Skip to main content
Download PDF

COVID-19 vaccine uptake and hesitation among men and women preparing for pregnancy: a cross-section survey based on the theory of planned behavior

BMC Public Health volume 23, Article number: 227 (2023) Cite this article

Abstract

Background

Given the accelerated speed of COVID-19 vaccine research and administration, the main barriers to herd immunity appear to be concerns about safety and efficacy. Men and women preparing for pregnancy may have the same concerns about COVID-19 vaccination, but few studies have focused on COVID-19 vaccine uptake and hesitation among them.

Methods

A cross-sectional study was conducted among men and women who were preparing for pregnancy in Southwest China. The questionnaire was designed based on the theory of planned behavior (TPB). Multiple logistic regression was used to explore the determinants of the behaviors of COVID-19 vaccination.

Results

A total of 2878 participants completed the survey. A total of 53.89% of participants received at least one dose of the COVID-19 vaccine. A total of 45.21% of participants would receive the COVID-19 vaccine in the future. A total of 0.90% of participants never thought about receiving the COVID-19 vaccine. Multiple logistic regression model 1 showed that female participants (OR:5.497, 95%CI: 4.292–7.041), participants who never received influenza vaccine (OR:2.664, 95%CI: 1.908–3.718), participants who had never been tested for COVID-19 (OR:2.244, 95%CI:1.504–3.349), participants who had higher score of negative attitude (OR:1.448, 95%CI: 1.219–1.719), participants who had lower scores of injunctive norms (OR:0.440, 95%CI: 0.360–0.537) and descriptive norms (OR:0.105, 95%CI: 0.088–0.126) were more likely to delay COVID-19 vaccination. Model 2 showed that participants who had lower scores for positive attitude (OR: 0.406, 95% CI: 0.230–0.716), injunctive norms (OR: 0.283, 95% CI: 0.130–0.614) and descriptive norms (OR: 0.060, 95% CI: 0.038–0.094) were more likely to refuse COVID-19 vaccination.

Conclusions

The COVID-19 vaccination rate of men and women preparing for pregnancy was significantly lower than the average vaccination rate of China. Gender, protective health behaviors, vaccination attitudes, and subjective norms had effects on the vaccination behaviors of couples preparing for pregnancy.

Peer Review reports

Background

The coronavirus disease 19 (COVID-19) has contributed substantially to excess deaths worldwide since the WHO declared a pandemic [1]. The COVID-19 pandemic has caused a significant threat to the public health system [2, 3]. According to the WHO COVID-19 dashboard, COVID-19 caused over 5.9 million deaths by February 2022 [4]. Developing wide-scale immunity among the population through vaccination is considered the most effective health approach to prevent and control the COVID-19 pandemic [5, 6]. By December 2022, the global fully vaccinated rate is 64.1%, with significant variation across countries and regions [4, 7]. Despite the high efficacy and short-term and medium-term safety of COVID-19 vaccines found in clinical trials, a certain number of people still delay or refuse COVID-19 vaccination [6, 8, 9]. Vaccine hesitation was defined by the WHO as a delay in acceptance or refusal of vaccination despite availability of vaccination services. It was identified as one of the top 10 threats to global health by the WHO in 2019 [10].

Given the accelerated speed of COVID-19 vaccine research and administration, the main barriers to herd immunity appear to be concerns about safety and efficacy [8]. Adverse effects on reproductive health have become a major concern for couples preparing for pregnancy [11]. However, in fact, the International Federation of Fertility Societies advises that women who are preparing for pregnancy have the option to proceed with efforts at conception and to seek a COVID-19 vaccine as soon as possible [12]. The National Health Commission of China also recommends that there is no reason to delay pregnancy attempts because of vaccination administration [13]. These recommendations are consistent with evidence of COVID-19 vaccination on reproductive health. There is evidence that COVID-19 vaccination does not result in any measurable effects on in vitro fertilization (IVF) treatment, including the number of oocytes retrieved, good-quality embryo rate, clinical pregnancy rate and pregnancy outcomes [14]. Likewise, COVID-19 vaccination did not affect the sperm quality and fertilization capacity of men and should be considered safe for men’s reproductive health [11]. Despite the evidence indicating that the COVID-19 vaccine was safe for human reproductive health, some couples seeking care at infertility clinics still hesitate or even refuse to receive a COVID-19 vaccine due to a lack of trust in public health authorities and access to rumors about the COVID-19 vaccine [15,16,17]. Therefore, men and women preparing for pregnancy may have the same concerns about COVID-19 vaccination.

