Medicine, Faculty of
Population and Public Health (SPPH), School of
DSpace
UBCV
Krug-Mushey, Alex
Master of Science - MSc
University of British Columbia
Background: While challenges surrounding vaccine acceptance in pregnancy were prevalent prior to the COVID-19 pandemic, this pandemic introduced a different context for pregnant people – including concerns about COVID-19 infection during pregnancy, changes to the format of perinatal care and social support, and the introduction of new vaccines. This thesis aims to examine these new influences on vaccine decision-making during pregnancy. Methods: Using data from a mixed-methods project headed by the University of British Columbia and McMaster University, this research seeks to answer the question, “How does trust influence the decision-making process of pregnant people around vaccination during pregnancy in the context of the COVID-19 pandemic?” Data from semi-structured interviews with 74 participants who gave birth in Ontario or British Columbia from May 1st, 2020 to December 1st, 2021 were analyzed. This process of reflexive thematic analysis was initially conducted with sensitizing constructs from the Theory of Reasoned Action, Theory of Planned Behaviour, and Health Belief Model but came to incorporate Maya J. Goldenberg’s “Crisis of Trust” framework following preliminary analysis. Results: With the role of trust as central to this analysis, an extended “Crisis of Trust” model was created, with three related, overlapping facets identified – trust in prenatal care providers, trust in institutions, and trust in networks. Trust in prenatal care providers was shaped by participants’ goals of alleviating their mental load, differential cultural norms influencing degrees of trust in healthcare providers, and perceived transparency of providers. Trust in institutions focused on overall trust in the government and healthcare system, trust in the goodwill of the pharmaceutical industry (or lack thereof) and perceptions of relationships between these institutions. Finally, trust in networks included social networks as a potent site of (dis)trust, lived experience forming an interpretive lens for prenatal care, and views of COVID-19 vaccines as a moral obligation or source of hope for the broader community. Conclusions: This study demonstrates that vaccine hesitancy in pregnant people extends beyond an informational problem into a deeper deficiency of trust. These insights allow for the implementation of public health policies which target these ideological conflicts to better improve vaccine acceptance.
TRIAD OF TRUST: VACCINE DECISION-MAKING BY PREGNANT PEOPLE DURING THE COVID-19 PANDEMIC IN BRITISH COLUMBIA AND ONTARIO by Alex Krug-Mushey B.Sc., Queen’s University, 2023 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Population and Public Health) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) April 2025 © Alex Krug-Mushey, 2025 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: Triad of Trust: Vaccine Decision-Making by Pregnant People During the COVID-19 Pandemic in British Columbia and Ontario submitted by Alex Krug-Mushey in partial fulfilment of the requirements for the degree of Master of Science in Population and Public Health Examining Committee: Dr. Devon Greyson, Assistant Professor, Population and Public Health, UBC Supervisor Dr. Monika Naus, Professor, Population and Public Health, UBC Supervisory Committee Member Dr. Meredith Vanstone, Associate Professor, Family Medicine, McMaster University Supervisory Committee Member Dr. Daniel Steel, Associate Professor, Population and Public Health, UBC Additional Examiner iii Abstract Background: While challenges surrounding vaccine acceptance in pregnancy were prevalent prior to the COVID-19 pandemic, this pandemic introduced a different context for pregnant people – including concerns about COVID-19 infection during pregnancy, changes to the format of perinatal care and social support, and the introduction of new vaccines. This thesis aims to examine these new influences on vaccine decision-making during pregnancy. Methods: Using data from a mixed-methods project headed by the University of British Columbia and McMaster University, this research seeks to answer the question, “How does trust influence the decision-making process of pregnant people around vaccination during pregnancy in the context of the COVID-19 pandemic?” Data from semi-structured interviews with 74 participants who gave birth in Ontario or British Columbia from May 1st, 2020 to December 1st, 2021 were analyzed. This process of reflexive thematic analysis was initially conducted with sensitizing constructs from the Theory of Reasoned Action, Theory of Planned Behaviour, and Health Belief Model but came to incorporate Maya J. Goldenberg’s “Crisis of Trust” framework following preliminary analysis. Results: With the role of trust as central to this analysis, an extended “Crisis of Trust” model was created, with three related, overlapping facets identified – trust in prenatal care providers, trust in institutions, and trust in networks. Trust in prenatal care providers was shaped by participants’ goals of alleviating their mental load, differential cultural norms influencing degrees of trust in healthcare providers, and perceived transparency of providers. Trust in institutions focused on overall trust in the government and healthcare system, trust in the goodwill of the pharmaceutical industry (or lack thereof) and perceptions of relationships between these institutions. Finally, trust in networks included social networks as a potent site of (dis)trust, lived experience forming an iv interpretive lens for prenatal care, and views of COVID-19 vaccines as a moral obligation or source of hope for the broader community. Conclusions: This study demonstrates that vaccine hesitancy in pregnant people extends beyond an informational problem into a deeper deficiency of trust. These insights allow for the implementation of public health policies which target these ideological conflicts to better improve vaccine acceptance. v Lay Summary As vaccine decisions can already be a complicated issue for pregnant people, the introduction of COVID-19 vaccines presented a new challenge. I examined the process by which pregnant people made these decisions during the pandemic and found that trust was a major influence. From this understanding, I found that three overlapping areas were key to these decisions: (i) trust in doctors and midwives providing pregnancy care, (ii) trust in government, drug companies, and the healthcare system (and the relationships between them), and (iii) trust in communities with other pregnant people. These results suggest that merely providing more information to pregnant people is not likely to improve their acceptance of these vaccines, so these insights can allow us to develop strategies that help improve people's trust in these three areas. vi Preface This thesis is the original work of Alex Krug-Mushey in working within the larger project “How do perceptions of Covid-19 risk influence health decisions in pregnancy? A mixed methods study”, a collaborative effort between UBC and McMaster University. The UBC Behavioural Research Ethics Board approved this larger study in August 2022 (#H22-01905), and an additional application for this thesis work was approved in March 2024 (#H24-00384). While all data collection occurred prior to my involvement in this project and was conducted by investigators at UBC and McMaster (headed by Dr. Devon Greyson and Dr. Meredith Vanstone), I alone was responsible for analyzing the collected semi-structured interview data via reflexive thematic analysis for themes relating to vaccine decision-making. Generative AI technologies were not used at any point in the drafting or preparation of this thesis. vii Table of Contents Abstract ............................................................................................................................. iii Lay Summary .....................................................................................................................v Preface ............................................................................................................................... vi Table of Contents ............................................................................................................ vii List of Tables .................................................................................................................... ix List of Figures .....................................................................................................................x List of Abbreviations ....................................................................................................... xi Glossary ........................................................................................................................... xii Acknowledgements ........................................................................................................ xiii Dedication .........................................................................................................................xv Chapter 1: Introduction ............................................................................................................... 1 Chapter 2: Background ............................................................................................................... 3 2.1 Vaccine Decision-Making & Vaccine Hesitancy ........................................... 3 2.2 Vaccination in Pregnancy ............................................................................... 5 2.3 Role of the COVID-19 Pandemic in Pregnancy Experiences ...................... 12 2.4 Study Objectives & Research Questions ...................................................... 18 Chapter 3: Methods ................................................................................................................... 20 3.1 Parent Study .................................................................................................. 20 3.2 Data Source ................................................................................................... 20 3.3 Participants .................................................................................................... 21 3.4 Data Analysis ................................................................................................ 23 viii 3.5 Positionality .................................................................................................. 32 3.6 Ethical Considerations .................................................................................. 33 Chapter 4: Results ..................................................................................................................... 35 4.1 Introduction ................................................................................................... 35 4.2 Trust in Prenatal Care Providers ................................................................... 38 4.3 Trust in Institutions ....................................................................................... 46 4.4 Trust in Community ...................................................................................... 52 Chapter 5: Discussion ............................................................................................................... 64 5.1 Extending the Trust-Based Model of Vaccine Hesitancy ............................. 64 5.2 Trust in Institutions ....................................................................................... 65 5.3 Trust in Healthcare Providers ....................................................................... 66 5.4 Trust in Community ...................................................................................... 67 5.5 Contextualization to Literature ..................................................................... 68 5.6 Strengths, Limitations, and Future Directions .............................................. 70 5.7 Implications................................................................................................... 71 5.8 Conclusion .................................................................................................... 76 References .........................................................................................................................78 Appendices ........................................................................................................................89 Appendix A: Consent to Contact Survey .................................................... 104 Appendix B: Semi-Structure Interview Guide ............................................ 106 Appendix C: Attribution Key for Participant Quotes ................................. 110 ix List of Tables Table 3.1. Demographic characteristics of all interviewed participants... ........................... 37 x List of Figures Figure 4.1. “Triad of Trust” Model for Vaccine Hesitancy in Pregnancy During the COVID-19 Pandemic ... ...................................................................................................................... 50 xi List of Abbreviations A/H1N1 – Influenza A Virus Subtype H1N1 BC – British Columbia CDC – U.S. Centers for Disease Control and Prevention, Atlanta GA CIHR – Canadian Institutes of Health Research COVID-19 – Coronavirus Disease 2019 DTaP-IPV-Hib – Diphtheria, Tetanus, Acellular Pertussis, Inactivated Poliovirus, and Haemophilus influenzae type b DTaP-HB-IPV-Hib – Diphtheria, Tetanus, Acellular Pertussis, Hepatitis B, Inactivated Poliovirus, and Haemophilus influenzae type b ED – Emergency Department ICES – Institute for Clinical Evaluative Sciences ICU – Intensive Care Unit MMR – Measles, Mumps, and Rubella vaccine NACI – National Advisory Committee on Immunization NICU – Neonatal Intensive Care Unit OB – Obstetrician OHIP – Ontario Health Insurance Plan ON – Ontario SARS-CoV-2 – Severe Acute Respiratory Syndrome Coronavirus 2 SOGC – Society of Obstetricians and Gynecologists of Canada Tdap – Tetanus, Diphtheria and Acellular Pertussis vaccine WHO – World Health Organization xii Glossary Disinformation – “False information that is intended to manipulate, cause damage and guide people, organizations and countries in the wrong direction” (1) Malinformation – “Information that stems from the truth but is often exaggerated in a way that misleads and causes potential harm” (1) Misinformation – “False information that is not intended to cause harm” (1) xiii Acknowledgements I express my sincerest gratitude to Dr. Devon Greyson, my remarkable supervisor, for the wealth of knowledge and guidance they’ve provided me throughout this work. Their confidence in me and my work has been instrumental in helping me progress in this research, and the connections they’ve provided me have been invaluable in continuing my academic program and looking toward my future pursuits. I want to thank my committee members, Drs. Monika Naus and Meredith Vanstone, for their valuable direction as my written thesis has come to take shape. I greatly appreciate the value they’ve brought to my work and academic development with their unique perspectives. I thank the investigators, staff, and students involved in the Vaccine Evaluation Centre’s qualitative research team. From early on in this project, the advice I’ve received from them, both directly and via discussions observed in our meetings, has been absolutely vital in helping me direct my course with this research. Additionally, I want to specifically thank Susmita Chakma and Jung Kandola for the support they’ve provided me through our thesis writing group meetings. I can’t communicate strongly enough how much I value the feedback and accountability they gave me through this group. I also give special thanks to the Greyson lab at UBC and the Vanstone lab at McMaster University. The incredible work done by both these teams has paved the way for this research and allowed me to conduct my analysis easily. I especially want to thank Ms. Caroline Mniszak for her valuable support in adjusting to the NVivo software and conducting my analysis. Her work and assistance, from conducting the BC portion of the interviews underlying this research to wonderful guidance in the analytical process (both from a software and design perspective), were so vital to this work that I couldn’t have done this without her. xiv Further, I recognize that I couldn’t be doing this work, which has been so meaningful to me, without the funding I received from the Canadian Institutes for Health Research (via grant number 179921), Vaccine Evaluation Centre (via a Graduate Research Assistantship), and Canadian Immunization Research Network (via a CIRN Traineeship). Finally, I give the utmost thanks to my family, friends, and colleagues, who have listened to my endless thoughts throughout the entire process of this research, have supported me through the triumphs and challenges, and have provided me with such steadfast support. xv Dedication To my parents – I couldn’t have gotten this far without you. Thank you for your support all these years and for believing in me even when I couldn’t. 1 Chapter 1: Introduction Vaccine hesitancy, defined by the World Health Organization (WHO) as “delay in acceptance or refusal of safe vaccines despite availability of vaccination services” (2), represents a major challenge in our attempts to prevent the spread of communicable disease. In particular, this is a vital concern in the protection of high-risk groups, including pregnant people and infants. For this reason, much research has been conducted to explore reasons for hesitancy for the vaccinations in pregnancy currently recommended in Canada. Three vaccines are currently recommended in pregnancy by the Society of Obstetricians and Gynecologists of Canada (SOGC) and the Canadian National Advisory Committee on Immunization (NACI) – (seasonal) influenza, COVID-19, and the combined tetanus, diphtheria, and acellular pertussis (Tdap) vaccine. These vaccines include those aimed primarily at protecting pregnant people, specifically influenza and COVID-19 vaccines, and those primarily aimed at providing passive immunity for infants prior to the commencement of infant vaccination, specifically Tdap. Furthermore, multiple changes to the circumstances of pregnancy within the COVID-19 pandemic are expected to influence vaccine acceptance during pregnancy. These include: (i) worries about COVID-19 infection during pregnancy, (ii) changes to the format of perinatal care to substitute in-person with telehealth appointments and/ or decrease the frequency of appointments, (iii) changing restrictions on visitors and support people in clinical settings, (iv) limitations to social support resultant from physical distancing requirements, and (v) the introduction of new COVID-19 vaccines and changing recommendations about their use during pregnancy. This research examined semi-structured interviews conducted with people who gave birth in British Columbia or Ontario during the COVID-19 pandemic as part of a parent study on the 2 influence of the COVID-19 pandemic on health decisions during pregnancy. This larger parent study was a joint effort of research teams based at the University of British Columbia and McMaster University. This thesis adopted a reflexive analysis approach to explore the themes related to vaccine hesitancy or vaccine acceptance present in these interviews. This analysis was an iterative process, initially incorporating sensitizing constructs from three commonly utilized models of vaccine acceptance (the Theory of Reasoned Action, the Theory of Planned Behaviour, and the Health Belief Model), before revision following preliminary analysis to include multiple concepts from Maya J. Goldenberg’s “Crisis of Trust” framework as influences in the ongoing analysis. As the focus of this research shifted to the concept of trust after preliminary analysis, this thesis sought to answer the question “How does trust influence the decision-making process of pregnant people around vaccination during pregnancy in the context of the COVID-19 pandemic?” Several themes were generated from participants’ accounts of their experiences navigating vaccination decisions during pregnancy in the context of the COVID-19 pandemic, each revolving around the role of trust in these decision-making processes. These overlapping themes form an expanded version of Goldenberg’s framing of vaccine hesitancy as a “Crisis of Trust” (3) that helps to explain how vaccine decisions occur on both an individual and societal level. This new framework also functions to demonstrate potential focuses for future interventions to increase vaccine acceptance in this population. 