Assessing risk perceptions that contribute to tetanus toxoid maternal vaccine hesitancy in Kilifi County, Kenya

Patience Kerubo Kiyuka; Rodgers Onsomu Moindi; Meshack Nzesei Mutua; Noni Mumba; Halimu Suleiman Shauri

doi:10.12688/f1000research.144710.1

Home Browse Assessing risk perceptions that contribute to tetanus toxoid maternal...

ALL Metrics

Views

Downloads

Get PDF

Get XML

Export

▬

✚

Research Article

Assessing risk perceptions that contribute to tetanus toxoid maternal vaccine hesitancy in Kilifi County, Kenya

[version 1; peer review: 2 approved with reservations]

Patience Kerubo Kiyuka ¹, Rodgers Onsomu Moindi², Meshack Nzesei Mutua³, Noni Mumba⁴, Halimu Suleiman Shauri⁵

Patience Kerubo Kiyuka ¹, Rodgers Onsomu Moindi², [...] Meshack Nzesei Mutua³, Noni Mumba⁴, Halimu Suleiman Shauri⁵

PUBLISHED 02 Apr 2024

Author details Author details

¹ CGMR-C, Kenya Medical Research Institute, Kilifi, 80108, Kenya
² Medical Services, Kilifi County Department of Health, Kilifi, Kenya
³ Liverpool School of Tropical Medicine, Liverpool, UK
⁴ Health System and Research Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
⁵ Pwani University, Kilifi, Kilifi County, Kenya

Patience Kerubo Kiyuka
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation

Rodgers Onsomu Moindi
Roles: Formal Analysis, Investigation, Methodology, Project Administration, Resources, Writing – Review & Editing

Meshack Nzesei Mutua
Roles: Funding Acquisition, Investigation, Methodology, Writing – Review & Editing

Noni Mumba
Roles: Investigation, Methodology, Resources, Supervision, Validation, Writing – Review & Editing

Halimu Suleiman Shauri
Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Sociology of Vaccines collection.

Abstract

Background

Vaccination is one of the most effective public health interventions today. However, a growing number of people perceive vaccines as unsafe and unnecessary.

Methods

We used a mixed method research in which we administered a quantitative survey to men and women of reproductive age, held Focus Group Discussions (FGDs) with expectant mothers, and interviewed Key Informants (KI) to understand maternal vaccine hesitancy within a rural setting of Kilifi County, Kenya.

Results

Of the 104 people surveyed, 70% of the participants were aware of the vaccine that expectant women receive, with 26% stating that they know people in their community who have refused or were hesitant to take maternal vaccination. Reasons for refusals include religion and rumours that have spread in the community that the tetanus toxoid vaccine was a family planning method. Stockout of the vaccine was identified as one of the healthcare factors affecting vaccine uptake. Healthcare workers were the most trusted source for information about maternal vaccines.

Conclusion

Dissemination of accurate information and continuous engagement with community members can build trust and confidence in maternal vaccines.

Keywords

vaccine hesitancy, maternal vaccines, tetanus toxoid, expectant mothers

Corresponding author: Patience Kerubo Kiyuka

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Kiyuka PK et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Kiyuka PK, Onsomu Moindi R, Mutua MN et al. Assessing risk perceptions that contribute to tetanus toxoid maternal vaccine hesitancy in Kilifi County, Kenya [version 1; peer review: 2 approved with reservations]. F1000Research 2024, 13:244 (https://doi.org/10.12688/f1000research.144710.1) First published: 02 Apr 2024, 13:244 (https://doi.org/10.12688/f1000research.144710.1) Latest published: 24 Jul 2025, 13:244 (https://doi.org/10.12688/f1000research.144710.2)

Introduction

Globally, the World Health Organization (WHO) estimates that in 2019 alone, 2.4 million children died in their first month of life (WHO 2020). Among the causes of these deaths are infectious diseases. Although substantial progress has been made in child survival since 1990, neonatal deaths remain relatively high in sub-Saharan Africa compared to other regions. Children born in sub-Saharan Africa are ten times more likely to die in their first month than their counterparts in high-income countries (WHO 2020). Maternal immunisation can contribute to a significant reduction in neonatal morbidity and mortality. For instance, it is estimated that maternal tetanus vaccine reduces mortality from neonatal tetanus by 94% (Blencowe et al. 2010). Immunization of pregnant women offers a chance to transplacentally transfer protective antibodies to the fetus, conferring protection to the vulnerable infants in the first six months of life when they are exposed but have not developed adequate functional antibody response (Marshall et al. 2016).

Despite the compelling benefits achieved through vaccination, there is a growing concern about vaccine hesitancy. The WHO Strategic Advisory Group of Expert on Immunization defines vaccine hesitancy as a ‘delay in acceptance or refusal of vaccination despite the availability of vaccination services’, which varies across time, place and the vaccine. Vaccine-hesitant individuals may accept all vaccines but remain concerned about vaccines; some may refuse or delay some vaccines but accept others; others may refuse all vaccines (Larson et al. 2014, 2015). In 2019, WHO listed vaccine hesitancy among the top ten public health threats that need attention, a rallying call to governments, public health officials, and advocacy groups to pay attention to this issue. Left unchecked, vaccine hesitancy and misinformation that can spread rapidly through the internet (Cornwall 2020; Enserink 2020) can significantly contribute to a decrease in immunisation rates and hamper the uptake of newly introduced vaccines (Schaetti et al. 2009; Larson, Brocard, and Garnett 2010). For example, in North East Nigeria, vaccine myths, hesitancy, and misinformation that spread within the communities provided significant setbacks to the campaign to eradicate polio (Usman, Bologna, and Stamidis 2019).

Currently recommended vaccines for pregnant women include tetanus toxoid, influenza vaccine and Tdap vaccine (Williams et al. 2019), although countries have different guidelines and can choose which vaccines to administer. The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus toxoid vaccine. However, the Ministry of Health is exploring evidence-based strategies ahead of the anticipation of rolling out the influenza vaccine (McMorrow et al. 2017; Dawa et al. 2019). The success of these vaccines depends on whether mothers decide to use them.

Several factors that contribute to vaccine hesitancy have been reported. These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (Bukenya and Freeman 1991) and health systems factors such as healthcare practices and vaccine logistical issues (Sridhar et al. 2014). Literature specifically looking at maternal vaccination in Kenya is sparse. Most studies have focused on coverage and implementation of Antenatal Care (ANC), and on whether ANC services contribute to better neonatal care and assessment of ANC services as a package (Afulani et al. 2019; Arunda, Emmelin, and Asamoah 2017). In this study, we aimed to assess factors contributing to maternal tetanus toxoid vaccine hesitancy within a rural setting of Kilifi County in Kenya.

Methods

Ethics statement

We obtained scientific and ethical approval from the Pwani University Ethics Review Committee; ERC/PU-STAFF/002/2020. The study got approval from the National Commission for Science Technology and Innovation (NACOSTI) under license number NACOSTI/P/20/6193. The county government Department of Health Services authorised the study to be carried out in Kilifi County.

Study design

The study design was cross-sectional, using a mixed methods approach for data collection where both quantitative and qualitative data were collected. We used the qualitative data for cross-validation and corroboration of the findings within the study. Since study activities were conducted during the COVID-19 pandemic, the study team followed the infection control guidelines put in place by the County Department of Health Services to reduce SARS-CoV-2 infections such as social distancing; regular hand washing; use of personal protective equipment to protect oneself and participants; and measuring temperatures of study team before each field visits. Eligible participants gave written consent before participation in the study.

Study location

The study was conducted in Kilifi County, located along the Kenyan Coast. In Kenya, the health delivery system is currently a devolved function of the 47 counties. It is organised into six levels but anticipated to transition to four levels: level four, National referral hospitals; level three, county hospitals; level two, primary care facilities (formerly the dispensaries and health centres); and level 1, community hospital (Muinga et al. 2020).

Study population

Our study randomly sampled expectant women attending ANC at Kilifi County Hospital (KCH), a level three hospital, and two dispensaries serving KCH, Mnarani and Ngerenya dispensaries, which are in level two selected based on the volume of expectant women they receive. We aimed to balance the study population selection to allow us to have a mix of both town settings (Mnarani) and rural settings (Ngerenya). We also randomly selected men and women of reproductive age at the community level in four different locations/wards (Tezo, Chasimba, Kibarani and Sokoni) and used Community Health Extension Officers to access our study population. The selection of study wards was based on immunisation coverage from Kilifi County’s Kenya Health Information System (KHIS). According to the 2019 KHIS data, the percentage of women who received their first tetanus toxoid vaccine ranged from 6% to 61.2% (lowest to highest) across the 35 administrative wards. We split the percentage of tetanus toxoid vaccine coverage into four quartiles (0-25, 25-50, 50-75 and 75-100) and then selected wards from each quartile as a representative.

