertently enrolled in clinical trials. These participants had received the vaccines and had since produced healthy babies, showing that the vaccines were safe (U.S FDA, 2020). Additionally, the registry studies from the V-safe pregnancy in the US (CDC, 2021) and the COVERED registry in Canada (COVERED, 2021) followed pregnant participants who chose to self-report their experiences and participate in follow-up for 12 months after receiving the vaccine. The preliminary findings from their studies showed that the new vaccines were safe to receive during pregnancy (Chambers, 2021; Shimabukuro, et al., 2021). Between the vaccine rollout in December 2020 and early March 2021, healthcare authorities provided conflicting recommendations because the evidence for the safety of the vaccine during pregnancy was rapidly changing. The first recommendations came from the WHO and identified pregnant or breastfeeding persons as those who should not receive a COVID-19 vaccine (WHO, 2020). However, in January 2021 the US CDC did not include pregnant people or people attempting pregnancy or breastfeeding as contraindications for receiving the mRNA COVID-19 vaccine (CDC, 2019-2021). In January, 2021 the American College of Obstetricians and Gynaecologists (ACOG) recommended that the decision to vaccinate during pregnancy be made case-by-case, based on an assessment and consultation 14 between the patient, physician, and healthcare team (American College of Obstetrician and Gynecologists, 2021). Later that same year, more evidence became available, and by March, 2021 the Society of Obstetricians and Gynaecologists of Canada (SOGC) released a statement that there were no contraindications to vaccination for pregnant persons and that COVID-19 vaccines are safe during pregnancy (SOGC, 2021). The recommendation to receive a COVID-19 vaccine during pregnancy resulted from an analysis of post-trial information showing the vaccine's safety in individuals who had inadvertently received the COVID-19 vaccine during pregnancy (Chambers, 2021; Shimabukuro, et al., 2021). 1.3.2 Disinformation and Misinformation The limited safety data for COVID-19 vaccines during pregnancy and the early conflicting vaccine recommendations from health authorities may have caused confusion and uncertainty in the decision to vaccinate. Individuals with negative views toward vaccines have used social media to spread vaccine disinformation, such as the mRNA of COVID-19 vaccines causing miscarriage and infertility (Lu-Culligan & Iwasaki, 2021). Similarly, findings from pre-Covid studies on vaccines in pregnancy, found that pregnant people often believe that vaccines during pregnancy can cause congenital defects and harm to the fetus, which leads them to reject vaccinations during pregnancy (Kay, Koelemay, Kwan-Gett, & Duchin, 2012; Tarrant, Wu, Yuen, Cheung, & Chan, 2013; Yudin, Salaripour, & Sgro, 2009). A review of 155 studies by Wilson et al. (2015) on the factors that influence vaccination acceptance during pregnancy found that safety was the focus in 41% (64/155) of the studies. More specifically, the authors noted that many of these concerns resulted from misconceptions regarding vaccine safety (Wilson, Paterson, Jarrett, & Larson, 2015). Similarly, the findings of a systematic review and meta-analysis by Bianchi et al. (2022) found that in 21 studies conducted during the pandemic on new vaccines administered during pregnancy, the majority showed that the reasons for vaccine refusal 15 were related to concerns about safety. The most common concern was a belief that there was a lack of information, that the vaccines were unsafe, and fears that unknown side effects may harm the foetus (Bianchi, et al., 2022). In another multi-country study, pregnant participants expressed safety concerns about potential unknown side effects and possible developmental issues that would only present later in the child’s life (Skirrow, Barnett, Bell, Riaposova, & Mounier-Jack, 2022). The researchers found that pregnant participants from the UK expressed a desire for absolute certainty that the vaccine would not harm their foetus or cause long-term effects, otherwise they would refuse the vaccine (Skirrow, Barnett, Bell, Riaposova, & Mounier-Jack, 2022). Researchers have found that anti-vaccine rhetoric suggesting that vaccines cause infertility and harm to fetal development is connected to and has evolved from previous anti-vaccine movements against other well-known vaccines, and that the rumours are recycled and updated to continue justifying anti-vaccine politics (Allen, 2007; LaSalle, 2020; Larson, 2020). For example, the MMR vaccine has been falsely connected to autism (Deer, 2010), and a later unfounded rumour linked the smaller head size in babies born to mothers infected with the Zika virus to the tetanus, diphtheria, and whooping cough (T-Dap) vaccine, which is also recommended during pregnancy (Larson, 2020). Previously, tetanus and polio vaccines were rumoured to actually be a program of intentional sterilization in Africa (Larson, 2020). There are also claims that mercury will harm the foetus if the influenza vaccine is given during pregnancy, and that HPV vaccines interfere with hormones in people of child-bearing age (LaSalle, 2020). The rumours produced by anti-vaccine messaging can persist for months or even years (Larson, et al., 2013). 16 In the era of social media, unfounded safety rumours about vaccines can rapidly go viral and reach millions of people (DiResta, 2018).The confusion of sharing information online is complex, inadvertent sharing of false information is known as misinformation, and happens when someone inadvertently shares misleading information. While disinformation is the creation and sharing of misleading information deliberately, with the aim of spreading a rumour (DiResta, 2018, p. 14). Fighting this disinformation as rapidly as it spreads is often futile (Larson, et al., 2013) because public health professionals and agencies usually have less funding, resources, and time than negative social media influencers whose goal is to gain large followings and discredit vaccine science (Allen, 2007). In an example from early in the pandemic, a person falsely claiming to be a Pfizer employee posted on a social media blog that antibodies elicited by the COVID-19 vaccine would attack the placenta of pregnant individuals (Male, 2021). While actual data released by Pfizer found no harmful effects of their vaccine on pregnant rats, and a separate study conducted using SARs-COV-2 IgG cord blood from newborns showed that a baby born to a mother given the Moderna vaccine at 36 weeks had protective COVID-19 antibodies (Glibert & Rudnick, 2021), the rumour persisted and led to substantial vaccine hesitancy in pregnant persons. There is clear evidence on the role social media has played in disseminating false information on COVID-19 vaccines, and that it has influenced pregnant individuals considering the vaccine. In a cross-sectional survey conducted in the United States, 33% of respondents cited their fear of the COVID-19 vaccine from the information they found online (Kreps, et al., 2020). Researchers indicated the importance pregnant participants placed on having sufficient knowledge and information as an influence for making the decision to vaccinate during pregnancy (Gencer, Ozkan, Okan, & Sercekus, 2021; Geoghegan, et al., 2021). An online 17 questionnaire conducted in Turkey found that 70.4% (n= 107) of the pregnant participants had a positive attitude to vaccinations and many self-reported confidences in their knowledge and had an intent to vaccinate (Gencer, Ozkan, Okan, & Sercekus, 2021). However, the researchers noticed that the main reason participants had hesitancies was due to hearing negative stories in the media or on the Internet, which created mistrust regarding the safety of the vaccine (Gencer, Ozkan, Okan, & Sercekus, 2021). Recognizing that pregnant study participants demanded more scientific evidence on vaccine safety early in the pandemic, Geoghegan et al. (2021) struggled to find legitimate sources of pregnancy-specific safety information. Findings from a study in Romania found that pregnant people were reluctant to receive the vaccine based on exposure to misinformation with 67.9% (n=125) indicating that they trusted vaccine misinformation obtained from social media (Citu, et al., 2022). 1.3.3 The Importance of HCPs During the pandemic emphasis has been made that HCP are the most trusted experts for reducing vaccine hesitancy (CDC, 2021). However, a recent qualitative study conducted in 2021 in Canada also found that half of the participants said that they did not talk to patients about COVID-19 vaccines unless specifically asked by the patient (Dube, et al., 2022). Their reluctance came from personal feelings that they should not play a role in promoting vaccines and the inadequacies surrounding their knowledge of the new vaccines (Dube, et al., 2022). Despite the challenges HCPs face with the lack of time and hesitancy when discussing vaccines with pregnant people, healthcare interactions are viewed as an important connection to conversing with honesty and have a significant impact on trust (Chervenak F. , et al., 2021). These HCP interactions have been highlighted as even more important for pregnant people who may have struggled to navigate healthcare during the global pandemic (Rasmussen, Kelly, Horton, & Jamieson, 2021). The current discussion within studies on COVID-19 vaccine’s 18 giving during highlight the crucial importance of HCPs toward creating trust and increasing vaccination for pregnant people during COVID-19 (Skjefte, et al., 2021; Ceulemans, et al., 2021; Desai, Kaur, Dong, & Rodriguez, 2021; Goncu Ayhan, et al., 2021). Sutton et al. (2021) suggested that patient education should come from HCP and experts; it should be accessible and uniform, and the researchers emphasize the need to increase health literacy on the dangers of pregnancy to communities that are most affected by higher exposure risks from the virus. Researchers have also recognized that individuals from black communities and communities with economic disparities have had higher mistrust issues towards the new vaccines, rooted in past medical testing a failure which affected their communities disproportionately (Batterbee, et al., 2021). Research on strategies to improve vaccine uptake for other routine vaccinations given in pregnancy has found that positive vaccine recommendations and accurate information from trusted HCPs is positively associated with vaccine uptake (Wilson, Paterson, Jarrett, & Larson, 2015; Bartolo, et al., 2019; Vilca, et al., 2020; Yuen & Tarrant, 2014). Researchers have also pointed to the importance of vaccine education that is culturally diverse and inclusive by providing translators and cultural appropriate messaging (Krishnaswamy, Cheng, Wallace, Buttery, & Giles, 2018).Previous research on increasing vaccine uptake during pregnancy has found that HCPs who offer vaccines onsite and are readily available at the same time as the appointment can significantly improve vaccine uptake (Ogburn, Eve, Espey, Contreras, & Arroyo, 2007; Mohammed, Mcmillan, Roberts, & Marshall, 2019; Bartolo, et al., 2019). However, research has also shown that HCPs often fail to recommend vaccines to their pregnant patients or do not have sufficient knowledge of vaccine recommendations during pregnancy, 19 thereby creating missed opportunities to vaccinate pregnant clients (Lutz, Carr, Cohn, & Rodriguez, 2018; Maher, et al., 2013; Yuen & Tarrant, 2014) 1.4 Research Problem Observational studies examining hospital admissions have confirmed that pregnant people with positive cases of COVID-19 have higher rates of adverse outcomes, morbidity, and mortality than their similar-aged non-pregnant peers (Villar, et al., 2021). Navigating the healthcare system and finding trustworthy information on vaccination have been difficult for pregnant persons during the pandemic (Rasmussen & Jamieson, 2020). The pandemic appears to be an unprecedented threat, potentially making pregnant people more willing to receive a COVID-19 vaccine. However, pregnant persons were excluded from the original clinical trials for new vaccines, which resulted in frequently changing recommendations for COVID-19 vaccination during pregnancy. The changing recommendations and the widespread disinformation on vaccines have led pregnant people to develop vaccine-related concerns. The changing recommendations and the wide spread of disinformation on the vaccines, led pregnant people to develop vaccine-related concerns. Thus, there is a need to explore and describe the concerns of pregnant people regarding COVID-19 infection and the COVID-19 vaccines to counter misleading information and promote vaccine confidence. 1.4.1 Significance of the Problem Historically, the primary reason cited for hesitancy around vaccination during pregnancy is safety, especially the safety of the foetus (Rasmussen S. A., et al., 2009; Lu, et al., 2012; Yudin M. H., 2014; Yuen & Tarrant, 2014; Bettinger, Greyson, & Money, 2016). In addition, previous studies on vaccine uptake showed low vaccination rates in pregnant person owing to safety concerns, inadequate patient education, and maternity healthcare providers’ failure to make routine recommendations on vaccination (Lu, et al., 2012). This longstanding maternal 20 vaccine hesitancy has been further exacerbated by conflicting information and rapid COVID-19 vaccine development (Skjefte, et al., 2021; Male, 2021). Pregnancy is a unique contextual factor, as it is a temporary state with a gestational period of nine months. While a non-pregnant person may receive a vaccine with confidence, pregnancy presents alternate and additional risks that can contribute to vaccine hesitancy and reluctance to receive a vaccine during pregnancy (Yuen & Tarrant, 2014). Historically, the majority of studies on maternal vaccine uptake have been conducted on seasonal influenza, pandemic H1N1 influenza, and pertussis vaccinations (Rasmussen S. A., et al., 2009; Lu, et al., 2012; Yudin M. H., 2014; Yuen & Tarrant, 2014; Bettinger, Greyson, & Money, 2016). Recent research from Australia on receiving vaccines during pregnancy has shown that pregnant people view themselves as the gatekeeper in making protective decisions regarding the safety of their foetuses (King, Chow, Leask, & Wiley, 2019). Many health and lifestyle choices are made during pregnancy, and pregnant people receive intense professional and public scrutiny influencing them to make safe choices (Bonhoeffer, et al., 2016). For example, pregnant people may modify their diet and avoid taking medication to protect the baby's development. With this in mind, the decision to receive a vaccine may seem counterintuitive and require caution (King, Chow, Leask, & Wiley, 2019). The challenge in deciding to vaccinate during pregnancy is the decision-making process between the risk of the disease and the benefits of prevention, and the perceived potential adverse events caused by the vaccine (Castillo, Patey, & McDonald, 2021; Bonhoeffer, et al., 2016; Arora & Lakshmi, 2021). Therefore, it is essential to recognize that concerns and perceptions towards vaccines in pregnancy are not the same as those found in the general population. 21 The COVID-19 pandemic and vaccines may represent the most extensive global vaccine campaign (Dube & MacDonald, COVID-19 vaccine hesitancy, 2022), and has provided researchers with the opportunity to explore the acceptance and refusal of COVID-19 vaccines at an immense scale. Multiple publications have shown that researchers have explored the global perceptions and concerns regarding receiving a COVID-19 vaccine. These studies included exploring the wiliness to vaccinate before the vaccines were developed and as well as studies conducted once the vaccines became available (Biswas, Alzubaidi, Shah, Abd-Alrazaq, & Shah, 2021; Machado, Roberts, Wong, van Kessel, & Mossialos, 2021; Aw, Seng, Seah, & Low, 2021). The gaps in the literature show that only a limited number of vaccine study publications focused on the perceptions pregnant people had toward the COVID-19 vaccines (Biswas, Alzubaidi, Shah, Abd-Alrazaq, & Shah, 2021; Machado, Roberts, Wong, van Kessel, & Mossialos, 2021). Furthermore, most of these publications use cross-sectional methods to explore the risk evaluations towards receiving the new vaccines during pregnancy. While these publications provided data on perceptions, the responses were closed-ended survey questions and written in responses with text limitations, which do not always provide participants with the opportunity to expand on their thoughts and perceptions. There remained an opportunity to conduct qualitative interviews that allowed people who are pregnant to provide rich descriptions of underlying perceptions, perceived risks and benefits, and their concerns about receiving a COVID-19 vaccine. 1.4.2 The Purpose Statement The purpose of this qualitative descriptive study was to describe the perceptions and concerns of pregnant persons residing in British Columbia who received a COVID-19 vaccine during pregnancy. By describing their perceptions, attitudes, beliefs, or concerns, participants in 22 this study may contribute to understanding influences that deter or encourage confidence to receive the COVID-19 vaccine during pregnancy. 1.5 Theoretical Framework The Health Belief Model (HBM) was used as a framework to facilitate data collection and analysis. The execution of a research study is shaped by the researcher's engagement with the literature and its use to guide the methods (Ravitch & Riggan, 2017). Frameworks assist in articulating assumptions, permitting the research to intellectually transition from describing a phenomenon observed to generalizing or highlighting key influencing concepts and previously defined circumstances readily found within the literature specific to the topic (Asher, 1984; Ravitch & Riggan, 2017). The framework, as well as its constructs and models, should be anchored to the research problem and appropriate to guide the investigation (Torraco, 1997; Ravitch & Riggan, 2017). 1.5.1 The Health Belief Model The HBM framework and constructs originated in social psychology in the 1950s. At that time, public health services shifted from disease treatment models to a preventative health focus to screen or detect asymptomatic diseases or prevent adverse health outcomes (Rosenstock I. M., 1974). The HBM has been used in research over the past six decades as a model for determining an individual's willingness to engage in preventative health behaviours. Traditional HBM constructs (Table. 1) are perceived susceptibility, severity, benefits, and barriers (Rosenstock, Stretcher, & Becker, 1988). In addition, cues to action were added by Hochbaum in 1958, which are described as internal and external triggers that remind an individual to perform health-promoting actions (Abraham & Sheeran, 2005; Hochbaum, 1958). According to Rosenstock (1974), if an individual feels susceptible to a health condition, they believe that the condition has potentially severe consequences, they believe health 23 behaviours will be beneficial in reducing the susceptibility or severity of the health outcome, and that the benefit outweighs potential barriers, they will be motivated to take the health action or engage in a health behaviour (Rosenstock, Stretcher, & Becker, 1988). In addition, cues to action, positive and negative reminders about the prevention may modify or indirectly influence the tendency to engage in health behaviours (Conner, Models of Health Behaviour, 2019). Health belief model constructs with definitions Construct Definition Perceived susceptibility The individual holds Beliefs about the likelihood of getting the disease or condition (Champion & Sugg Skinner, The Health Belief Model, 2008) Perceived severity Beliefs about the seriousness of contracting a disease or condition, including consequences (i.e., morbidity and mortality) (Rosenstock I. M., 1974; Champion & Sugg Skinner, The Health Belief Model, 2008) Perceived barriers Beliefs about obstacles or barriers to preventive action (i.e., the cost is too high, distance to locations for treatment) (Rosenstock I. M., 1974; Abraham & Sheeran, 2005) Perceived benefits Beliefs that deciding to accept the preventative health measure leads to increased positive health outcomes (i.e., health screening, receiving a vaccination) (Rosenstock I. M., 1974; Champion & Sugg Skinner, The Health Belief Model, 2008) Cues to action Information, and positive or negative factors that could trigger a reminder or influence the outcome (i.e., Media campaigns, healthcare practitioners providing reminders, discussing the vaccine with friends and family) (Rosenstock I. M., 1974; Champion & Sugg Skinner, The Health Belief Model, 2008) Table 1 Health Belief Model The HBM remains the most widely used theory for evaluating health behaviour interventions (Champion & Sugg Skinner, The Health Belief Model, 2008; Orji, Vassileva, & Mandryk, 2012). COVID-19 has reinvigorated the use of the HBM. Globally, researchers are 24 applying the HBM constructs to promote preventative measures for COVID-19, including health policy, vaccine research, and patient interactions in pharmacies (Carico, Sheppard, & Borden Thomas, 2021; Wong, et al., 2021; Jose, et al., 2021). In addition, the HBM has three decades of design and implementation research, which makes it replicable and applicable to the current COVID-19 vaccine context (Conner, Cognitive Determinants of Health Behavior, 2010; Orji, Vassileva, & Mandryk, 2012). 