3 Chapter 2: Background 2.1 Vaccine Decision-Making & Vaccine Hesitancy With the prevalence of vaccination programs against communicable diseases in developed countries, particularly in childhood, vaccine uptake (coverage) has been a limiting factor in the effectiveness of immunization programs. Vaccine hesitancy, defined by the WHO as “delay in acceptance or refusal of safe vaccines despite availability of vaccine services,” has become a major concern of vaccination programs, particularly in the Global North (2). Both vaccine acceptance and vaccine hesitancy represent sides of a continuum of attitudes towards vaccines that range from complete confidence in the safety and necessity of vaccines to complete skepticism (with the latter often including belief in malicious objectives underlying vaccination strategies). These attitudes have been described to occur both as “default” positions, which are applied to vaccines overall, or “reactive” positions, which are more localized (including attitudes specific to individual vaccines or in response to current events) (4). Multiple models for vaccine hesitancy and vaccine decision-making have been suggested, including the 3C, 5C, and 5A models, and existing psychological frameworks for decision-making, the Health Belief Model, the Theory of Reasoned Action, and the Theory of Planned Behaviour (5). The first three of these models were specifically developed to address vaccine hesitancy. The 3C model, developed by the Strategic Advisory Group of Experts on Immunization (SAGE) Working Group on Vaccine Hesitancy in 2014, describes vaccine hesitancy as a combination of three factors: complacency, convenience, and confidence (5,6). In 2018, the 3C model was further expanded by a team of German researchers to include the factors of calculation and collective responsibility, resulting in the 5C model (5,7). The 5A model was proposed in 2016 as an 4 alternative explanation of the major influences on vaccine uptake, citing the factors of access, affordability, awareness, acceptance, and activation (5,8). Finally, the Health Belief Model, Theory of Reasoned Action, and Theory of Planned Behaviour are models which were not developed specifically for the issue of vaccine hesitancy but have been quite useful in this realm and are frequently utilized in vaccine hesitancy research (5). Due to their strong connection to the current literature on vaccine hesitancy/ vaccine acceptance, these models are included as influences in this thesis work and thus are expanded upon in Chapter 3: Methods. 2.1.1 Trust in Vaccine Decision-Making From earlier conceptions of vaccine hesitancy, the role of trust has been notable. While often considered as a peripheral influence on many of the factors indicated in the aforementioned models of vaccine hesitancy and vaccine decision making rather than a central factor, trust in health professionals and institutions have been vital. Risk perceptions associated with the diseases that vaccinations are aiming to protect against were shown to be influenced by the epistemic trust that individuals have with the body providing this information (whether an individual healthcare provider or a more distanced institution, such as government or the regional public health body).(4) Notably, Goldenberg’s work on trust in vaccine hesitancy inverted this narrative to play trust as the central characteristic in the current context of vaccine hesitancy. While demonstrated through much of her work, this was best exemplified in the “Crisis of Trust” framework established in her 2021 book. This view of trust in vaccine hesitancy underlay much of this thesis work and thus this “Crisis of Trust” framework is expanded upon in Chapter 3: Methods. (3,9) 5 2.2 Vaccination in Pregnancy Despite evidence showing the importance of vaccination during pregnancy based upon the primary goals of protection of the pregnant person and/or passive protection of the infant before they are able to receive infant vaccinations, vaccine hesitancy continues to represent a threat to the effectiveness of these vaccines. The COVID-19 pandemic, declared by the WHO in March 2020, introduced many unprecedented new variables to the vaccine decision-making processes, including the introduction of new vaccines, changes in the format of prenatal care, and overall, a significant degree of pandemic-related stress for many pregnant people. The importance of vaccination during pregnancy has been recognized by the Society of Obstetricians and Gynecologists of Canada (SOGC) and the National Advisory Committee on Immunization (NACI) in Canada for many years, with NACI and SOGC recommending influenza vaccines for all pregnancies during influenza season starting in 2007 and 2008 (respectively) due to concerns about risks of infection during pregnancy for the pregnant person and to confer protection for the infant in early life (10,11). Additionally, NACI and SOGC have recommended the combined tetanus, diphtheria, and acellular pertussis (Tdap) vaccine for all pregnant people since 2018 to provide passive immunity to the infant prior to the beginning of their vaccination series at two months of age (12,13). SOGC and NACI began recommending COVID-19 vaccines for all unvaccinated pregnant people (and whenever a new COVID-19 vaccine dose is recommended for the general public) in April and May of 2021 (respectively) as evidence continued to emerge around the risks of infection in pregnancy and the safety of COVID-19 vaccines for pregnant people (14,15). For the purposes of this thesis, the literature reviewed here will be international in scope when considering the medical and physiological basis of infection and vaccination, while scope 6 will be limited to the United States and Canada for social aspects of vaccination due to concerns of transferability between social contexts. While the United States is an imperfect model for Canadian social concerns of vaccination in pregnancy (due to demographic differences and privatization of the health system), it has been included as it is still considered relatively socially comparable, and the quantity of literature has been insufficient to limit this literature review to only Canada. Furthermore, vaccine availability and recommendations tend to be similar between the United States and Canada. Disease control guidelines and vaccination recommendations in Canada tend to be highly influenced by those of the United States, with NACI recommendations influenced by the Advisory Committee on Immunization Practices in the United States due to the role of liaison members between these committees. Thus, I expected similarities between the United States and Canada in both the social contexts of the pandemic and vaccination guidelines during pregnancy. 2.2.1 Seasonal Influenza Vaccination Influenza infection during pregnancy presents a significant risk to both the pregnant person and the development of the fetus. Pregnant people have a greater risk of seasonal influenza infection (16) and both hospitalization (16–18) and ICU admission (16) related to influenza. Additionally, hospitalization with influenza is associated with greater risks of preterm delivery (19–21), low birth weight (20,21), and adverse neurodevelopmental outcomes (22,23) for the infant. Evidence suggests that influenza vaccination in pregnancy is likely to be protective against many of these risks, as vaccination is associated with lower risks of preeclampsia (24), fetal mortality (9,14), preterm birth (9,14), low birth weight (21), and both influenza infection and 7 influenza-related hospitalization for the infant in the first six months of life (16,25,26). However, despite these benefits and the current NACI and SOGC recommendations, seasonal influenza vaccine uptake remains lower in pregnant people than in other high-risk populations. Estimates for seasonal influenza vaccine uptake in pregnant people range from 28.7% to 44% (27–31). Lower uptake rates have been observed in pregnant people who have delayed or inadequate prenatal care (32). It is currently unclear whether this is due directly to the inaccessibility of prenatal care providers or if this trend represents a confounding relationship with another socioeconomic factor. Additionally, pregnant people with pre-existing medical conditions are more likely to display lower rates of vaccine hesitancy (32), which may be connected to greater contact with providers and/ or greater perceived vulnerability to (severe) COVID-19 infection. 2.2.2 Tetanus, Diphtheria and Acellular Pertussis (Tdap) Vaccination The Tdap vaccine is a combination vaccine that protects against three different infections: tetanus, diphtheria, and pertussis. In Canada, this vaccination is particularly vital in pregnancy in protecting infants against pertussis, which disproportionally impacts infants, with infants under one year of age having the most significant risks of both contracting pertussis and severe infection, especially for those less than three months of age (33,34). This timing corresponds to the period before infants qualify for vaccination, as the first vaccinations including tetanus, diphtheria, and acellular pertussis are provided at two months (either the DTaP-HB-IPV-Hib or DTaP-IPV-Hib combination vaccine, depending on province or territory (35)). Thus, passive immunity transferred through the placenta through immunization in late pregnancy is required for protection before active vaccination of the infant. Due to the severe outcomes of pertussis in this youngest age group, increasing emphasis has been placed on Tdap vaccination during pregnancy. 8 Compared to infant vaccination and cocooning (vaccination of everyone with the capability of spreading pertussis to the infant), vaccination in pregnancy has been established as the most effective intervention to prevent infant pertussis infection (36,37). These vaccines have been demonstrated to have no increased risk of stillbirth, neonatal death, low birth weight, and congenital malformations when pregnant people are vaccinated with Tdap (compared to those unvaccinated) (38,39). Additionally, studies have demonstrated a decreased risk of preterm birth, NICU admission, pre-eclampsia and eclampsia when pregnant people are vaccinated with Tdap (compared to those unvaccinated) (38,39). With such observational studies, this effect is likely not entirely due to the vaccination itself, as self-selection into the vaccinated group may correspond with other protective behaviours; however, vaccine effectiveness for preventing pertussis infection in infants 0-3 months of age is estimated at 69% to 91% (33,36,37). Effectiveness estimates for preventing pertussis-related hospitalizations and deaths are 66%-94% and 95%, respectively (38). Analysis from a cohort of participants who gave birth from January through March 2022 in Ontario demonstrated 28.7% prenatal uptake of Tdap during the pandemic (31). This is consistent with a continuation of the trend of increasing Tdap uptake during pregnancy in Ontario, from 0.4% for pregnancies conceived in the 2011/2012 fiscal year to 29.2% for those conceived in the 2019/2020 fiscal year (28). It is expected that the NACI recommendation of this vaccination during pregnancy in the 2017/2018 fiscal year was a significant contributor to this increasing rate, with a nine-fold increase in coverage following this recommendation (28). Further, the funding of these vaccines in Ontario starting in April 2022 is expected to further contribute to these increases, though literature on these more recent trends has not yet emerged (28). 9 2.2.3 COVID-19 Vaccination In May 2021, NACI extended vaccination recommendations for SARS-CoV-2 vaccines to include pregnant people as a high-priority group (14). These came following the initial recommendation that pregnant people should not be routinely vaccinated for COVID-19 (due to their exclusion from clinical trials) in December 2020 (14). These recommendations were issued based on the observed risks of COVID-19 infection for pregnant people and outcomes of COVID-19 immunization observed in pregnant people vaccinated as part of the general public. Notably, pregnant people were excluded from initial vaccine trials of both mRNA vaccines – BNT162b2 (produced by Pfizer-BioNTech) and mRNA-1273 (produced by Moderna), as well as the protein subunit Nuvaxovid vaccine (produced by Novavax) and viral vector vaccines Vaxzevria (produced by AstraZeneca) and Jcovden (produced by Janssen) (40,41). This exclusion from vaccine trials necessitated the use of post-market surveillance and other studies in the general public in developing NACI recommendations in pregnancy (40). Current NACI recommendations for COVID-19 vaccination during pregnancy indicate that pregnant people should be offered mRNA vaccines (due to the much greater volume of information on their use in pregnancy) unless contraindicated, in which case the Nuvaxovid vaccine may be provided (41). While earlier recommendations stated that the viral vector vaccines may be used in pregnancy if mRNA vaccines are contraindicated, these vaccines are no longer authorized for use in Canada, and how often they were used in pregnancy while on the market is currently unclear (40,42). Pregnant people have been observed to be at higher risk of COVID-19 complications (43–45), including preeclampsia (46,47), eclampsia (46,47), mortality (48), placentitis (47) and caesarean deliveries (49). Additionally, COVID-19 infection in pregnancy poses many increased 10 risks to the fetus, including fetal distress (46–48), abnormal fetal heart rate (50), fetal mortality (48,50–53), low birth weight (47,48,52), increased NICU admissions (48–50,52,54), low Apgar scores (52), and preterm birth (46–50,53,54). Although the mechanisms are still unclear, infants exposed to COVID-19 infection in utero had greater rates of hospitalization and ED visits in the first year of life (55), as well as higher rates of neonatal death (52). Specifically, ED visits for hypoglycemia, jaundice, and respiratory or urinary tract infections were significantly increased in those with this exposure compared to infants without known exposure (55). Though pregnancy has an independent effect on COVID-19 risk, this appears to be compounded by many social influences. The risk of severe COVID-19 disease is disproportionately increased for racialized and low-income pregnant people (45), as well as pregnant people living in high-density neighbourhoods (45,56). Despite recommendations and the designation of pregnant people as a high-priority group, COVID-19 vaccine uptake has remained lower in pregnant people compared to the general population, though estimates vary between studies. In Ontario, studies have found an uptake rate for the COVID-19 vaccines, either preconception or during pregnancy, of 79.6% for the first dose and 75.5% for the second dose (31). These rates are still slightly lower than those observed in the general public in Ontario, with 82.7% of the population five years old or older receiving at least one dose during the study period (57). Many socioeconomic factors were also associated with COVID-19 vaccination rates in Canada, with lower uptake observed in those with lower family income and education levels (31). While racial and ethnic factors are less commonly described in Canadian literature, lower rates of COVID-19 vaccine uptake during pregnancy are associated with Hispanic and/or non-White backgrounds in the United States (58). In contrast, some Canadian studies have indicated that 11 Indigenous pregnant people had greater COVID-19 vaccine uptake in pregnancy (possibly due to the prioritization of remote/ isolated Indigenous communities in the vaccine distribution and earlier age-based rollout to Indigenous people), and racial background was otherwise not found to be significant (59). Finally, healthcare providers' recommendations of vaccination in pregnancy and greater self-perceived knowledge of COVID-19 vaccination and infection during pregnancy were associated with substantial increases in rates of COVID-19 vaccine uptake during pregnancy (58,60). 2.2.4 Vaccination in Pregnancy in Prior Pandemic Context (Spotlight on A/H1N1) In considering the role of the COVID-19 pandemic on pregnant people and their decision-making processes around vaccination and prenatal care, the 2009 Influenza A/H1N1 pandemic serves as a valuable model. Similar risk factors for severe disease were identified for pandemic influenza A/H1N1 and SARS-CoV-2, including older age, chronic respiratory or cardiac conditions, diabetes, obesity, and pregnancy (61,62). Research conducted around the A/H1N1 pandemic suggests a connection between risk awareness of the disease and vaccination uptake in that a greater perceived risk of pandemic influenza was correlated with greater uptake of the A/H1N1 vaccine (63,64). This pandemic also highlighted many barriers to A/H1N1 vaccination in pregnancy. The most common concerns highlighted by pregnant people were those of unknown or delayed vaccine effects (often related to concerns of the “newness” of the vaccine or perceptions of insufficient testing), omission bias (favouring the harms associated with lack of action to the harms related to the action of vaccination), natural ideology (favouring the “natural immunity” resultant from infection over the immunity generated by vaccines), and aversion to ambiguity (concerns 12 associated with the lack of clear information available about both A/H1N1 itself and the vaccine) (63). Specific barriers encountered by foreign-born pregnant women were also observed, including a lack of access to information in their native language (65). This lack of information necessitated greater reliance on the inherent trust of vaccines and their healthcare providers (65). For many pregnant participants, this greater reliance on trust in healthcare providers was informed by cultural norms associated with the role of medical professionals and inherent trust in their expertise (65). A/H1N1 vaccination rates in pregnancy were also observed to follow a socioeconomic gradient, with the highest vaccination rates observed among neighbourhoods with the highest income and education levels and lowest concentrations of immigrants (66). 2.3 Role of the COVID-19 Pandemic in Pregnancy Experiences COVID-19, caused by the virus SARS-CoV-2, first emerged in Wuhan, China in December 2019 and was declared a pandemic in March 2020 (67,68). This pandemic impacted pregnant people in Canada in several ways, including concern about the infection itself, navigating decision-making about the emerging COVID-19 vaccines, changes in the format of perinatal care to include virtual care and/or fewer appointments, (anticipated) changes to the format of hospital support during birth and postpartum, and pandemic-related physical distancing decreasing access to social support. 13 2.3.1 Concern About COVID-19 Infection Worries directly relating to COVID-19 infection risk have been reported to influence pregnant people’s experiences throughout the perinatal period. These worries were found to be significantly correlated with feelings of depression and/or anxiety prenatally and postpartum (69). These worries were also found to be an area of concern for people giving birth in hospitals during the pandemic (70). For many, these worries were magnified through their pregnancy due to the uncertainty of the risks to both themselves and their fetuses if they were to be infected with COVID-19, challenges regarding the safety of medications during pregnancy in the case of illness, and projected lack of available health services (71). 2.3.2 Changes to Format of Perinatal Care The pandemic prompted changes in the format of perinatal care, including decreasing the frequency of routine appointments and shifts to virtual care (defined as any provider-patient interaction not occurring in person, including via telephone conversation, video conferencing, or other digital communications) (72). In multiple studies, 23-40% of pregnant people had at least one appointment with their prenatal healthcare provider cancelled, with many (but not all) rescheduled with virtual appointments (73,74). One study out of Ontario found that 73% of people in early pregnancy between June and August of 2020 had at least one virtual appointment during their pregnancy (74). Both providers and pregnant people have remarked that their ability to form strong rapport in prenatal care was noticeably decreased due to the format of virtual appointments (75,76). This impacts how patients connect with their providers, which may limit the ability of providers to adequately advise on vaccination during pregnancy and the ability of providers to offer prenatal vaccinations. COVID-19 vaccines could not be provided at prenatal clinics, and 14 virtual care does not allow for interventions such as immunization. Given the existing understanding of the importance of provider recommendations and provider rapport in vaccine decisions in pregnancy (as well as the benefits that come from the convenience of in-clinic vaccinations), it is expected that these changes in the overall setting of prenatal care will impact the decision-making processes of those pregnant during the COVID-19 pandemic (77–80). Additional changes to the context of pregnancy during the COVID-19 pandemic include the exclusion of support people from attending prenatal appointments. Pregnant people across Canada noted this restriction, with estimates of approximately 91% of pregnant people not being able to bring a partner or support person to in-person prenatal appointments (73,74). Many pregnant people described this as a significant aspect of the loss of social support they observed due to the COVID-19 pandemic (76). These social restrictions due to the pandemic were also observed to have significant effects on mental health during pregnancy. Cancellation of at least one prenatal care appointment was associated with increased odds of clinical symptoms of depression and anxiety (73). Pregnant people described fears around giving birth without their partner or a support person present as one of the major contributors to feelings of depression or anxiety (69). Further, many pregnant participants have described a sense of losing control and autonomy due to the pandemic restrictions and associated uncertainty, and people pregnant during the pandemic were demonstrated to have a significantly increased risk of clinical anxiety or depression scores compared to a pre-pandemic cohort (71,81). Finally, many birthing people described hospital visiting restrictions and decreased length of stay as contributing to these feelings of social isolation (70). These changes to availability of health services during the COVID-19 pandemic are far from unique to prenatal care, and many health consequences are observed for the delays to care 15 and cancelled appointments for healthcare needs considered less acute than active labour. For example, while these consequences to changes in formats of prenatal care are observed as increased rates of perinatal anxiety and depression, the consequences of delays to cancer screening, diagnosis, and treatment are observed in advanced cancer stages at detection, worsened prognoses and higher mortality rates (82–84). 