Behavioral and social drivers of vaccination framework

To guide the assessment of the factors contributing to the maternal vaccine hesitancy, we adapted WHO’s behavioral and social drivers (BeSD) of vaccination framework (Figure 1). The BeSD model comprises four key domains of behavioural and social drivers of vaccination which, put together, influence vaccine uptake:

1. Thinking and feeling, which includes the cognitive and emotional responses of people to vaccine-preventable diseases and vaccines;
2. Social processes, which include social norms about vaccination and receiving recommendations to be vaccinated.
3. Motivation, which includes the intention, willingness, and hesitancy of people to get vaccinated; and
4. Practical issues, which include the experiences people have when trying to get vaccinated, including barriers faced, e.g. accessing the clinic or costs of transport to the clinic.

Figure 1. The WHO behavioural and social drivers of the vaccination framework, available at https://www.who.int/teams/immunization-vaccines-and-biologicals/essential-programme-on-immunization/demand.

Questionnaire and question guide design

Data collection question guides and questionnaire design were based on quantitative surveys, interview guides and priority indicators corresponding to the BeSD framework’s four domains (Brewer et al. 2017). The questionnaire had a mix of open-ended questions and closed questions on a five-point Likert scale. Senior members of the research team reviewed the questionnaire and question guides and modified them appropriately to fit the local context while retaining the intended meaning. The questions were translated into Kiswahili, a local language for ease of administration. Interview guides were used flexibly to support rich and broader discussion around maternal vaccine hesitancy issues.

Data collection

Before data collection the study team underwent training on the overall aims and objectives of the study, the consenting process and the data quality and management processes. Following the training, we conducted Focus Group Discussions (FGDs) comprising of 10-12 expectant women, and administered survey questionnaires to randomly selected men and women of reproductive age (n=104). For the FGDs, we targeted high volume facilities that could allow us to capture a diverse population of expectant women and balance town and rural areas. We used convenient sampling to identify expectant women for the FGDs. They (FGDs) were conducted at participating hospitals during maternal child health clinic days. FGDs lasted between 60-90 minutes. We also conducted interviews with six key informants lasting between 30-60 minutes. Key informants included healthcare workers involved in administering maternal vaccines and County healthcare vaccine managers. Interviews with KI were conducted at their workstations, either in the clinic or at their hospital office workstations. Both the FGDs and KIs were audio-recorded using an encrypted audio recorder. The interviews were also captured by a note-taker in handwritten notes. Two researchers (PKK and ROM) conducted all the interviews face-to-face. All study participants provided written informed consent. Data collection was done between September and October 2020.

Data analysis

Quantitative survey data was analysed using STATA version 16. Baseline characteristics of participants including gender, marital status, level of education, and religion are presented as frequencies and percentages. Audio transcripts were transcribed verbatim in MS Word. For analysis, a predetermined coding structure consisting of the four domains of the BeSD conceptual framework was used. Code reports were generated and analysed by PKK and ROM

Results

The survey respondents were a random sample of 104 adults. Their characteristics and summary are shown in Table 1. Women made up 63 (61%) of the study population, and 80 (77%) of the participants were married. Most participants had primary-level education. The median age was 33 years.

Table 1. Baseline characteristics for the study participants.

Characteristics	n (%)
Gender
Male	40 (38.46)
Female	63 (60.58)
Missing	1 (0.96)
Marital status
Single	18 (17.31)
Married	80 (76.92)
Divorced	4 (3.85)
Missing	2 (1.92)
Level of education
Never went to school	7 (6.73)
Primary education	46 (44.23)
Secondary education	33 (31.73)
Diploma	11 (10.58)
University education	7 (6.73)
Religion
Christianity	89 (85.58)
Islam	12 (11.54)
Other	1 (0.96)
Missing	2 (1.92)
Age (in years)
Median Interquartile range (IQR)	33 (27-43)

General vaccination knowledge and awareness

To assess the level of awareness, we asked respondents whether they had ever heard of a vaccine, whether they knew which vaccines expectant women receive and whether they had ever heard of the tetanus toxoid vaccine. Almost all respondents, 98% (102/104), were aware of vaccines, but only 70% (73/104) knew which vaccine women receive when they are expectant. Interestingly, 93% (97/104) reported knowing the existence of tetanus vaccine.

Expectant mothers reported that the healthcare worker informs them about the vaccine they received, although they don’t interrogate what the vaccine does.

When you are told you are being given the tetanus injection, you know it protects both you and the child concerning tetanus, so we don’t ask questions with regard to its purpose … We are not usually told why we are getting the injection. Expectant Mother FGD4

Healthcare workers agree with the mothers, that they are aware that they should receive a vaccine. Sometimes, the mothers themselves can inquire why their counterparts were receiving the vaccine and not them. As per the Kenya Expended Programme for Immunization schedule, mothers are supposed to get the vaccine according to their number of pregnancies. What the mothers aren’t aware of is the importance of receiving the vaccine.

I could say that most mothers know they are supposed to get immunisation when expectant … Knowledge is low in terms of knowing like what the vaccine does, why they are being immunised and what it entails. There is a gap there, but they know they are supposed to come to the clinic. They know that when they come, they’re supposed to get a vaccination for tetanus and several jabs. Key informant 01

Reasons for not taking maternal tetanus toxoid vaccine

Of all the participants interviewed, 26% (27/104) reported that they knew people in their community who had ever refused a vaccine when expectant and 8% (8/104) had ever heard of negative information about vaccines in the recent past.

Some of the reasons for vaccine refusal include rumours in the community that the tetanus vaccine is for family planning.

You hear people say that they are for family planning; people say that they reduce your fertility. Expectant Mother FGD4

There are also instances where expectant mothers fail to receive the vaccine due to home deliveries.

There is a neighbour who was expectant from home … For all the nine months she has been home … She even delivered at home recently. Expectant Mother FGD2

There were also concerns about women receiving an HIV test during their ANC visits.

Getting tested (for HIV) is why they fear coming to clinic … Because when you come, you cannot get services until your HIV status is known. Expectant Mother FGD1

The respondents also adduced religious reasons. Indeed, several studies have examined whether religion influences childhood immunisation uptake (Costa et al. 2020; Fournet et al. 2018), including the adolescent human papillomavirus (Best et al. 2019). Within our setting, participants reported that people from particular religious groups do not subscribe to vaccine uptake when expectant or even for their children.

There are those who don’t come to the clinic at all and they have other reasons like religion … There is a church that doesn’t believe in hospital and its services … They say God will help … They conceive and get to delivering without any vaccinations … God keeps them safe … They exist, but there are not so many; others are in that sect but still come for clinic … But those who hold on to that faith don’t come totally. Key informant 002

Role of decision-makers within the household

The decision on whether a young mother will seek vaccination is partly informed by the advice she will receive from decision-makers in the homestead. At least within our settings, a mother-in-law or older woman has a role in influencing health care services including vaccination.

There are those old women, our grandmothers, who in their time did not go to the hospital or anywhere when they became expectant; even in delivery, they got assistance from village Traditional Birth Attendants (TBAs) so as a daughter-in-law when you marry into that home, it is not easy to convince this woman to go to the hospital because they say I gave birth to your husband and I did not go to the hospital and I gave birth without any issues and right now he has grown without any problems, he is okay till now he has married you, so don’t stress yourself, just stay here I will look after you or a friend of mine will look after you. Expectant Mother FGD1

Trust in healthcare workers and the government

The Wellcome Global Monitor Report 2018 the world’s largest study into how people around the world think and feel about science and major health challenges, estimates that globally, 73% of people highly trust healthcare workers for their sources of information. We asked participants to rank from a list of healthcare workers, family or other relatives, radio/TV and friends, which are their most trusted sources of information about vaccines for expectant mothers. We found that 77% (80/104) of participants used healthcare workers as their source of information about vaccines for expectant mothers. Most participants, 84% (87/104) ranked healthcare workers as their most trusted source of information, with 34% (35/104) ranking their friends as the least they could consult on information about maternal vaccines.