To explain the vaccination behaviors of our participants, the theory of planned behavior (TPB) was selected as the theoretical framework for this study, which is widely used in predicting and explaining human behavior in specific contexts. As reported, the theory of planned behavior (TPB) has the highest predictive power in determining vaccination behaviors [18]. A previous study also used the TPB as a part of the theoretical framework to explore the determinants of COVID-19 vaccine acceptance among adults [19]. According to the TPB, behavior is driven by the intention to carry out the behavior, ultimately determined by attitudes, subjective norms, and perceived behavioral control. Attitudes toward a behavior can be positive and negative. Subjective norms include injunctive norms (describing how individuals should act from the perspective of family and society) and descriptive norms (describing how families, friends and people around actually act). Perceived behavioral control represents the perceived barriers and self-efficacy of performing a behavior, including internal control and external control [2, 18, 20]. We adapted the original framework slightly to match our research purposes.

Due to a lack of trust in public health authorities and access to rumors about the COVID-19 vaccine, men and women preparing for pregnancy may still hesitate or even refuse to receive a COVID-19 vaccine, but few studies have focused on COVID-19 vaccine uptake and hesitation among them. Along with quantifying the prevalence of COVID-19 vaccine uptake and hesitation, it is crucial to find the determinants of their decision-making process that result in delay or refusal of vaccination so that targeted interventions can be designed to increase COVID-19 vaccine uptake [18].

Methods

Study design and sample

This was a STROBE checklist-compliant study. A cross-sectional study was conducted among men and women who were preparing for pregnancy between July 2021 and February 2022 in Southwest China. Invitations to participate in this survey were distributed to the eligible population via hospitals, communities and the Internet. Snowball sampling was used to recruit participants. Considering that the COVID-19 vaccination rate was 64.1% [4], the minimum sample size was calculated as 2213 with a 95% CI and 2% margin of error.

Measurements

The self-designed questionnaire was based on a literature review and expert consultation. The first section of the questionnaire included information on the sociodemographic characteristics of the participants, such as age, gender, marital status, education level, place of residence, and family per capita monthly income. The second section of the questionnaire included medical insurance, history of influenza vaccination, and testing for COVID-19. The third section of the questionnaire was the 5-point Likert scale based on the TPB, including attitudes (positive and negative attitudes), subjective norms (injunctive and descriptive norms), and perceived behavioral control (internal and external control). The Cronbach α coefficients of attitudes, subjective norms, and perceived behavioral control were 0.788, 0.775, and 0.874, respectively. The global Cronbach’s α coefficient was 0.824, and the construct validity index was 0.909, which showed that this questionnaire had good reliability and validity. Responses range from “Very much agree” to “Very much disagree”. The last question investigated COVID-19 vaccination uptake and intentions. It takes about 5 min to fill out our questionnaire.

Statistical analysis

The qualitative data were described by composition ratio, and the chi-square test was used for bivariate analysis. The mean and standard deviation (M ± SD) were used to describe the quantitative data with normal distribution and approximately normal distribution, and ANOVA was used for bivariate analysis. Predictor variables (p < 0.1) were entered into the multiple logistic regression. Multiple logistic regression was used to explore the influencing factors of the behaviors of COVID-19 vaccination. SPSS23.0 (SPSS Inc., Chicago, IL) was used for statistical analysis. In all analyses, a p value of < 0.05 indicated statistical significance.