2.3.3 Changes to Hospital Support During Birth A mixed-methods study of people’s hospital birthing experiences found that individuals giving birth in Ontario during the COVID-19 pandemic had significantly shorter postpartum hospital stays compared to those before the pandemic, according to hospital administrative data (70). Participants described worries about the possibility of COVID-19 exposure during their hospital stay, feelings of isolation due to visitor restrictions while in the hospital, and, for some, the perception of being “rushed” out of the hospital following their birth and not being allowed an adequate amount of time to recover (70). While these experiences occurred after the prenatal vaccination decision-making described in this research, communications with people who gave birth earlier in the pandemic may have affected the participants’ levels of worry and anxiety, subsequently influencing their decision-making processes. 16 2.3.4 Impact of Physical Distancing on Social Support Physical distancing was a highly integral part of the experience of the perinatal period for many participants. Pregnant people described a multifaceted impact of physical distancing in increasing their feelings of depression and/or anxiety, including via the loss of pregnancy-related celebrations and milestones, loss of community (especially for those with family living far away or in areas with high transmission rates), loss of public supports for pregnant people and new parents, and feelings of isolation due to restrictions during hospital birth (69,70). 2.3.5 COVID-19 Vaccine Decision-Making Many of the studies on prenatal vaccines in the COVID-19 pandemic have focused exclusively on the United States. While the United States is contextually similar to Canada in many respects, it is unclear how the differences between Canada’s publicly-funded health insurance system vs the privatized health system in the United States may have impacted the progression of this pandemic, as well as the impact of differential guidance between the countries (85). For example, the incongruence observed between statements of the president of the United States and the guidance of the Centers for Disease Control and Prevention (CDC) was expected to have negatively impacted public confidence, whereas, in Canada, there was much greater congruence in the Prime Minister’s and Chief Public Health Officer’s guidance (85). For this reason, the wealth of research that has emerged from the United States regarding vaccine uptake in pregnancy during the COVID-19 pandemic may inform this thesis, but must be understood within this context. In the United States, factors associated with the non-uptake of vaccines during pregnancy included: being younger, having health insurance via Medicaid or Medicare (86) (two government health insurance programs), being non-Hispanic Black, and having fewer chronic health conditions (87). 17 Factors associated with increased vaccine uptake included trust in vaccine information from the healthcare providers and social norms (such as pro-vaccine attitudes observed in family and friends) (87). The uptake of routine vaccinations in pregnancy (specifically Tdap and seasonal influenza) in the United States was noticeably decreased during the pandemic, hypothesized to be a lack of access to healthcare providers for vaccination or discussion of the vaccines and increased concerns around leaving home and possible exposure to COVID-19 (88). Many concerns were found to be associated with COVID-19 vaccine hesitancy in pregnant people in the United States, including potential harm to the fetus, "hasty" approval and lack of data, and general lack of information around long-term risks (89). Within Canada, it has been noted that pregnant people have had a lower rate of COVID-19 vaccine uptake than a similarly-aged cohort of non-pregnant females (90). The concerns commonly cited for this hesitancy have borne striking resemblance to both those of American pregnant people and those of pregnant people regarding the 2009 pandemic influenza vaccine, including concerns of yet-unknown long-term effects on the fetus/child and concerns of "hasty" approval (60,90). Another common barrier to COVID-19 vaccine uptake in pregnancy has been omission bias, as many people favour the unknown risks of possible COVID-19 infection (risks of inaction) to the unknown dangers of the COVID-19 vaccines (risks of action) (60,90,91). Many socioeconomic factors were associated with lower rates of COVID-19 vaccine uptake in pregnancy, including lower socioeconomic status overall, lower neighbourhood income, and high material deprivation (60,90,91). Other demographic and lifestyle-related factors associated with vaccine hesitancy included younger age (also observed in American pregnant people), living in a rural area, and being a smoker or using other substances during pregnancy (60,90,91). Finally, many of the information factors associated with vaccine hesitancy in Canadian pregnant people included belief 18 in social media-based information, accessing knowledge from non-credible sources, lack of knowledge on the burden of disease for COVID-19, and lack of information on vaccines from trusted health providers (60,90,91). 2.4 Study Objectives & Research Questions While routine vaccine decisions in pregnancy have been examined in many contexts, previous pandemics (notably the A/H1N1 pandemic of 2009) have demonstrated that this context may introduce pandemic-specific influences on vaccine decision processes during pregnancy (92,93). These factors include trust in the government’s pandemic response, trust in media reporting regarding the pandemic and concerns regarding the pharmaceutical industry’s involvement in vaccine promotion (92,93). For this reason, there is a clear need for adaptable research on the decision-making process of pregnant people around vaccination in the context of the COVID-19 pandemic. Thus far, few studies have emerged, particularly in Canada, examining how pregnant people experience the decision-making process around COVID-19 vaccines during pregnancy. Thus, this thesis seeks to answer the overarching research question: “How does trust influence the decision-making process of pregnant people around vaccination during pregnancy in the context of the COVID-19 pandemic?” During the course of this analysis, two additional sub-questions emerged. Firstly, “How is the concept of ‘trusting the science’ constructed and interpreted by pregnant people during the COVID-19 pandemic?” examines the role of a predominant narrative during the pandemic – one of overall trust in science that seeks to describe vaccine decisions as purely motivated by objective facts and evidence (94). This narrative appears to assume that there is an obvious, correct answer 19 to these decisions based on science and more-than-adequate evidence to inform these decisions (94). Secondly, “What relationships or other forms of trust have shaped vaccine decision-making of pregnant people in the COVID-19 pandemic?” echoes the social constructivist philosophical framework underlying this research. This sub-question seeks to address how social interactions inform this decision-making process, including how factors of the pandemic may impact these interactions. These interactions include those pregnant people have with their perinatal healthcare providers and other interactions within the health system, as well as with others in their network, including family, friends, and peers. 20 Chapter 3: Methods 3.1 Parent Study This thesis reports on one qualitative analysis within a larger project headed by Drs. Devon Greyson and Meredith Vanstone, at the University of British Columbia and McMaster University, respectively. This broader study used mixed methods and involved concurrent quantitative and qualitative analyses. The quantitative strand utilized administrative data (from ICES in Ontario) to examine outcomes regarding vaccination, perinatal care, mental health and social support between three cohorts, described as “Pre-Pandemic” (births in the first quarter of 2019) “Early-Pandemic” (births in the first quarter of 2021) and “Later-Pandemic” (births in the first quarter of 2022). The qualitative strand involves the analysis of interviews conducted with people who were pregnant and gave birth during the early pandemic (second quarter of 2020-end of 2021) concerning four key themes – vaccination, perinatal care, social support, and mental health. This thesis will analyze the theme of vaccination. 3.2 Data Source To examine the decision-making process of pregnant people during the COVID-19 pandemic, analysis was performed on a series of semi-structured interviews conducted virtually between July 2022 and July 2023. These interviews were conducted as part of the larger study, “How do perceptions of Covid-19 risk influence health decisions in pregnancy? A mixed methods study”, led by Dr. Devon Greyson at the University of British Columbia and Dr. Meredith Vanstone at McMaster University. Interviews were conducted virtually, with the interviews for participants who gave birth in British Columbia conducted by one team member from the Greyson 21 lab at the University of British Columbia and the interviews for participants who gave birth in Ontario conducted by a team of six interviewers and trainees from the Vanstone lab at McMaster University. This larger study received ethics approval from the appropriate behavioural ethics boards at the University of British Columbia (H22-01905) and Hamilton Integrated Research Ethics Board (14632) in 2022, while this thesis analysis received approval from the University of British Columbia Behavioural Research Ethics Board in 2024 (H24-00384). 3.3 Participants Study participants were recruited via multiple pathways. Recruitment information and posters were shared with family medicine and perinatal health clinics in various locations in British Columbia and Ontario. Physical recruitment notices were placed in locations frequented by pregnant and parenting people, such as libraries, community centers, or pharmacies. Also, study information was advertised in online pregnancy and parenting-related forums to utilize these established networks of pregnant people and parents. Interested pregnant people and parents who contacted the study team using the contact information provided in these advertisements were directed to an online survey (provided in Appendix A) to screen for eligibility for enrollment and consent to contact. Seventy-four participants who gave birth in Ontario or British Columbia from May 1st, 2020 to December 1st, 2021 were selected for and completed interviews. This includes 43 participants within Ontario and 30 participants in British Columbia. The interview guide (provided in Appendix B) was generated via a collaborative effort between Drs. Greyson and Vanstone’s research groups to address participants’ experiences with four themes: vaccination (during pregnancy and in childhood), perinatal care, social support, and mental health. 22 Table 3.1. Demographic characteristics of all interviewed participants. Baseline characteristic n % Province (n, %) British Columbia 30 41.1 Ontario 43 58.9 Quarter of Birth (n, %) 2020 Q3 11 15.1 2020 Q4 12 16.4 2021 Q1 7 9.6 2021 Q2 15 20.5 2021 Q3 7 9.6 2021 Q4 14 19.2 Race (n, %) White 47 64.4 Indigenous 1 1.4 Black 4 5.5 East Asian 9 12.3 South Asian 5 6.8 Southeast Asian 1 1.4 Latin American 1 1.4 Middle Eastern 3 4.1 Multi-Racial 2 2.7 Highest Level of Education High School 8 11.0 College/ Trade School 15 20.5 University 35 47.9 Postgraduate/ Professional Studies 15 20.5 Age at Interview (median, SD) 32 4.4 Age at Birth (median, SD) 31 4.6 Prenatal Care Provider Type(s)† Family Doctor 28 38.4 OBGYN 56 76.7 Midwife 53 72.6 Doula 3 4.1 Public Health Nurse 1 1.4 Place of Residence Urban 40 54.8 Suburban 23 31.5 Rural 9 12.3 Remote 1 1.4 Partnered with Coparent 71 97.3 † Percentages do not add up to 100% due to the ability of participants to indicate more than one provider type. 23 3.4 Data Analysis This thesis analysis involved the implementation of reflexive thematic analysis (95,96) of the interview transcripts, focusing on the themes of vaccination in pregnancy. While an inductive approach was taken to identify initial codes, several theories were incorporated as sensitizing constructs. These sensitizing constructs were drawn from the Theory of Reasoned Action/ Theory of Planned Behaviour, and the Health Belief Model (77,78,80,97). Following preliminary analysis and associated discussions with my supervisor, I incorporated Maya J. Goldenberg’s “Crisis of Trust” framework in this analysis and shifted away from the previous focuses on the Theory of Reasoned Action, Theory of Planned Behaviour, and Health Belief Model (3). 3.4.1 Theory of Reasoned Action & Theory of Planned Behaviour The Theory of Reasoned Action, proposed by Fishbein and Ajzen in 1975, and its extended form, the Theory of Planned Behaviour, are two predictive theories of behavioural psychology commonly implemented to examine vaccine decision-making (77,78,97). The Theory of Reasoned Action posits that intention for a particular behaviour is formed by attitudes about the behaviour and subjective norms (consisting of what the decision-maker believes those in their life would want them to do). According to this theory, the behavioural intention is then converted into a behaviour. In its extension, the Theory of Planned Behaviour theorizes that behavioural intention is also moderated by the decision maker’s perceived control. While this additional factor of perceived control has not been as strongly supported by the literature as a contributor to vaccine decision-making in high-resource settings (64,98), it was still included as a sensitizing construct in this thesis for comprehensiveness. 24 Additionally, the Theory of Planned Behaviour has demonstrated some use in both the Influenza A/H1N1 and COVID-19 pandemics. As summarized by Tostrud and colleagues, the Theory of Planned Behaviour explained 66% of the variance in pandemic influenza vaccine intention among pregnant people and 74% of the variance in COVID-19 vaccine intention among non-pregnant people (both in the United States during these respective pandemics) (5). While there is demonstrated utility of this model for vaccine intentions, these studies were not invulnerable to the criticism this model faces for predicting intentions well but not necessarily capturing the translation of these intentions into vaccine decisions. 3.4.2 Health Belief Model The Health Belief Model, developed by Rosenstock in 1980, describes health behaviours as the result of five factors: (i) perceived susceptibility to illness, (ii) perceived severity of illness, (iii) perceived benefits of taking action, (iv) perceived barriers to taking action, and (v) cues to action (80). In the context of vaccination during pregnancy, these “cues to action” are most often observed in discussions with perinatal healthcare providers (99). A recent example of the applicability of this model to vaccination decision-making in pregnancy was a study conducted by Bettinger et al. in 2016 (63). In this study, the researchers found that pregnant participants’ experiences of vaccine decision-making echoed the factors of the health belief model in terms of perceived susceptibility and severity of disease, perceived risks and benefits of vaccination, and calls to action. They found that perceived susceptibility and severity appeared to correlate more strongly with public health messaging and media coverage than actual risk (63). The balancing of vaccination risks and benefits seemed to be a highly heterogeneous process, informed by media coverage, (mis)information, and previous “cautionary tales” such as 25 the thalidomide tragedy (63). Finally, the cues to actions observed for this focus group included factors of healthcare provider recommendations and information provided by the media (63). 3.4.3 “Crisis of Trust” Framework In her 2021 book “Vaccine Hesitancy: Public Trust, Expertise, and the War on Science,” Maya Goldenberg proposes the role of public trust in science and scientific experts as the major contributors to the current crisis of vaccine hesitancy (3). Preliminary coding of this analysis’ transcripts revealed a repeating theme of “trust,” both through explicit references and more implicit discussion, which implies trust is a significant mediating factor in this decision-making process. Resultantly, this analysis has been organized around the theme of trust. While this analysis was not strictly applying Goldenberg’s framework, elements of this model were used as sensitizing constructs, inspiring some of the interpretations and connections constructed from the transcripts. From Goldenberg’s work, the most pertinent themes identified involved perceptions of information itself (including the concepts of epistemic trust and science as social knowledge), institutions and their reputations (including the perceived integrity of institutions and experts and the effect of public health injustices on public confidence), processes of trusting (via “leaps of faith”), and the social values of trust (including the function of trust in community as a mechanism of social cohesion and the role of the perceived externality of “scientific mavericks”). (3,9) 26 3.4.4 Rationale for Methodology & Philosophical Framework As much of the information collected from participants demonstrates the role of their social networks and interactions in navigating vaccine decision-making during pregnancy, this thesis employs a social constructivist framework. In applying this framework, this thesis adopts the ontological assumption of a multiplicity of realities – multiple realities exist based on their subjective construction. In this thesis, this ontology implies that each participant’s experience is their reality, irrespective of whether these realities are considered objective or refutable. The epistemological component of this framework necessitates the results of this thesis as co-constructions of the participants and the researchers. While it seeks to honour the participants’ experiences, the themes are created using participants’ descriptions but are subject to the researcher’s interpretations. Furthermore, it is vital to acknowledge this research's social and societal context, including the social realities of both the participants and researchers. Thus, there is a significant focus on reflexivity and positionality associated with both the social constructivist framework and the methodology of reflexive thematic analysis. Based on the theoretical framework and research objectives, the two most applicable methods seemed to be constructivist grounded theory and reflexive thematic analysis. While either method may have answered this research question, reflexive thematic analysis was chosen for several reasons. Firstly, the role of this thesis analysis as existing within a larger project and multiple analyses being conducted on the same semi-structured interview transcripts makes constructivist grounded theory unfeasible due to the inability to concurrently conduct data collection and analysis, which is required to ensure the level of theoretical saturation necessary for grounded theory approaches (100–102). Secondly, reflexive thematic analysis was favoured due to the greater flexibility in coding, as the standard line-by-line coding demonstrated in grounded 27 theory cannot necessarily incorporate larger contexts within the interviews and may miss some of the more latent meanings within the text (101,102). Finally, the increased flexibility allowed by reflexive thematic analysis compared to grounded theory allows us to better account for participants' decision-making processes and their experiences navigating these decisions during the pandemic. In this analysis, I consider not only the decisions participants are making and the influences on these decisions, but also the greater context around these decision-making process scenes and the experience of being pregnant during the pandemic. This includes any stigma that is faced by participants as a result of their decisions or their beliefs around vaccination, which is vital in informing how we address vaccine hesitancy in this population. 