As the healthcare workers are the frontline government service providers, we tested the level of trust in the government and whether participants thought vaccines should be compulsory. Approximately 77% (80/104) and 20% (21/104) of the participants strongly agree or agree, respectively, that they trust that the government is deciding in their best interest with regard to vaccines for expectant mothers. In contrast, 53% (55/104) and 23% (24/104) of the participants strongly agree or agree, respectively, that vaccines for expectant mothers should be made compulsory.

Health systems factors

Among the key informants, one reason maternal vaccine uptake is low is vaccine stockout, which affects vaccine delivery.

At times we get stock outs … yes as much as they (expectant mothers) would wish to get the vaccine by the time they come the vaccine is not there. Key informant 4

The attitude of the healthcare worker also plays a role on whether a mother will come back to take the vaccine or even visit the antenatal clinic.

Another thing which will make these mothers not to come is the attitude of the health provider at the facility. If a mother comes every day and am like you are shouting at me you are not giving me attention, it is like I tell you are not listening to me you are so arrogant I will not come back, I would rather stay at home. Key informant 6

Healthcare workload was noted as affecting vaccine delivery, especially in the lower-level health facilities whose main responsibility is to administer vaccines and offer other ANC services.

Only one nurse runs majority of our dispensaries and only one staff … running a facility you are the one giving immunizations, you are the one taking care of the pregnancy, you are the one taking care of the sick ones who are coming in, so it is actually hectic and by the end of the day they also need to rest … come at night, they cannot work day and night, at night they are home … and over the weekends again they are taking their offs. Key informant 5

Since 2013, the Kenyan government has introduced two policies to reduce maternal and neonatal deaths: the abolition of client user fees and the provision of free maternity services in public health facilities (Pyone, Smith, and Van Den Broek 2017). We, therefore, tested to what extent other factors such as cost in terms of fare to the clinic, waiting time at the clinic, the time needed to get to the clinic, the timing of the clinic and distance to the clinic prevented expectant mothers from going to get the vaccine. In all instances, these factors affected vaccine uptake only to some extent (Figure 2).

Figure 2. Factors affecting maternal vaccine uptake.

Discussion

It is well-accepted that maternal vaccination significantly reduces neonatal morbidity and mortality (Blencowe et al. 2010). However, a growing number of people perceive vaccines as unsafe and unnecessary (Omer et al. 2009). In this study, we sought to understand factors that influence maternal vaccine uptake. We report results from the contextual influences and individual/social group influences.

Almost everyone reported general knowledge of the existence of vaccines. However, few knew how the tetanus toxoid maternal vaccine works and why it is administered to mothers. The lack of knowledge can be partly explained by the low education levels of our study participants; most of them had primary-level education. It is important to note that participants generally agreed that the tetanus vaccine was good for the mothers. Several factors limited maternal vaccine uptake. Rumours and misinformation around the tetanus vaccine within the community caused fears among expectant mothers. It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls. The fact that boys were excluded from the campaign made the community suspicious that the vaccine was to control fertility among young women. The majority of Kenyans identify themselves with a particular religion. Indeed, in this study, almost all of the participants were Christians. We found that particular religious groups or sects were against modern medicine and particularly advised their congregants against using family planning methods. Additionally, they made those who heard the rumours about tetanus vaccine as a form of birth control to avoid going for the vaccine. It is worth noting that the government, through the Public Health Department, has put in place mechanisms to trace those missing out on vaccination and sometimes using the law to encourage vaccine uptake.

Although there has been concerted efforts by the Kenyan government to increase hospital access by rural mothers, a study conducted by Moindi et al., exploring risk perceptions associated with home deliveries estimated that approximately 26% of mothers in Kilifi County delivered at home (Moindi et al. 2016). We found that Traditional Birth Attendants (TBAs) remained important because mothers could access them easily and faster, especially if the dispensaries were far. Some mothers only sought the services of these TBAs throughout their pregnancy and, as a result, miss out on vaccinations. Within our setting, healthcare-seeking behaviours are partly influenced by older women within the homestead. We found that if these older women did not go to ANC clinics, they tended to discourage young mothers married to their sons from attending the clinic for vaccines when expectant.

Global trends indicate that healthcare workers remain the most trusted sources of information on health matters. In this study, the majority of the participants said they could consult healthcare workers on information related to vaccines. Very few people searched the internet if they had issues with vaccines. Considering this is a predominantly rural population, the cost of internet and smartphones could be a limiting factor.

Health system factors such as vaccine stockout were also identified by the key informants as a challenge to vaccine delivery. As much as the healthcare workers would like to maintain a high vaccine coverage, issues such as delays in vaccine delivery to the health facilities meant that even when mothers showed up and demanded vaccination, the vaccines were out of stock, causing a missed opportunity. Similar to what has been found in Ethiopia (Gebremichael et al. 2018), Tanzania (Maluka et al. 2020) and Uganda (Kajungu et al. 2020), we observed that if a healthcare worker was harsh, abusive or rude, it could discourage women from attending ANC clinics, which has a ripple effect on the uptake of vaccines by the mothers.

Most of our study populations were drawn from rural areas, including rural towns. It has been shown that rural areas tend to have lower education and health literacy (Das et al. 2017), factors important for vaccine uptake (Lorini et al. 2018). Therefore, our findings need to be interpreted within the context in which the study was done. Future studies are required to explore in-depth maternal vaccine hesitancy issues in urban areas in which the population have varying education levels and socioeconomic status.

Conclusion

Our study highlights factors that contribute to low maternal vaccine uptake. Continuous community engagement is required to address the fears, misconceptions, and rumours around tetanus vaccine uptake, which is important for laying the ground for future vaccine rollout for expectant mothers.

Data availability

Underlying data

Harvard Dataverse - https://doi.org/10.7910/DVN/2T6T5G (Kiyuka 2024).

This project contains the following underlying data:

• Delinked _risk perception maternal vaccine study data.xlsx (delinked raw data)
• KI and FGD interview guides.docx
• Survey questionnaire.docx.

Data available at the Harvard Dataverse https://doi.org/10.7910/DVN/2T6T5G, (Kiyuka 2024) under the CC0 1.0 license

Acknowledgement

This research would not have been possible without the immense support of the Kilifi County Department of Health, Community Health Volunteers, local chiefs and community members who participated in the study. We thank Pwani University for the scientific and ethical review. This manuscript was submitted for publication with the permission of the Director KEMRI.