1.5.1.1 The HBM within the research design The HBM framework is used throughout this thesis to guide the literature review, data collection, and data analysis. The HBM was used to design questions for interviewing participants and to create deductive codes that assisted in the analysis of the descriptive responses. The constructs are further anchored by using three sub research questions: • To inquire perceived susceptibility and perceived severity; What are the concerns of pregnant people on the risks and outcomes of COVID-19 infection during pregnancy? • To inquire about perceived benefits and perceived barriers; What beliefs do pregnant people hold regarding the benefits and barriers of being vaccinated during pregnancy? • To inquire about cues to action; What are the major influences on a pregnant individual's health beliefs and behaviours regarding the COVID-19 virus and vaccinations? Most importantly, the HBM provided a common language defined in the constructs to frame the results and the discussion, on the perceptions and concerns of receiving COVID-19 vaccination during pregnancy. 1.6 Overview of this Thesis This thesis comprises four chapters that focus on the perceptions of COVID-19 infection and COVID-19 vaccination uptake among pregnant persons. In this Chapter, I presented an 25 overview of the pandemic and the development of COVID-19 vaccines and their use in pregnant persons, the purpose statement and research questions, the conceptual model, and a brief review of the background literature. In Chapter 2, I describe the details of the qualitative descriptive method, the interview process, the use of directed content analysis, and ethical considerations, and Chapter 3 presents the study results. Chapter 4 concludes the thesis with a discussion of the study findings and implications, reflexivity, limitations, and Chapter 5 is the conclusion. 26 Chapter 2: Methodology The previous chapter described the background and, significance of the problem, the milestones in the evolution of the pandemic and the development of the COVID-19 vaccines, and described the benefits of receiving a COVID-19 vaccine during pregnancy. I also outlined the research questions and provided an overview of the HBM framework. In this chapter I will discuss the methodology, including the research design, the participant recruitment strategy, the data collection and analysis procedures, and the ethical considerations. This study was designed to allow pregnant people to describe their perceptions and experiences of being pregnant during the COVID-19 pandemic and on receiving the COVID-19 vaccines. 2.1 Qualitative descriptive healthcare research I used a qualitative descriptive (QD) design for this study. A QD approach follows the general principles of natural inquiry (Lincoln & Guba, 1985). QD uses this naturalist paradigm to allow the researcher to be active in the process and apply their knowledge (Sullivan-Bolyai, Bova, & Harper, 2005; Parahoo, 2014; Neergaard, Olesen, Anderson, & Sondergaard, 2009). The ontological positions of QD comes from relativism, making the literal description of an event or phenomenon subjective (Parahoo, 2014; Sandelowski, 2010), and the epistemology uses subjectivism making the knowledge on the topic or phenomenon independent for each individual, with many interpretations that make up the reality, which may vary from person to person (Bradshaw, Atkinson, & Doody, 2017; Willis, Sullivan-Bolyai, Knafl, & Cohen, 2016). When these underpinnings are used the QD methodology design is pragmatic; descriptions of an event are given by participants, then these are summarized using interpretation by the researcher who applies their reflections and understanding to summarize the event (Sandelowski, 2010; 27 Colorafi & Evans, 2016). QD studies focus on low inference description and are amenable to health research because they provide responses on the health issue from the individuals perspective (Colorafi & Evans, 2016). Furthermore, QD allowed me to make use of a theoretical framework, and the embedded theory within the framework allows a starting point for gaining additional perspectives (Colorafi & Evans, 2017; Colorafi & Evans, 2016). The HBM framework anchored and guided the direction for my thesis, the framework was also applied to the study design. The HBM was used to create an interview guide and the HBM constructs contributed to the opening categories for the deductive coding analysis. Qualitative research in healthcare provides a myriad of information on healthcare systems, it looks at the processes and investigates the personal nature of the patient or individuals’ experiences within the healthcare system (Lamprell, Rapport, & Braithwaite, 2021). The QD approach is congruent to healthcare research because it provides a comprehensive summary of a healthcare topic using the language found in everyday terms (Sandelowski, 2000, p. 336), as described by individuals who are experiencing healthcare rather than applying clinical health jargon. Instead of producing conceptual knowledge or theories, qualitative descriptive approaches in healthcare research are used to find insights on the context of an issue or a possible gap in care (Chafe, 2017; Colorafi & Evans, 2016). The goals and outcomes are focused on immediate changes to improve the quality of health and healthcare practice (Chafe, 2017). This research study focused on the descriptions of pregnant people who provided their perspectives and vaccine decision making during the COVID-19 pandemic. and may provide recommendations for short-term solutions or immediate changes. Pregnant persons’ experiences of COVID-19 and healthcare practices during the pandemic were constantly changing, which made investigating this topic especially challenging. Therefore, this research investigates the 28 perspectives of this specific group during a specific time in the pandemic. However, pregnant people will remain at risk for contracting COVID-19 and its subvariants, and it is likely that seasonal doses will continue to be recommended. As the pandemic evolves, new vaccines may be developed. Therefore, the perspectives of our study participants, while reflecting their feelings on their personal susceptibility and the severity of COVID-19 during pregnancy, may evolve and change over time. 2.2 Research design I used the flexible guidelines provided by Colorafi and Evans (2016) on designing a qualitative descriptive research study, an approach which allows for a broad range design choices, such as the use of any framework, variable techniques for sampling, data collection and analysis methods, along with organization of descriptions and data (p. 17). In this section I will provide more detail and rationale on the choices I made for sampling, data collection, data analysis, ethical considerations, reflexivity, and rigor. 2.2.1 Participants and Sampling For this qualitative study, I focused on pregnant people, taking into consideration gender fluidity and including anyone with the capacity to be pregnant. While an individual may unquestioningly receive a vaccine when they are not pregnant, their pregnancy may present them with unique considerations (Yuen & Tarrant, 2014). Therefore, recruitment for this study used purposive sampling, at a participant level, with specified criteria to recruit appropriate participants (Creswell & Poth, 2018). I conducted this study within British Columbia looking for pregnant residents, at any stage in their pregnancy, and I was open to participants who received, delayed, or refused a COVID-19 vaccine. Disclosure of their vaccine status was not required for study participation. Recruitment used three strategies: (1) posters advertising the study in the prenatal unit at Kelowna General Hospital and at The Bridge Child and Family Services; (2) paid 29 advertisements on Facebook and Instagram between September and October of 2021; and (3) snowball sampling techniques whereby study participants were encouraged to promote the study to their pregnant peers (see Appendix A). I set the participant selection criteria to strengthen the rigor of my qualitative research and to ensure that the participants had experience with the topic being studied, while still ensuring that multiple perspectives were included (Creswell & Poth, 2018). The participant inclusion criteria for this study were: residing in the province of British Columbia; 18 years of age and over; pregnant at the time of interview; communicate effectively in English (level of proficiency did not exclude participation); and access to an internet-connected device. The participant exclusion criterion were: experienced major mental health problem or mood disorders; major pregnancy complications; or severe medical conditions not related to the pregnancy. The recruitment advertisement provided contact information and an email address (See Appendix A). Emails received from potential participants were reviewed with assistance from the study research coordinator. After this initial contact, I directly contacted potential participants for further eligibility screening. Participants were screened for location, pregnancy stage and status, medical and gestational complications, and availability. Once eligibility was confirmed, I provided the online link for the informed consent and scheduled the interviews. 2.2.2 Data Collection Using an open-ended interview guide based on the constructs of the HBM (see Appendix B), I conducted individual semi-structured interviews with each participant. Open-ended interview questions encourage responses beyond yes or no, and participants may describe events using their own words and examples (Kvale, 2007). The semi-structured interview format allowed the participants to share their perspectives and experiences, while I refocused the topic 30 towards the HBM constructs. I also used probing techniques such as asking participants to expand on details, requesting clarifications on terms they used, and inquiring about further thoughts and feelings (Alvesson, 2011). At the same time the guide was not rigid and allowed for spontaneity which occurs naturally in conversation (Galletta & Cross, 2013; Charmaz & Belgrave, 2012) The open-ended questions were modified from previous quantitative and qualitative research studies that used the HBM (Yuen, Dodson, & Tarrant, 2016) and focused on the participants’ knowledge of the disease, fears surrounding the disease, attitudes and beliefs on vaccines, sources of information searched, and interactions with HCP, family, and friends. The interview guide was developed to provide structure based on the theoretical framework and to facilitate the analysis (Ravitch & Riggan, 2017; Hsieh & Shannon, 2005, p. 1281). Each interview was thirty to ninety minutes in length, and after the first five interviews, based on participants’ comments and insights, some additions were made to the interview guide. After the first few interviews, I noticed that the participants discussed their perspectives on the proposed vaccine mandates and described their concerns about the increasing number of cases from the new circulating variants (i.e., the Delta variant). To maintain consistency, additional probs were added to encourage consistency and to continue discussions on the proposed vaccine mandates and variants of concern (Appendix B) 2.2.2.1 Audio recordings During the pandemic, due to restrictions on face-to-face interactions, researchers were not permitted to conduct in-person interviews. Protocols were established by the University of British Columbia Behavioural Research Ethics Board (BREB) to accommodate research while following public health guidelines. In accordance with this protocol, I conducted all the interviews using Zoom, a secure online video-based platform, from a private office in my home. 31 The participants used an internet connected device and comfortable space at their discretion, with the choice to have their video turned off. The interviews were conducted between September 1 and October 31, 2021, and were recorded using the Zoom software, and the recordings were stored according to the protocols set out by the University of British Columbia. For this study no video imagery was maintained and only audio was kept for transcription purposes. 2.2.2.2 Transcription Using the original audio recordings, the interviews were transcribed verbatim (Alvesson, 2011), using the automatic captioning feature in the Zoom software. I reviewed each audio file and transcript independently, making corrections and formatting the documents. Any information that could be used to identify a participant, such as names or locations, was removed from the transcripts. To improve readability in the results section I made minor adjustments to participant quotes, removing repeated words and improving grammar, while maintaining the original descriptions provided by the participants (Silverman, 1993; Galletta & Cross, 2013). The final transcripts were uploaded into the data management software and prepared for analysis. I reviewed the transcripts and audio multiple times, which helped to create familiarity with the data. Familiarity helps identify passages that corresponded to constructs of the HBM that would be highlighted and coded in the analysis (Hsieh & Shannon, 2005) 2.2.2.3 Data management I used NVivo 12 research software for data management. The software was designed to enhance qualitative research and provided tools to develop insights for more comprehensive findings (Nvivo12, released March 2020). I selected this software for the convenience it provided for secure storage, organizing the data sets, tracking memos and notes, linking key literature (Given, 2008), and sorting the HBM construct categories. For this research I did not 32 use a software compatible automated code matrix for analysis assistance. Instead, I used the manual functions to highlight passages of importance and reviewed the transcript’s line by line. 2.2.3 Data analysis For this study, I considered the requirements of a qualitative descriptive analysis. I needed a process that was congruent with interpreting the categories that emerge from the participants' descriptions and combines an analysis that validates the role of the researcher as an expert on the topic (Colorafi & Evans, 2017; Colorafi & Evans, 2016; Neergaard, Olesen, Anderson, & Sondergaard, 2009). Sandelowski's (2010) seminal work on qualitative descriptive methods helped me understand that this research study cannot be "conceptually naked" (p. 79). I recognize that my synthesis and processing of the interview data is subject to my knowledge and ideas on COVID-19 and the HBM. I also recognize that a qualitative descriptive approach follows natural inquiry and is subjective and pragmatic (Guba & Lincoln, 1989). Unlike, phenomenology, where the researcher is exploring a participants descriptions free of their own perspectives; qualitative description is guided by concepts and accepts the researcher is knowledgeable on the healthcare topic (Willis, Sullivan-Bolyai, Knafl, & Cohen, 2016) Therefore, when analyzing and summarizing the descriptions provided by the participants, I wanted to stay close to their original meaning while still providing insights informed by the literature on receiving vaccines during pregnancy (Sandelowski, 2000; Colorafi & Evans, 2016) . 2.2.3.1 Directed Content Analysis I developed a deductive process that adapted the qualitative version of directed content analysis outlined by Hsieh and Shannon (2005). The main strength of their analysis approach is the flexibility to adapt coding categories to support, extend and challenge the HBM constructs. Coding is a common technique in qualitative analysis, and it is a process of analysis that refers to the steps the researcher takes to arrange and systemize ideas within their data set into relevant 33 supporting evidence (Given, 2008; Mihas, 2019) The coding process is often creative and may not be as transparent as a quantitative process (Mihas, 2019); however, the framework helped to provide a deductive starting point (Colorafi & Evans, 2016) that creates definitions and contributed to establishing confirmability. The content, text, comments, and ideas within the interview transcripts, are coded by highlighting line by line and connecting the descriptions back to the main code categories or subcategories (Hsieh & Shannon, 2005). The goal of the analysis was to identify and categorize the HBM constructs within the descriptions participants provided about their experiences with COVID-19 and the COVID-19 vaccines. I used a hierarchy process and created main category codes starting with each sub research question and the next category codes used the HBM construct: perceived susceptibility, severity, benefits, barriers, and cues to action. I also created subcategory codes which loosely followed predetermined definitions and low inference assumptions to narrow down what I was looking for within each construct. An example of a main category code would be sub research question one, then the construct perceived susceptibility, and the subcategory code would use the definitions, or assumptions using the words, thoughts and feelings provided in the participant 34 descriptions. These early sets of code categories allowed me to highlight all the sentences or passages that corresponded to the constructs from the HBM (see Figure 1). I took the time to refine each category further. The focus was on matching units of sentences or paragraphs within each category and subcategory and comparing similar responses from other participants. This was done by reviewing the highlighted passages to identify the commonalities between participants' descriptions. Next, I clustered and grouped these commonalities into categories based on similar language and frequently experienced feelings or shared thoughts (Creswell & Poth, 2018; Hsieh & Shannon, 2005; Willis, Sullivan-Bolyai, Knafl, & Cohen, 2016). This provided further refined evidence to support the HBM constructs. For example, more than one participant worried about contracting COVID-19 when the number of cases increased in their community; the main category code was susceptibility, the subcategory code was perceived susceptibility, and the refined code becomes worried about What are the concerns of pregnant people regarding the risks and outcomes of COVID-19 infection during pregnancy?• Descriptions of Perceived Susceptibility and Perceived Severity Perceived Susceptibility • Beliefs about the likelihood of getting COVIDCOVID- 19 Exposure Risks• I worry about the unknown potentials for exposureFigure 1 Sample of Code Categories 35 susceptibility or contracting the virus. Then it is further refined to exposure risks, and finally terms from the participant such as “caused by increased cases in the community.” 