3.4.5 Reflexive Thematic Analysis Thematic analysis was established in the 1990s as a qualitative research method focused on textual pattern recognition, largely of interview data, but could include many different forms of data depending on the study. As identified by Braun and Clark, this can consist of several frameworks often associated with specific theoretical underpinnings. A positivist or post-positivist theoretical framework is often associated with coding reliability thematic analysis, an interpretivist or social constructivist framework is associated with reflexive thematic analysis, and codebook thematic analysis is often associated with a mixed framework, which may include interpretivist/ social constructivist and positivist/ post-positivist theory elements. First published by Braun and Clark in 2006, Reflexive Thematic Analysis relies largely on the researcher's reflexivity, a practice of reflecting on one’s relationship to the topic being examined and the research process overall. While reflexivity has been conceptualized in many ways (particularly varying between disciplines), I have expanded upon the understanding of this 28 practice utilized in this research in the section below (3.4.6: Reflexivity). Consistent with the theoretical framework of social constructivism, this acknowledges the role of the researcher in creating themes rather than a concept of themes emerging “organically” from the data. This method has a large amount of flexibility, including both inductive/deductive and semantic/latent coding. While there is this flexibility of method, Braun and Clark have outlined a particular process for the undertaking of reflexive thematic analysis consisting of six steps or stages: (i) dataset familiarizing, (ii) coding, (iii) generation of initial themes, (iv) reviewing & further developing themes, (v) refining, defining & naming themes, and (vi) writing up the analysis. In utilizing the theoretical flexibility of Braun and Clarke’s framework for reflexive thematic analysis, I began with a review of the existing literature on vaccination in pregnancy to establish the sensitizing constructs which would lead this analysis. In this review, I identified the Theory of Reasoned Action and Health Belief Model as the most applicable to this research. I noted the components of these theories I would be aware of in conducting analysis. This consisted of extracting six general themes: (i) beliefs about the effectiveness of vaccines, (ii) beliefs about their personal (or their fetus’s) susceptibility to these vaccine-preventable diseases, (iii) beliefs about the severity of these vaccine-preventable diseases, (iv) beliefs about the attitudes others in their network hold about vaccines, (v) perceived importance of complying with the norms of their networks, (v) perceived barriers to vaccination, and (vi) the role of cues to action (often from healthcare providers). Following this, I began familiarizing myself with the dataset by reading through the transcripts in full while making reflexive notes that included my reactions to these interviews, overall impressions, and preliminary themes I saw. After approximately three complete readthroughs, I shifted into the initial coding phase of my analysis, opting for a process of 29 identifying broader codes and gradually parsing out more specific and implicit codes. After some initial coding of the transcripts, I discussed many of the codes I had produced with my supervisor, mainly focusing on how I saw trust as integral to the participants’ experiences. From this discussion, my supervisor introduced me to Maya J. Goldenberg’s “Crisis of Trust” framework, and I came to use this to inform my further analysis. These earlier stages of coding were conducted in the software NVivo, using many branches of subcodes to discern individuals’ experiences and how they connect. During the stages of coding, this process occurred as an interplay between my work in NVivo and my research journal, with much of my coding evolving to be informed by my reflections on how my views on vaccination inform the lens through which I view participants’ experiences and the broader societal contexts underlying these decision-making experiences. I continued this coding process, reading through the transcripts and codes repeatedly until I could not see any new factors in the transcripts that may inform new codes or integrate into existing codes. Throughout this phase, I discussed coding and reflexivity strategies with my supervisor and with peers working in qualitative research on similar studies and found many of their insights helpful in guiding and troubleshooting this process. Subsequently, I transitioned into a more physical method of organizing these codes into themes by transcribing the major codes I formed (those which were connected to the experiences of multiple participants) onto sticky notes and creating visual clusters with these notes. Reflexive journaling also formed a vital component of this phase, with my journal entries describing my reflections on the connections between the broader social context and the experiences described in the transcripts. Further, I distinguished the theme of trust into many foci of trust, which I once again clustered into three areas: community, healthcare providers, and institutions. 30 Finally, I reviewed the transcripts again to ensure they aligned with these themes and nuances, which may not have been initially captured. After approximately four complete readthroughs of the transcripts, I was satisfied with the depth captured from the transcripts and entered into the stage of writing up the analysis. This process was also highly informed by discussions with my qualitative researcher peers and supervisor, including discussions on the importance of the language used in this write-up and strategies for describing the results of this analysis. 3.4.6 Reflexivity A vital component of Braun and Clark’s process of reflexive thematic analysis is the incorporation of reflexivity throughout the process. While an essential component in much qualitative research, various scholars have conceptualized reflexivity quite differently, making it challenging to define distinctively. Finlay and Gough describe, “The etymological root of the word ‘reflexive’ means ‘to bend back upon oneself’” (103). It follows that reflexivity aims to hold a mirror up to the researcher, forcing them to consider their role in the research and the subject being examined. This reflexivity includes the researcher’s positionality, including social roles and positions, which may influence their understanding of the subject and their lived experiences. Still, it extends further into deeper beliefs and assumptions, including reactions to the participants and the data collected. In this research, I incorporate reflexivity via a research journal that is continually updated throughout the process – from initial data familiarization to the current writing-up process. These reflexive notes are designed to include several dimensions, including my positionality and how it influences my perspective on vaccination and pregnancy overall, the reactions I observe in myself 31 to various components of the interviews and participant responses, and my reactions to the research process itself. I aim to incorporate personal, methodological, and contextual reflexivity in the abovementioned processes (104). While this only encompasses three of the four major domains of reflexivity, the nature of my role in this research has greatly limited my ability to engage in interpersonal reflexivity (and its applicability to my research) (104). I entered this research project after the data collection stage and after the interviewing of participants, thus preventing the direct interpersonal contexts necessary for this area of reflexivity. I independently analyzed these transcripts as the sole researcher analyzing this theme, thus preventing interpersonal reflexivity in a between-researchers format. My continuing processes of reflexivity are used to inform all stages of my analysis, interpretations, and write-up. Below is a short excerpt from an entry within this research journal, which demonstrates how this reflexivity is a reflection on both how my lived experiences and preconceptions influenced my analysis and how the analysis influenced my own preconceptions. “I’ve noticed in particular that the role of community trust is one area in which I’ve greatly changed my views through this research. I think the role of “mom groups” is often demonized in discussions [of researchers] of vaccine trust and hesitance [in the literature (at times)] – both in ways that have an understandable root and in some ways that I would consider rather condescending and paternalistic at their heart.” (Excerpt from my research journal, June 5th, 2024) 32 3.5 Positionality In conducting this research, I note that I do not have personal experience with many of the topics examined. I am not a parent, nor have I had the experience of pregnancy. As a result, I found that much of my existing knowledge before engaging with the transcripts of this research was informed only by stories from family members and a more academic understanding formed by research on perinatal experiences. Therefore, I relied significantly on discussions with members of the research team with experiences of pregnancy and parenthood to ensure that I was integrating many of the interpretations they formed as a result of their lived experiences. These reflections were largely with my supervisor, Dr. Devon Greyson and the team member who conducted the interviewers with the BC participants, Ms. Caroline Mniszak. In this research, I also relied on my experiences of womanhood. Despite not identifying as a woman, my experiences being read as a woman and the integration of feminism in my life have led me to an understanding of the role of pregnant people in society that I may not have developed if not for these experiences. Furthermore, my role as a female who has planned to have children in the future for some time caused me to have prodded further into pregnancy experiences in my family than I may have otherwise. Finally, other factors of my demographics and lived experience likely influenced biases inherent to my interpretation of participants’ experiences, including my role as a White settler on the lands of the Coast Salish Peoples known colloquially as “Vancouver,” my role as a graduate student, and my background in biomedical sciences (and the inherent biases of this trained empirical way of thinking). Additionally, while I did not have my own experiences of pregnancy to draw on in the analytic process, the input of team members with experiences of pregnancy was invaluable. In particular, the disclosures interviewers made of their own experiences (particularly those of 33 pregnancy during the COVID-19 pandemic) likely increased participants’ comfort and vulnerability in these interviews, thus improving the richness of the data. While this positionality is a known consideration in qualitative research, it further solidifies the importance of trust in community discussed in Chapter 4 of this thesis. 3.6 Ethical Considerations As this research includes human participants and discussions of vaccination attitudes, beliefs, and intentions are sensitive topics for many people, this research is not without ethical risk. Notably, the research team involved in all stages of this project purposefully includes both perinatal clinician collaborators (who aided in study design, participant recruitment, and knowledge translation) and those with lived experience of pregnancy during the COVID-19 pandemic. Including the perspectives of clinicians and pregnant (or previously pregnant) people helps ensure that our research aligns with the needs of these communities, strengthening the understanding of these experiences developed in our analyses and improving the potential impact of our findings. This inclusion also safeguards the sensitivity to the needs and values of pregnant people, which we must maintain in all stages of this research. Additionally, members of the research team were required to declare financial conflicts, and none were identified. Within the interviewing stages, many safeguards were provided for participants, including emphasis on the revocability of their consent at any time and the ability to opt out of any question and answer only to the degree that they are comfortable. Additionally, ethics in this analysis are maintained via analysis of de-identified interview transcripts and the protection of participant information by ensuring that data is stored on an encrypted, password-protected device during active analysis and a secure institutional server at all other times. Participant privacy is also 34 reinforced by the care taken (e.g., not to disclose details that, when put together, could be identifying for any given participant) when including quotes and descriptions in the study's write-up. 35 Chapter 4: Results 4.1 Introduction Of the 73 participants interviewed in this study, this current analysis was derived from 63 transcripts (86.3%). The remaining 10 transcripts were utilized in theme generation due to insufficient richness or depth in the vaccination portion of these interviews. This included participants providing short answers to the researchers’ vaccine-related questions or declining to answer the questions altogether. The majority of the interviewees whose transcripts were not included in this theme development were pregnant prior to their eligibility for COVID-19 vaccines, as only one of these ten participants was offered a COVID-19 vaccine during pregnancy (and they declined this vaccination). In comparison, 33 (52%) of the included participants were offered COVID-19 vaccines during their pregnancy and 21 (63%) of those offered these vaccines were vaccinated for COVID-19 during pregnancy. Vaccine uptake for Tdap in the participants excluded from this analysis appeared to be lower than those included, with 30% receiving the vaccine, compared to 65% in the included 63 participants. In this section, the quotes provided from interviews with the participants are attributed to the participant ID and include context on the province in which the participant gave birth, the month and year they gave birth, whether they were offered a COVID-19 vaccine during their pregnancy, and (if so) whether they accepted this vaccine, according to the key provided in Appendix C. Trust was the key theme derived from these interviews, expressed both implicitly and explicitly. In the context of the early COVID-19 pandemic, which was marked by many unknowns—both about the virus itself and the vaccines against it—Goldenberg’s description of trust as a “leap of faith” was highly relevant (3). This trust was shown in three foci – prenatal care 36 providers, institutions, and community. Figure 4.1 was created to represent these three foci, within fifteen subthemes arranged within these three foci and their intersections. While this model cannot accurately demonstrate all interactions between factors, it was created to demonstrate the richness of these connections and function as a visual of the results of this research. Figure 4.1: “Triad of Trust” Model for Vaccine Hesitancy in Pregnancy During the COVID-19 Pandemic 37 This theme of trust was foremost expressed in prenatal care providers, with these professionals, when adequately accessible, acting as key informants on the current scientific consensus on both the COVID-19 pandemic and vaccinations in pregnancy. At times, this trust was relied on to decrease the mental load pregnant people experienced in retrieving and interpreting health information. The trust in the expertise of medical professionals was also mediated by pregnant people’s internalized cultural norms about the relationship between healthcare providers and patients, as well as participants’ perceptions of the honesty and transparency of their providers. The personal nature of providers stating their recommendations as the choices they would make for themselves or their families appeared to provide much greater comfort to participants than more normative framings. Trust in institutions was also a key consideration in these vaccine decision-making processes. Participants described their trust in government, a major influence on how they were considering these vaccination campaigns, to be influenced by more general philosophies regarding the role of government and their views on specific governmental leaders. Further, pregnant people’s trust in the medical system was largely mediated by their views of their positionality, as they described roles working within the medical system as influencing their views of the system overall. Finally, few expressed trust in the private pharmaceutical industry, but many discussed their trust in its regulation as a major focus, heavily influenced by their understanding of the vaccine approval process in Canada. Much of the richness in this area of trust existed within the interactions of these various institutions and how they were perceived by participants. The final focus of trust described, trust in community, involved concrete, interpersonal trust in individuals and more abstract trust in the broader community. Due to the limitations of physical distancing during the pandemic, participants described online communities as a 38 significant part of their support systems and a major influence on vaccine decision-making processes, with levels of trust in others online varying substantially between participants. The isolation of pregnant people’s partners from prenatal care appointments impacted the support pregnant people typically received from having their partner with them, as well as preventing valuable interactions with the healthcare provider in partnerships where both parents are attempting to make joint decisions during the pregnancy. The broader community was also a focus of reciprocal trust for some participants, reflecting a hope that if they protect the broader community by getting vaccinated, the community will do the same for them and their babies. 4.2 Trust in Prenatal Care Providers Representing a principal source of health information for many pregnant people, prenatal care providers were commonly relied on to provide and interpret the most up-to-date information on the COVID-19 pandemic and vaccinations and to advise on best practices in a personalized manner. For these reasons, this interpersonal trust of healthcare providers formed an integral facet of many participants’ vaccine decision-making processes. This trust was shaped by multiple factors, including reliance on prenatal care providers in aiding decision-making as a mechanism to reduce their mental load, cultural norms in views of healthcare providers, the perceived benevolence and transparency of healthcare providers, and the awareness of the healthcare provider’s own lived experience of pregnancy. 39 4.2.1 Trust in Care Providers as a Strategy to Reduce Mental Load Interestingly, many participants described purposefully trusting the information provided by their healthcare providers to decrease their mental workload with decision-making. In particular, this was commonly associated with pregnant people who were aware that they had high levels of anxiety – specifically regarding pregnancy or the COVID-19 pandemic, or just more generalized anxiety. This combination of high anxiety and self-awareness allowed these participants to undergo what appears to be a small cost-benefit analysis as to what degree they wish to engage in independent fact-seeking (if at all). I also suffer really badly with anxiety so I try not to research things and I trust the experts. I think it’s better for me that way. (P30 ON Sep20 nCV) Conversely, this desire to decrease mental load in these decisions was also raised in situations involving the lack of provider recommendation (often due to conflicting priorities in their role or vaccine conversations “slipping through the cracks,” especially for pregnant people seeing a rotating team of providers rather than just one) being interpreted as reassurance that vaccines were not recommended for them during this pregnancy. This often appeared to be the case explicitly for pregnant people who were counselled on vaccines during previous pregnancies or who otherwise had greater knowledge of the vaccine recommendations during pregnancy. In contrast, this appeared more implicitly for pregnant people unaware that vaccines were recommended during pregnancy, reflected by both those who had vaccine recommendations in subsequent pregnancies and those who demonstrated this justification of lacking vaccine recommendations in response to the interviewer’s questions regarding vaccination during pregnancy. 