References

Afulani PA, Buback L, Essandoh F, et al.: Quality of Antenatal Care and Associated Factors in a Rural County in Kenya: An Assessment of Service Provision and Experience Dimensions. BMC Health Serv. Res. 2019; 19(1): 684. PubMed Abstract | Publisher Full Text | Free Full Text
Arunda M, Emmelin A, Asamoah BO: Effectiveness of Antenatal Care Services in Reducing Neonatal Mortality in Kenya: Analysis of National Survey Data. Glob. Health Action. 2017; 10(1): 1328796. PubMed Abstract | Publisher Full Text | Free Full Text
Best AL, Thompson EL, Adamu AM, et al.: Examining the Influence of Religious and Spiritual Beliefs on HPV Vaccine Uptake Among College Women. J. Relig. Health. 2019; 58(6): 2196–2207. PubMed Abstract | Publisher Full Text | Free Full Text
Blencowe H, Lawn J, Vandelaer J, et al.: Tetanus Toxoid Immunization to Reduce Mortality from Neonatal Tetanus. Int. J. Epidemiol. 2010; 39(SUPPL. 1): i102–i109. PubMed Abstract | Publisher Full Text | Free Full Text
Brewer NT, Chapman GB, Rothman AJ, et al.: Increasing Vaccination: Putting Psychological Science Into Action. Psychol. Sci. Public Interest. 2017; 18(3): 149–207. PubMed Abstract | Publisher Full Text
Bukenya GB, Freeman PA: Possible Reasons for Non-Completion of Immunization in an Urban Settlement of Papua New Guinea. P. N. G. Med. J. 1991; 34(1): 22–25. PubMed Abstract
Bushar JA, Kendrick JS, Ding H, et al.: Text4baby Influenza Messaging and Influenza Vaccination Among Pregnant Women. Am. J. Prev. Med. 2017; 53(6): 845–853. PubMed Abstract | Publisher Full Text | Free Full Text
Cornwall W: Officials Gird for a War on Vaccine Misinformation Fears of a Rushed COVID-19 Vaccine and Rise of Social Media Demand New Messaging Strategy. Science. 2020; 369: 14–15. American Association for the Advancement of Science. PubMed Abstract | Publisher Full Text
Costa JC, Weber AM, Darmstadt GL, et al.: Religious Affiliation and Immunization Coverage in 15 Countries in Sub-Saharan Africa. Vaccine. 2020; 38(5): 1160–1169. PubMed Abstract | Publisher Full Text | Free Full Text
Das S, Mia MN, Hanifi SMA, et al.: Health Literacy in a Community with Low Levels of Education: Findings from Chakaria, a Rural Area of Bangladesh. BMC Public Health. 2017; 17(1): 203. PubMed Abstract | Publisher Full Text | Free Full Text
Dawa J, Chaves SS, Nguz AB, et al.: Developing a Seasonal Influenza Vaccine Recommendation in Kenya: Process and Challenges Faced by the National Immunization Technical Advisory Group (NITAG). Vaccine. 2019; 37(3): 464–472. PubMed Abstract | Publisher Full Text
Enserink M: Fact-Checking Judy Mikovits, the Controversial Virologist Attacking Anthony Fauci in a Viral Conspiracy Video. Science. 2020 May. Publisher Full Text
Eppes C, Alison W, Whitney You KA, et al.: Barriers to Influenza Vaccination among Pregnant Women. Vaccine. 2013; 31(27): 2874–2878. Publisher Full Text
Fournet N, Mollema L, Ruijs WL, et al.: Under Vaccinated Groups in Europe and Their Beliefs, Attitudes and Reasons for Non Vaccination Two Systematic Reviews. BMC Public Health. 2018; 18(1): 196. PubMed Abstract | Publisher Full Text | Free Full Text
Gebremichael MW, Worku A, Medhanyie AA, et al.: Women Suffer More from Disrespectful and Abusive Care than from the Labour Pain Itself: A Qualitative Study from Women’s Perspective. BMC Pregnancy Childbirth. 2018; 18: 392. BioMed Central Ltd. PubMed Abstract | Publisher Full Text | Free Full Text
Kajungu D, Muhoozi M, Stark J, et al.: Vaccines Safety and Maternal Knowledge for Enhanced Maternal Immunization Acceptability in Rural Uganda: A Qualitative Study Approach. PLoS One. 2020; 15(12 December): e0243834. PubMed Abstract | Publisher Full Text | Free Full Text
Kiyuka P: Replication Data for: Assessing Risk Perceptions That Contribute to Tetanus Toxoid Maternal Vaccine Hesitancy in Kilifi County, Kenya. Harvard Dataverse. 2024. Publisher Full Text
Larson HJ, Brocard P, Garnett G: The India HPV-Vaccine Suspension. Lancet. 2010; 376: 572–573. Elsevier. PubMed Abstract | Publisher Full Text
Larson HJ, Jarrett C, Eckersberger E, et al.: Understanding Vaccine Hesitancy around Vaccines and Vaccination from a Global Perspective: A Systematic Review of Published Literature, 2007-2012. Vaccine. 2014; 32: 2150–2159. Elsevier BV. PubMed Abstract | Publisher Full Text
Larson HJ, Jarrett C, Schulz WS, et al.: Measuring Vaccine Hesitancy: The Development of a Survey Tool. Vaccine. 2015; 33(34): 4165–4175. Publisher Full Text
Williams L, Anna RM, Mwananyanda L, et al.: Maternal Vaccine Knowledge in Low- and Middle-Income Countries—and Why It Matters. Hum. Vaccin. Immunother. 2019; 15: 283–286. Taylor and Francis Inc. PubMed Abstract | Publisher Full Text | Free Full Text
Lorini C, Santomauro F, Donzellini M, et al.: Health Literacy and Vaccination: A Systematic Review. Hum. Vaccin. Immunother. 2018; 14(2): 478–488. PubMed Abstract | Publisher Full Text | Free Full Text
Maluka SO, Joseph C, Fitzgerald S, et al.: Why Do Pregnant Women in Iringa Region in Tanzania Start Antenatal Care Late? A Qualitative Analysis. BMC Pregnancy Childbirth. 2020; 20(1): 126. PubMed Abstract | Publisher Full Text | Free Full Text
Marshall H, McMillan M, Andrews RM, et al.: Vaccines in Pregnancy: The Dual Benefit for Pregnant Women and Infants. Hum. Vaccin. Immunother. 2016; 12: 848–856. Taylor and Francis Inc. PubMed Abstract | Publisher Full Text | Free Full Text
McMorrow ML, Emukule GO, Obor D, et al.: ‘Maternal Influenza Vaccine Strategies in Kenya: Which Approach Would Have the Greatest Impact on Disease Burden in Pregnant Women and Young Infants?’ Edited by David L. Swerdlow. PLoS One. 2017; 12(12): e0189623. PubMed Abstract | Publisher Full Text | Free Full Text
Moindi RO, Ngari MM, Nyambati VCS, et al.: Why Mothers Still Deliver at Home: Understanding Factors Associated with Home Deliveries and Cultural Practices in Rural Coastal Kenya, a Cross-Section Study Global Health. BMC Public Health. 2016; 16(1): 114. PubMed Abstract | Publisher Full Text | Free Full Text
Muinga N, Magare S, Monda J, et al.: Digital Health Systems in Kenyan Public Hospitals: A Mixed-Methods Survey. BMC Med. Inform. Decis. Mak. 2020; 20: 2. BioMed Central Ltd. PubMed Abstract | Publisher Full Text | Free Full Text
Omer SB, Salmon DA, Orenstein WA, et al.: Vaccine Refusal, Mandatory Immunization, and the Risks of Vaccine-Preventable Diseases. N. Engl. J. Med. 2009; 360(19): 1981–1988. PubMed Abstract | Publisher Full Text
Pyone T, Smith H, Van Den Broek N: Implementation of the Free Maternity Services Policy and Its Implications for Health System Governance in Kenya. BMJ Glob. Health. 2017; 2(4): e000249. PubMed Abstract | Publisher Full Text | Free Full Text
Schaetti C, Hutubessy R, Ali SM, et al.: Oral Cholera Vaccine Use in Zanzibar: Socioeconomic and Behavioural Features Affecting Demand and Acceptance. BMC Public Health. 2009; 9(1): 99. PubMed Abstract | Publisher Full Text | Free Full Text
Sridhar S, Maleq N, Guillermet E, et al.: A Systematic Literature Review of Missed Opportunities for Immunization in Low- and Middle-Income Countries. Vaccine. 2014; 32: 6870–6879. Elsevier Ltd. PubMed Abstract | Publisher Full Text
Usman S, Bologna L, Stamidis KV: The Core Group Partners Project in North East Nigeria: Community Engagement Strategies to Combat Skepticism and Build Trust for Vaccine Acceptance. Am. J. Trop. Med. Hyg. 2019; 101(4): 68–73. PubMed Abstract | Publisher Full Text | Free Full Text
WHO: Newborns: Improving Survival and Well-Being’. 2020.2020. Reference Source

Comments on this article Comments (1)

Version 2

VERSION 2 PUBLISHED 24 Jul 2025

Revised

Comment

Version 1

VERSION 1 PUBLISHED 02 Apr 2024

Discussion is closed on this version, please comment on the latest version above.

Author Response 20 Sep 2024

Patience Kiyuka, CGMR-C, Kenya Medical Research Institute, Kilifi, 80108, Kenya

20 Sep 2024

Author Response

“The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus toxoid vaccine” – As of 2019, nearly all countries, especially those that procure their vaccines through the UNICEF ... Continue reading “The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus toxoid vaccine” – As of 2019, nearly all countries, especially those that procure their vaccines through the UNICEF Supply Division had replaced tetanus toxoid vaccine (TT) with tetanus and diphtheria toxoid (Td) vaccines based on the recommendation of the WHO Strategic Advisory Group of Experts (SAGE). This latter vaccine provides protection both against tetanus and diphtheria. You may wish to mention this in the appropriate section of the paper

Response: We thank the reviewer for bringing this crucial update to our attention. We will rephrase the statement to read: The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus-diphtheria (Td) vaccine.