2.2.3.2 Creating findings I reviewed all the data more than once and coded until abstraction reached beyond codes to reflect interpretations or larger meanings of the data (Creswell & Poth, 2018, p. 449). The final refined codes focused on the sub research questions and assisted in re-conceptualizing the evidence from the participants' descriptions to provide dimension and properties to create results. I took inspiration from MacFarlane and O'Reilly-de Brun (2012), who beautifully explain "think of [your] data set as a panoramic picture, of scenes" and the framework "as a camera with four different coloured filters," and the filters they explained when applied highlight the "specific over all connections" (p. 116) The final results and discussion are reflected in Chapter 3, and use a straightforward descriptive summary and the constructs of the HBM. 2.3 Ethical Considerations This research study collected data from human participants who were pregnant during the COVID-19 pandemic. The study was deemed medium risk under the tri-council research ethics policy statement. The study proposal was approved by the UBC BREB (#H21-01543). Participants taking part in one-on-one interviews were considered vulnerable and may experience some emotional distress when discussing pregnancy and the COVID-19 pandemic. Participants were also offered a detailed explanation of the interview participant's rights, that their participation was voluntary, and they had the option to withdraw consent at any time. The COVID-19 pandemic has contributed to stress and anxiety for all individuals and each interview participant that they could stop the interview at any time and if needed they were provided with instructions to follow up with their physician regarding any concerns outside of the scope of this study. In addition, participants experiencing undue stress would be offered mental health support 36 and provided with hotline phone services and links to the Canadian Mental Health Association (Canadian Mental Health Association British Columbia Division, 2020). To protect the pregnant participants and to maintain a high ethical standard, this research study adopted the standards set forth by the world medical association and followed “The Declaration of Helsinki” (World Medical Association, 2013) This research was funded by Genome BC, with partnerships from The Bridge Child and Family Services and Interior Health. The data collected contributes to fulfillment of the requirements for a master’s thesis and to the COVID-19 vaccine hesitancy research being conducted by the UBCO maternal and child health lab. All participants received a $50 gift card as an honorarium. Participants were pre-screened for inclusion criteria, and following selection, provided informed consent via a Qualtrics online consent form before conducting the interview. 2.4 Rigour and Reflexivity There is an ongoing debate on establishing rigour in qualitative research and that doing so upholds standards found in quantitative methods (Davies & Dodd, 2002). While I want qualitative methods to be honoured for its creativity and flexibility, I cannot ignore my biases and how they may affect the findings. Therefore, the best option for rigour in qualitative descriptions is the practice of reflexivity (Davies & Dodd, 2002). Postmodern research has made reflexivity a central component of the research process (Kovach, 2009) and is a used by the researcher to be mindful of their positionality when creating “truthful” or “trustworthy” research (Choi, 2016; Colorafi & Evans, 2016). More than a decade old and rooted in the qualitative practices of feminist inquiry, autoethnography and resistance research, reflexivity has been represented as the researchers' self-reflection, 'critical-reflexivity' and the examination of their location and privilege (Liamputtong, 2007; Choi, 2016; Herising, 2005; Kovach, 2009). In other words, reflexivity is the researcher examining their power role as 37 a researcher and their biases in observation or sensemaking for the study, community, and data. "Reflexivity, then, would be characterized as a skill or practice whereby we 'interrogate the truthfulness of the tale, and provide multiple answers'" (Herising, 2005, p. 136). I must acknowledge my privilege of working from home, which has allowed me to feel safe and isolated from the COVID-19 virus, which may not be the case for some study participants. In addition, COVID-19 is not experienced equally; our income and work requirements, access to medical resources, and location in the world are factors that determine exposure to the virus. I also acknowledge my personal bias towards the new COVID-19 vaccines. I have taken a pro-vaccine status, but I respect the rights to autonomy and personal choice of participants who do not wish to vaccinate. I equally recognize the literature I put forth assumes a pro-vaccine position. I will also provide post-study reflections in Chapter 4, which will allow me to discuss struggles and choices made throughout the process. Rigour in qualitative description may also be discussed as validity and reliability in the research. To establish trustworthiness and authenticity (Colorafi & Evans, 2016) I have made considerations and attempted to meet the criteria suggested by Lincoln and Guba (1985): 1. Confirmability: I have given explicit details on procedures and created an audit trail, using NVivo software and records found on the research teams one drive. 2. Dependability: I maintained consistency by using the theoretical framework to create the interview questions, using the same data collection procedures with all participants and this included adding questions that reflected important information on the topic provided in the first 5 interviews. 38 3. Credibility: The data analysis was reviewed multiple times with members of the larger team and reviewing the analysis to the theoretical framework of the HBM, with final reviews and changes made collaboratively with the research supervisor. 4. Transferability: Finally, a review was conducted to discuss the limitations and suggest future research based on information that was beyond the scope of the project. 2.5 Plans for Results The results will be addressed in Chapters 3 and 4 of this study. The researcher's committee will review it as the final step for completion of a Master of Art with the specialization of Interdisciplinary graduate studies – Global Studies. An oral presentation session was presented at the national community health nursing conference (CHCN2022), where some of the preliminary findings were shared. A shorter summary will be compiled to be included in the final study reports for the larger study “Vaccine Hesitancy in BC: Understanding COVID-19 Vaccine Perceptions During Pregnancy, Breastfeeding, and Parenthood”, provided to the community partners and our funders. 39 Chapter 3: Results This QD study’s purpose was to describe pregnant participants’ perceptions and concerns regarding COVID-19 and receiving a COVID-19 vaccine during the pandemic. In this chapter, I sought to answer the three sub research questions (see page 22), using directed content analysis, with the HBM constructs as a guiding framework. I have organized the chapter into three main sections, each of which addresses the research question, and describe the categories from the content analysis (see Appendix C: Figure 8.) I reviewed the transcripts exhaustively, and both categories and subcategories emerged. The subcategories presented within each section of this chapter are conceptual (Ravitch & Riggan, 2017), congruent with the literature (Merriam, 2009) and represent the participants described experiences (Sandelowski, 2010). In short, the main categories are the sub research questions; the next category levels are corresponding constructs focused within the question; perceptions of susceptibility, severity, barriers, benefits, and cues to action; and then subcategories identified from descriptions provided by the participants. 3.1 Demographics Despite efforts to recruit participants from maternal clinics and hospital departments, all participants came from online advertisements that ran on Facebook and Instagram. A total of 26 participants were selected and interviewed. However, during data analysis, we discovered that one of the participants was located outside of British Columbia. This individual was still provided with the study honorarium, but the interview data was removed excluded from the analysis. This left 25 participants, the relevant criteria were that each participant reside in British Columbia (BC), and that they were pregnant during the time of the study, however more detailed demographics were collected which provide greater detail on the variables within the sample and 40 may be used to locate my participants comparatively for similar research that has been conducted. More details on the participants’ demographics can be seen in Table.2. Interview participant demographics (N=25) Age N (%) 20-29 3 (12.0) 30-39 20 (80.0) 40-49 2 (8.0) Gender Female 25 (100) Relationship Married/common-law 25 (100) Education Completed College/Technical Diploma 4 (16.0) Completed University Bachelor's Degree 16 (64.0) Completed Postgraduate school or more 5 (20.0) Household income $30-59K 1 (4.0) $60-89K 5 (20.0) 41 $90-119K 9 (36.0) $120-149K 6 (24.0) ≥150K 4 (16.0) Number of children None 11 (44.0) 1 12 (48.0) 2 or more 2 (8.0) Health Authority Fraser 10 (40.0) Coastal 8 (32.0) Interior 5 (20.0) Island 2 (8.0) Country born Canada 18 (72.0) Outside of Canada 7 (28.0) Ethnicity* White 19 (76.0) 42 Chinese 2 (8.0) Middle Eastern 2 (8.0) South Asian 2 (8.0) Southeast Asian 1 (4.0) Table 2 Demographics *Category is not mutually exclusive Participants provided more details and declared their location within BC by health authority, 40% (n=10) lived in the Fraser Health Region, 32% (n=8) in Coastal Health, 20% (n=5) in Interior Health, and 8% (n=2) in the Island Health Region. Most participants,72% (n= 18); were born in Canada and were White,76% (n=19). Each participant identified as female and were in a long-term relationship, with married or common law status. The education levels showed that 64% (n=16) had completed an undergraduate degree, 20% (n=5) had completed postgraduate studies and the remaining 16% (n=4) had a technical or college level. To maintain anonymity, the participants have been randomly assigned a participant number. This protects the individuals so they cannot be identified by, interview date, stage of pregnancy, or name. All data, including the transcript files and analysis, have been deidentified and all deidentified raw and analyzed data remains stored securely on a UBC OneDrive, where researcher access levels were determined by the main research supervisor. 3.2 Research Question 1: What are the concerns of pregnant people regarding the risks and outcomes of COVID-19 infection during pregnancy? Through conversations and semi-structured interview questions, the participants described their worries about the risks and consequences of COVID-19, sharing their thoughts, 43 emotions, and concerns about likelihood of being infected and their understanding of the potential for serious outcomes during pregnancy. Their answers indicated that they were concerned about the possibility of getting COVID-19, as well as anxious about their families, friends, and the community. Nevertheless, the descriptions of the potential severity of the contracted illness varied in terms of the risks to personal health if they were to be infected with COVID-19. Notably, those who believed age and natural immunity were factors that made the virus less dangerous. Figure 2 illustrates the categories and subcategories that make up the participants' worries about the risks and results of COVID-19 during pregnancy. 3.2.1 Perceived Susceptibility The majority of the participants believed that COVID-19 was highly contagious within their communities and that they were susceptible to the virus. The COVID-19 pandemic was perceived as real, and that anyone could become infected. No study participants felt that the COVID-19 virus or the pandemic were a hoax. Participants described situations where they felt Concerns of pregnant people regarding the risks and outcomes of COVID-19Perceived SusceptibilityCOVID-19 Exposure RisksIncreased cases and new variats of COVID-19Exposure from outside factor beyond controlHousehold or faimilywork and communityPerceived Severity Worry and anxiety about contracting COVID-19 Perceptions on age and natural immunityFigure 2 Susceptibility and severity 44 there was a potential risk for catching the virus, and perceiving their own susceptibility was evident in vaccinated and unvaccinated participants. 3.2.1.1 COVID-19 Exposure Risks Participants often described feeling afraid of contracting COVID-19 in terms of being exposed or coming into contact with the virus. They were more worried about contracting the virus when the number of positive cases increased rapidly, and new variants were discovered with reported changes in transmissibility. They also worried more about exposure to the virus when faced with situations that they could not control, such as grocery shopping, living with unvaccinated family members, or in-person work environments. 3.2.1.1.1 Increased case numbers and new variants Participants described their obsession with following the daily BC COVID-19 reports, watching the case numbers for their region, and staying informed on public health guidelines. These concerns decreased for a short period over the summer of 2021 when case numbers declined and public health authorities relaxed some of the rules which allowed individuals to meet in public spaces, mask mandates were dropped, and social distancing relaxed to allow larger numbers of people to gather. However, when cases numbers increased again, the fear and anxiety returned. Yeah, the first few months of summer, were the first few months of my pregnancy. I had no fear of [COVID] because of the way things were trending. Now, in the interior, the numbers are going up; it is now back on everyone's radar. Yeah, the fear is there for sure. Something that is on my mind a lot. (Participant 22) Many participants connected the WHO’s announcement of the Delta variant, and the previously relaxed public health rules during the summer of 2021 to the sudden exponential increase of COVID-19 cases in their communities. One participant called it a “frenzy of enthusiasm” explaining how quickly people started to see their family and friends after a long period of 45 isolation. However, they also expressed feelings of jealousy because they did not feel safe or ready to return to large gatherings while pregnant. They did not blame their friends and family for their excitement, they were upset that the case numbers subsequently increased, which resulted in more restrictions being imposed. Yeah, I would say I am definitely worried about [COVID], and I really do not want to get sick. I am definitely nervous about getting sick, increasingly nervous about getting sick as you know cases rise and the variants of course a very, you know, real thing. (Participant 6) Participants from smaller rural communities did note that there were often little to no COVID-19 cases in their communities and attributed this to their natural social distances from neighbours and being more isolated than large urban communities. However, one participant expressed how quickly their small, isolated community was affected “almost overnight” as the case numbers increased causing them “an anxiety they previously did not have.” There was a sudden influx in my community, we had nothing for the past year and a half. Then this summer we started getting two or three cases a week and very quickly that turned to 40 cases in a week, which is drastic for the population. I don't know, we have maybe 3 or 4000 people. That is a big number amongst a small amount of people. (Participant 25) Only one participant stated that the increased case numbers in their community was what directly contributed towards their decision to vaccinate. What really made me change my mind was that the cases in the local area [Redacted] started rising…When the cases were low, I was like, well, I am not going to get vaccinated because there isn't really that much of a chance of getting [covid] at this point that's like barely anyone has it in this area. (Participant 11) 3.2.1.1.2 Exposure from outside factors beyond control Participants also recognized situations beyond their control that may put them at risk for exposure, such as returning to in-person work, conducting errands in their community and living with someone who was not vaccinated. They were also worried about younger members of their 46 family, children who were under 12 who could not receive the vaccine or family members who refused the vaccine, as potentially putting them at risk for being exposed to the virus. My stepson comes over after having gone to school and he is exposed to all kinds of things. I mean it is just something that you would have to carry on with, but it is a worry. (Participant 13) My daughter is thirteen, she is in grade eight, in middle school. I consider that a risk. She is going to school; she is exposed to hundreds of kids. I consider that a risk. I go to the grocery store to feed my family; I consider that a risk. I have had unvaccinated family members show up at my house and want to rub my belly because I am pregnant. I consider, you know not social distancing, and that is a risk… I see risks in a lot of different places. (Participant 22) While multiple participants reported that they took an early maternity leave to prevent exposure to COVID-19 at work, unfortunately this option was not available to everyone, and some participants still had to do in-person work. A few even disclosed their pregnancy to their employer at a time they did not even feel comfortable to tell family or friends in the hope that this would make their employer more cautious. At work there was someone who had COVID… they took two weeks off as required… They came back. I don't know it was still freaky because you do not know for sure that they are not contagious anymore. (Participant 11) 3.2.2 Perceived Severity Despite participants’ previously described feelings of susceptibility to the virus, their perceptions of the severity of the virus if they were to be infected were highly variable. Some participants understood the severity and potential risks, while others perceived that the severity was exaggerated and that they were at low risk for severe outcomes if they contracted the virus during the course of their current pregnancy. 