40 I feel like with my first [pregnancy], the doctor kind of dropped the ball with, like one of the vaccines because it was so chaotic with the pandemic and everything, and it was kind of like, yeah, you’ll be fine. (P211 BC Dec21 oCVa) This viewpoint reinforced many existing theories on the importance of prenatal care providers as sources of information regarding vaccines and communicating cues to action for vaccination. In this way, many participants reflected both trust in healthcare providers’ recommendations around vaccination and the lack thereof, assuming that there must be justification for a lack of recommendations and that this was a conscious choice of the provider. These attempts to justify the lack of provider recommendations, however, were not universal, as a small number of participants described worries about the possibility of important prenatal care (including vaccination) being missed or slipping through the cracks with the strains on the healthcare system due to the pandemic. 4.2.2 Cultural Norms of Trust in Healthcare Providers Although only addressed directly by a few participants, the role of cultural norms in the level of scrutiny or inherent trust healthcare providers are given appears to underlie many of the provider-patient interactions described by our pregnant participants. In particular, two different clusters of norms are present – norms of inherent respect for healthcare providers carried by immigrants from their countries of origin and changing norms in Canada, reflecting increasing heterogeneity in attitudes of trust in providers. Firstly, some participants chose to share their immigration pathways, describing retaining many cultural norms around respect and trust for healthcare providers from their home countries (particularly trust in doctors). 41 Nobody pressured me but, so my background is I come from India, we listen to the doctors, we don’t ask questions in India. (P213 BC Dec20 nCV) This second cluster, the changing norms of trust in healthcare providers in Canada, encompassed many of the beliefs typically associated with the anti-vaccine movement and belief in medical “mavericks”, as Goldenberg terms them. While the prevalence of challenging and questioning healthcare providers has been rising in Canada, norms of inherent trust in providers were still common among our participants, suggesting that these ideas around questioning providers represented greater heterogeneity of social norms rather than a broad shift of public opinion. It was just easy. I’m a very firm believer in Western medicine. My doctor went to school much longer than I would. (P38 ON Mar21 nCV) Additionally, many participants described their trust in their providers’ recommendations by contrasting their views against the conceptualization of due diligence in vaccine decisions described by some other pregnant people, commonly encompassing norms of questioning doctors, exploring the information available through other sources, including online forums, social media groups, online blogs, news media and academic journal articles and the obligation to “do your own research” (P32 ON May21 oCVd). These participants sometimes implied that the historical status quo had been to inherently trust medical providers to provide accurate, evidence-based vaccination advice, as demonstrated below. [I consider routine vaccinations important] because it saves lives. I mean, people have done this for, I don’t know, hundreds of years, like I don’t really want to cause like a widespread thing across my community. And I got vaccinated, my parents got vaccinated, like no one ever questioned anything. (P210 BC Sep21 oCVa) 42 The opposing view was also seen in some of the participants, with the concept of “doing your own research” and the pressure they are facing to ensure they are conducting these independent investigations appearing as recurring themes, representing a countering norm to the implied historical view of inherent trust in healthcare providers. A majority of participants indicated at some point in the interview that they were “doing their own research” (or some other paraphrasing) about the vaccines, with a few then going on to clarify the sources or strategies they were implementing, as a way from separating themselves from the people they saw as browsing inaccurate information and claiming to “do their research.” I purposely looked a lot. Like, I did my own research and I don’t mean like I looked on YouTube videos on the toilet. I feel like I did my own research and I know how to do proper research. (P16 ON Nov21 oCVa) 4.2.3 Perceived Honesty and Transparency The perception of honesty and transparency from providers (or lack thereof) was commonly mentioned as underpinning participants' trust in prenatal care providers. Remarkably, participants considered these views of honesty and transparency separately, with honesty being examined as a trait inherent to their providers and transparency concerning providers’ actions (or inaction) in providing vaccine counselling. The primary factor that influenced perceptions of provider honesty or dishonesty was the existing level of rapport with the providers before vaccine discussions. This was observed on both ends of the spectrum of rapport in our interviews as an influence on the interpretations of provider recommendations for or against vaccination in pregnancy. 43 So, I actually spoke to my family doctor about it, who has been my family doctor since I was, like, for like 25 years, and she basically was saying let’s weigh your risk of exposure, how often you’re going out. This is a really new vaccine. So, she kind of, I was torn about it. But family doctor kind of said, basically, I feel like it’s reasonable to hold off until baby’s here. But the OB was very insistent that I get it. (P22 ON Jul21 oCVd) In these cases where pregnant people had such long-standing relationships with their providers, many strongly emphasized their providers’ recommendations in their vaccination decision-making, often with little to no opposition or questioning. In stark contrast, vaccine recommendations (especially those considered very strong recommendations) in the absence of any existing rapport were often considered quite coercive and strongly dismissed by participants. This was observed, in particular, by one previously unvaccinated participant during their time in hospital around the time of their child’s birth. These seemingly overzealous vaccination conversations with medical professionals without building rapport appeared to have the opposite of the desired effect, causing these patients to be less inclined towards vaccination following these conversations. I talked to [two healthcare professionals with existing rapport] about it and I felt confident enough to get the [COVID-19] vaccine in the fall. Because they weren’t shoving it down my throat like some of the nurses at the hospital kept asking me for a little bit I think if I can recall. And I just didn’t like that, because I’m like I don’t know you, you’re a stranger to me. (P231 BC Oct21 oCVa) Conversely, the perception of prenatal care providers’ transparency was primarily focused on the counselling and information they provided to the participants. In particular, participants described 44 responding positively to their healthcare providers offering counselling that included qualified or nuanced information and providing access to primary sources for information, specific statistics, or professional anecdotes. These factors demonstrated increases in the perceived rapport of prenatal care providers, trust in these providers, and acceptance of vaccine recommendations. I had talked to my nurse practitioner about it, and she had kind of read a few different studies [of] people who’d gotten the vaccine even as early as first trimester, and had perfectly healthy babies. And then she had said that she had a few coworkers who worked in the local ICU […] So, she just kind of mentioned, you know, these are real cases happening in our local hospital. So, because of the studies I wasn’t aware of, and the fact that that was such a serious risk to me, I decided to get it. (P20 ON Oct21 oCVa) As demonstrated in the prior quote, research-based and anecdotal information from healthcare providers were both highly valued by many participants, with the perception that providers were directly passing along all the information available to them increasing the perceived integrity of these providers. This positive characterization of perinatal care providers appeared to allow participants greater comfort in broaching this “leap of trust” to vaccine acceptance. [T]he fertility doctor had been so open about the studies that she was being – had access to. That's the only thing I would have looked for. […] I'm not a researcher, I'm not a scientist, I'm not a doctor. And I trust those people to do the research and understand the research to a better level. So, they're the only opinions that matter. (P216 BC Nov21 oCVa) Further, there appeared to be an association between participants’ increased comfort with providers’ disclosure of their current sources and greater trust in the expertise of researchers and scientists. Intuitively, this greater trust in the expertise of those conducting this academic research 45 and the clinicians communicating the results contributed to participants' epistemic trust in the information they received. 4.2.4 Lived Experience and Empathetic Communication in Prenatal Care While prenatal care providers were vital to participants’ vaccine decision-making, they were not all viewed equally. The lived experience of prenatal care providers appeared to modify participants’ trust in their recommendations. Providers’ personal experiences around vaccine decisions and their empathetic communication of the choices they would make if they were in their patient’s situation were a strong influence. [My children] haven’t gotten their COVID shots yet, but I do intend to […] I actually had an appointment with my pediatrician today and I asked his advice. […] He said yeah, he would do it for his own kids so. I haven’t booked it yet, but I intend to do it. (P16 ON Nov21 oCVa) Additionally, providers who were pregnant themselves or who had pregnant partners and were navigating many of these decisions around vaccination during pregnancy at the same time were seen as some of the most potent sources of information. [T]he substitute doctor, who saw me maybe a few times, she was herself pregnant as well. […] So, when I asked her about, well should I get it or not, the vaccination – the vaccine, I guess like she makes it a little bit more convincing for me because she – her baby was about to come out and then she had a big belly and then she said well one dose is better than nothing. So, I’m like oh, I guess I’ll do it. (P230 BC Nov21 oCVa) 46 4.3 Trust in Institutions Trust in institutions generally appeared as the most abstract of these three areas of trust (with some exceptions, such as more generalized views of trust in community mentioned later). The focuses of this area of trust were varied, with the specific institutions including government, the medical system, and the pharmaceutical industry (with the focus often not being trust in each institution individually but rather in the interplay between them). Further, the forms trust took varied from more focused on key representatives of the institutions (such as high-ranking government officials representing the government as a whole) to more broad trust in these institutions to upkeep appropriate procedures and ethical practices (such as trust focused on the vaccine approval process being upheld by both government and industry). 4.3.1 Trust in Government The interplay of the role of governmental interference and participants’ overall trust in government appeared to be mediated by both the views pregnant people hold on the role of government overall, including political philosophies of big government and personal liberty, as well as their specific views on the current political leaders, with many explicitly addressing the role of the prime minister and ministers of health (at both the national and provincial level). When participants described negative feelings towards what they considered excessive governmental interference or the federal and provincial leaders at the time, they demonstrated a greater propensity towards a narrative of the vaccination strategies as coercive or controlling. In contrast, participants who expressed positive views of governmental interference and the steps taken by the provincial and federal governments to counter the COVID-19 pandemic in improving community 47 health tended to be more receptive to the role of the government in vaccine procurement and distribution. We also didn’t like the whole governmental push for vaccines. […] [I]t just felt for us more like it was a governmental money thing. So, for us, you know, it was like, well, why is, you know, Justin Trudeau sitting here and pushing this vaccine on people when, like, he’s not a doctor? […] We have our own political thoughts on that. But it felt like it was too much of a push at the time. (P203 BC Aug20 nCV) The concerns expressed by participants about the role of government in forms of coercion and control around the COVID-19 vaccines are further reinforced by more restrictive pandemic control strategies, especially lockdowns and vaccine mandates. The latter concern was demonstrated both with vaccine mandates relating to workplaces and schools and the “vaccine passports” seen in both British Columbia and Ontario at various points during the COVID-19 pandemic. I think that – this is off-topic – the vaccine passports are a little ridiculous. I have friends who decided not to be vaccinated for many reasons, and I felt like there’s too much shame put on that for a medical [journey]. (P20 ON Oct21 oCVa) Further, the concerns about governmental interference were extended to question underlying motivation, with many perceiving the connection of the Canadian government with private pharmaceutical companies as an economic incentive for the government to encourage these vaccines rather than a genuine public health concern. So, I feel [the COVID-19 vaccine is] a very touchy subject for people, but I think that it was primarily money and government-based, which is why, still to this day, they’re being so heavily pushed. (P09 ON Dec20 nCV) 48 The uncertainty felt by many participants who perceived these ulterior motivations to governmental recommendations, and thus a sense of distrust towards much of the information about the vaccines being provided to the public, created a greater worry about the safety and necessity of the vaccines. While this distrust didn’t necessarily alter these participants’ perception of either the risks of vaccination or COVID-19 infection, it created a “cloudiness” around their weighing of the risks and benefits of vaccination. Similar to what was seen in many participants who perceived a lack of strong evidence around the vaccines or other murkiness in the information, this lack of clarity often led the participants to “err on the side of caution” and favour the potential risks of inaction over the potential risks of action (vaccination). 4.3.2 Trust in the Medical System Interestingly, participants who worked in the medical system or another health science-related field described variable effects of this role on their vaccine decision-making via greater insight into the medical system's inner workings. Many participants described this understanding of the medical system as causing them to feel better informed and more confident in the vaccines due to better access to studies and other “strong” information about the vaccines and infection in pregnancies and greater accessibility of colleagues to answer their questions. I also am a bit privileged because, of course, I work in obstetrics, and the head of OB was there one day, and I said, hey, Dr [OB name], can you tell me more about this? What should I do? And so, she gave me her perception on it. (P205 BC Jun21 oCVa) Still, a small number of participants described their understanding of the medical system as creating a view of the perinatal care providers as inseparable from the systems in which they act and unable to act as separate agents and provide personal advice. While these views do not reflect 49 an inherent distrust of healthcare providers, they prevent those who have a distrust of the medical system from viewing their healthcare providers as independently trustworthy. I had actually talked to my family doctor and the OB at the time, and they both recommended it. I also as a – I work in the health-care field. As a health-care worker, I also know they are obligated to encourage that, as well. (P04 ON Apr21 oCVd) Often, the image was painted of a kind provider under the influence of a coercive medical system, which is pressuring them into providing the “official line” as their advice. This distrust was not typically of the providers themselves (as the participants continued to view them as benevolent individuals trying to help them) as much as distrust that the providers’ advice is genuinely coming from them. This distrust led many participants to seek out expert sources without this affiliation with the medical system (at least, not in their relationship with the participant), such as family or friends who worked in health care but were advising them in a non-professional manner. Similar to the benefits participants with a background in healthcare found in accessing information, many friends and family with backgrounds in the natural sciences or healthcare were relied upon as key sources of scientific research, breaking down the barriers of accessing these studies that participants without a scientific background encountered, both in terms of perceived inaccessibility of the research itself and inaccessibility of its language to a layperson audience. My best friend […], she works in healthcare and she’s a strong [proponent] of [the COVID vaccine]. She was directing me towards a lot of legitimate research sources that confirmed that the vaccine is not harmful. (P16 ON Nov21 oCVa) While the role of experts within participants’ personal networks in providing access to literature that these participants may not otherwise have access to was certainly beneficial, it also illuminated 50 an area where other pregnant people may be lacking information. This perceived inaccessibility of scientific information represented a vital concern due to the increased accessibility observed of the circulating mis-, dis- and malinformation online. 