“Several factors that contribute to vaccine hesitancy have been reported. These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (Bukenya and Freeman 1991)” – You may wish to revisit the paper cited here as it refers to missed opportunities for immunization (MOI) which is influenced by factors beyond hesitancy. For example, it is unclear how vaccine logistical issues, which contributes to MOI will affect hesitancy.
Response: We have revised the statement with a correct citation
These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (R. J. Wilson et al. 2015)…

In the introduction section of the paper, it will be useful to provide and/or cite literatures on the importance and influence on immunization uptake by males, especially the heads of the households. This will allow for a better understanding of why males were also interviewed
Response: We will add the following paragraph to the introduction
Other factors that influence motivation for maternal vaccine uptake include the views of the people around the expectant women. It has been shown that husbands and mothers-in-law play a role in the expectant women's decision-making process during pregnancy, including whether to take or not take a vaccine, coupled with the fact of the woman’s limited autonomy within the family setting, especially so within the African context (Johm et al. 2021). In other settings, expectant women seek advice on whether to be vaccinated or not from their female family members such as sisters who already have children, mothers and aunts but less so from their male partners (R. Wilson, Paterson, and Larson 2019)

Methods – Study populations
It will be useful to give a bit of an insight into the random sampling method of the expectant women attending ANC and men and women of reproductive age at the community level in four different locations/wards
Response: We thank the reviewer for pointing this out and apologize for any confusion this statement might have caused. We will revise to ensure consistency throughout the text.
We used convenient sampling for expectant women attending the ANC clinic at select participating health care facilities of Kilifi County Hospital (KCH), Mnarani and Ngeranya dispensaries. We identified women and men of reproductive age at the community level through the assistance of Community Health Extension Officers, who have good knowledge of their communities and also served as study facilitators. Other studies have also used this approach (Watson-Jones et al. 2015).

Any reason why the coverage of the first dose of TT was used rather than at least two doses (TT2+)? One dose TT is not known to confer any level of immunity against tetanus, while a child born to a mother who receives at least two well-spaced doses is considered to be protected at birth (PAB) against tetanus.
Response: In general, in Kenya, tetanus-diphtheria (Td) vaccine uptake remains low (Otieno et al. 2021, 2017–2018). We used the first dose of vaccine as indicative of coverage to guide us to select study sites and not to directly link it to immunity accorded by the vaccine per se.

Methods – data collection
How many FGDs were conducted?
Response: Our study used the triangulation method to understand factors contributing to maternal vaccine uptake within the rural setting of Kilifi, Kenya. We conducted four focus group discussions with expectant women. The FGDs took place at the participating health care centers. Furthermore key informant interviews and survey questionnaires were also used to help us understand the contextual factors for maternal vaccine uptake.

Results
General vaccination knowledge and awareness
It will be useful to disaggregate this data by sex, to assess the knowledge about maternal immunization between males and females.
Response: We thank the reviewer for this comment. We will insert a table breakdown of the responses by sex, below is those who responded yes to the general vaccination knowledge and awareness.

Question
Males N (%)
Females N(%)

Have you ever heard of a vaccine?
38 (95)
63 (100)

Do you know which vaccine women get when expectant?
22 (55)
50 (79.4)

Have you ever heard of tetanus vaccine
36 (93.2)
60 (95.2)

Discussion
“Rumors and misinformation around the tetanus vaccine within the community caused fears among expectant mothers. It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls. The fact that boys were excluded from the campaign made the community suspicious that the vaccine was to control fertility among young women” - It will be useful to know if the same perception holds for tetanus vaccines given through the routine immunization system, during ANC visits. The delivery of tetanus and diphtheria toxoid-containing vaccines along life-course: 3 primary series of DTP during infancy, 1st booster dose at 2nd year of life, 2nd booster dose during school entry (4 - 7 years) and 3rd booster during early adolescence (9 - 15 years) does not have gender discrimination and may help to dispel the existing rumor
Response: We thank the reviewer for this comment. We agree that rolling out the DTP life course vaccine to both girls and boys may perhaps dispel the rumours. Future studies will be needed to monitor community perceptions as the vaccine is rolled out and careful risk communication strategies implemented.

References
Johm, Penda, Nicole Nkoum, Amie Ceesay, El Hadji Mbaye, Heidi Larson, and Beate Kampmann. 2021. ‘Factors Influencing Acceptance of Vaccination during Pregnancy in The Gambia and Senegal’. Vaccine 39 (29): 3926–34. https://doi.org/10.1016/j.vaccine.2021.05.068.
Otieno, Nancy A., Fauzia A. Malik, Stacy W. Nganga, Winnie N. Wairimu, Dominic O. Ouma, Godfrey M. Bigogo, Sandra S. Chaves, et al. 2021. ‘Decision-Making Process for Introduction of Maternal Vaccines in Kenya, 2017–2018’. Implementation Science 16 (1): 39. https://doi.org/10.1186/s13012-021-01101-7.
Watson-Jones, Deborah, Nelly Mugo, Shelley Lees, Muthoni Mathai, Sophie Vusha, Gathari Ndirangu, and David A. Ross. 2015. ‘Access and Attitudes to HPV Vaccination amongst Hard-To-Reach Populations in Kenya’. PLoS ONE 10 (6): e0123701. https://doi.org/10.1371/journal.pone.0123701.
Wilson, R., P. Paterson, and H. J. Larson. 2019. ‘Strategies to Improve Maternal Vaccination Acceptance’. BMC Public Health 19 (1): 342. https://doi.org/10.1186/s12889-019-6655-y.
Wilson, Rose J., Pauline Paterson, Caitlin Jarrett, and Heidi J. Larson. 2015. ‘Understanding Factors Influencing Vaccination Acceptance during Pregnancy Globally: A Literature Review’. Vaccine, Advancing Maternal Immunization Programs through Research in Low and Medium Income Countries, 33 (47): 6420–29. https://doi.org/10.1016/j.vaccine.2015.08.046.
“The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus toxoid vaccine” – As of 2019, nearly all countries, especially those that procure their vaccines through the UNICEF Supply Division had replaced tetanus toxoid vaccine (TT) with tetanus and diphtheria toxoid (Td) vaccines based on the recommendation of the WHO Strategic Advisory Group of Experts (SAGE). This latter vaccine provides protection both against tetanus and diphtheria. You may wish to mention this in the appropriate section of the paper

Response: We thank the reviewer for bringing this crucial update to our attention. We will rephrase the statement to read: The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus-diphtheria (Td) vaccine.

“Several factors that contribute to vaccine hesitancy have been reported. These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (Bukenya and Freeman 1991)” – You may wish to revisit the paper cited here as it refers to missed opportunities for immunization (MOI) which is influenced by factors beyond hesitancy. For example, it is unclear how vaccine logistical issues, which contributes to MOI will affect hesitancy.
Response: We have revised the statement with a correct citation
These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (R. J. Wilson et al. 2015)…

In the introduction section of the paper, it will be useful to provide and/or cite literatures on the importance and influence on immunization uptake by males, especially the heads of the households. This will allow for a better understanding of why males were also interviewed
Response: We will add the following paragraph to the introduction
Other factors that influence motivation for maternal vaccine uptake include the views of the people around the expectant women. It has been shown that husbands and mothers-in-law play a role in the expectant women's decision-making process during pregnancy, including whether to take or not take a vaccine, coupled with the fact of the woman’s limited autonomy within the family setting, especially so within the African context (Johm et al. 2021). In other settings, expectant women seek advice on whether to be vaccinated or not from their female family members such as sisters who already have children, mothers and aunts but less so from their male partners (R. Wilson, Paterson, and Larson 2019)

Methods – Study populations
It will be useful to give a bit of an insight into the random sampling method of the expectant women attending ANC and men and women of reproductive age at the community level in four different locations/wards
Response: We thank the reviewer for pointing this out and apologize for any confusion this statement might have caused. We will revise to ensure consistency throughout the text.
We used convenient sampling for expectant women attending the ANC clinic at select participating health care facilities of Kilifi County Hospital (KCH), Mnarani and Ngeranya dispensaries. We identified women and men of reproductive age at the community level through the assistance of Community Health Extension Officers, who have good knowledge of their communities and also served as study facilitators. Other studies have also used this approach (Watson-Jones et al. 2015).

Any reason why the coverage of the first dose of TT was used rather than at least two doses (TT2+)? One dose TT is not known to confer any level of immunity against tetanus, while a child born to a mother who receives at least two well-spaced doses is considered to be protected at birth (PAB) against tetanus.
Response: In general, in Kenya, tetanus-diphtheria (Td) vaccine uptake remains low (Otieno et al. 2021, 2017–2018). We used the first dose of vaccine as indicative of coverage to guide us to select study sites and not to directly link it to immunity accorded by the vaccine per se.