3.2.2.1 Worry and anxiety about contracting COVID-19 When responding to questions on their concerns about contracting the virus during pregnancy, many participants described COVID-19 as an “unknown” or expressed “feelings of 47 uncertainty” because at the time of the interviews, the pandemic was still new and also continuously evolving. The participants commonly described COVID-19 using words like “fear”, “worry” and felt apprehension and uncertainty about the potential severity of outcomes if they were to contract COVID-19. Many participants described both the fear of contracting the disease with the imagined worst outcomes and the “unexpected anxiety during pregnancy” that these fears had caused. Being pregnant was recognized by some participants as posing a higher risk for severe disease if they were to contract the virus. When I think about [COVID], I feel worried. If I get it, I'll end up in the hospital and have it worse than I typically would if I wasn't pregnant. I am in good health generally, but being pregnant… I have heard stories of pregnant people having it worse and ending up in the hospital. So, I think that has been causing me some anxiety. (Participant 10) Very worried. I was definitely worried about it before I got pregnant, and after becoming pregnant, it was a whole extra level of being freaked out. From what I have heard, people get a lot sicker when they are pregnant. COVID-19 is not like if you catch a cold because you have no immune system; that was kind of the biggest thing that scared me. (Participant 11) Most participants recognized that their pregnancy put them at risk for severe complications. They were concerned about potentially losing the pregnancy, the baby having long-term complications caused by preterm birth, and their biggest fear was being admitted to an ICU and put on a ventilator. Participants described serious outcomes and consequences of COVID-19 infection in pregnant women from news stories of real patients and medical experts describing the severe consequences of contracting COVID-19 during pregnancy. Recounting these stories often triggered emotional responses and there were audible indications that the topic was upsetting for some participants, with noticeable long pauses and crying. Participants would describe these news stories as triggering their worst fears and how they felt a personal connection because "it could very easily have been me." One participant responded to my 48 question about pregnancy and the COVID-19 virus, by talking about a news story they watched that showed unvaccinated pregnant people who were admitted to ICU because of severe complications from the virus. I know that pregnant women have a lowered immune system to begin with and [I have] been hearing news stories about pregnant women who maybe have not been vaccinated at all who end up in the emergency room or the ICU eventually…having that higher risk of contracting something is definitely of concern. (Participant 16) There were also a few participants who personally knew someone who died, and this increased their awareness of the possibilities of mortality. One participant described the death of a close family friend that made them worry more because they realized "not only old people who are overweight, 70 or 80, may be affected, but also younger people" (Participant 4). Another participant who had seen a friend experience severe disease outcome felt strongly that "if people saw COVID-19 in the hospital, they would see that it was not just older people who died but those who were younger as well" (Participant 25). Conversely, other participants focused more on stories that reflected lower severity of the virus and made a connection to hope or hopefulness in order to reduce their stress while pregnant. For example, they described believing in a scenario where COVID-19 infection might be less severe for themselves, and although they allowed for the possibility of a severe outcome, they believed that they would have a less severe outcome. Accordingly, they described second-hand accounts of friends or family who contracted COVID-19 and had mild symptoms that only lasted for 10 to 14 days. After rest and time off from work the individual returned to everyday life without any major complications. While these descriptions may also overlap with the cues to action discussed later within this chapter, the examples and second-hand accounts about people 49 experiencing only mild COVID-19, did make participants less worried about having serious disease during their pregnancy. These participants did recall seeing the media reports about pregnant people in the ICU, but they also expressed a need to hear about less serious or normal outcomes. I think the difference is like, you know, those are just more like factual, you know, experiences of how covid impacts people where it's like the fear tactics are really like when the news is only focusing on the really extreme cases so when the news is posting about 21- or 22-year-olds who have died from covid... How many pregnant people didn't end up in the ICU because of covid? [The Media] is only sharing one side of things. (Participant 6) We do a lot of research on what’s out there not just from what we see on the Canadian media or what the British Columbia Government wants us to hear. (Participant 21) Furthermore, some participants suggested they would feel better if the media stories on the severity of COVID-19 infection during pregnancy also included information on the age, vaccine status and underlying health conditions that may have contributed to the serious outcome. 3.2.2.2 Perceptions on age and natural immunity Only a few participants consider themselves to be at low risk for serious outcomes. They described COVID-19 as being severe only in individuals over 65 years of age or people who suffer from chronic illnesses. These participants perceived that their age and healthy immune system would reduce the chances of severe disease or mortality, emphasizing that the majority of cases leading to hospitalization or death were in seniors or individuals who had underlying health conditions. When you look at who's getting sick, it's often older people, people with compromised immune systems, people with obesity, like people who are not healthy. (Participant 18) I have a very strong immune system; I'm very healthy and very active. So, I worry about how [COVID-19] would impact me because I have asthma. And at the same time, I have confidence in my immune system that I would not be a person who became ill enough to require medical intervention. (Participant 6) [As] a regular young healthy person, I wasn't too concerned myself. (Participant 12) 50 Two individuals did suggest that vitamins should be used instead of vaccines, with one participant believing that vitamins were curative and deciding to take vitamins instead of receiving the COVID-19 vaccine. These two participants strongly felt their natural immunity and vitamins would help prevent a severe case of the disease and protect the health of their baby. They also perceived a dichotomy between healthy and unhealthy, and felt “obesity” and “autoimmune diseases” occur in individuals “who do not care for their health”. They felt healthy routines and active lifestyle would keep them from being hospitalized with COVID-19. 3.3 Research Question 2: What beliefs do pregnant people hold regarding the benefits and barriers of being vaccinated for COVID-19 during pregnancy? Through conversations and semi-structured interview questions, the participants described their beliefs and concerns about the new COVID-19 vaccine, sharing their thoughts, feelings, attitudes, and concerns about receiving a COVID-19 vaccine during pregnancy. Their answers indicated their perceived benefits, understanding the importance of being vaccinated for their health, the health of the baby, and the future potential for the baby after it would be born. They also indicated their concerns that contributed to barriers, indicating the reasons they may be hesitant, delaying the vaccine, or outright refusal to be vaccinated with the new COVID-19 vaccines. Their descriptions contained reasons they felt the vaccine would be harmful, along with specific concerns directly related to the speed of development and worry about the lack of research information, because COVID-19 was less than a year into development. Figure 3 illustrates the categories and subcategories that make up the participants' perceptions of the benefits and barriers to receiving a COVID-19 vaccine during pregnancy. 51 3.3.1 Perceived Benefits Most participants described the vaccine as important for protecting their health and the baby's health from potentially contracting the virus. They had positive reasons for receiving the vaccine; recognizing that receiving it was less risky than the disease and being vaccinated would allow returning to pre-covid activities or ending lockdowns. The positive descriptions signaled a trust in the science and the information that formal health authorities, infectious disease specialists, and government sources provided. 3.3.1.1 COVID-19 Vaccines are safer than the COVID-19 virus Most Participants believed that receiving a COVID-19 vaccine was less risk than contracting the virus. They described vaccines as crucial for building immunity and protecting themselves and their unborn baby from the virus. They expressed a trust in the science of the vaccines and, in some participants, recognized that the vaccine may not prevent COVID-19 but it regarding the benefits and barriers of being vaccinated for COVID-19 during pregnancyPerceived Benefits COVID-19 Vaccines are safer than the COVID-19 virusConfidence and trust in the science of vaccinesVaccines and returning to normalcy Perceived BarriersThe COVID-19 vaccines were developed quicklyUnknown risks caused by the vaccineIndecisive feelings about the COVID-19 vaccines Figure 3 Benefits and Barriers 52 would reduce disease severity, prevent severe complications, and reduce the risk of hospitalization. The pros of getting the vaccine are obviously [the vaccine] makes sense compared to potentially catching COVID. (Participant 1) The word that comes to mind is science, and I think hopeful. Yeah, it is positive; I have positive thoughts around the vaccine. (Participant 17) 3.3.1.2 Vaccines and returning to normalcy There was a sense of rejoicing towards the vaccines among some participants, with comments such as “I’ve just been happy to have both shots” (Participant 17). Many participants were thrilled by the possibility that the vaccine would contribute to a return to a normal daily lifestyle or routines that existed before the pandemic. In addition, some described getting the vaccine as a duty to “contribute to the community,” to stop the spread (Participant 1). I'm glad that there is a vaccination against [COVID] now, and I'm glad that I was able to receive it and I'm happy that a lot of people seem to be getting vaccinated so we can hopefully get back to normal soon. (Participant 2) 3.3.1.3 Confidence and trust in the science of vaccines To some participants, the COVID-19 vaccine appeared to be developed quickly, and while some participants often shared stories about feeling hesitant, in the end they felt confident in receiving the vaccine. One participant was determined to wait for the birth of the baby before getting the vaccine; however, the numbers increased in their community, and they then wished they had gotten it sooner. Participants described their stories of overcoming their hesitancy, and that they spent time and care in making their vaccine decisions. I am unsure if [the vaccine] will protect my baby, but I have felt confident in the fact that they'll protect me while I'm pregnant, and then there won't be any complications. (Participant 20) 53 Overall, there was a strong sense among most participants that the vaccines provided safety, would allow the participants to avoid the worst outcomes from the virus, and were promoted by trusted sources. I definitely feel more comfortable having both vaccines and I think once you have your two doses if you were to catch COVID your symptoms should be much milder and more manageable, so I am comfortable with that. (Participant 12) The majority of the participants recognized that the vaccine was a benefit to their health and would allow them to feel safe from the virus during their pregnancy. As discussed in the previous section, the media coverage of pregnant individuals placed on ventilators represented a genuine risk to them. Protecting themselves with the vaccine may not stop the virus, but it was perceived as a better choice than getting seriously ill and needing to be admitted to the ICU. One participant trusted the vaccine so much that they wanted to promote it to other pregnant women. After receiving their vaccine, they proposed a desire to create personalized messaging for other pregnant women to inform them about the vaccine's benefits. While I don't really like the performative nature of pregnancy; such as announcements and pictures and social media post. But part of me really wanted to you know make an announcement about this pregnancy and in particular to say ‘Listen I got vaccinated.’ I got my first dose and 10 days later I got pregnant, I got my second dose when I was 12 weeks pregnant, and here is my 20-week ultrasound picture, and everything looks fantastic. The baby is doing great, and I am doing great. (Participant 7) 3.3.2 Perceived Barriers Only two participants described structural barriers preventing access to the new COVID-19 vaccine: a missed appointment and vaccines being unavailable within their community. However, both were able to eventually get vaccinated, making these only short-term barriers. A small number of participants, however, described concerns and fears of vaccine side effects causing harm or unknown consequences for the unborn baby. 54 The fears and concerns described were primarily the fear of miscarriage or potential future health problems in the baby. These concerns possibly indicated that some participants perceived the vaccine as a greater risk than contracting the virus during pregnancy. These participants connected their hesitancy to a lack of research on the vaccine and that they were unable to find information on vaccine safety and efficacy. Some of these fears that the vaccine could cause miscarriage or harm to the fetus were connected to online misinformation and disinformation that had further exacerbated the participant's concerns towards receiving the vaccine. 3.3.2.1 The COVID-19 vaccines were developed quickly Within these descriptions from participants who were hesitant about the vaccine, was a consistent pattern of wanting two, three, five or seven years of research conducted before they would consider the vaccine. Their perception was that developing a vaccine in one year was insufficient and that there may be long-term conditions or side effects that would only be discovered after multiple years of research. Among these participants, there was a belief that safety data on receiving the vaccine during pregnancy was absent and there was a general perception that the scientific process was shortchanged to provide the vaccines as fast as possible. Until we are two years post vaccine we are not going to know if there are developmental disabilities or brain development issues. So far, there is no data to support that and that is fantastic, but again until we are two years down the road, we are really not going to know. (Participant 24) My biggest fear is that I want to see let's say five years of data. I don't want to see like everybody says it is fine… but I would like to see more data, five years, seven years something, not one year only of research. (Participant 8) [The decision] is not just about me but about protecting the baby as well… but I want to wait like one or two more years just to see the long-term side effects, if there is any before taking the vaccine. (Participant 13) 55 3.3.2.2 Unknown risks caused by the vaccine Some participants stated that the vaccine as a greater risk to their health, or for their unborn baby, compared with being infected with the virus. The main reason for refusing the vaccine during pregnancy was concerns that the vaccine could cause side effects or would harm fetal development. There were also concerns about infertility and fears that the vaccines would cause miscarriage. In addition, participants who opposed receiving the vaccine during pregnancy described the new vaccines as not being thoroughly researched. They worried that subsequent studies could show new evidence that vaccines caused harmful congenital disabilities but that the data would not be discovered until three, five, or seven years later, as a result of new research. For me it comes down to medical interventions like this type of vaccine are [typically/ normally] studied for years, three, five years, and we have not had the opportunity to do that. [long pause and a deep breath] and so we don't know… we don't know about any potential long-term impacts for these babies as they become toddlers and children. We don't know if they will be prone to a certain disease, autoimmune disorders, or autism… (Participant 6) I repeatedly heard participants describe fears that came from a lack of information on the safety and efficacy of the new vaccines and a lack of studies specific to pregnancy. Most individuals who were still unvaccinated during their pregnancy were struggling to find information on the safety of COVID-19 vaccines during pregnancy. Due to struggles conceiving their pregnancy, some participants did not want to take the vaccine without finding definitive information that the vaccine does not cause infertility or miscarriages. Without “more information”, they felt the vaccine was an unknown risk to their pregnancy. Mostly not knowing what the effects are, and not having a lot of studies and a lot of information. When the vaccines first came out, I looked at the material data sheets… at the bottom of the sheet it stated [the vaccine] was not tested for fertility, and long-term outcomes have not been tested. That really freaked me out…you know there are not really any studies…not enough of a percentage of people studied to convince me to do it. (Participant 11) 56 The vaccine is fairly new. There is not much research done or long-term study on it. Because we had two miscarriages, I have been hesitant to put anything unknown or that doesn't have long term study into my body. (Participant 15) 3.3.2.3 Indecisive feelings about the COVID-19 vaccines In 2021, information on vaccines was becoming more and more emotionally charged. While some participants admitted that the vaccine provided benefits, a small number felt anxious post-vaccination, wondering if they might have made a mistake. This was consistent with other feelings of uncertainty because the pandemic was constantly changing, and so was the messaging about receiving a vaccine during pregnancy. They worried after already receiving the vaccine that they may have made the wrong choice and would learn later that they caused their female baby infertility or that the vaccine would not protect anyone from the virus. I think it is difficult not to have a small seed of doubt planted, because you are reading all of these opinions that getting the vaccine when you are pregnant is terrible. [Stories claiming] I know somebody who lost their baby, this happened and that happened, and when all of the comments are like that, it is …I still know at the end of the day that I did the right thing for me and that I did the right thing for my family, but a part of me still questions: is there any truth to any of these things? There is still a little bit of discomfort in hearing the negative. (Participant 16) Some participants struggled to trust any data they found that supported vaccine safety, based on their understanding of past and historical medical failures. They referenced examples whereby some medications were found to cause harm, but the evidence was not found until after babies were born with a birth defect. These examples contributed to their inability to trust any information on COVID-19 vaccines. They found information that suggested the vaccine was safe, but also found information suggesting the vaccine may be harmful to their baby. I was not super comfortable, and I know there is some conflicting data out there about the vaccine ingredients being harmful for your baby. I do not know how much of the information I really trust. But I feel like there is a possibility, I know in the past there 57 were drugs approved for pregnant women and then later on they have really negative outcomes… nobody really knows until you have more long-term studies. (Participant 12) Without trust in any of the information, making no decision on the vaccines was considered the easiest choice. When I asked for more clarification, the participant elaborated that they simply did not get the vaccine “just in case the information caught up in confusion turned out to be true” (Participant 12). Ultimately, being pregnant and the baby's health were cited as both the reason for receiving and not receiving the vaccine. To demonstrate this, I have selected two examples. In this first example, the participant received the vaccine because they perceived it as a benefit during pregnancy. If I had not been pregnant, I probably would not have gotten the vaccine. Being pregnant, I got the vaccine because I was thinking more broadly about the bigger picture. [Specialists are] saying that [the vaccine] might give antibodies to the baby. (Participant 21) While in the second example, the participant stated that being pregnant is the perceived barrier; “I would be vaccinated by this point if I was not pregnant” (Participant 6), they described themselves as someone who had received vaccines in the past but felt nervous about receiving the COVID-19 vaccine because they were considering the health outcome for the baby. 3.4 Question 3: What are the major influences on a pregnant individual's health beliefs and behaviours regarding the COVID-19 virus and vaccinations? During the semi-structured interviews, the participants shared informal stories that served as reminders of or influences on vaccination. Nevertheless, not all the major influences mentioned by the participants resulted in vaccination. Some participants reported feeling uncertain, and interactions in seeking more information may have caused their hesitancy towards the new COVID-19 vaccines, and they began to worry about the safety and effectiveness of the 58 vaccines for pregnant persons. Figure 4 shows the categories and subcategories of the major influences that acted as cues; not all interactions generated motivation for preventive health or receiving a COVID-19 vaccine. The responses from the participants varied and indicated that getting a COVID-19 vaccine during pregnancy in the midst of the global pandemic was associated with strong feelings, worries, and beliefs. Figure 4 Cues to Action 3.4.1 Cues to action Interactions with HCPs played an important role in encouraging pregnant participants to receive the COVID-19 vaccine. The HCP’s mentioned included general practitioners (GPs), maternal specialists from obstetrics and gynecology (OBGYNs), and midwives. Additionally, seeking information about the vaccine’s safety and efficacy was another influential factor in their decision-making process. Every participant mentioned experiences online, that they found more information, which further shaped their decision. However, some participants encountered misinformation and disinformation from online sources that increased their vaccine concerns. the major influences on a pregnant individual's health beliefs and behavioursCues to actionInteractions and discussion with HCPInformation from a knowledgeable HCPHesitancy from the HCPInformation Sources on COVID-19Information from Social MediaInformation from Traditional Media Discussing vaccines with friends and familytaboo topic59 Furthermore, participants saw stories featuring pregnant individuals with COVID-19 being admitted to the hospital, which may have influenced their decision to get vaccinated. Lastly, this section explores the participants’ experiences of discussing vaccinations with family and friends. Previous studies on vaccinations have shown that family and friends can serve as reminders to receive vaccines. However, in the case of COVID-19 vaccines, discussing the topic was sometimes described as taboo and led to strained relationships or even the termination of friendships. 