Results

Sociodemographic characteristics and health predictors of COVID-19 vaccination

A total of 2878 participants completed the survey. Participants’ demographic characteristics and health predictors of COVID-19 vaccination are shown in Table 1.

Table 1 Sociodemographic characteristics and health predictors of COVID-19 vaccination (N = 2878)
Full size table

TPB variables associated with COVID-19 vaccination

A total of 53.89% (1551/2878) of participants received at least one dose of the COVID-19 vaccine. A total of 45.21% (1302/2878) of participants received the COVID-19 vaccine in the future. A total of 0.90% (26/2878) of participants never thought about receiving the COVID-19 vaccine. The means and standard deviations of TPB variables associated with COVID-19 vaccination are shown in Table 2.

Table 2 TPB variables associated with COVID-19 vaccination (N = 2878)
Full size table

Bivariate analysis of COVID-19 vaccination

Table 3 shows the associations between the independent variables and the COVID-19 vaccination of participants. Gender, influenza vaccination history, testing for COVID-19 and TPB variables were shown to be associated with COVID-19 vaccination. More details are shown in Table 3.

Table 3 Bivariate analysis of COVID-19 vaccination (N = 2878)
Full size table

Multiple logistic regression of COVID-19 vaccination

Table 4 shows the multiple logistic regression analysis of COVID-19 vaccination of participants. These variables in regression models explained 43.9% of the variance in COVID-19 vaccination. Participants who had received the COVID-19 vaccine were set as the reference group. Model 1 showed that female participants (OR:5.497, 95%CI: 4.292–7.041), participants who never received influenza vaccine (OR:2.664, 95%CI: 1.908–3.718), participants who had never been tested for COVID-19 (OR:2.244, 95%CI: 1.504–3.349), participants who had higher score of negative attitude (OR:1.448, 95%CI: 1.219–1.719), participants who had lower scores of injunctive norms (OR:0.440, 95%CI: 0.360–0.537) and descriptive norms (OR:0.105, 95%CI: 0.088–0.126) were more likely to have COVID-19 vaccination hesitancy. Model 2 showed that participants who had lower scores for positive attitude (OR: 0.406, 95% CI: 0.230–0.716), injunctive norms (OR: 0.283, 95% CI: 0.130–0.614) and descriptive norms (OR: 0.060, 95% CI: 0.038–0.094) were more likely to refuse COVID-19 vaccination.

Table 4 Multiple logistic regression of COVID-19 vaccination
Full size table

Discussion

This study focused on the COVID-19 vaccination behaviors of men and women preparing for pregnancy. In this study, the results revealed that 53.89% of the population had received at least one dose of the COVID-19 vaccine, 45.21% of the population would receive the COVID-19 vaccine in the future, and 0.90% of the population never thought about receiving the COVID-19 vaccine. The vaccination rate was slightly lower than the global average vaccination rate (60.0%) and significantly lower than the average vaccination rate of China (90.0%) [4]. These results verified our hypothesis that a certain number of men and women preparing for pregnancy delayed or even refused to receive the COVID-19 vaccine.

Our results showed that the average vaccination rate for men was higher than that for women, which was inconsistent with previous studies conducted in China and a global survey across 19 countries [21, 22]. We inferred that the reason might be that women preparing for pregnancy are more cautious about vaccines and are concerned about adverse effects. These concerns might be caused by misinformation about the COVID-19 vaccine on social media [23, 24]. Therefore, future health education and science popularization programs should pay more attention to women preparing for pregnancy and provide more correct information about the COVID-19 vaccine to prevent misconceptions from taking hold [23].