Methods – data collection
How many FGDs were conducted?
Response: Our study used the triangulation method to understand factors contributing to maternal vaccine uptake within the rural setting of Kilifi, Kenya. We conducted four focus group discussions with expectant women. The FGDs took place at the participating health care centers. Furthermore key informant interviews and survey questionnaires were also used to help us understand the contextual factors for maternal vaccine uptake.

Results
General vaccination knowledge and awareness
It will be useful to disaggregate this data by sex, to assess the knowledge about maternal immunization between males and females.
Response: We thank the reviewer for this comment. We will insert a table breakdown of the responses by sex, below is those who responded yes to the general vaccination knowledge and awareness.

Question
Males N (%)
Females N(%)

Have you ever heard of a vaccine?
38 (95)
63 (100)

Do you know which vaccine women get when expectant?
22 (55)
50 (79.4)

Have you ever heard of tetanus vaccine
36 (93.2)
60 (95.2)

Discussion
“Rumors and misinformation around the tetanus vaccine within the community caused fears among expectant mothers. It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls. The fact that boys were excluded from the campaign made the community suspicious that the vaccine was to control fertility among young women” - It will be useful to know if the same perception holds for tetanus vaccines given through the routine immunization system, during ANC visits. The delivery of tetanus and diphtheria toxoid-containing vaccines along life-course: 3 primary series of DTP during infancy, 1st booster dose at 2nd year of life, 2nd booster dose during school entry (4 - 7 years) and 3rd booster during early adolescence (9 - 15 years) does not have gender discrimination and may help to dispel the existing rumor
Response: We thank the reviewer for this comment. We agree that rolling out the DTP life course vaccine to both girls and boys may perhaps dispel the rumours. Future studies will be needed to monitor community perceptions as the vaccine is rolled out and careful risk communication strategies implemented.

References
Johm, Penda, Nicole Nkoum, Amie Ceesay, El Hadji Mbaye, Heidi Larson, and Beate Kampmann. 2021. ‘Factors Influencing Acceptance of Vaccination during Pregnancy in The Gambia and Senegal’. Vaccine 39 (29): 3926–34. https://doi.org/10.1016/j.vaccine.2021.05.068.
Otieno, Nancy A., Fauzia A. Malik, Stacy W. Nganga, Winnie N. Wairimu, Dominic O. Ouma, Godfrey M. Bigogo, Sandra S. Chaves, et al. 2021. ‘Decision-Making Process for Introduction of Maternal Vaccines in Kenya, 2017–2018’. Implementation Science 16 (1): 39. https://doi.org/10.1186/s13012-021-01101-7.
Watson-Jones, Deborah, Nelly Mugo, Shelley Lees, Muthoni Mathai, Sophie Vusha, Gathari Ndirangu, and David A. Ross. 2015. ‘Access and Attitudes to HPV Vaccination amongst Hard-To-Reach Populations in Kenya’. PLoS ONE 10 (6): e0123701. https://doi.org/10.1371/journal.pone.0123701.
Wilson, R., P. Paterson, and H. J. Larson. 2019. ‘Strategies to Improve Maternal Vaccination Acceptance’. BMC Public Health 19 (1): 342. https://doi.org/10.1186/s12889-019-6655-y.
Wilson, Rose J., Pauline Paterson, Caitlin Jarrett, and Heidi J. Larson. 2015. ‘Understanding Factors Influencing Vaccination Acceptance during Pregnancy Globally: A Literature Review’. Vaccine, Advancing Maternal Immunization Programs through Research in Low and Medium Income Countries, 33 (47): 6420–29. https://doi.org/10.1016/j.vaccine.2015.08.046.
Competing Interests: NA Close
Report a concern
Discussion is closed on this version, please comment on the latest version above.

Author details Author details

Patience Kerubo Kiyuka
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation

Rodgers Onsomu Moindi
Roles: Formal Analysis, Investigation, Methodology, Project Administration, Resources, Writing – Review & Editing

Meshack Nzesei Mutua
Roles: Funding Acquisition, Investigation, Methodology, Writing – Review & Editing

Noni Mumba
Roles: Investigation, Methodology, Resources, Supervision, Validation, Writing – Review & Editing

Halimu Suleiman Shauri
Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

version 2

Revised

Published: 24 Jul 2025, 13:244

https://doi.org/10.12688/f1000research.144710.2

version 1

Published: 02 Apr 2024, 13:244

https://doi.org/10.12688/f1000research.144710.1

© 2024 Kiyuka PK et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Download

Export To

metrics

	Views	Downloads
F1000Research	-	-
PubMed Central Data from PMC are received and updated monthly.	-	-

Citations

SEE MORE DETAILS

CITE

how to cite this article

Kiyuka PK, Onsomu Moindi R, Mutua MN et al. Assessing risk perceptions that contribute to tetanus toxoid maternal vaccine hesitancy in Kilifi County, Kenya [version 1; peer review: 2 approved with reservations]. F1000Research 2024, 13:244 (https://doi.org/10.12688/f1000research.144710.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

track

receive updates on this article

Track an article to receive email alerts on any updates to this article.

Open Peer Review

Version 1

VERSION 1

PUBLISHED 02 Apr 2024

Views

Reviewer Report 26 May 2025

Berhaun Fesshaye, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

Approved with Reservations

https://doi.org/10.5256/f1000research.158548.r381572

This is an interesting manuscript exploring the reasons for hesitancy towards tetanus vaccination during pregnancy. I have a few comments/suggestions for the authors.

Methods:
Please revise for brevity and clarity. How many FGDs were conducted? What was the final sample for the FGDs? Were the 104 survey participants a sub-sample of the FGD sample or were these a separate sample?

Were there any data cleaning procedures that the authors feel it is appropriate to report? Did the authors deal with any missing data during analysis?

Results:
Please aim to only present your study results in the results section. Compare and contrast with the literature in the discussion section.

In figure 2, it would be helpful if the x axis title was a bit more descriptive. For example: (Percentage of participants (N=104)).

If word limits allow it, it would be nice to see some more illustrative quotes throughout the results. For example, if the results state that multiple participants reported similar themes, including 2 or 3 three quotes would be great.

Discussion
Please ensure citations are included if what is stated is not directly from your results.

Try not to introduce new results within the discussion section.

Are there more limitations that the authors thought of? For example, response bias in the questionnaire portion?

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Maternal immunization; vaccine acceptance

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

Report a concern

Author Response 10 Sep 2025

Patience Kiyuka, CGMR-C, Kenya Medical Research Institute, Kilifi, 80108, Kenya

10 Sep 2025

Author Response
This is an interesting manuscript exploring the reasons for hesitancy towards tetanus vaccination during pregnancy. I have a few comments/suggestions for the authors. We appreciate the reviewer’s kind words.

... Continue reading
This is an interesting manuscript exploring the reasons for hesitancy towards tetanus vaccination during pregnancy. I have a few comments/suggestions for the authors. We appreciate the reviewer’s kind words.

Methods:
Please revise for brevity and clarity. How many FGDs were conducted? What was the final sample for the FGDs? Were the 104 survey participants a sub-sample of the FGD sample or were these a separate sample?
Response: We thank the reviewer for this comment. Under the study population we will add, ‘We conducted four FGDs comprising of 10-12 participants.’ The final sample size of the FGDs was 45.
We apologize for the confusion. The 104 surveyed were not a sub-sample of the FGD, rather they were a randomly selected separate population.

Were there any data cleaning procedures that the authors feel it is appropriate to report? Did the authors deal with any missing data during analysis?
Response: We thank the reviewer for this comment. We will revise our qualitative and quantitative data section as follows: The qualitative data were audio-recorded, transcribed verbatim, and translated into English. We conducted thematic analysis following Braun and Clarke's (2006) approach, with a particular focus on latent themes. This analytical level moves beyond surface-level content to examine the underlying assumptions, conceptual frameworks, and ideologies shaping participants' responses (Braun & Clarke, 2006, p. 84). Our analysis sought to identify meaningful patterns that could inform our research questions, paying particular attention to the implicit meanings and theoretical constructs embedded in the data.
On missing data: for the qualitative data, participants were allowed to opt oout of answering any questions. Missing data for quantitative data in included in the figures as missing data as indicated in Table 1 and figure 2 as non-responders.