3.4.1.1 Interactions and discussion with HCPs Many participants mentioned that their decision to receive the vaccine was influenced by discussions with their healthcare professionals. While the formal recommendation for pregnant women to receive the vaccine was not issued until March, participants described engaging in conversations and posing questions to their HCPs even before official safety guidelines were available. These interactions reflected participants' initial skepticism and reluctance to trust unverified information about the new vaccines. However, in the end, most participants emphasized their trust in their healthcare experts as the ultimate authority when it came to determining the safety of vaccination during pregnancy. These descriptions highlighted the significant role played by HCPs in motivating participants to choose vaccination. Alternatively, participants who indicated that their health practitioners provided generalized information or missed the opportunity to discuss the vaccine expressed hesitations and felt compelled to seek alternative sources for vaccine-related information. In some cases, participants perceived the omission of vaccine discussion with their HCPs as an affirmation of their own beliefs that the vaccine might be dangerous. These missed opportunities, for meaningful conversations may have contributed to the individuals developing opposing opinions and ultimately refusing to be vaccinated. 60 3.4.1.1.1 Information from a knowledgeable HCP Participants emphasized the importance of having a knowledgeable healthcare practitioner who not only validated their concerns but also took the time to address their questions regarding the new COVID-19 vaccines. Initially, these participants were hesitant and harbored doubts, particularly regarding potential harmful ingredients and their limited understanding of the scientific mechanisms behind the vaccines. They expressed worries about being unable to ask these questions openly due to fears of being stigmatized or judged for their perceived lack of healthcare literacy. However, the participants described overcoming these fears as a result of empathetic interactions and open discussions about the vaccine with their HCPs. These positive experiences instilled a sense of trust and confidence in the participants, allowing them to feel safe in expressing their concerns and seeking clarification. By fostering an environment of understanding and providing thorough explanations, HCPs played a crucial role in alleviating the participants' hesitations and increasing their overall acceptance of the COVID-19 vaccines. I felt, the [GP] validated my concerns, because he didn't say you're crazy and you're stupid and you're going to kill your baby If you don't do this, because I was kind of scared that that would happen. (Participant 14) I had my questions for my doctor [asking] if this would affect the baby at all? To which she had said no. And, I have a good relationship with her, and I felt that I could trust that. (Participant 17) The participants emphasized the importance of HCPs not laughing or stigmatizing their concerns and instead taking the time to evaluate each one, even when the participants themselves feared that their ideas might be seen as ridiculous or obvious. My physician and I have talked a lot about this, vaccine hesitancy should never be an argument. I think the first thing you need to do is validate hesitancy concerns. Never ever balk at a question or, you know, roll your eyes, anything like that. [pregnant 61 individuals] concerns are valid, their questions are valid. And I think that's step one, is just listening to their concerns. (Participant 19) For participants to develop trust, they expressed the need for consistent messaging and a uniform knowledge base on the new vaccines. They believed that all HCPs should provide the same information to ensure congruent messaging. However, some participants who had multiple HCPs throughout their pregnancy noticed inconsistencies in the messaging and advice regarding the safety of the new vaccines. I am aware that there's a lot of questions from people out there, … So maybe certain people need more than just a casual kind of reassurance from their doctor … so there could be maybe a stronger message coming from the doctors who are working with women who are pregnant. (Participant 23) There were concerns among participants regarding the lack of consistency in pregnancy-specific patient education from HCPs, that led to perceptions that the COVID-19 vaccine might not be safe. Specifically, two participants mentioned their perception that doctors did not collectively agree on the vaccine’s safety. They believed this lack of consensus stemmed from insufficient research on the vaccine's effects during pregnancy. Consequently, participants expressed concerns that if doctors did not have enough information to confidently recommend the vaccine during pregnancy, it could potentially pose risks to their health or the health of their baby. I'm sad, it's sad to say this, I know doctors have gone through lots of training, have lots of years’ experience, but I find it difficult to trust them. … the science doesn't match what they say. [Doctors] probably all agree on how to do a heart surgery, but they don't all agree on COVID. So, so it's just hard, it's hard to sort of trust, I don't really have trust in the, in the system. (Participant 21) It feels like there's not enough research even for [Doctors/Medical experts] because we all can agree, let's say smoking can kill you, it causes lung cancer right. It's well-known fact and everyone every doctor will tell you the same thing. But on this matter [referring to COVID-19 vaccines] they all have different opinions, which, to me, indicates that it's not enough resources for them to have one opinion on something, because everything like big and important, they all agree on the same thing, but for this one [referring to 62 COVID-19 vaccines], they have different opinions and in the end again I think because it's new. (Participant 8) One participant also described a situation where their family doctor and their OBGYN gave different advice. These two very conflicting interactions made the participant hesitant. In the end, however, they choose the advice from their OBGYN believing that the knowledge from the specialist would be focused on their pregnancy and safety for their developing baby. I actually had a little bit of mixed advice between my family doctor and my OBGYN. Yeah, where my family doctor was more advising yes you can get [the COVID-19 vaccine] earlier, but I went with the advice of my OBGYN just because it had to do with my pregnancy basically. He was sort of my number one that I was listening to for advice on that. (Participant 5) In many cases, participants emphasized the pivotal role of discussions with their doctors as the “tipping point” in their decision to receive the vaccine during pregnancy. Without these conversations, they admitted that they might not have chosen to get vaccinated. Participant 16 specifically stated, “[T]he largest factor was the doctor's advice”. Furthermore, participants expressed a higher level of trust if they had a relationship with the HCP of more than two years. Additionally, participants found the presence of compassion convincing, particularly when the healthcare practitioner was female and had personal experience with childbirth. The participants regarded the practitioner as the expert, and in one instance, the participant changed their mind about vaccination when their family doctor carefully explained the science, highlighting important details such as the mild and localized effects of vaccines at the injection site and the safety for the fetus. [The Doctor] put me at ease when she explained about the mRNA [vaccine]. That [it is] not actually the active virus getting into your body and also that that [the vaccine] can't get through to the baby inside the uterus…the benefits outweighed all the damages, if any 63 chance that I could have caught the virus. So that affect[ed] my decision on getting the vaccine. (Participant 4) [The doctor] said that he understood my hesitancy that there is risk with the unknown as well. (Participant 14) 3.4.1.1.2 Hesitancy from the HCP Alternatively, perceived negative interactions with HCPs sometimes lead to confused feelings and less confidence in receiving a COVID-19 vaccine. If an interaction with their healthcare practitioner left the participant with more questions than answers, they worried about whether the vaccine was actually safe. Some participants who negatively described their medical appointments also perceived the vaccine as dangerous before going to the appointment. Regardless of what their provider stated, the comments from their healthcare practitioner may have been used to reaffirm their negative perception towards vaccines. Another situation was that the HCP did not provide enough time to discuss the vaccine with the participant, and were a missed opportunity to encourage vaccination. Still other participants described confusing interactions where the healthcare practitioner did not encourage or discourage vaccination, and instead asked the pregnant patient to make their own decision to vaccinate. [The Doctor was] ambivalent for sure, she said she didn't feel confident to advise me one way or the other. (Participant 6) I got my first shot, but I was really hesitant and like even my doctor was hesitant at first, like towards the beginning of my pregnancy she was like I don't know there's kind of no studies about pregnant women. I haven't seen it happen with any pregnant women so maybe let's just hold off. (Participant 11) I'm seeing an OBGYN, and they write me every single week. And then they've always they haven't encouraged it, but they haven't discouraged…. So, they've always left it up to me like it's my choice, but they can't confirm that it was safe for the baby. So then that's why I chose not to take it. (Participant 13) 64 Conversely, some participants used the words "pushy" and described their healthcare practitioner's information as "robotic" and perceived the encounter as propagating scare tactics to coerce the participant to be vaccinated. My doctor said with the variant, that’s coming this fall. The delta variant. It’s quite dangerous for pregnant women, you could end up in like the ICU, you could end up delivering your baby early and not be able to see your baby, you could die from it. So, to me that’s like a scare tactic. (Participant 18) Overall, participants who choose not to get vaccinated perceived their interactions with their HCPs as negative and these participants did not change their mind about the vaccine. On the other hand, participants who had hesitancy and wanted the vaccine were simply left feeling like the provider did not give enough evidence on the safety and efficacy. In both cases participants described their need for more information and were more inclined to search online sources for answers. 3.4.1.2 Information Sources on COVID-19 As previously noted, many participants perceived that there wasn't enough research or information on the vaccine. Every participant reported using social media and described their struggles to search for safety information using online searches. In contrast, official government sources used by participants were web pages from the Government of Canada, World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), BCCDC. Participants also relied on government social media sites for updated information on COVID-19 and the vaccines. Participants frequently used the term "studies," but it was not clear if these were academic peer-reviewed studies or informal findings. However, the word "studies" was frequently used when discussing online sources. 65 3.4.1.2.1 Information from social media Participants consistently expressed a desire to find information on the safety and efficacy of COVID-19 vaccines during pregnancy. However, they faced challenges when seeking independent vaccine information. One participant even read from a pamphlet they obtained from a community resource centre in August 2021, stating that it noted the vaccines were not recommended for individuals with autoimmune diseases or pregnant women. When asked to clarify the pamphlet was dated February 2021, which is before the recommendation changes from SOGC in March 2021. During the interview, the participant expressed frustration with the confused messaging and attempted to ask for more information during the interview. Participants also described difficulties interpreting formal messaging from government websites. For example, one participant mentioned being confused by online advertisements featuring pregnant women in connection to the vaccine but was unable to confirm if the vaccine was safe. They also recounted a conversation with their doctor where they learned that pregnant individuals were not included in the new vaccine trials. I was kind of thrown off a bit in the beginning when I saw [advertisements] on Facebook from BC health that had pregnant women on them…before there were any medical studies done on pregnant women… yet the BC health was advertising this. (Participant 11) Other participants noted the consistent changes in the messaging surrounding the COVID-19 vaccines. Examples of confusing messaging included misunderstandings about the number of vaccine doses, with participants unsure if they needed one dose or two doses, and possibly even three doses. Participants also observed differences in messaging for pregnant women across different countries. While most participants expressed trust in formal messaging and sought vaccine information from reliable sources like the CDC, WHO and official 66 government web pages, they acknowledged that relying solely on these sources did not provide an absolute sense of safety because the vaccine was so new. The participants described a struggle with the formal messaging provided by government and health authorities regarding vaccination during pregnancy. They found that the information provided only summary statements on vaccine safety, and they observed that this information changed periodically. As a result, participants felt limited by the formal sources and felt the need to search for additional information from alternate sources, primarily social media. Some participants found it is hard to distinguish between "established studies " (Participant 12) or false information online. Specifically, one participant felt that using search engines like Google would only yield content claiming that the vaccine is safe. They believed that the truth about unsafe vaccines exists but was being suppressed. You can't find anything against the vaccine on Google. It's all CDC, Health Canada, all just talking about how the [COVID-19] vaccine is good. But I've seen videos on [pause]. I don't even know the website, but I think it was a Christian page, and it was a doctor who lost his job for speaking out against [COVID-19 vaccines]. I've seen another video about a nurse in the hospital talking about how the numbers are skewed and just all these things get taken down, and you can't find them if you search on Google or search on YouTube. (Participant 15) Alternately, another participant reacted with anger toward content posted online from a white male chiropractor, who made anti-vaccine claims outside of their expertise and knowledge. The [Instagram] post was a gentleman known locally. He talked about how the vaccine mandates and the vaccine passport are essentially medical apartheid. How awful it was that he couldn't go to the private tennis club he'd been going to for the last 10 years. And he took a picture of himself, in fancy clothing, sitting on his very fancy car outside of this fancy tennis club and posted it. The amount of privilege in this post is just ridiculous. (Participant 7) The participant pointed out that the post was lacking the capacity to understand how hurtful the false comparison was for black South Africans who suffered actual oppression during apartheid. 67 Like many participants they attempted to take action by reporting and blocking the individual on Instagram. Many participants had become frustrated with the constant and never-ending social media discussion on vaccines. Despite their desire to find more information they felt overwhelmed and frustrated, which led them to avoid using social media altogether. I reviewed studies on [COVID-19 vaccines]. They have shown that [COVID-19 vaccines] are effective. So, I would rather believe health professionals or scientists than some dude on YouTube who says it's all a fluke and COVID is not dangerous. (Participant 2) 3.4.1.2.2 Information from Traditional Media Many participants relied on traditional media sources, such as television, radio and newspapers for information on COVID-19 and the vaccines. This included watching televised updates provided by national and provincial government health authorities, news programs from reputable Canadian networks like CBC and CTV; and reading news reports both in print and online from press syndicates sourced worldwide. Again, media reports of severe cases of COVID-19 in pregnant women featured in the media caused high levels of anxiety and stress. I have heard stories of pregnant people having [COVID-19] and then ending up in the hospital, so I think that's been causing me some anxiety. (Participant 10) One participant shared their experience of envisioning themselves in the ICU and feeling anxious and distressed each time they heard stories about pregnant ICU patients. This sentiment was shared by other participants, highlighting the devastating mental health impact of such media coverage. While some participants acknowledged the importance of vaccination to avoid severe illness, a larger majority stated that media coverage was not what influenced them to be vaccinated. Several participants also avoided the news media due to the upsetting nature of constant stories COVID-19, particularly related to pregnancy. Some participants also expressed skepticism towards media "scare tactics" and government messaging that was perceived as 68 propaganda. One participant specifically voiced a lack of trust in ICU stories covered by the media. 