We found that participants who never received the influenza vaccine or had never been tested for COVID-19 were more likely to delay receiving the COVID-19 vaccine, which was consistent with a previous study [8]. We inferred that the reason might be health literacy, which is considered to be a contributor to people’s health behaviors [25]. As reported, health literacy was found to be positively related to the capacity to adopt preventive measures such as getting vaccines, testing for COVID-19 and wearing face masks [25, 26]. A previous study also reported that increasing people’s health literacy could lead to reduced vaccine hesitancy [26]. Therefore, vaccine promotion strategies should be tailored for couples preparing for pregnancy, especially those with low health literacy.

We found that participants who were more negative toward the COVID-19 vaccine were more likely to delay vaccination, and participants who were less positive toward the COVID-19 vaccine were more likely to refuse the COVID-19 vaccine. These findings were consistent with previous studies, which reported that attitudes toward vaccines were associated with vaccination intentions [2, 8]. This study confirmed the associations between the attitudes and vaccination behaviors of participants.

We found that injunctive norms (describing how individuals should act from the perspective of family and society) and descriptive norms (describing how families, friends and people around actually act) showed strong effects on vaccination behaviors, including vaccine uptake and hesitation. These findings were consistent with a previous study, which verified the associations between subjective norms (injunctive norms and descriptive norms) and vaccination intention [2]. Based on these findings, we inferred that the vaccination attitudes and behaviors of family and society had effects on the vaccination behaviors of couples preparing for pregnancy. Future health education and science popularization programs should focus on these variables.

We found that perceived behavioral control was not a determinant of behaviors related to the COVID-19 vaccine, which was inconsistent with previous studies focusing on vaccination intentions [27, 28]. We inferred that the reason might be the different populations and different dependent variables. This study focused on the behaviors of COVID-19 vaccination, which might be different from vaccination intentions.

The present study has three main limitations. First, snowball sampling was used to recruit participants, which might have been overestimated due to selection bias. Second, the participants were recruited from Southwest China, which might limit the generalizability of the findings to people from other areas in China or from other countries. Third, our participants also recruited couples undergoing IVF cycles and who might have lower COVID-19 vaccination rates for different reasons, but we did not compare them to normal couples. Future search studies should focus on couples who are undergoing IVF.

Implications

To achieve herd immunity among the population through vaccination, we need to persuade more people to get vaccinated. This study found that a certain number of men and women preparing for pregnancy delayed or even refused to receive the COVID-19 vaccine. These results could help health authorities in China identify priority populations that need special attention in COVID-19 vaccination campaigns. Our study also identified several influencing factors related to vaccine uptake and hesitancy of couples preparing for pregnancy, including gender, protective health behaviors, vaccination attitudes, and subjective norms. These findings could provide evidence for health authorities in China to design suitable interventions for increasing the vaccine uptake rate.

Conclusion

The COVID-19 vaccination rate of men and women preparing for pregnancy was significantly lower than the average vaccination rate of China. Women preparing for pregnancy were more likely to delay receiving the COVID-19 vaccine than men preparing for pregnancy. Participants who never received the influenza vaccine or had never been tested for COVID-19 were more likely to delay receiving the COVID-19 vaccine. Vaccination attitudes and subjective norms had effects on the vaccination behaviors of couples preparing for pregnancy. To achieve herd immunity, vaccine promotion strategies should be targeted at these populations and be tailored based on these findings.

Availability of data and materials

The data that support the findings of this study are available from West China Second University Hospital, but restrictions apply to the availability of these data, which were used under license for the current study and are not publicly available. Data are, however, available from the authors upon reasonable request and with permission of West China Second University Hospital.

References

  1. Hagger M, Hamilton K, Predicting. COVID-19 booster vaccine intentions. Applied Psychology: Health and well-being; 2022.

    Google Scholar 

  2. Wolff K. COVID-19 vaccination intentions: the theory of Planned Behavior, optimistic Bias, and anticipated regret. Front Psychol. 2021;12:648289.

    Article  Google Scholar 

  3. Al-Mohaithef M, Padhi B. Determinants of COVID-19 Vaccine Acceptance in Saudi Arabia: a web-based National Survey. J Multidiscip Healthc. 2020;13:1657–63.