4.3.3 Trust in the Pharmaceutical Industry While few participants commented on the specific formulation and technologies of the mRNA COVID-19 vaccines, these comments were generally associated with strong disdain for these vaccines and the RNA technology. Unfortunately, these participants did not generally expand upon why they had specific distrust for these vaccines (possibly due to likeability bias incited by the perception of pro-vaccination attitudes in the interviewers). While it may be possible that these are the result of certain mis- and disinformation campaigns about RNA vaccines, the lack of elaboration left a lack of clarity as to the source of this distrust. Given that it’s an RNA vaccine, I was against it from the get-go. And how fast they had to develop it and whatnot. Like I have my own inhibitions and they could be founded, they could be unfounded, it’s a personal opinion. I don’t trust them at all. (P223 BC Sep20 nCV) While concerns specifically relating to the formulation of the vaccines were rare, the concept of hasty vaccine development, which has permeated the literature, was seen in many of our interviews. There appeared to be a great divide between the participants, with as many strongly of the belief that the vaccines were too quickly developed and inadequately tested as those of the belief that the Canadian government was, as a general rule, quite stringent about testing of the vaccines it approves for use in Canada. While this dimension of trust (or, rather, subdimension) had been focused on the trust pregnant people have in pharmaceutical companies, it is apparent 51 that neither group truly trusted the pharmaceutical industry itself in its management. Instead, the latter group has much greater trust in the ability of governing bodies to oversee appropriate vaccine development and testing by pharmaceutical companies. [The COVID-19 vaccine] kind of seemed very experimental. And I understand it had to be experimental because this was a new virus. But it just seemed like the rollout of everything came out so quickly. None of it was FDA-approved yet. (P203 BC Aug20 nCV) The perception of insufficient oversight in the vaccine approval process was strongly connected to distrust of the connection between the government and the pharmaceutical industry. While most participants displaying this distrust believed that the Canadian government’s perceived goals of control of the general public or economic gain (via unclear mechanisms) were the primary motivators in this partnership, a small number offered an alternative narrative. This small subsection did not necessarily view the government and industry as “on the same side” or conspiring together; instead, they viewed Health Canada as inadequate at ensuring the vaccines developed for use in Canada are safe and properly tested. In contrast, understanding and appreciation of the lengthy process of vaccine approval in Canada had a demonstrable association with trust that due process was being followed and that the vaccines were safe with appropriate oversight from Health Canada. While there was less specificity in the description of the areas of trust (compared to distrust), many participants described the stringency of vaccine development and approval processes as a reason they believed the vaccines offered in Canada safe. I think I’m familiar enough – so knowing the amount of studies and testing that goes into it – so yes, I feel safe with all of them and I think they are great to have. […] I know that there’s testing that goes into [the COVID vaccines]. They’re not just whipping them out of 52 nowhere – and that they are very similar to other vaccines that we’ve had – so I felt confident with them. (P36 ON May20 nCV) 4.4 Trust in Community In this sample, community was discussed as a rather multifactorial concept which encompassed both participants’ geographical regions (particularly in discussions of the state of the COVID-19 pandemic and rates of spread) and social networks (particularly concerning the role of online communities in providing support and advice). Many participants specifically focused on their inner circles, especially the family members they live with, including their partners, children, and (in some cases) parents, an area of overlap between the broader geographic community and their social network. Trust in community has been a demonstrated facet of health decision-making during pregnancy since ancient times, yet it is one that has been under-explored in many respects. In particular, this was an aspect of vaccine decision-making processes which was highly affected by the context of the COVID-19 pandemic, as physical distancing restrictions necessitated many of these community connections to be in virtual formats rather than the typical in-person contexts. Additionally, many of the common settings in which pregnant people could connect with each other, such as pregnancy groups and prenatal yoga, were often cancelled due to the pandemic. Thus, pregnant participants were compelled to rely more on online forums or social networks for this connection. Limitations on the presence of support people at in-person prenatal appointments further limited the sense of community pregnant people were feeling and resulted in feeling rather isolated in their vaccine decision-making. Finally, trust in community also functioned as a 53 facilitator of vaccine acceptance in some respects, as the reciprocal trust participants had with their broader community (beyond just other pregnant people) created feelings of a moral duty of vaccination to protect others. 4.4.1 Online Social Networks Social media (and other online communication methods) featured as a prominent player in vaccine hesitancy during the COVID-19 pandemic. While vaccine acceptance continued to be a norm for most people, these social networks could create the perception of normativity of vaccine refusal for those who participate in them. However, as evidenced by the persistence and propagation of these networks, they appeared to serve a vital purpose for pregnant people. In our interviews, multiple participants commented on the effects of online groups on their lives, both positively and negatively. In the wake of pandemic restrictions and the inaccessibility of many prenatal services (such as prenatal yoga and other in-person pregnancy groups) due to concerns about COVID-19 risk, many described missing the connections with other pregnant people they either had previously or would have had otherwise. And again, just being alone the whole time. And even that camaraderie you feel with other pregnant women, [we] were scared to talk to each other. […] I missed a bit of that. (P11 ON Sep20 nCV) This isolation felt by so many pregnant people during this time caused many of them to seek out this sense of community elsewhere, often via online social networks. These online groups provided participants with support in both practical and social ways. What I did have was, I was part of, and I still am part of, the online group [of] about 30 ladies who all had their kids in September. So, everybody kind of talked about, you know, 54 their experiences and everybody can bounce off ideas like ‘OK, my kid is doing this, is this normal?’, you know. So, it was a support group online before you freak out and go to the doctor. So that helped. (P02 ON Sep20 nCV) For the more routine vaccinations (seasonal influenza and Tdap), participants often demonstrated strong normativity of vaccination with their friends’ and families’ pregnancy histories. This demonstrated a certain assumed nature that they would get these vaccines, as they discussed it as “routine” and just what you do in pregnancy. Due to these normative views on the vaccines (and their trust in the friends and family endorsing them), participants often remarked that they did not need to undergo the same information-seeking that they expected with the COVID-19 vaccines. While these norms were most strongly received by participants when coming from those with whom they already had a strong interpersonal relationship, the promotion of these norms in online communities significantly reassured some participants about the safety and usefulness of these vaccines. On Facebook groups, it seemed like a lot of people got [the Tdap vaccine] and it was a good thing for the baby, and I didn’t see any sort of side effect to that. (P32 ON May21 oCVd) While there was an aspect of social support provided by many of these virtual “mom groups” (as many participants referred to them), they were not without detriment. The abundance of anti-vaccine sentiments within these groups created anxiety for many participants, both those who would consider themselves quite pro-vaccine and those who were more on the fence about the COVID-19 vaccines. However, these groups appeared to have a much more minimal impact on those participants who described having a strong local network of friends and/or family, regardless 55 of whether they were living with these connections/ connecting in person or staying in touch remotely. In particular, the ability to adapt pregnancy-specific social events (such as baby showers) to the pandemic setting (via video conferencing, limiting numbers for gatherings, or planning distanced outside events) was demonstrated to be highly correlated to more limited reliance on online social networks. This suggested that these online social networks did serve a decisive role in meeting participants’ social needs, even if they described some of their interactions with them as negative. Additionally, this suggested that the ability of these participants’ social networks to adapt to remote contact decreased the reliance on online social networks, possibly decreasing the exposure to mis-, dis-, and malinformation pregnant people had. Therefore, while the amount of trust pregnant people had in the information they received via these networks varied considerably, we may be able to reduce the exposure pregnant people have to misinformation by ensuring that their social needs are adequately met. In this same strain, paying attention to creating monitored social networks and ensuring the spread of adequate vaccine information while providing this same social support may offset the role of these existing networks. Additionally, this is another area where more stringent policies on mis-, dis-, and malinformation by social networks may help (though it is arguable that the monitoring and removing of this inaccurate information often does not keep up with the spread and may be criticized as censorship). One participant noted that many fact-checking features on Facebook helped identify potential misinformation and allowed her to form an informed opinion about the information being presented. This same participant also noted that she used social media largely to keep in contact with friends and family, further suggesting the role of social media in maintaining connectedness with social networks, something that will be vital in providing support 56 during the stresses of pregnancy and the newborn period (potentially decreasing the likelihood of mental health challenges, both during pregnancy and in the postpartum period). These groups also provided practical care, as one participant described how discussions in the “mom group” around limiting visitors postpartum presented her with a potential option she had not considered – waiting several weeks to have visitors. When a vacuum of information is provided and clear recommendations on COVID-19 risk in the neonatal period are not readily available, these groups appear to fill these gaps. In these sorts of groups, there appeared to be an inherent trust of other group members to have their child’s best interests in mind. This contract of goodwill reflected an inherent trust in others with lived experience. Still, the nature of social media-based online communities necessitates that one cannot guarantee that the party on the other end of any conversation is who they represent themself to be. This suggested that those participants with a strong trust in these communities may not have been cognizant of this reality and may have a higher level of trust that the other party is not deceiving them, may have been aware of this reality but relying on trust in numbers, or may have been in a vulnerable position in not having a solid social network and thus having to rely more heavily on online networks. As exemplified by the inherent trust of others within online “mom groups” (as termed by multiple participants), lived experience and, in particular, shared navigation of these experiences was deeply valuable to pregnant people in this process. This seems to reflect the notion that “it takes a village” – this necessity of community care cannot be understated in our understanding of vaccine decision-making during pregnancy. While these groups provided vital support to pregnant people, we must be cognizant of the effects of their shift to online mediums (primarily via social media) on vaccine decision-making processes. This move presented new safety and security problems for these platforms and the increased propagation of mis-, dis, and malinformation via 57 these platforms. These concerns were expressed by several participants, typically those who were quite pro-vaccination and considered official scientific and medical sources as the crucial sources of vaccine information. The anti-vaccination messages presented on social media, while not necessarily a factor causing pregnant people to change their minds about vaccines, created a sense of confusion and conflict that increases anxiety surrounding vaccine decision-making. [I tried to avoid] social media, like what other people were saying on social media on the various mom groups that I was part of and that sort of thing. There was a lot of misinformation around at that point as well, and I think that was part of the – you know people will take advantage of misinformation to create chaos. (P226 BC Aug21 oCVa) Many participants described exposure to anti-vaccine content as a confusing factor, including after pregnancy. In the quote below, the participant demonstrated that their reliance on their healthcare provider’s opinion for their decisions about vaccinations functioned to decrease their mental work in independently searching for and evaluating sources, even if not intentional, but that this heterogeneity of information available online caused them some doubts and confusion afterwards. I got all the things because at that point I didn’t know there’s something called anti-vaccine. […] But now there’s some research. I think now I’m like, did it compromise immunity? […] So these confusions started creeping in, but at that point, I just went with the general opinion. (P204 BC Nov20 nCV) Accessibility of information appeared to be a driving force toward much of this mis-, dis-, and malinformation. As participants described the inaccessibility of information on the vaccine approval process and associated testing, a need for information that is more technical than that provided to the general public by public health bodies but more accessible than scientific literature, 58 it was clear that the “information” constructed by these “alternative” sources filled this need for many pregnant people. One participant, who was employed as a researcher, reflected: I think if I was like an average woman who didn’t have a scientific background, it would’ve been really frustrating because I think the avenues that I used to find literature and information are something that only an academic really knows. Like, so I think it would’ve been nice if that information I found on my own was more accessible. (P01 ON May21 oCVa) While most highly vaccine-accepting participants described these social media-based sources as either having no effect on or destabilizing their confidence in vaccines, it is notable that a small number noted an opposite impact based upon the notion that they were seeing information from all perspectives in considering their decisions. Oh, well, media I just made sure that any, like, I was in different moms’ groups. […] I always liked to read the pros and cons of, so I was happy I had access to that so I’m not ignorant of what the side effects if any could be. So, yeah, I was happy to have access to that. But eventually everything just helps me make my decision. (P03 ON Nov21 oCVa) The role of the community in decision-making appeared to be much more vital in decision-making around the COVID-19 vaccines than influenza or Tdap vaccines. Overall, significantly more consideration went into COVID-19 vaccine decision-making in general. Still, it appeared that the lack of information available from healthcare providers caused many participants to rely more heavily on the opinions of others in navigating these decisions. This community decision-making also appeared to counteract the sense of isolation pregnant people felt in navigating these decisions, mainly due to the physically isolated nature of healthcare during the pandemic and the patient 59 autonomy-focused healthcare system, which placed both the decision-making ability and responsibility on the pregnant person. In this analysis, this model was described as burdensome in some respects, as pregnant people described challenges in finding accurate information, interpreting the uncertainties present in emerging information, and synthesizing a complete understanding to inform vaccine decisions from contrasting pieces of information. These deficiencies in scientific literacy result in the ability (and societal expectation) of pregnant people to determine their care without adequate tools to make these decisions. 4.4.2 Partner Isolation in Prenatal Care The exclusion of support people and partners from any in-person prenatal appointments (including ultrasounds) created a sense of loss of support for participants in their prenatal care. Participants often described feeling more alone and that they felt a large amount of pressure due to being the sole person responsible for navigating prenatal care and not having their partners to support them. While not cited directly by participants, this sense of isolated decision-making likely underlay the pressure participants felt in their decision-making and the perceived necessity of having all the information and “doing your own research.” Additionally, the combination of this feeling of isolated decision-making was likely to amplify the anxiety prompted by uncertainties around the vaccines (COVID-19 in particular). I kind of felt alone in the moment. And I was kind of going through this – although I had support at home – I felt when it came down to going to the appointments and going to work and kind of facing all that was going on in the world – that I was pretty alone, yes. (P40 ON Aug20 nCV) 60 In addition to this sense of isolation, participants described greater difficulty processing much of the information provided to them via prenatal care providers in these appointments without their support people. Prenatal care providers were described as being quite empathetic towards these difficulties, but it seems likely that this solo processing of information may impact how much pregnant people absorb from their appointments and how well they can connect with their prenatal care providers and build trust. The lack of access to support people in prenatal care appointments was described as resulting in a lack of emotional and practical support in these appointments. The former (demonstrated in the quote from Participant 11 below) resulted in pregnant people having difficulty fully absorbing the information they are given and results in a limited capacity to connect with the prenatal care providers and plan their next decisions based on this new information, while the latter (demonstrated in the quote from Participant 217) resulted in difficulties being able to manage the cognitive load for participants in ensuring they asked all the questions about vaccines that they wanted to and that they were able to fully able to absorb (and later recall) the answers their providers gave. The only thing I would put emphasis on is [not having] my husband through anything […] [After bad news] I had to then drive home by myself because I didn’t have him there and just a lot of those things that you’d benefit from having someone […] there to help you when you get news like that (P11 ON Sep20 nCV) I think just in the moment, those questions don’t always come. […] I'm thinking of those questions about the vaccines and stuff [after]. So, the times that my husband was allowed to come, it was really helpful […] While I'm sitting there thinking, oh my God, […] he was kind of that calmer one who's actually listening to a lot of the things. (P217 BC Apr21 nCV) 61 Due to the described role of prenatal care providers as cushioning these difficulties, it was also clear that those with lesser trust in their prenatal care providers were likely to be more strongly impacted by these limitations. This absence of partners from prenatal care appointments also results in a fracturing of the typical decision-making patterns for those who prefer for both parents of the child to be involved in decisions made during the pregnancy (for those who consider the pregnant person to be the main authority with some input from their partner as well as those who consider this an equal-weight, joint decision-making process). In this gap of lacking communication between the prenatal care provider and the other parent, the pregnant person is positioned as a mediator between their partner’s perspectives and the healthcare provider’s. This adds the increased pressure of considering both their own and their partner’s questions during prenatal care appointments and explaining the information provided by the healthcare provider. In combination with the challenges in scientific literacy described by many of the participants, this additional role for pregnant people is expected to represent a major social and mental burden. 