3.4.1.3 Discussing vaccines with friends and family Participants frequently experienced discomfort when discussing vaccines with their family and friends. In several instances, participants reported strained relationships and no longer communicating with those who did not share the same views on receiving a vaccine during pregnancy. The recurring feelings of discomfort, sadness and anger prompted the interviewer to introduce a trigger warning and provide the option for participants to skip questions related to vaccine information and discussions with family and friends It became evident that participants considered the topic of COVID-19 vaccines to be highly divisive, leading to heated discussions and strained relationships. 3.4.1.3.1 Taboo Topic Participants expressed a preference for discussing the topic of receiving a vaccine during pregnancy with individuals who held similar beliefs. Whether participants reported being vaccinated or unvaccinated, they shared that positive affirmations regarding their choices were typically received from those who shared the same vaccine status. Engaging in conversations about vaccines, regardless of their COVID-19 vaccine status, was challenging when discussing their choices with individuals who held differing perspectives. Participants frequently avoided discussing vaccines with anyone, as the subject had become “taboo”. Avoiding the vaccine conversation was done to avoid conflict and maintain relationships. We don't really talk much about [COVID-19 vaccines], because everyone is trying to be respectful…So, for us, especially being pregnant and vulnerable and emotional we try to stay away from any risk of causing upset. (Participant 8) I don't really see people that much, but when we talk on the phone, we won't really necessarily talk about vaccines. (Participant 12) 69 Chapter 4: Chapter 4: Discussion and Conclusion The previous chapter reported the results of the deductive content analysis anchored with the HBM framework to present the participants’ descriptions of COVID-19 and new COVID-19 vaccines. I provided key results which described the perceptions, health beliefs, and concerns of participants residing in BC who were pregnant during the global pandemic. The participants discussed their perceived risks of contracting the virus, their perceived benefits and barriers to receiving a COVID-19 vaccine, and the influences on their health beliefs and behaviours. In this chapter, I will summarize and discuss the results, provide recommendations, identify limitations, and briefly reflect on the research project. 4.1 Summary of the results Most participants understood the importance of vaccination for protection from COVID-19 infection and severe health outcomes that could result in loss of the baby. However, some believed that COVID-19 was not a serious risk or threat because they were young and had a healthy immune system that would protect them. There were also many participants who described vaccine concerns and fears based on the speed of development and a lack of research or information on vaccine safety. A few even believed that the vaccine would cause congenital defects or future health issues that would not be discovered until years later. Multiple descriptions were provided by the participants about their interactions on social media and searching online for vaccine information. Participants struggled to discriminate between official expert information and false or misleading information sources. Many wanted more information that would prove or guarantee the absolute safety of vaccination and that the new COVID-19 vaccines would not harm their fetus. 70 During the pandemic, the state of pregnancy made participants more cautious, and unlike other routine vaccines, participants described being more guarded in sharing their vaccine status with anyone, often avoiding situations that may cause an emotional outbursts or judgements from other people on their personal safety in receiving a vaccine or how they should manage exposures to the virus. Participants described refusing COVID-19 vaccine advice from family, friends, and strangers, which did not match their own values or choices. Instead, many preferred to believe trusted information that came from medical experts. However, some participants still perceived a lack of transparency amongst the medical experts from confusing mixed messages and a lack of consistent uniformity on the safety and efficacy of the COVID-19 vaccines if received during pregnancy. For those who were hesitant or delayed the vaccine, there was a feeling of unease. They were neither completely satisfied nor uncertain of the vaccine. Rather they worried about and feared unknown potential health risks from receiving the vaccine. They hoped it was harmless, they hoped it was effective, and above all they wished there had been more support and clear information. 4.2 Discussion: The descriptions provided by the participants have demonstrated the similarities and experiences faced by many other individuals from around the globe who were navigating the evolving COVID-19 pandemic during pregnancy. It is important to locate the results within the context and discussion from the studies on perceptions of COVID-19 and COVID-19 vaccines in pregnancy that have been conducted globally. These represent the perceptions of pregnant persons toward COVID-19 which contributed to receiving or refusing the new COVID-19 vaccines The findings from BC provide a localized viewpoint but can also be used to supplement the experience of pregnancy during a global crisis. The global community impacted the participants since they kept up with the daily news, and despite isolation, they created a 71 community through online resources that enabled them to interact with other pregnant people. During the pandemic, pregnant individuals in Canada were following the health guidelines set out by the WHO, as executed by the government of Canada’s health resources, and the brands of COVID-19 vaccines that were made accessible to Canadians. Access to COVID-19 vaccines and the brands available may have been different in other countries, but receiving these vaccines was still discussed in the context of perceptions, attitudes, beliefs, and concerns about receiving the vaccine in pregnancy, and on the determinants of uptake and hesitancy. In this discussion, I will include some data from these studies conducted around the world, noting the similarities, and taking into account any differences. The participants made it clear that their health choices during the pandemic centered on making the right choice for their health and the health of their developing foetus. The discussion is presented using the HBM and focusing on the risks of COVID-19 infection during pregnancy, the benefits, and barriers of the COVID-19 vaccines during pregnancy, and the major influences towards motivating health beliefs. 4.2.1 Risks of COVID-19 infection during pregnancy The participants of this study were aware that there was a genuine risk of contracting COVID-19 during pregnancy and that this risk of being exposed to the virus was often outside of their control. They described feeling anxious and worried about the possibility of exposure or of contracting the virus. Their fear of the virus increased when there were reports of a rising number of cases in their area or changes in the rate of transmission due to new variants of concern, such as the Delta variant. To reduce their risk of exposure, most participants followed public health guidelines, such as hand hygiene and social distancing. A few participants also described being more cautious because of their pregnancy and they took additional steps beyond the mandated health guidelines, such as abstaining from shopping, taking maternity leave earlier 72 to be isolated at home, and creating personal household rules to further safeguard themselves during pregnancy. However, perceptions towards the threat of contracting COVID-19 have many global variations and understanding the potential of contracting the virus is not always associated with increased cases and high levels of community transmission. In their study, Skjefte (2021) found that a higher disease burden was not necessarily a motivation to seek vaccination against COVID-19. In their cross-sectional survey of pregnant and lactating women in sixteen countries, the researchers asked participants about their willingness to receive a maternal vaccine should one be developed. Study findings show that participants from countries with high incidence rates, such as the US and Russia, were less worried about the potential threat of COVID-19, and in these countries some participants believed that COVID-19 was a hoax (Skjefte, et al., 2021). The researchers also noted that countries with fewer healthcare resources and lower hospital capacity, had participants with higher levels of fear about contracting the virus, even if the country was experiencing low incidence rates of COVID-19 (Skjefte, et al., 2021). In a part of China, Tao et al. (2021) found vaccine skepticism in educated pregnant women who had access to internet connected devices and considered the potential threat of COVID-19 as less severe. Furthermore, there is evidence that some pregnant women, despite residing in conditions that may heighten their susceptibility to contracting COVID-19, such as having a comorbidity and living with a family member with a higher exposure risk, did not perceive COVID-19 as serious and didn’t consider the virus a significant risk to their personal health (Sutton, et al., 2021). A US study also discovered that some pregnant participants had not been vaccinated against COVID-19 and were not worried about contracting the virus because they trusted their natural immunity and believed they had likely already been infected with the virus (Siegel, et al., 2022). 73 Therefore, although most participants in this study perceived that COVID-19 posed a risk to them and their fetus, the global perception of the risk of contracting COVID-19 varies. While COVID-19 transmission rates have dropped below pandemic levels and are now monitored on primarily a local level, the WHO still recognizes pregnant persons as a highly vulnerable population (WHO, 2023). The risk of contracting COVID-19 may not be higher than the risk in general population, but pregnancy remains a significant risk factor for more severe outcomes. Although the majority of participants in this study were aware of the risks of contracting COVID-19 and were confident that the vaccine would reduce symptoms, some thought that being young or having a strong immune system would protect them from the virus, and that their healthier lifestyle would make an infection with COVID-19 less severe. In some cases, this contributed to a reluctance to receive the vaccine. This perception was likely influenced by the messaging conveyed by global and local health authorities, which frequently emphasized the excess risk of severe outcomes due to age and comorbidities. Although official messaging from health authorities made it clear that everyone is vulnerable to COVID-19, their emphasis on age and pre-existing health conditions may have inadvertently created a false sense of security among young and healthy individuals that they were not at risk of severe outcomes or death. Similarly, perceptions that COVID-19 will be less severe based on being younger and healthy have been found in another pregnancy and breastfeeding vaccine study conducted in Canada (Lee, et al., 2023), However, the researchers also pointed out that the study was conducted around March of 2022 when the incidence of COVID-19 had gone down, potentially making participants feel safer. This misperception was not only observed in pregnant persons, but also more broadly in younger age groups. In the scoping review on determinants of COVID-19 vaccine uptake among adults over the age of 18, the researchers found that young and healthy 74 groups of participants were more likely to perceive that COVID-19 was not that serious and therefore contributed to COVID-19 vaccine hesitancy (Biswas, Alzubaidi, Shah, Abd-Alrazaq, & Shah, 2021). However, higher instances of presuming perceptions on health based on being youthful will be seen in pregnancy, because pregnant participants are not expected to be individuals over the age of sixty-five. Misconceptions that natural immunity will offer better protection from COVID-19 infection was cited as a reason for rejecting COVID-19 vaccines and was not limited to pregnancy. A study in Pakistan showed over one-half (55%) of participants believed that natural immunity was a better alternative to receiving a COVID-19 vaccine (Abbas, et al., 2022). In a US study conducted shortly after the introduction of the COVID-19 vaccines, healthcare workers, including pregnant women, were asked about their vaccination status and the reasons for either accepting or declining the vaccine. The researchers found that the second most common reason for refusing a COVID-19 vaccine was the perception that the risk of catching the virus or becoming severely ill was low (Sutton et al., 2021). The myths and misconceptions surrounding the belief that natural immunity and age reduce susceptibility and severity of the virus parallel previous instances of anti-vaccine rumours suggesting that natural immunity is superior (Allen, 2007). These misconceptions have historically impeded efforts to promote vaccination during pregnancy or other vaccination campaigns. Misunderstandings about the severity of other illnesses are currently contributing to the decreased uptake of vaccines such as diphtheria/tetanus/acellular pertussis (Tdap), inactivated polio vaccine IPV, or seasonal influenza vaccines routinely given during pregnancy (Wilson, Paterson, Jarrett, & Larson, 2015). Research has shown that rates of influenza vaccination are low in pregnant individuals, and there is evidence that pregnant people 75 underestimate the seriousness of influenza infection (Yuen & Tarrant, 2014), despite data clearly showing that pregnant people are at risk for severe influenza resulting in hospitalization and birth complications (Bettinger, Greyson, & Money, 2016). As a result, most professional organizations recommend that HCPs who work with pregnant persons discuss the potential risks of respiratory infections during pregnancy with their patients (Wilson, Paterson, Jarrett, & Larson, 2015). To ensure the ongoing protection of our communities, it will be important to continue the COVID-19 vaccine programs, including education on the risks of respiratory infections during pregnancy and the importance of booster vaccinations against new virus variants. In addition, it will be important to continue to communicate the severity and risks of the disease to the public, vulnerable populations, and pregnant people. 4.2.2 Benefits and barriers of being Vaccinated for COVID-19 during pregnancy The descriptions provided only a small glimpse into how participants perceived the pandemic and how they navigated the expectations placed on them to prevent contracting the virus during pregnancy. For most participants, this meant that they chose to receive the vaccine, despite all the unknowns, variants of the virus, changes in regulations, and fast-paced development of the vaccines. They felt that the benefit of the COVID-19 vaccine outweighed the risk of contracting the COVID. They described receiving the vaccine in terms of protecting themselves to protect their developing foetus and hoped that it may provide possible protection against the new virus once the baby was born. Similar findings are found in the cross-sectional survey conducted in Ohio between March and April of 2021. Reasons given for wanting a vaccine were that COVID-19 may be dangerous during pregnancy and that getting the COVID-19 vaccine during the pandemic was also a benefit for the baby (Kiefer, et al., 2022). There is also evidence that connected higher vaccine acceptance during pregnancy to lower- and middle-income countries, where education 76 on the risks from the virus and the benefits of the vaccine were the responsibility of local HCPs and who pregnant persons trusted for their expertise (Ransing, et al., 2022). While most studies on COVID-19 vaccines administered during pregnancy placed heavy emphasis on the vaccine as a health benefit and educating them on receiving the vaccine for preventing severe complications , there is evidence from Belgium that suggested some pregnant women wanted the vaccine less for their health and more as a solution to ending forced lockdowns (Ceulemans, et al., 2021). Some participants were anxious about the COVID-19 vaccine and wanted to make sure it was absolutely safe for the baby. Some participants perceived that the COVID-19 vaccine posed more danger to the baby than the COVID-19 virus, since it was developed quickly without enough research. A few participants had the vaccine but then worried they had made a mistake and were angry that they may only find out later the choice harmed their baby. Potential vaccine barriers included fear of serious health issues for the baby once they were born, this was described using the terms “autism” or “developmental delays.” Insufficient research and the vaccine's rushed release heightened some of the participants’ fears. Participants expressed lingering concern that scientists would discover the vaccine was dangerous, but they would not know until two to seven years later. Similar barriers regarding the new COVID 19 vaccines were found in the responses of pregnant participants from Italy in January 2021, who cited that the top two reasons for not receiving the new COVID-19 vaccine were the fear of the baby’s health consequences and the short time frame for developing the vaccines (Carbone, et al., 2022). Beliefs that the vaccine was a higher risk to health than the COVID-19 virus were also reported by a Canadian study conducted in May and June 2021 (Reifferscheid, et al., 2022). These researchers noted that despite evidence from the US and Canada showing that pregnant people were receiving COVID-77 19 vaccines, participants still worried getting a COVID-19 vaccine was at a higher risk than the virus, with many noting the lack of pharmaceutical trials in pregnancy (Reifferscheid, et al., 2022). Furthermore, global vaccine concerns were summarized in the scoping review of COVID-19 maternal vaccination studies conducted by Bianchi et al. (2022), who found that before the vaccines were developed the global hesitancy rate in pregnant and lactating women was approximately 39%. Once vaccines were available, the hesitancy rate rose to about 58% in the first half of 2021, but later in the pandemic in the second half of 2021, the vaccine hesitancy rate was back to about 38%. Bianchi et al.’s research also identified the primary reasons for vaccine hesitancy as insufficient information on the safety and effectiveness of the vaccine during pregnancy, a belief that the vaccine is hazardous to the mother or foetus, and the future possibility of adverse events, particularly developmental issues in the child's early years. Additionally, a lack of transparency from pharmaceutical companies and the rapid development of COVID-19 vaccines further exacerbated negative attitudes (Bianchi, et al., 2022). Participants’ perceptions and motivations during the pandemic, including their consideration of the benefits and barriers of vaccination during COVID-19, were not only described as wanting to make the healthiest choices for themselves, but also emphasized their concern for the developing baby. In this study, there was a consensus in describing these concerns through statements like “as long as the baby is happy and healthy” or “as long as my baby is healthy.” This may be understood as a protective role of pregnant people negotiating a health decision for their unborn fetus (King, Chow, Leask, & Wiley, 2019). Their terms, phrases, comments, and feelings may have reflected the idea that if they did not make the best or the right choice about vaccination, they would be at fault for any resulting miscarriage or harm to the foetus. 