On revise for brevity and clarity
We will cut this section from the study design section
“Since study activities were conducted during the COVID-19 pandemic, the study team followed the infection control guidelines put in place by the County Department of Health Services to reduce SARS-CoV-2 infections such as social distancing; regular hand washing; use of personal protective equipment to protect oneself and participants; and measuring temperatures of study team before each field visits.”

We will revise the data collection section to read as follows:
Before data collection, the study team was trained on the study objectives, consent process, and data management. We then conducted:

Focus Group Discussions (FGDs): 10–12 expectant women per group, selected via convenience sampling from high-volume facilities to ensure urban-rural diversity. FGDs (60–90 min) took place during maternal health clinic days.

Surveys: Administered to 104 randomly selected men and women of reproductive age.

Key Informant (KI) Interviews: Six interviews (30–60 min) with healthcare workers and vaccine managers, conducted at their workplaces.

All FGDs and KIs were audio-recorded (encrypted) and noted by hand. Two researchers (PKK and ROM) conducted face-to-face interviews. Written consent was obtained from all participants. Data collection occurred between September and October 2020.

Results
Please aim to only present your study results in the results section. Compare and contrast with the literature in the discussion section.
Response: We thank the reviewer for this comment. We will remove the following statement below from the results section that suggests we are comparing or contrasting our results with other studies

Indeed, several studies have examined whether religion influences childhood immunisation uptake (Costa et al. 2020; Fournet et al. 2018), including the adolescent human papillomavirus
(Best et al. 2019).

The Wellcome Global Monitor Report 2018 the world’s largest study into how people around the world think and feel about science and major health challenges, estimates that globally, 73% of people highly trust healthcare workers for their sources of information.

Since 2013, the Kenyan government has introduced two policies to reduce maternal and neonatal deaths: the abolition of client user fees and the provision of free maternity services in public health facilities (Pyone, Smith, and Van Den Broek 2017).

In figure 2, it would be helpful if the x axis title was a bit more descriptive. For example: (Percentage of participants (N=104)).
Response: We thank the reviewer for this comment. We will relabel the axis as Percentage of participants (N=104) as shown below
for fig refer to following link: https://f1000research-files.f1000.com/linked/749716.Fig.1-_Ms.id__144710.png

If word limits allow it, it would be nice to see some more illustrative quotes throughout the results. For example, if the results state that multiple participants reported similar themes, including 2 or 3 three quotes would be great.
Response: We thank the reviewer for this comment.
We will add the following two quotes under:
Healthcare workload

[We need more nurses. Currently in this Maternal Child Health (MCH) clinic, you can see this room is closed - it's supposed to provide postnatal care, cervical cancer screening, and family planning services. But because we're understaffed, we've had to close it. Now just one nurse must provide all these services in a single room, which forces clients to wait extremely long hours. This situation ultimately discourages mothers from returning to the clinic. Key informant 2]

[Then another thing we should add our manpower because me as nurse X I cannot say I know this and this and it’s me only every day, Key Informant 4]

Under stockout we will also add the following quote
[Frequent stock outs so they will tell you every time we come, there are stock outs so better we remain at home, Key informant 5]

Reasons for not taking reasons for not taking maternal tetanus toxoid vaccine
Due to home delivery
[The other one is my sister you tell her to go to clinic, and she tells you I am okay, no need for me to go to clinic, I will deliver at home, is it a must I go to hospital? Expectant mother FGD 1]

[There are those who give birth at the hospital but there are others who are afraid like me, I have given birth three times at home but then I have been told that I must give birth at the hospital Expectant mother FGD 4]

These home deliveries are facilitated mostly by midwives or traditional birth attendant
[Then there are the midwives they have a habit of asking you to visit them so that they can check the child’s progress, Expectant mother FGD2]

[I once carried my pregnancy to the end, from the first to the ninth month and never visited the clinic even once … I did not come for clinic not even a single day. I was going to these midwives who massaged me and told me my baby was okay, Expectant mother FGD 4]

General vaccination knowledge and awareness
We will add the following statement
Most expectant women know that the vaccine is useful for protecting them and their unborn child
[That injection we were taught that it helps prevent tetanus and when a mother is pregnant, the foetus gets immunity against tetanus because of the injection given to the mother. Expectant mother FGD 3]

[I had been told it protects both the mother and the child, but it did not affect me. Expectant mother FGD 1]

Discussion
Try not to introduce new results within the discussion section.
We appreciate the reviewer’s valuable feedback, which strengthens the rigor of our discussion. As suggested, we have incorporated direct participant quotes in the revised manuscript to reinforce the consensus that the vaccine was perceived as beneficial for mothers, further validating our discussion point.

Please ensure citations are included if what is stated is not directly from your results.
We will include a citation for the following statements:

It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls https://www.afro.who.int/news/kenya-rolls-out-massive-measles-rubella-and-tetanus-campaign.

The majority of Kenyans identify themselves with a particular religion. We will rewrite this statement to read
According to the 2019 Kenya census majority of Kenyans identify themselves with a particular religion https://www.knbs.or.ke/2019-kenya-population-and-housing-census-results/.

It is worth noting that the government, through the Public Health Department, has put in place mechanisms to trace those missing out on vaccination and sometimes using the law (we will remove the word law with community lead interventions) to encourage vaccine uptake
https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/kenya/kenya_cmyp_2015-2019.pdf.

As guided by the reviewer we have added quotes in the results section to support this statement in the discussion section
We found that Traditional Birth Attendants (TBAs) remained important because mothers could access them easily and faster, especially if the dispensaries were far.

Acknowledgement
We thank the reviewer for their meticulous critique, which has strengthened the rigor and clarity of our work. All changes will be implemented in the revised manuscript.
This is an interesting manuscript exploring the reasons for hesitancy towards tetanus vaccination during pregnancy. I have a few comments/suggestions for the authors. We appreciate the reviewer’s kind words.

Methods:
Please revise for brevity and clarity. How many FGDs were conducted? What was the final sample for the FGDs? Were the 104 survey participants a sub-sample of the FGD sample or were these a separate sample?
Response: We thank the reviewer for this comment. Under the study population we will add, ‘We conducted four FGDs comprising of 10-12 participants.’ The final sample size of the FGDs was 45.
We apologize for the confusion. The 104 surveyed were not a sub-sample of the FGD, rather they were a randomly selected separate population.

Were there any data cleaning procedures that the authors feel it is appropriate to report? Did the authors deal with any missing data during analysis?
Response: We thank the reviewer for this comment. We will revise our qualitative and quantitative data section as follows: The qualitative data were audio-recorded, transcribed verbatim, and translated into English. We conducted thematic analysis following Braun and Clarke's (2006) approach, with a particular focus on latent themes. This analytical level moves beyond surface-level content to examine the underlying assumptions, conceptual frameworks, and ideologies shaping participants' responses (Braun & Clarke, 2006, p. 84). Our analysis sought to identify meaningful patterns that could inform our research questions, paying particular attention to the implicit meanings and theoretical constructs embedded in the data.
On missing data: for the qualitative data, participants were allowed to opt oout of answering any questions. Missing data for quantitative data in included in the figures as missing data as indicated in Table 1 and figure 2 as non-responders.

On revise for brevity and clarity
We will cut this section from the study design section
“Since study activities were conducted during the COVID-19 pandemic, the study team followed the infection control guidelines put in place by the County Department of Health Services to reduce SARS-CoV-2 infections such as social distancing; regular hand washing; use of personal protective equipment to protect oneself and participants; and measuring temperatures of study team before each field visits.”

We will revise the data collection section to read as follows:
Before data collection, the study team was trained on the study objectives, consent process, and data management. We then conducted:

Focus Group Discussions (FGDs): 10–12 expectant women per group, selected via convenience sampling from high-volume facilities to ensure urban-rural diversity. FGDs (60–90 min) took place during maternal health clinic days.

Surveys: Administered to 104 randomly selected men and women of reproductive age.

Key Informant (KI) Interviews: Six interviews (30–60 min) with healthcare workers and vaccine managers, conducted at their workplaces.

All FGDs and KIs were audio-recorded (encrypted) and noted by hand. Two researchers (PKK and ROM) conducted face-to-face interviews. Written consent was obtained from all participants. Data collection occurred between September and October 2020.

Results
Please aim to only present your study results in the results section. Compare and contrast with the literature in the discussion section.
Response: We thank the reviewer for this comment. We will remove the following statement below from the results section that suggests we are comparing or contrasting our results with other studies

Indeed, several studies have examined whether religion influences childhood immunisation uptake (Costa et al. 2020; Fournet et al. 2018), including the adolescent human papillomavirus
(Best et al. 2019).