4.4.3 COVID-19 Vaccines as Moral Obligation in the Reciprocal Trust of Community While many pregnant people considered the harms and benefits to themselves and their children as their primary concern, many also viewed receiving the COVID-19 vaccine as a moral obligation to the broader community. This was reflected in remarks participants made about getting vaccinated as “the right thing to do.” (P37 ON Nov20 nCV) This moral obligation emerged from a form of reciprocal trust the participants engaged in with their broader community. This trust allowed them to believe that if they did their part to protect those around them by getting a vaccine, the community would reciprocate this, allowing for better protection of themselves 62 (particularly while pregnant) and their infants after birth. This understanding relied on both a collectivist view, in which the broader community is at the centre of their concern, and an understanding of the importance of herd immunity as the most effective form of protection for the most vulnerable (including pregnant people and young children). These vaccines were also described as a source of hope for participants during the pandemic. In this sense, the COVID-19 vaccines were viewed as a collective effort composed of individual actions to end the pandemic, and each individual must do their part for them to be successful. This shifted conversations around vaccination from views of individual protection to a perspective of altruism and collectivist efforts. However, it is important to note that many participants describing this more collective-focused perspective on vaccination were those for whom the COVID-19 vaccine was not yet available during pregnancy. Thus, this may have reflected a more general view on vaccination that did not account for the specific (perceived) vulnerability of pregnancy, which may overshadow these altruistic drivers for those concerned about the risks of the COVID-19 vaccine. [F]rom the beginning, I had a full and positive view of the [COVID-19] vaccines. I was hoping they would get us out of the madness. (P10 ON Dec20 nCV) This view of the vaccine as primarily a protection of the collective rather than the individual was also encapsulated in many participants’ views on the vaccine in a more general sense. I do believe people should be getting [the COVID-19 vaccines]. And it’ll help, like lower the amount of people who are going to end up with COVID. (P13 ON Nov21 oCVa) A hierarchy of concern seemed to be reflected by these pregnant participants, with their children (both in utero and otherwise) being of utmost priority, often followed by prioritizing the 63 collective hope of getting out of the pandemic before individual protection against COVID-19. Outside of pregnancy, an understanding of the risk factors of severe disease that were often discussed in the media resulted in a view that young, healthy people who did not have any of the risk factors were unlikely to have poor outcomes of COVID-19 and, thus their protection was not as vital. Thus, they prioritized this altruistic protection for those at the most significant risk in society but emphasized protecting the people in their lives considered to be at high risk due to age, immunocompromise, or other risk factors more emphasized by public health messaging than pregnancy (particularly in their inner circle and immediate family). While their child(ren) was considered the most important to protect, spouses and parents were also commonly cited as others they wished to protect with their vaccination decisions. Experiences such as personal immunocompromise often underlay greater emphasis on this role of community benefit and moral obligation. Participants described their experience of relying on herd immunity for particular vaccines as demonstrating how vital community vaccination is in their lives and, thus, how much more they value broad vaccination (and sometimes vaccine mandates). I wish there was a way they would make every vaccine more mandatory, like when you couldn’t go places unless you had your COVID vaccines. Personally, [because I’m someone who] had these, and I know I don’t get the MMR immunity, I just – I am one of the people who does rely on the herd immunity for the MMR. (P12 ON Sep20 nCV) 64 Chapter 5: Discussion 5.1 Extending the Trust-Based Model of Vaccine Hesitancy In seeking to examine the experiences of navigating vaccine decision-making among pregnant people in British Columbia and Ontario, this study developed an understanding that placed trust as central to these experiences. As Goldenberg’s framework of vaccine hesitancy as a “Crisis of Trust” provided a valued inspiration to this work, these findings are situated within and represent a further expansion of this framework. Similarly to how Goldenberg notes that parents’ “leaps of faith” based on trust are influenced by multiple areas, this analysis found that this trust is influenced by healthcare providers, peers, and overall trust in institutions (9). Resultantly, this central element of trust clustered into the three major overlapping themes discussed in this analysis – trust in institutions (including government, the pharmaceutical industry, and the health system), trust in healthcare providers, and trust in community (with a focus on the role of lived experience). However, the interpretation of these findings is challenged by heterogeneity in how pregnant people conceptualize these domains. For some, trust in institutions focused on the system as a whole (in a more abstract sense), while for others, this trust focused on key representatives of the system (in a more concrete sense). In this manner, the trust in institutions observed in this study can be seen as three strategies to evaluate epistemic trust - evaluation toward an abstract organization based upon previous interactions with this organization, evaluation based upon interpersonal trust in some intermediary perceived to represent the broader organization, or evaluation of an organization based on an evaluation of the standards and processes they employ (for example, the vaccine approval process). For participants in this analysis, the most commonly observed intermediaries were high-level governmental officials representing the government and 65 their healthcare providers representing the broader healthcare system (demonstrating an area of overlap between the themes of trust in institutions and trust in healthcare providers). Further, various areas of overlap were observed between these three distinct themes, including the perceived influence of the broader health system on healthcare providers and the impact of knowledge of their healthcare providers’ lived experiences with pregnancy (particularly during the pandemic and in navigating these vaccine decisions). 5.2 Trust in Institutions Previous studies have also noted the context of trust in institutions as influential in pregnant people’s vaccine decision-making, with concerns around vaccination campaigns having political motives, distrust of the healthcare system, and distrust in the government being described as significant barriers to vaccine uptake (105). While echoing this existing understanding, this research uses its qualitative approach to extend this further to examine the interplay between trust in government (and specific political leaders), the healthcare system, and industry. Previous literature has demonstrated that this distrust of the government and the healthcare system is often influenced by continuing histories of abuse and discrimination by these institutions, as Avorgbedor and colleagues highlighted (106). Continuing anti-racist and decolonial efforts in rebuilding the health system to support historically oppressed groups are necessary to improve this trust in the long term. In this analysis, I appreciated that greater perceived interference of government and/or industry in the health system and public health strategies was connected to greater distrust of vaccination campaigns (and the vaccines themselves). In this aspect, some participants described 66 a sense of coercive force on the part of the government, which was augmented by the intensity of other public health measures, especially the role of “vaccine passports” in accessing certain spaces. Further, a study from the United Kingdom demonstrated that trust in healthcare providers and the National Health System was reduced during the pandemic, suggesting a devaluation of the information provided by these official sources (107). While the study of Bruno and colleagues (107) focused on the impact of this trust on perceptions pregnant people had of influenza vaccines, this thesis has found similar importance of this area of trust for COVID-19 vaccine decisions during pregnancy. As both studies were conducted during the pandemic, this provides further evidence that the effects of the pandemic on public trust in the health system have significant consequences for vaccine decision-making. 5.3 Trust in Healthcare Providers The importance of healthcare providers’ recommendations has long been established in models of vaccine decision-making, but the framing of trust in healthcare providers has been less commonly explored (105). The role participants described of interpersonal relationships with healthcare providers in evaluating their recommendations demonstrates that this trust is required for providers’ recommendations to promote vaccine uptake. Many studies examining the uptake of COVID-19 vaccines in pregnancy using the Health Belief Model or Theory of Reasoned Action demonstrated these recommendations as an influential factor in participants’ decision-making processes around both COVID-19 vaccines and influenza vaccines in pregnancy, but this contextualization via the mechanism of trust has been better demonstrated in the more theoretically open method of thematic analysis utilized in this research (63,89). 67 Literature has supported that prenatal care via a provider with a more longitudinal relationship (such as a family physician) is associated with greater uptake rates of Tdap and influenza vaccines compared to care via a new provider (such as an obstetrician or midwife) (31). This association has often been attributed to the ability of family physicians to provide vaccines during in-person appointments or greater vaccine counselling confidence among family physicians than other prenatal care providers (31,108). However, the results of this research suggest an alternative interpretation of many of these findings, as the greater trust participants described in their prenatal care providers with a greater length of relationship may mediate these differences in uptake. 5.4 Trust in Community Many of the concerns raised by participants about limited support due to pandemic-related restrictions were reflected in much of the existing literature, as other pregnant people across Canada and the United States reflected on the feelings of worry and loss of support associated with limitations on support at prenatal care appointments, uncertainty about support availability later in pregnancy, during labour, and postpartum, and lacking much of the enrichment they were expecting or previously received with in-person prenatal resources (71,76). Studies as far back as 2011 demonstrated the role of the internet in providing social support and addressing the informational needs of pregnant people, though the specific formats of this connection have changed over the years (109,110). Due to the significant impact of the COVID-19 pandemic on social support and the ability to connect in person, this online support was particularly vital. Over the past 15 years, research has demonstrated that normative beliefs within pregnant people’s social circles profoundly impact health decisions during the prenatal period, often 68 contextualizing this influence within models such as the Health Belief Model (6,87,99). However, the understanding of this thesis attempts to contextualize these normative beliefs as aspects of trust held within their community (whether this is considered within individual relationships or a broader, more abstract community). This perceived moral responsibility of vaccination, while not framed as a form of reciprocal trust per se, has been demonstrated by other researchers in the uptake of COVID-19 vaccines by pregnant people, as Regan and colleagues note that 18.6% of participants received a COVID-19 vaccine during pregnancy with the aim of protecting the broader community (111). 5.5 Contextualization to Literature While this research represents an expansion of the role of trust in vaccine decision-making during pregnancy, which has not previously been seen, few findings of this study are truly unique to the existing body of literature. Many of the specific concerns about the vaccines that study participants raised were similar to those raised by pregnant people in previous pandemic contexts (namely influenza A/H1N1), including the “newness” of the vaccines and insufficient testing (63). The norms of inherent trust in healthcare seen in pregnant people born outside of Canada during the influenza A/H1N1 were also observed in this research (65). Notably, the limiting of the study population in this research to those comfortable speaking in English for their interviews suggested that the inherent trust demonstrated in the influenza A/H1N1 pandemic context was not solely due to necessity because of the linguistic inaccessibility of pandemic-related information (65). Trust in healthcare providers and the impact of social norms on vaccine uptake observed in studies from the United States were also found to be contributing factors via the trust in healthcare providers and trust in community observed in this research (87). 69 Distrust of the medical system and negative experiences with healthcare professionals were also implicated as major contributors to the lower uptake of COVID-19 vaccines by Black and Latinx pregnant people in the United States (112). For this reason, it appears that trust in both healthcare professionals and the health system are vital in increasing vaccine uptake in these communities, as demonstrated in my research. Further, the role of community observed in my research could also be extended to acknowledge the role of racialization in navigating medical decisions and, as Rawal and colleagues describe, connection to community-based organizations may bridge the gap between the formal medical institution and these vaccine-hesitant pregnant people (112) This trust in healthcare providers and health institutions, including the health system and public health agencies, was demonstrated as a significant contributor to vaccine acceptance among pregnant people across high-income countries worldwide (113). However, many of these studies demonstrated that this trust in the sources of information related to COVID-19 infection and vaccines were not the only major contributors to vaccine decision-making among pregnant people and informational factors were also a concern (113). As many of these studies do not particularly differentiate between pregnant people’s appraisal of the information they are receiving and specifically their appraisal of the sources of information and their trust in them, further research is needed to determine whether these represent confidence in information or trust in institutions/ providers. Further, in contrast to the role of culture of origin in greater trust in healthcare providers demonstrated by a small number of participants in my research, Regan and colleagues demonstrated lower rates of vaccine intention and uptake among pregnant people born overseas (111). This may be due to several factors: (i) sociocultural difference between the United States and Canadian context, (ii) culture of origin being indirectly or unconsciously related to vaccination 70 decision-making (which would not be reflected in interviews), and (iii) additional demographic factors, including socioeconomic status within the United States or Canada, acting as confounding variables in the relationship between country of origin and vaccine decision-making. Finally, the role of informational needs is an issue which has been demonstrated in some literature, including specific concerns related to safety resulting in pregnant people delaying vaccination until greater information was available, but has not been directly targeted by my research (114). In integrating these concerns with my research and the lack of inclusion of these factors within this model, it is clear that the “Triad of Trust” model developed as part of this project is unlikely to have captured the full picture of vaccine decision-making among pregnant people during the COVID-19 pandemic and requires further testing and refinement to be considered a complete model. 5.6 Strengths, Limitations, and Future Directions This analysis elicited little information on vaccine decision-making beyond the COVID-19 vaccines due to the partly participant-led nature of the semi-structured interview format and the apparent eagerness of participants to discuss the COVID-19 vaccines (with a lesser interest in lengthy discussions of routine vaccinations in pregnancy), the perception by some participants that routine vaccinations were brushed aside in light of the pandemic, and the description provided by some that the decision-making process for what they perceived to be the “well-researched” vaccines was much less of a conscious effort. While this allowed for depth of information on COVID-19 vaccine decision-making, it meant that what was intended as the original focus of this study – decision-making around vaccines, including COVID-19 as well as Tdap and seasonal 71 influenza, shifted to a focus solely on COVID-19 vaccines. The findings may still apply to the decision-making processes for other, routine vaccines, but this generalizability is uncertain based on the current analysis. Given the focus on COVID-19 vaccines in this research, further studies may be useful to better understand pregnant people’s decision-making processes around Tdap and influenza vaccines in the current, late-pandemic landscape. These studies of how best to support vaccine decision-making among pregnant people, while important now, will be increasingly important as new vaccines are expected to be introduced to this population in the future, including those against Respiratory Syncytial Virus (RSV) and Group B Streptococcus. Notably, the sample that was interviewed was predominantly white (64.4%) and highly educated (89.0% completed some form of post-secondary education, with 20.5% holding a postgraduate or professional degree). Due to sample size limitations often inherent to these research methods, this sample is unlikely to reflect the views and needs of minority groups within the Canadian population. If the opportunity exists for further research, this may be improved by purposeful outreach to other groups which are likely to be underrepresented in research, including non-white, less educated, and non-cisgender pregnant people. 5.7 Implications This research demonstrates that the issue of vaccine hesitancy relies much more heavily on the role of trust in multiple dimensions. Especially in the context of an emerging pandemic with new vaccines (often lacking in evidence of safety or efficacy in pregnant or chestfeeding people), the lack of accessible information results in pregnant people having to strongly rely on the “leaps of faith” Goldenberg describes into epistemic trust (9). While some aspects of trust are hard to 72 change, such as that of trust in institutions, many specific influences were identified by participants, which may allow for greater trust in other areas. Participants described their providers’ transparency regarding their sources (including more detailed information, clinical anecdotes, and even sharing of scientific papers) as a major contributor to them developing greater confidence in the information they received from healthcare providers and the vaccines. Further, the role of lived experience and providers sharing the decisions they are making (or would make) for themselves or their families increased pregnant people’s vaccine confidence. Based on these sentiments, prenatal care providers may tailor their vaccine counselling approaches to include a degree of sharing scientific literature with patients who may be interested in these sources but unsure how to find them independently. This approach would be bolstered by public health bodies focusing on producing the intermediate sources desired by multiple participants – including more in-depth information on vaccines than is currently available on the websites of local public health bodies but in a format that is not beyond the scientific literacy level of participants (as many describe the articles published in scientific journals to be). Additionally, despite being highly educated, the scientific literacy levels of many of the participants appeared to be a major barrier to their information-seeking, particularly with regard to the ability to search for accurate, reliable information online. For this reason, it would be prudent to pursue a larger-scale survey to examine the current scientific literacy levels of the general population (particularly in their information-seeking skills) and, if this appears to be a broader issue and not isolated to our sample, evaluate strategies to alleviate this literacy gap. These strategies to improve perceptions of provider transparency and accessibility of scientific information are expected to improve trust in healthcare providers. Further, as participants described responding well to healthcare providers who placed themselves in the narrative of these 73 decisions through discussions of the choices they would make for themselves or their families, this framing may be useful in clinical discussions to improve the acceptance of vaccine recommendations by pregnant people. However, clinicians should be cautious with this approach, as it is possible that existing rapport and length of relationship may confound the effect observed by this framing, as stronger rapport and longer relationships may cause prenatal care providers to be more comfortable placing themselves in the patient’s position in this way. Finally, this trust in healthcare providers also requires provider confidence in vaccine counselling to result in improvement of vaccine uptake. This has been a concern previously raised, particularly with regard to the vaccine counselling skills (and confidence) of midwives, and further research is needed to examine both the extent of this confidence gap and possible strategies to alleviate it (although greater emphasis on this facet of the role and training in counselling are hypothesized to be applicable) (115). The lived experience of others was observed to play a major role in participants’ trust in communities of pregnant people. These communities of support, seemingly instinctively formed but in altered formats with the digital age and the role of physical distancing during the pandemic, were a trusted source of knowledge and advice for some pregnant people involved, whether we consider this trust justified or misplaced. As