78 4.2.3 The influences on Health behaviours during COVID-19 and Vaccine decisions Due to the uncertainty of both pregnancy and risks from a contagious pandemic, pregnant persons, who often lived in isolation, were most influenced in their healthcare decision-making by conversations with their doctors and information found online through social media. For some, this was more influential than the local and national television media, which often shared stories of unvaccinated pregnant individuals who were receiving life-saving care due to severe cases of COVID. What was most notable was that family and friends, even pregnant friends, were not that influential on the participants’ views toward the COVID-19 vaccines. As such, conversations about vaccines were avoided, largely due to the potential to cause discord and arguments among friends and family. In this section, I will discuss one of the most important influences on vaccination beliefs and behaviours, which was the participant’s HCPs, who were largely viewed as experts on the vaccine. I will also discuss the importance of social media, which provided 24-hour live information but was not always trustworthy. Lastly, I discuss the often issue of engaging in discussions about the vaccine, which were largely considered taboo. The COVID-19 pandemic has led to substantial shifts in health literacy. Vaccination promotion has historically faced resistance during pregnancy, and now there are additional challenges due to heightened controversy surrounding the topic. 4.2.3.1 Influence of conversations with HCPs The HCP was viewed by most participants as the most influential person to motivate them to get the COVID-19 vaccine. HCPs provided reliable information and were perceived as honest and trustworthy. Advice and guidance from HCP were described as more reliable than online resources or official COVID-19 information provided by pharmaceutical companies or the government. Participants who chose to be vaccinated during pregnancy wanted personal interactions and empathy, as well as information on vaccine safety and efficacy. Participants 79 indicated that they trusted HCPs, such as doctors, midwives, and OBGYNs. Other researchers have also emphasised the importance of empathetic care from HCPs, which includes involving the patient in health decisions to reduce anxiety and provide expert information (Ceulemans, et al., 2021; Aisyah, Fitriyani, & Pambudi, 2022; Reifferscheid, et al., 2022). Participants in this study shared personal and validating experiences with HCPs that motivated them to get vaccinated. However, a few participants in the study reported negative experiences with HCPs, such as brief conversations or cold, untrustworthy responses. Some participants said the vaccine was not discussed during their appointments, which may have prevented a thorough discussion of the risks from COVID-19 and the COVID-19 vaccine’s importance to maintain health in pregnancy. Promising research has come from Desai et al. (2021), who found that 45.8% of pregnant participants were willing to receive the new COVID-19 vaccine after speaking with a healthcare provider. Ransing et al. (2022), found pregnant women in Pakistan felt more comfortable about the COVID-19 vaccine after a trusted doctor answered their questions and dispelled their fears that vaccines would hurt the baby. Therefore, the researchers proposed motivational interviews for pregnant patients to address vaccine hesitancy. These 20–30-minute interviews, conducted in person or by phone, should ask questions, address fears, and provide informed advice on the COVID-19 vaccines (Ransing, et al., 2022). However, HCPs often lack the time for such lengthy discussions (LaSalle, 2020), or may become apathetic and give up when faced with aggression or refusal to discuss vaccines (Chervenak, McCullough, & Grunebaum, 2022). To combat apathy and hesitation towards vaccines in pregnancy, researchers suggest HCPs take part in continuing education programs to stay informed on vaccines in pregnancy and learn strategies to motivate vaccination using the limited time they have (Rasmussen S. A., et al., 2009; LaSalle, 2020). 80 The study findings support those reported elsewhere, that the most influential person to help pregnant individuals to make vaccine decisions continues to be the HCP (Yuen & Tarrant, 2014). It is important that these interactions are culturally inclusive (Batterbee, et al., 2021), provide empathy and personalization (Lamprell, Rapport, & Braithwaite, 2021), and acknowledge the potential side effects and aftercare specific to pregnancy (Aisyah, Fitriyani, & Pambudi, 2022). To stay up to date, continuing education programs have been developed for HCPs on topics such as motivational interviews and understanding vaccine hesitancy, with most stressing the importance of making an impact in a short amount of time (Omer, Poland, & Chamberlain, 2019; LaSalle, 2020) 4.2.3.2 The Influences of social media One of the biggest challenges described by participants was their personal difficulty in finding information that confirmed that the COVID-19 vaccines were safe in pregnancy. The lack of access to this information or the absence of these resources was frequently described as the reason participants started searching through online sources, such as “mommy groups” and social media posts, and why they often joined sites on social networks that discussed the safety of COVID-19 vaccines in pregnancy. Searching the Internet for healthcare answers is not new; it allows anonymity and privacy while providing quick answers. Yom-Tov (2016) found that this reduces anxiety in people asking for help. Online health information has two sides: the upside is 24-hour access to answers to health questions and possible increased health literacy and confidence; the downside is that information is not checked for accuracy. People creating health content or answering health questions do not need credentials or to cite sources (Yom-Tov, 2016). Online information may contain misleading information, or misinformation, which becomes shared without the individual recognizing that they incorrectly provide inaccurate health information (DiResta, 2018). This may lead individuals to confusion about their health 81 rather than provide clarity or answers to their questions. Even more problematic is disinformation, intentional falsehoods usually on health-related matters, which are intentionally spread to redirect an individual towards alternatives views that may be harmful to their health (DiResta, 2018). Multiple participants described their inability to tell the difference between official health authority vaccine information sources and vaccine information provided by unverified sources. While none of these participants felt COVID-19 was a hoax, there were still a few who strongly believed the antivaccine rhetoric and described vaccines as dangerous, harmful, and threatening to fertility based on materials they found on social media. These participants quoted the vaccine information developed by covid-famous social media influencers and decided that the anti-vaccine ideology aligned with their personal beliefs. While answering the interview questions, the same participants described their COVID-19 vaccine hesitancy or refusal by providing reasons that contained anti-science, anti-mask, and anti-mandate opinions. One participant insisted that Google was deleting the truth about the vaccine being unsafe. Before the vaccines became available, Skjefte et al. (2021) suggested that policymakers and health authorities should anticipate false information about vaccines in pregnancy and create transparency in messaging to dispel myths. They argued that providing expert information was essential to build vaccine confidence in vulnerable populations like pregnant persons (p. 209). Toa et al. (2021) emphasized the need to disseminate accurate information to the public, particularly to educated women, as false health claims were already circulating on the Internet. Social media platforms attempted to provide accurate health information, including disclaimers and warnings (Frenkel & Kang, 2021), but it remains difficult to differentiate between official COVID guidelines and false claims. 82 Once vaccines became available, COVID-19 vaccine studies that focused on pregnant persons started to find that participants interacted with online information before making their decision to vaccinate. Riad et al. (2021) found that 8.3% of pregnant participants in the Czech Republic were influenced by social media in their decision to vaccinate. The researchers did not want to emphasize any negative potential or false information on social media, arguing that their participants could distinguish between true and false facts. They asserted that social media can be used to spread accurate information and increase COVID-19 vaccine uptake during pregnancy, and that negative use of social media against COVID-19 vaccines is a political issue in Western societies (Riad, et al., 2021). However, numerous vaccine studies from around the world have shown links between social media falsehoods on COVID-19 vaccines and vaccine refusal (Biswas et al., 2021). A survey of 776 people in Greece found that 40% relied on the Internet and Facebook for COVID-19 information (Skarpa & Garoufallou, 2021). Studies in Nigeria showed that people frequently shared and reposted COVID-19 information on social media without confirming the original source (Adesegun et al., 2020). Berry et al. (2021, p. 1144) reported that "misinformation about the vaccine through social media is rampant and evolving" after compiling the most common patient questions that HCPs were asked, these common questions were riddled with myths about on COVID-19 vaccines that the patients had found online. In this study, some participants reported that they were able to identify the truth about vaccinations and they often blocked information containing false narratives and specific anti-vaccine viewpoints. Most described being angry at falsehoods, “conspiracies” and information from fake medical practitioners being shared online. Included in these descriptions were stories about “disowning” family members, changes in friendships. In some cases, it caused the 83 participant to stop interacting with online information by leaving social media sites all together. Studies show that anti-vaccine influencers work continuously to coordinate efforts to gamify social media algorithms that will promote misinformation and make it go “viral” (DiResta, 2018). However, not everyone is susceptible to these negative social media posts, and there are researchers who emphasize that the best way to counter the anti-vaccine movement online is for HCPs and experts in immunology to be vocal online, creating videos, blogs, and social media posts that provide accurate knowledge translation to the general public (LaSalle, 2020). This highlights the positive side of social media, and the possibility of using it to promote the uptake of the COVID-19 vaccine during pregnancy. Most studies conducted on maternal vaccine hesitancy and covid-19 have also recommended the importance of creating accessible educational materials that simplify the safety and efficacy of vaccines. Gencer et al. (2021), suggested based on their findings that HCPs and informatics experts produce correct and clear information on COVID-19 vaccine safety during pregnancy, and that this information should be disseminated over multiple websites and social media platforms. Evidence from Ukraine, during the illegal occupation by Russia, found that social media was the most accessible source to disseminate information on the COVID-19 vaccine, and the Ministry of Health used multiple social media platforms to provide information on how to get a vaccine during the war, and the importance of getting a vaccine to end the pandemic (Zoaib, et al., 2022; UNICEF, 2022). In Canada, Indigenous communities have seen success that increased the uptake of COVID-19 vaccines by using social media that includes messages of indigenous autonomy and community-specific language through the use of the hashtags, Indigenous TikTok, and beautiful Indigenous art (Richardson & Crawford, 2020). 84 Researchers who track anti-vaccine information online have pointed to potential risks for many years (DiResta, 2018; Larson, et al., 2013), but COVID-19 has made the phenomenon of sharing health information on the Internet and social media more evident. In a narrative review of vaccines in pregnancy that focused on studies that were improving vaccine uptake published from 2019- 2022, the researchers indicated that vaccine hesitancy and refusal are on the rise and identified that social media was having the highest impact on hesitant individuals who were vulnerable to messaging from anti-vax groups using social media to share misinformation (Mitchell, Schulkin, & Power, 2023). 4.2.3.3 Influences from friends and family Unlike the HBM, which views peer pressure and input from family and friends as cues for action and motivation (Conner, Models of Health Behaviour, 2019; Champion & Sugg Skinner, The Health Belief Model, 2008), the participants often described advice on COVID-19 and vaccines given during pregnancy as unsolicited advice. The participants also expressed an extreme emotional rejection of friends or family who shared positions that did not match their own opinions on COVID-19. When vaccine advice was received or given, participants placed heavy emphasis on accepting only information that matched their pre-existing beliefs about the threat of the virus and the effectiveness of the vaccines; all other information was considered “conspiracies.” Participants’ feelings extended to the decision to disallow any unvaccinated family or friends to visit, and friends and family members who posted or sent negative messages were blocked. In some cases, participants felt sad and angry when the differences in opinions on vaccines resulted in the dissolution of long-standing relationships. While there were participants who had lost a family or friend to the covid virus, this did not always correlate with taking the disease more seriously. Often, the opposite was noticed; despite the symptoms or outcomes seen 85 in family or friends, participants maintained their pre-existing beliefs regarding thoughts and concerns about their own safety. Looking at studies from around the world, many different factors affected their vaccine discussions with partners, family, and friends, and how these discussions influenced vaccine decision making in pregnancy. In a Czech Republic study, researchers noted that a positive outlook on vaccination during pregnancy correlated with participants discussing the vaccination with their partner or immediate family, in their results only a small number of participants (10%, n=36) self-reported that a spouse or partner made the final decision to receive a COVID-19 vaccine (Riad, et al., 2021). Naqvi et al. (2022) conducted a survey in seven low-to middle-income countries and noted that among the more hesitant pregnant women, those who indicated they were still not quite ready to receive the vaccine, 58.7% wanted to discuss their issue with their family before making the final decision (Naqvi, et al., 2022). However, other studies have reported that individual beliefs and concerns about vaccines were not changed after discussions with family and friends. In a study from Pennsylvania conducted between May and December 2020, participants made their vaccination decision independently and were unmoved in their position regardless of family members comorbidities or their position on the vaccine (Sznajder, et al., 2022). In this same study, researchers found that participants’ willingness to vaccinate was low and vaccine uptake was influenced by personal beliefs, political values, or cultural understanding (Sznajder, et al., 2022). These recent shifts away from being influenced by the opinions of family and friends was also seen in research from Peru, which focused on the new recommendation for pregnant individuals to receive the Tdap and seasonal influenza vaccine at 20 weeks of gestation. This study was conducted just prior to the pandemic, but the findings showed that pregnant 86 individuals were choosing to vaccinate on their own, with very few participants being influenced by input from family or friends (Carcelen, Vilajeliu, Malik, Gilman, & Omer, 2021). Previously in 2018, findings from a study in El Salvador suggested that discussing maternal vaccines with the family was considered a necessary step before making any final health decisions, and pregnant individuals were comfortable sharing their opinions for or against vaccines using online social media (Fleming, et al., 2018). This may signal that the influence of friends and family on vaccine choices is a recent change or that these preferences vary across countries and regions of the world. Before the pandemic, many studies on influenza and other recommended vaccines during pregnancy explored participants' willingness to vaccinate and found correlations between vaccine uptake and discussing their choice with family and friends. Researchers have focused on the importance of maternal advice and found that beliefs about receiving a vaccine during pregnancy were often aligned with those of the participant's mother and childbearing friends (Meharry, Colson, Grizas, Stiller, & Vazquez, 2013). Meharry et al (2013) found that pregnant women who received mixed information from HCPs often sought advice and clarity from family and friends before making their final decisions on vaccines in pregnancy. Other researchers have studied the influence of partners on a pregnant person's decision to vaccinate, which is often linked to cultural practices or where the husband makes decisions for the household (Ozer, Arikan, Kirecci, & Ekerbicer, 2010; Ymba & Perrey, 2003). The changes in the way pregnant persons currently seek advice regarding their vaccine and health choices during pregnancy may signify a shift in their confidence away from discussing vaccines and vaccination information or beliefs with family and friends. However, this may also reflect the larger social and political differences sparked by COVID-19 and more 87 prevalent anti-vaccine messaging. People may feel more guarded when discussing vaccines, and this may not be the same in each country. However, this study was limited to perceptions, concerns, and beliefs that influence health decisions, and the implications surrounding the divisions and controversy that make COVID -19 vaccines a taboo subject could not be further explored. 4.3 Recommendations Although the WHO Director General formally announced an end to the global health crisis on May 5, 2023 (WHO, 2023), the COVID-19 virus remains transmissible and COVID vaccines will continue to be required. The WHO SAGE Committee for Immunization has updated its COVID-19 vaccine recommendations on March 23, 2023 recommending continuing to prioritize populations at the greatest risk of death or severe disease from COVID-19 infection, using seasonal boosters, or case-by-case vaccination to maintain resilient health systems (WHO, 2023). Pregnant persons remain among the highest priority groups. It is expected that COVID-19 vaccines will become seasonal vaccinations, similar to influenza, and it remains imperative to continue the promotion of COVID-19 vaccines during pregnancy. Participants said that their HCP's advice and information had the greatest impact on their health behaviours during the pandemic. They viewed HCPs as the most reliable experts on health and pregnancy during the pandemic and on the safety of new COVID-19 vaccines. Participants asked for honest and transparent information on the risks of the vaccines for their foetuses and wanted specific information related to pregnancy. Participants emphasized that personalized, genuine, and empathetic interactions with HCPs, free of stigma, were essential for them before receiving the COVID-19 vaccine during pregnancy. Thus, HCPs should continue to recommend and promote COVID-19 vaccinations during pregnancy. They should document concerns, make ethical considerations (LaSalle, 2020), stay informed as information evolves (Rasmussen & 88 Jamieson, Coronavirus Disease 2019 (COVID-19) and pregnancy: Responding to a rapidly evolving situation, 2020), and remind pregnant patients that vaccines benefit not only them and their new baby, but also their community (Chervenak, McCullough, & Grunebaum, 2022). Future studies should look at the significance of consistent healthcare messaging on vaccines for pregnant people and focus on HCPs knowledge of vaccines during pregnancy. Participants asked for more information, stating that it was difficult to navigate information resources. Thus, the second recommendation is to create multimedia sources with accurate, up-to-date information on COVID-19 vaccine safety and efficacy with pregnancy-specific information. Participants wanted information to be accessible to the public, suggesting bus ads, podcasts, commercials, and pamphlets. The results of this study have already been shared with members of the UBC vaccine hesitancy project and assisted in creating materials for advertisements, using video clips, and radio campaigns promoting COVID-19 vaccines in pregnancy. 