    Article  Google Scholar 

  4. ; WHO. WHO Coronavirus (COVID-19) Dashboard Geneva: WHO, February. 2022 [Available from: https://covid19.who.int.

  5. Zheng C, Shao W, Chen X, Zhang B, Wang G, Zhang W. Real-world effectiveness of COVID-19 vaccines: a literature review and meta-analysis. Int J Infect Dis. 2022;114:252–60.

    Article  CAS  Google Scholar 

  6. Al-Mohaithef M, Padhi B, Ennaceur S. Socio-demographics correlate of COVID-19 vaccine hesitancy during the Second Wave of COVID-19 pandemic: a cross-sectional web-based survey in Saudi Arabia. Front Public Health. 2021;9:698106.

    Article  Google Scholar 

  7. Patwary M, Alam M, Bardhan M, Disha A, Haque M, Billah S et al. COVID-19 Vaccine Acceptance among Low- and Lower-Middle-Income Countries: A Rapid Systematic Review and Meta-Analysis.Vaccines. 2022;10(3).

  8. Trent M, Seale H, Chughtai A, Salmon D, MacIntyre C. Trust in government, intention to vaccinate and COVID-19 vaccine hesitancy: A comparative survey of five large cities in the United States, United Kingdom, and Australia.Vaccine. 2021.

  9. Khairat S, Zou B, Adler-Milstein J. Factors and reasons associated with low COVID-19 vaccine uptake among highly hesitant communities in the US. Am J Infect Control. 2022;50(3):262–7.

    Article  Google Scholar 

  10. WHO. Ten Threats to Global Health in 2019. February, 2021 [Available from: https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019.

  11. Reschini M, Pagliardini L, Boeri L, Piazzini F, Bandini V, Fornelli G, et al. COVID-19 vaccination does not affect Reproductive Health Parameters in Men. Front Public Health. 2022;10:839967.

    Article  Google Scholar 

  12. Ory S, Veiga A, Horton M, Gianaroli L. Joint IFFS/ESHRE statement on COVID-19 vaccination for pregnant women and those considering pregnancy. Hum Reprod Open. 2021;2021(2):hoab016.

    Article  Google Scholar 

  13. China TNHCo. COVID-19 Vaccine Technical Guide. Chin J Clin Infect Dis. 2021;14(2):89–90.

    Google Scholar 

  14. Huang J, Xia L, Lin J, Liu B, Zhao Y, Xin C, et al. No effect of inactivated SARS-CoV-2 vaccination on in vitro fertilization outcomes: a propensity score-matched study. Inflamm Res. 2022;15:839–49.

    Article  Google Scholar 

  15. Diaz P, Reddy P, Ramasahayam R, Kuchakulla M, Ramasamy R. COVID-19 vaccine hesitancy linked to increased internet search queries for side effects on fertility potential in the initial rollout phase following emergency use authorization. Andrologia. 2021;53(9):e14156.

    Article  CAS  Google Scholar 

  16. Han A, Lee D, Kim S, Choo C, Park J, Lee J, et al. Effects and safety of COVID-19 vaccination on assisted reproductive technology and pregnancy: a comprehensive review and joint statements of the KSRM, the KSRI, and the KOSAR. Clin Exp Reprod Med. 2022;49(1):2–8.

    Article  Google Scholar 

  17. Sethi S, Kumar A, Mandal A, Shaikh M, Hall C, Kirk J, et al. The UPTAKE study: a cross-sectional survey examining the insights and beliefs of the UK population on COVID-19 vaccine uptake and hesitancy. BMJ Open. 2021;11(6):e048856.

    Article  Google Scholar 

  18. Hossain M, Alam M, Islam M, Sultan S, Faysal M, Rima S, et al. Health Belief Model, Theory of Planned Behavior, or psychological antecedents: what predicts COVID-19 vaccine hesitancy better among the bangladeshi adults? Front Public Health. 2021;9:711066.