these natural communities appear to be a vital resource for pregnant people but are common sites for spreading mis-, dis-, and malinformation, it follows that these communities should be incorporated into our strategies for improving vaccine confidence in pregnancy. The values found by pregnant people in these forms of online social support included information seeking/ sharing, social interaction/ companionship, and choosing to seek information outside of healthcare providers due to the perception that they did not have time to address questions (109,110). Naturally, these factors are expected to be even more emphasized 74 in cases such as the COVID-19 pandemic when information is scarce or inaccessible, traditional forms of social interaction are limited, and perinatal care is more limited or shifted to virtual care. For these reasons, it follows that the apparent inevitability of these online communities makes them particularly important to incorporate into perinatal care to help counter any vaccine-related mis-, dis- or malinformation which may circulate. This strategy, while logically consistent with the information we have received from pregnant people about their needs in navigating these decisions, has not previously been tested, either in a pilot or larger-scale project. For this reason, a pilot study of either developing moderated social networks for pregnant people as an integrated part of the health system or as integrated into an existing social media platform would be a reasonable next step in moving towards such a strategy. Further, multiple participants within this study described the importance of third-party fact-checking on social media sites in aiding their ability to discern the accuracy of pandemic- and vaccine-related information they encountered. However, despite initial attempts to remove posts and groups spreading mis-, dis- and malformation and institute fact-checking policies earlier in the pandemic, the prominent social media companies have changed directions. In January 2025, Meta Platforms, Inc. (parent company of Facebook, Instagram, and Threads) and X Corp. (parent company of X (formerly Twitter)) both decreased regulations regarding misinformation on their platforms, including a switch from third-party fact-checking to a “community notes” approach. This new approach allows users to flag posts they consider misleading rather than the previous automated moderation or fact-checking systems (116). These changes to policy are discussed by both their CEOs as attempts to protect “free expression” (116). Of contextual importance, many recent changes in company policy about reduced fact-checking on these platforms have occurred near the time of the election and inauguration of President Donald Trump in the United States 75 (where both companies are based), a president who has been regarded as a major source of misinformation during the COVID-19 pandemic (117). Finally, pregnant people’s trust in institutions is far more complicated to repair and maintain. As the intersections of the pharmaceutical industry with the government and public health bodies represent major focuses for some pregnant participants, these relationships must be carefully managed to ensure acceptability to the public. While this may not seem like the most vital priority in times when public health efforts are simply focused on trying to limit the spread of a pandemic, the role participants described of their distrust in government or the pharmaceutical industry in vaccine decision-making demonstrates the monumental impact the interactions with industry, as demonstrated by how these vaccine strategies are references in government and public health communications can have on public trust in vaccines. While the role of public relations is still a significant focus of government and public health bodies during pandemic situations (especially in the wake of many of the current issues of public trust), this further solidifies how important these communications strategies are in the effectiveness of vaccine strategies. Additionally, these industry-government connections as a focus of distrust for some participants suggest a theme that we can be wary of as a potential theme of mis-, dis-, or malinformation in the future and can seek to mitigate. Unfortunately, possibly due to concerns of their thoughts being controversial or political to the interviewers, the participants who were suspicious about these relationships seemed uncomfortable expanding further on their specific concerns which we may be able to address. This hesitance to get into further details was demonstrated by very general statements such as “it was a governmental money thing” (P203 BC Aug20 nCV). 76 5.8 Conclusion Vaccine hesitancy is of vital concern in the current era of vaccine research in Canada, representing a highly multifactorial issue which overlaps multiple areas of the natural and social sciences. While multiple models have been established for the causes of vaccine hesitancy (and, consequently, strategies to improve vaccine acceptance), the continuing changes in societal contexts, vaccine technologies, and circulating diseases create a need for these to be continually refined and updated over time. The occurrence of pandemics of novel pathogens represents a major challenge for public health researchers and a strong opportunity to refine these models. For this reason, this thesis work developed an expanded, trust-based model to explain many of the factors of vaccine hesitancy during pregnancy in Canada within the context of the COVID-19 pandemic. This model, composed of three interacting aspects – trust in healthcare providers, trust in institutions, and trust in community, seeks to examine not only how each of these areas of trust functions but to explain how their interactions help pregnant people to approach their decision-making on vaccines, particularly for novel pandemic vaccines. However, this model is not, at this point, designed to be all-encompassing, and many other factors (including the role of personal risk assessments) may exist in conjunction with these aspects of trust but were outside the scope of this thesis. For this reason, further research is needed to develop a more complete model before it is integrated into future studies of decision-making during pregnancy. While this model seeks to explain these vaccine decision-making processes during pregnancy, its development via a two-province sample of 73 pregnant people and its incomplete nature suggests that it needs further evaluation via future studies before it can be considered a strong, generalizable model of this process. Further, future research may allow for a better understanding of how the findings of this study were influenced by the COVID-19 pandemic 77 context and how much these are continuing factors in vaccine hesitancy in future contexts, such as future vaccines for use during pregnancy (including Respiratory Syncytial Virus (RSV) and Group B Streptococcus vaccines). Although these decisions appear centred around trust, scientific literacy was a significant modifier in multiple aspects of this model. Therefore, improvements in scientific literacy are also vital and inseparable from many of these trust-based concerns. 78 References 1. Canadian Centre for Cyber Security. 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J Assoc Inf Sci Technol. 2022 May;73(5):726–37. 89 Appendices Appendix A: Consent to Contact Survey Preamble Statement We invite you to share your thoughts on how your perception of Covid-19 risk influenced health decisions you made during pregnancy. This research involves a 45-60 minute interview conducted by researchers from McMaster University and the University of British Columbia. The interview can be done at the time most convenient for you and can take place over the phone or by video call through Zoom. Your name and responses will be kept completely confidential and you will receive a $25 gift card as a token of appreciation for your time. Your participation in this study would be completely voluntary and you are free to withdraw at any time. If you are interested in learning more, please answer the following questions so we may contact you and provide you with more information. You will have the opportunity to decide whether or not you want to participate in the study at that time. This current document will help determine whether you are eligible, and if so, gives us permission to contact you and share more information about our study. This survey is part of a study that has been reviewed and cleared by the Hamilton Integrated Research Ethics Board (HiREB – Protocol # 14632). 1. Did you give birth between May 1, 2020 and December 1, 2021? [Yes/No] 1. No → exit survey – Thank you for your time but you are not currently eligible for this study. 2. Did you give birth to more than one child during the period of May 1, 2020 and December 1, 2021? [Yes/No] 3. Within this time period, what Month and Year did you give birth? If you gave birth to more than one child in this period, please list all relevant dates. It is not necessary to provide the DAY of birth, just the month and year. [Open Text] 4. Did you give birth in Ontario or British Columbia? [Ontario/British Columbia/Neither] 1. Neither → exit survey – Thank you for your time but you are not currently eligible for this study. 5. Are you 18 years of age or older? (Yes or No) 1. No → exit survey – Thank you for your time but you are not currently eligible for this study. 6. Interviews for this study will be conducted in English. Are you comfortable speaking in English? (Yes or No) 1. No → exit survey – Thank you for your time but you are not currently eligible for this study. 7. I give permission for research staff to contact me and to give me more information about this study. I understand that providing my contact information does not mean I am obligated to participate in the study. I understand that if I do choose to participate in the interview, I will be asked to provide consent to participate in the study at another time. (Yes or No) 1. No → exit survey – Thank you for your time but you are not currently eligible for this study. 90 We want to make sure we are speaking with a wide variety of people. The following questions will not affect your eligibility to participate in this study: 8. What is your ethnicity or race? (Open Text) 9. What is your age in years? (Open Text) 10. What is your gender? (open text) 11. Was the baby born between May 1, 2020 and Dec 1, 2021 your first child? (Yes/No) 12. If this was not your first child, how many other children live with you? (open text) 13. Including your children, how many people do you live with? 14. What is your main source of income (employment, savings, family member, government benefits, other) Thank you for this information. The next questions are about the best way to contact you to share more information about the study and receive your consent to book an interview. 15. What name should we call you? (Does not need to be your legal name) (Open Text) 16. What is the best way to contact you? *Please ensure you have entered your contact information correctly before submitting* (Select as many as they wish: email, phone call, text message) 17. If you would like to be contacted by email, what is your e-mail address? (Open Text) 18. If you would like to be contacted by phone call or text message, what is your phone number? (Open Text- enough characters that they could provide different numbers for call/text if necessary) 19. The best time to contact you (Open Text/Dropdown) 20. What time zone do you live in? (Dropdown) 91 Appendix B: Semi-Structure Interview Guide How do perceptions of Covid-19 risk influence health decisions in pregnancy? – Interview Guide Introduction to the study Our study is interested in how your perception of Covid-19 risk influenced the decisions you made about pregnancy in three different areas: prenatal care, vaccination, and social support. We know that those decisions are related to so many other things in life, so I’m going to start by asking a few questions about what your life was like at the time you became pregnant, and how the pandemic affected you. Then we will move into some specific questions about those three areas: prenatal care, vaccination, and social support. Informed Consent Script: Did you receive and review a copy of the informed consent letter? Did you have the opportunity to ask questions and were they answered to your satisfaction? Do you understand that you have the right not to participate and the right to withdraw at any time? Do you understand that any information you provide will be kept confidential, unless required by law, and that only the study researchers and staff involved in this study, independent ethics committees and inspectors from government regulatory agencies will have direct access to the information you provide? And finally, do you consent to participating in this recorded interview? INTRODUCTION 1. Just to situate us within the pandemic, do you remember what month and year it was when you first found out you were pregnant? 2. Could you tell me a bit about what your life was like right around the time you found out you were pregnant? Who did you live with, how did you spend your time, that kind of thing. a. Employed? Doing what kind of work? b. Partner/family situation? 3. What do you remember about what pandemic was like that time, when you first became pregnant? a. Public health restrictions? b. What was your work situation like? c. Vaccines available? 4. We know that many pregnancies are not planned, but that doesn’t mean they’re not wanted. On the spectrum of very carefully planned to a complete surprise, where was this pregnancy? a. If planned- how did the pandemic influence your decision to try and have a baby? b. If not-so-planned, how did the pandemic influence your reaction to finding out you were pregnant? 5. Is this your first child? a. If no, how many others live in your household? How old were they when this child was born? 92 RISK PERCEPTION 1. Thinking back to when you were pregnant, what did you think would happen if you personally were infected with Covid? a. Were your thoughts about the risk of covid different or the same compared to before you became pregnant? b. If any, what kinds of things did you do to try and avoid infection? c. Were there things you wanted to do to avoid infection but weren’t able to do (e.g. work from home?) d. If infected with COVID: how did getting COVID influence your decision making in pregnancy? i.Did getting COVID change the way you thought about the risks? Ok, thanks for sharing that information. I’m now going to ask you about three different types of decisions you had to make while pregnant. PRENATAL CARE 1. First I’m going to ask you about some decisions relevant to the type of prenatal care you received. To set the stage, what kind of prenatal care provider did you have? 2. [if multiparous] You told me earlier this wasn’t your first child- how did the pandemic change the way that you interacted with your healthcare provider, compared to before the pandemic? a. Probes: Virtual visits? Partner present? Extra care? Different things offered? Options to decline certain aspects of care? 3. [if nulliparous] I know this was your first child so it was your first time receiving pregnancy care, but was there anything that seemed different or related to the pandemic? a. Probes: Virtual visits? Partner present? Extra care? Different things offered? Options to decline certain aspects of care? 4. Did you have an option for virtual appointments or in person? a. What made you decide to do one over another? b. What did you like about this type of care? c. What didn’t you like? 5. Most people get offered what’s called a glucose challenge test while they are pregnant, to see if they are at risk of having a particular kind of diabetes that happens during pregnancy. In this test, you drink a very sugary liquid and then wait a few hours and have your blood drawn to see how your body processed the sugar. a. Were you offered this test? Was it your decision whether or not to accept it? 1. What were your considerations while making this decision? b. Did your healthcare provider offer an alternative to testing for diabetes? 6. Did you get to make a decision about where you were going to give birth? a. How did the pandemic influence that decision? 7. Tell me about what it was like to be in labour during the pandemic. How did the pandemic influence this experience? 8. After you gave birth, how long did you stay in the hospital? a. How did the pandemic influence your time in hospital after having your baby? 1. Probe: visitors or a support person? b. Was it your choice about when to go home? What influenced that decision? 93 VACCINATION Now I’m going to ask you a few questions about vaccines offered when you were pregnant, and how you decided to take those vaccines. 1. Now, what do you think about the COVID-19 vaccine specifically? a. If there was hesitancy: What changed your mind? Specific moment? Person? Policy? 2. Thinking back to when this vaccine was available and when you were pregnant. a. Do you remember when you were first eligible for a vaccine? b. Where were you in your pregnancy at that time? IF ELIGIBLE FOR COVID VACCINE DURING PREGNANCY: 1. Talk me through the decision-making process, from when you were first eligible for the Covid vaccine to the end of your decision about it. 2. Did you talk about the Covid vaccine with your health care provider? a. What did they recommend? b. What questions did you have? c. Were they able to answer those questions? d. Did they provide other information? 3. When deciding whether to get the COVID-19 vaccine… a. Who else did you talk with when making the decision? b. What information did you look for? c. Was the information you found clear? d. Was there any information you looked for and didn’t find? e. What kind of information was influential or important to your decision? f. How did you decide what information to trust? CONTINUE WITH EVERYONE: 1. There are other vaccines that are offered in pregnancy. One is the Tdap vaccine, which is for diptheria, tetanus, and whooping cough. Were you offered this vaccine? 2. Talk me through your decision-making process about this vaccine, from when you were offered to when you made the decision. a. Who else did you talk with about the tdap vaccine decision? b. what information did you look for? c. Was the information you found clear? d. Was there any information you looked for and didn’t find? e. What kind of information was influential or important to your decision? f. How did you decide what information to trust? 3. Do you see any differences between the Covid vaccine and the Tdap vaccine? a. Were you more comfortable with one over the other? Why? 94 SOCIAL SUPPORT AND MENTAL HEALTH 1. During the pandemic, many people had to make tough decisions about limiting their social contacts. How did you handle this challenge while you were pregnant? 2. Was there anyone you wanted to see but chose not to? 3. When someone invited you to do something, like participate in a baby shower, meet up for dinner, or go to a birthday gathering, how did you make that decision? 4. We know that many people experienced depression or anxiety during the pandemic, and that pregnancy can be a particularly vulnerable time of life for feeling depressed or anxious. Did you experience any feelings of depression or anxiety when pregnant? a. How did these feelings affect you? b. What strategies did you use to manage these feelings? 5. What activities or strategies did you find helpful in maintaining your mental health? 6. Did you ever consider accessing help for your mental health? a. Were you able to access help? How did that go? b. What type of support did you seek? Why that type? c. What was the experience like? 7. Did you have any supports at home? a. What were they like? 8. While pregnant, what worried you the most? 9. After giving birth, did you have any physical help at home? CLOSING 1. Those are all the questions I had. Is there anything I didn’t ask you that you think is important for me to know? That’s the end of our interview. I want to thank you for your time, and thank you for sharing your experiences with me. I know it takes a level of trust to do that and I’m so grateful that you’ve entrusted me with your thoughts, feelings, and experiences. I hope you have a wonderful rest of your day, and if you don’t have any more questions, you are welcome to leave whenever you’re ready. 95 Appendix C: Attribution Key for Participant Quotes Element Translation P### Participant ### ON Gave birth in Ontario BC Gave birth in British Columbia Xxx## Month and year the participant gave birth, according to MonYY format nCV Not offered a dose of a COVID-19 vaccine during pregnancy oCVd Offered 1+ dose(s) of a COVID-19 vaccine during pregnancy, declined oCVa Offered 1+ dose(s) of a COVD-19 vaccine during pregnancy, accepted
Thesis/Dissertation
eng
Population and Public Health
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Greyson, Devon
Triad of trust : vaccine decision-making by pregnant people during the COVID-19 pandemic in British Columbia and Ontario
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