4.4 Limitations The complexities of vaccine hesitancy described by participants were sometimes due to social and cultural factors beyond the constructs defined in the HBM. The HBM does not consider personal habits and routines, social approval, non-health reasons, or hazardous environments outside individual control when determining the motivators for or against seeking preventative health (Abraham & Sheeran, 2007; Janz & Becker, 1984). Qualitative descriptive healthcare research is often described as giving only a small snapshot, or a starting point that is only scratching the surface of a research topic (Neergaard, Olesen, Anderson, & Sondergaard, 2009; Willis, Sullivan-Bolyai, Knafl, & Cohen, 2016). Ethnographic methodologies may provide deeper perspectives on context, looking further into the social and cultural perspectives embodied in reproductive politics that I did not have time to 89 explore. Another option may be to explore the experience of receiving a COVID-19 vaccine during pregnancy using grounded theory, which may provide more insights into policies and clinical practices that improve vaccine uptake on a yearly basis. Thus, while this study provided some information from a group of pregnant people with varying experiences, it was a small study that focused on their personal beliefs, thoughts, and motivations of the study participants that may not be representative of the larger population of pregnant people within BC and globally. A limitation of this study was that the HBM could never have predicted a category for negative health actions caused by a complex world of algorithms and anti-vaxx social media amplification using real-time reporting of COVID-19 from a device that fits in the palm of your hand. The HBM was originally created to determine how and why people use health services (Rosenstock I. M., 1974), and was developed before the Internet. Prior to this, myths and stigma challenging a preventative health service were disseminated through news broadcasts, neighbourhood pamphlets, and stereotypes perpetuated by word of mouth (Rosenstock I. M., 1974). Finally, this study had only 25 participants, which falls within the range of 20 -30, recommended for collecting data through semi-structured interviews and qualitative health research (Charmaz K. , 2014; Creswell & Poth, 2018); however, qualitative research does not always follow the rule of thumb for interpretive justifications (Malterud, Siersma, & Guassora, 2016). Twenty-five participants may still be too small to represent the diversity of pregnant people in British Columbia. The sample was exclusively female and did not include participants who had different gender identities or methods of becoming a parent. While six participants indicated being born outside of Canada, their responses did not seem atypical of other participants and therefore did not allow me to further explore possible racial or cultural 90 differences among the study participants. This may have been because of a long period of acculturation among these participants but leaves room for future research to focus on participants who are new to Canada. Furthermore, despite efforts to recruit participants from community settings all of the study participants came from online advertisements on Facebook and Instagram. While the online advertisements make the study more accessible to a larger number of candidates, it also creates the potential for bias, through samples made up of singular representation such as pregnant people who use internet technologies, which may indicate less heterogeneity in the sample. 4.5 Reflexivity Reflexivity is pragmatic and in line with the natural inquiry of qualitative descriptive research (Seale, 1999), offering the opportunity to contemplate a research project's process. Nevertheless, it should not only be complaints and confessionals (Seale, 1999) but should also focus on practical learning experiences and the transition from theory to praxis. I would like to concentrate less on the difficulties and more on the opportunities to enhance my future research and where I can make improvements. 4.5.1 The interview process As a novice researcher, I sought advice from several textbooks with guidance on how to conduct semi-structured interviews (Brinkmann & Kvale, 2015; Kvale, 2007), including Charmaz and Belgrave (2012). The most important advice was to keep the interview guide in the general direction of the conversation but to be open to comfortably changing topics or unexpected responses. In my experience with patient interviews, the emphasis is on empathy and providing the right medical resources, which is quite distinct from research interviews. In order to be prepared, I collaborated and practiced with other members of the research team in order to get a better feel for interview strategies, along with attempting to make sure I maintained a 91 neutral expression and did not inadvertently respond negatively to unexpected answers. The aim of our interview guide was to investigate positive health motivations and to gain insight into what contributes to vaccine hesitancy. However, this research was conducted concurrently with an anti-vaccine convoy, a Canadian protest on COVID-19 vaccine mandates, and some participants felt emotional and resentful. One participant, without warning, abruptly accused me of arguing with her while I asked the interview questions. After the interview, I examined the audio and transcript to confirm that there was no indication of an argument or shift in tone. Upon assessing the situation at the conclusion of the project, I noticed that some participants wanted to express anti-vaccine messaging and may have deliberately sought to alter the focus. The interview containing aggression and accusations has taught me that if a conversation veers off track or becomes hostile, an alternative approach is to try to redirect it (Charmaz & Belgrave, 2012) or to politely conclude the interview (Brinkmann & Kvale, 2015), thank the participant, and move on. 4.5.2 Analysis process Methodological experts reviewed my proposal and suggested using Thematic Analysis (TA). I studied multiple materials on the subject, but I felt like I was forcing the data into themes instead of letting chunks of meaning become increasingly smaller to form themes (Braun & Clarke, 2022). However, even TA specialist Braun and Clark (2022) noted that novice researchers may use naming systems from thematic models to deductively code, but this is only going to the surface level, but qualitative researchers using deductive frameworks could use directed content analysis. I realized that I was using a deductive model, with predetermined categories that started with research questions, followed by HBM categories, and finally shared descriptions from participants with subcategories. 92 Another issue with my analysis was diverting from the scope set out in the research proposal; the HBM constructs were the focus, and the research questions were looking for motivations to act towards receiving a vaccine as a preventative measure. Reviewing and exploring perceptions and using beliefs, concerns, and influences. Despite the project falling into an interdisciplinary focus, exploring the history of anti-vaccine messaging was beyond the scope of this thesis. From these pitfalls, I have gained new insight into qualitative analysis and may be able to use TA in a future project. 4.6 Conclusions It is rare for researchers to be a part of their research history. Research on COVID-19 and vaccines has been challenging given the ever-changing nature of the pandemic and vaccine development. When I started my research, active cases still threatened everyone’s lives. As I interviewed participants, the vaccines had only been available for a few months, and within Canada, opposition towards health mandates started to grow. I did not anticipate that vaccination would become a heated topic protested on the streets, nor did I imagine that researching maternal vaccines would elicit such deep emotional responses. In the writing and presentation stage, I am living in the "new normal”, the term we all seem to accept as a post-pandemic return to daily life. This thesis can be read as the introduction was what we understood at the beginning, while the findings may reflect the experiences of pregnant persons navigating early vaccines. The discussion then ties everything together by situating maternal vaccines within the COVID narrative, as it continues to unfold. Through in-depth and open-ended interviews and structured data analysis, I explored and described the underlying reasons behind vaccine hesitancy and identify potential barriers that hinder optimal vaccine uptake. By using established qualitative research methodologies and leveraging my pharmacy background, I aimed to shed light on the unique challenges and 93 considerations faced by pregnant people when considering COVID-19 vaccination. The information gained from this research project will inform targeted interventions, tailored communication strategies, and healthcare policies that will support pregnant persons to make informed choices about their own health and the health and well-being of their unborn child. The findings of this qualitative study will also hopefully contribute to the collective effort of addressing vaccine hesitancy and fostering a healthier future for both expectant parents and their infants. Although a small qualitative study, the HBM approach revealed many similar descriptions of pandemic experiences during pregnancy and the complex beliefs, attitudes, and concerns influencing the acceptance or refusal of COVID-19 vaccines that align with other global research on the subject. This reflects that the perceptions and concerns shared by participants were not limited to pregnant people experiencing COVID-19 in British Columbia. Studies from around the world also found that when making the decision to vaccinate, pregnant people in those countries were also concerned about the speed of development of the vaccine and the potential harm to the foetus, were also seeking more information on the safety and efficacy of the vaccine, and wanted to ensure that the vaccine was 100% safe for their baby. Pregnant people living through the pandemic turned toward finding answers online and created communities to find and share knowledge to help them navigate their pregnancies during unprecedented times. However, these same online communities may have had some unintended consequences, and most participants experienced difficulty separating vaccine facts from fiction in the information they found online. Overall, the participants of this study worried about potential exposure to COVID-19, understood that if they contracted the virus, there were unknown risks to their health, and most 94 understood that receiving the COVID-19 vaccine was the best option for protecting their health and the health of their babies. There were also a few participants who felt the vaccines heralded the prospects of returning to a more normal life, and the vaccine was a joy that would end social distancing restrictions and allow people to gather in public spaces again. However, the findings still showed that while the benefits of COVID-19 vaccines remain promising and new vaccines will continue to be needed each year, participants still described being less worried about the severity of the virus and felt the virus was less risky to their health than receiving a vaccine that had less than a year of research. The findings on maternal vaccines, such as influenza, are similar to the current findings, with a few pregnant persons being apathetic to the virus and vaccine. Previous rumours regarding vaccines during pregnancy, such as fertility and miscarriage fears or developmental issues, are still present. This implies that risk/benefit analysis may not be sufficient enough to motivate pregnant people to receive vaccines alone. The importance of this global study is recognizing the larger trend that pregnant people around the world remain at risk of COVID-19, but vaccine promotion continues to be challenged by negative vaccine rumours, which may show a change in vaccine literacy worldwide. Contributing to this is the growing increase in misleading online information, and pregnant people were not the only individuals to struggle with discerning formal vaccine literature backed by science and information filled with misinformation and disinformation produced by famous politicians, media stars, and social media influencers with large followings who simply used their status to discourage vaccination or increase hesitancy. Information on COVID-19 shared online was not vetted for accuracy, posts were not required to validate any claims; while participants felt trust in the global pregnant community online, there was no guarantee that the 95 information was accurate. There are also recent studies from north and south America showing an increased difficulty discussing vaccines with family and friends (Sznajder, et al., 2022; Carcelen, Vilajeliu, Malik, Gilman, & Omer, 2021), and historically vaccine decisions were made in pregnancy after consulting immediate partners or family and friends who have also had children. In this study, participants described feeling uncomfortable discussing their vaccine status with family or friends while describing situations where vaccine disagreements led to arguments. Often, they avoided individuals who did not have the same vaccine beliefs or, in extreme cases, dissolved relationships. Negative information spreading quickly online combined with this new discomfort or taboo of talking about vaccines because this causes arguments may cause increases in the challenges of vaccine literacy seen around the world and this increases vaccine hesitancy. As the severity of COVID-19 begins to wane, the focus on healthcare will move away from systems of information provided directly from global experts and move towards the responsibilities of local healthcare. The shift to the micro level will need to target HCPs and clinical facilities which will be responsible for adapting methods to increase vaccine literacy and vaccine uptake. Currently, the WHO's SAGE working group (2023) still emphasizes the importance of pregnant persons receiving a COVID-19 vaccine to protect themselves, their unborn child, and the baby in the first six months of life. COVID-19 vaccines are likely to become seasonal, and the importance of receiving a vaccine in pregnancy will continue to be reinforced. It is necessary to continue to amplify the importance of vaccines during pregnancy. 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When I say the word “COVID-19 vaccination”, what are some thoughts that come to your mind? Probes: How important are COVID-19 vaccines for pregnant individuals? Why or why not? Can you explain or clarify? Are they safe in pregnancy? What are the Benefits? Added: If they disclose their vaccine status, I ask them follow ups about their daily life? The BC government has prioritized pregnant people to receive the COVID-19 vaccine. Please describe your understanding about the importance and benefits of receiving the COVID-19 vaccine during your pregnancy? Probes: Are they effective at preventing COVID-19 infection? Will they protect the baby after birth? Added: where did you get the information on (safety/miscarriage/comments? 118 Are you willing to receive the COVID-19 vaccine during this pregnancy? Why or why not? Probes: Describe /explain specific concerns Is the Concerns regarding the pregnancy? Fetus? Added: What are your thoughts on the “vaccine pass ports” or vaccine mandates? How do the mandates influence your daily life? How do you think the COVID-19 vaccine would affect your health, or your baby’s health during pregnancy? Probes: Concern regarding possible side effects during pregnancy? Note the participant normally brought upside effects and unknowns without prompt, most times I asked for clarifications can you explain that again, I am not sure I understand is this a concern or a side effect, belief or fear, can you tell me more about how this makes you feel? Concern regarding negative consequences to pregnancy or to unborn baby? Added: Can you tell me more about the information source; can you explain what side affects you are worried will show up later in life? Can you tell me how that makes you feel? How you know you can trust the source/feelings about trustworthy sources? In your social and peer groups and among other pregnant individuals you may know, how do they feel about receiving the COVID-19 vaccine during pregnancy? Probes: Willingness to get vaccinated? Concerns about the COVID-19 vaccine? Added: Do you openly discuss vaccines with family and friends? Can you tell me how these conversations make you feel? Can you clarify? (Only if they discuss vaccines with pregnant friends) Do you promote vaccination / Do they promote vaccination. 119 Can you tell me about any advice that you have received from family, friends, or health professionals for or against receiving the COVID-19 vaccine during pregnancy? Probes: Opinions and concerns of significant others? How important are these opinions to you? Is your partner vaccinated? Why or why not? Family? Redirect if unclear: When discussing the COVID-19 vaccine with a health care professional who brought up the vaccine? (Did you ask or was in unsolicited/unprompted) Who was the healthcare practitioner? Who has this commentary/advice come from? If they did not bring up the vaccine, how did they make you feel *Did they respect your autonomy, and can you clarify what you mean when you say autonomy? Added: Did you discuss your vaccination choices in pregnancy with your partner? Was the information sent from family/friends unsolicited? Did you trust their source? Why or why not? Did your relationships with friends or family change from discussing COVID-19 or the vaccine? Does the information provided by a friend or family member change your trust or safety? Of the relationship? Can you tell me about where you personally get your information on COVID-19 and the COVID-19 vaccines? Probes: Who Produced these sources? Did you go to CDC sites/BC Government/WHO? Do you trust these sources? Why or why not? Added: How do they know a source is trustworthy, why, the feeling and clarifying the sources they used. Where did you go? Can you clarify or give me more information about the site and why do you trust the commentary/advice? I don’t understand can you please define this, how does it make you feel, I don’t want to coopt what you said, is this what you mean? can you please clarify? 120 In a magical or perfect world what does COVID-19 information look like for you? Redirect: Based on the current way we are receiving COVID-19 information and vaccine information, what would you change? Do you have any other thoughts or concerns about COVID-19 vaccines during pregnancy or the COVID-19 virus that you have not stated yet and would like to tell us? 121 Appendix C Directed content analysis. Figure 8 Full content analysis Concerns of pregnant people regarding the risks of COVID-19 infectionPerceived SusceptibilityExposure risksPerceived Severity Worry and anxiety Healthy and youngBeliefs of pregnant people regarding the benefits and barriers of vaccinationPerceived Benefits Vaccines are Safer than COVIDReturn to Normalcy Confidence and Trust Perceived Barriers Developed QuicklyUnknown Risks Indecisive feelingsInfluences on health beliefs and behaviors of pregnant people toward vaccination during pregnancyCues to ActionInteractions with HCPsInformation Sources Traditional MediaFriends and Family
Thesis/Dissertation
eng
Interdisciplinary Studies
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Tarrant, Marie
Perceptions of COVID-19 vaccines among pregnant people in BC : a qualitative study
Text