    Article  Google Scholar 

  19. Patwary M, Bardhan M, Disha A, Hasan M, Haque M, Sultana R et al. Determinants of COVID-19 Vaccine Acceptance among the Adult Population of Bangladesh Using the Health Belief Model and the Theory of Planned Behavior Model.Vaccines. 2021;9(12).

  20. Ajzen I. The Theory of Planned Behavior. Special Issue: Theories of Cognitive Self-Regulation. 1991.

  21. Wu J, Li Q, Silver Tarimo C, Wang M, Gu J, Wei W, et al. COVID-19 vaccine hesitancy among Chinese Population: a Large-Scale National Study. Front Immunol. 2021;12:781161.

    Article  CAS  Google Scholar 

  22. Lazarus J, Ratzan S, Palayew A, Gostin L, Larson H, Rabin K, et al. A global survey of potential acceptance of a COVID-19 vaccine. Nat Med. 2021;27(2):225–8.

    Article  CAS  Google Scholar 

  23. Skafle I, Nordahl-Hansen A, Quintana D, Wynn R, Gabarron E. Misinformation about Covid-19 Vaccines on Social Media: Rapid Review.J Med Internet Res. 2022.

  24. Odeh-Natour R, Shapira M, Estrada D, Freimann S, Tal Y, Atzmon Y, et al. Does mRNA SARS-CoV-2 vaccine in the follicular fluid impact follicle and oocyte performance in IVF treatments? Am J Reprod Immunol. 2022;87(5):e13530.

    Article  CAS  Google Scholar 

  25. Zhang H, Li Y, Peng S, Jiang Y, Jin H, Zhang F. The effect of health literacy on COVID-19 vaccine hesitancy among community population in China: the moderating role of stress. Vaccine. 2022;40(32):4473–8.

    Article  CAS  Google Scholar 

  26. Zhang F, Or P, Chung J. The effects of health literacy in influenza vaccination competencies among community-dwelling older adults in Hong Kong. BMC Geriatr. 2020;20(1):103.

    Article  Google Scholar 

  27. Servidio R, Malvaso A, Vizza D, Valente M, Campagna M, Iacono M et al. The intention to get COVID-19 vaccine and vaccine uptake among cancer patients: An extension of the theory of planned behaviour (TPB).Support Care Cancer. 2022.

  28. Dou K, Yang J, Wang L, Li J. Theory of planned behavior explains males’ and females’ intention to receive COVID-19 vaccines differently.Hum Vaccin Immunother. 2022:2086393.

Download references

Acknowledgements

Not applicable.

Funding

Not applicable.

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology Nursing, West China Second University Hospital/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China

    Anjiang Lei, Chunyang Xi, Xiaoxue Luo, Yan Pu & Huaxuan You

  2. Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China

    Anjiang Lei, Chunyang Xi, Xiaoxue Luo, Yan Pu & Huaxuan You

Authors
  1. Anjiang Lei
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chunyang Xi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Xiaoxue Luo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yan Pu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Huaxuan You
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Study design: A.L. and H.Y.

Statistical analysis: A.L., C.X. and H.Y.

Data collection: X.L., Y.P. and C.X.

Original draft writing: A.L. and H.Y.

Manuscript editing: all authors.

Corresponding author

Correspondence to Huaxuan You.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of West China Second University Hospital, Sichuan University (No. 2022035). Informed consent was obtained from participants before starting the data collection. All procedures in this study were conducted in accordance with the ethical standards of the responsible committee on human study and with the Helsinki Declaration and later revision.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lei, A., Xi, C., Luo, X. et al. COVID-19 vaccine uptake and hesitation among men and women preparing for pregnancy: a cross-section survey based on the theory of planned behavior. BMC Public Health 23, 227 (2023). https://doi.org/10.1186/s12889-023-15171-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12889-023-15171-3

Keywords

BMC Public Health

ISSN: 1471-2458

Contact us