The Wellcome Global Monitor Report 2018 the world’s largest study into how people around the world think and feel about science and major health challenges, estimates that globally, 73% of people highly trust healthcare workers for their sources of information.

Since 2013, the Kenyan government has introduced two policies to reduce maternal and neonatal deaths: the abolition of client user fees and the provision of free maternity services in public health facilities (Pyone, Smith, and Van Den Broek 2017).

In figure 2, it would be helpful if the x axis title was a bit more descriptive. For example: (Percentage of participants (N=104)).
Response: We thank the reviewer for this comment. We will relabel the axis as Percentage of participants (N=104) as shown below
for fig refer to following link: https://f1000research-files.f1000.com/linked/749716.Fig.1-_Ms.id__144710.png

If word limits allow it, it would be nice to see some more illustrative quotes throughout the results. For example, if the results state that multiple participants reported similar themes, including 2 or 3 three quotes would be great.
Response: We thank the reviewer for this comment.
We will add the following two quotes under:
Healthcare workload

[We need more nurses. Currently in this Maternal Child Health (MCH) clinic, you can see this room is closed - it's supposed to provide postnatal care, cervical cancer screening, and family planning services. But because we're understaffed, we've had to close it. Now just one nurse must provide all these services in a single room, which forces clients to wait extremely long hours. This situation ultimately discourages mothers from returning to the clinic. Key informant 2]

[Then another thing we should add our manpower because me as nurse X I cannot say I know this and this and it’s me only every day, Key Informant 4]

Under stockout we will also add the following quote
[Frequent stock outs so they will tell you every time we come, there are stock outs so better we remain at home, Key informant 5]

Reasons for not taking reasons for not taking maternal tetanus toxoid vaccine
Due to home delivery
[The other one is my sister you tell her to go to clinic, and she tells you I am okay, no need for me to go to clinic, I will deliver at home, is it a must I go to hospital? Expectant mother FGD 1]

[There are those who give birth at the hospital but there are others who are afraid like me, I have given birth three times at home but then I have been told that I must give birth at the hospital Expectant mother FGD 4]

These home deliveries are facilitated mostly by midwives or traditional birth attendant
[Then there are the midwives they have a habit of asking you to visit them so that they can check the child’s progress, Expectant mother FGD2]

[I once carried my pregnancy to the end, from the first to the ninth month and never visited the clinic even once … I did not come for clinic not even a single day. I was going to these midwives who massaged me and told me my baby was okay, Expectant mother FGD 4]

General vaccination knowledge and awareness
We will add the following statement
Most expectant women know that the vaccine is useful for protecting them and their unborn child
[That injection we were taught that it helps prevent tetanus and when a mother is pregnant, the foetus gets immunity against tetanus because of the injection given to the mother. Expectant mother FGD 3]

[I had been told it protects both the mother and the child, but it did not affect me. Expectant mother FGD 1]

Discussion
Try not to introduce new results within the discussion section.
We appreciate the reviewer’s valuable feedback, which strengthens the rigor of our discussion. As suggested, we have incorporated direct participant quotes in the revised manuscript to reinforce the consensus that the vaccine was perceived as beneficial for mothers, further validating our discussion point.

Please ensure citations are included if what is stated is not directly from your results.
We will include a citation for the following statements:

It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls https://www.afro.who.int/news/kenya-rolls-out-massive-measles-rubella-and-tetanus-campaign.

The majority of Kenyans identify themselves with a particular religion. We will rewrite this statement to read
According to the 2019 Kenya census majority of Kenyans identify themselves with a particular religion https://www.knbs.or.ke/2019-kenya-population-and-housing-census-results/.

It is worth noting that the government, through the Public Health Department, has put in place mechanisms to trace those missing out on vaccination and sometimes using the law (we will remove the word law with community lead interventions) to encourage vaccine uptake
https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/kenya/kenya_cmyp_2015-2019.pdf.

As guided by the reviewer we have added quotes in the results section to support this statement in the discussion section
We found that Traditional Birth Attendants (TBAs) remained important because mothers could access them easily and faster, especially if the dispensaries were far.

Acknowledgement
We thank the reviewer for their meticulous critique, which has strengthened the rigor and clarity of our work. All changes will be implemented in the revised manuscript.
Competing Interests: None Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 10 Sep 2025

Patience Kiyuka, CGMR-C, Kenya Medical Research Institute, Kilifi, 80108, Kenya

10 Sep 2025

Author Response
This is an interesting manuscript exploring the reasons for hesitancy towards tetanus vaccination during pregnancy. I have a few comments/suggestions for the authors. We appreciate the reviewer’s kind words.

... Continue reading
This is an interesting manuscript exploring the reasons for hesitancy towards tetanus vaccination during pregnancy. I have a few comments/suggestions for the authors. We appreciate the reviewer’s kind words.

Methods:
Please revise for brevity and clarity. How many FGDs were conducted? What was the final sample for the FGDs? Were the 104 survey participants a sub-sample of the FGD sample or were these a separate sample?
Response: We thank the reviewer for this comment. Under the study population we will add, ‘We conducted four FGDs comprising of 10-12 participants.’ The final sample size of the FGDs was 45.
We apologize for the confusion. The 104 surveyed were not a sub-sample of the FGD, rather they were a randomly selected separate population.

Were there any data cleaning procedures that the authors feel it is appropriate to report? Did the authors deal with any missing data during analysis?
Response: We thank the reviewer for this comment. We will revise our qualitative and quantitative data section as follows: The qualitative data were audio-recorded, transcribed verbatim, and translated into English. We conducted thematic analysis following Braun and Clarke's (2006) approach, with a particular focus on latent themes. This analytical level moves beyond surface-level content to examine the underlying assumptions, conceptual frameworks, and ideologies shaping participants' responses (Braun & Clarke, 2006, p. 84). Our analysis sought to identify meaningful patterns that could inform our research questions, paying particular attention to the implicit meanings and theoretical constructs embedded in the data.
On missing data: for the qualitative data, participants were allowed to opt oout of answering any questions. Missing data for quantitative data in included in the figures as missing data as indicated in Table 1 and figure 2 as non-responders.

On revise for brevity and clarity
We will cut this section from the study design section
“Since study activities were conducted during the COVID-19 pandemic, the study team followed the infection control guidelines put in place by the County Department of Health Services to reduce SARS-CoV-2 infections such as social distancing; regular hand washing; use of personal protective equipment to protect oneself and participants; and measuring temperatures of study team before each field visits.”

We will revise the data collection section to read as follows:
Before data collection, the study team was trained on the study objectives, consent process, and data management. We then conducted:

Focus Group Discussions (FGDs): 10–12 expectant women per group, selected via convenience sampling from high-volume facilities to ensure urban-rural diversity. FGDs (60–90 min) took place during maternal health clinic days.

Surveys: Administered to 104 randomly selected men and women of reproductive age.

Key Informant (KI) Interviews: Six interviews (30–60 min) with healthcare workers and vaccine managers, conducted at their workplaces.

All FGDs and KIs were audio-recorded (encrypted) and noted by hand. Two researchers (PKK and ROM) conducted face-to-face interviews. Written consent was obtained from all participants. Data collection occurred between September and October 2020.

Results
Please aim to only present your study results in the results section. Compare and contrast with the literature in the discussion section.
Response: We thank the reviewer for this comment. We will remove the following statement below from the results section that suggests we are comparing or contrasting our results with other studies

Indeed, several studies have examined whether religion influences childhood immunisation uptake (Costa et al. 2020; Fournet et al. 2018), including the adolescent human papillomavirus
(Best et al. 2019).

The Wellcome Global Monitor Report 2018 the world’s largest study into how people around the world think and feel about science and major health challenges, estimates that globally, 73% of people highly trust healthcare workers for their sources of information.

Since 2013, the Kenyan government has introduced two policies to reduce maternal and neonatal deaths: the abolition of client user fees and the provision of free maternity services in public health facilities (Pyone, Smith, and Van Den Broek 2017).

In figure 2, it would be helpful if the x axis title was a bit more descriptive. For example: (Percentage of participants (N=104)).
Response: We thank the reviewer for this comment. We will relabel the axis as Percentage of participants (N=104) as shown below
for fig refer to following link: https://f1000research-files.f1000.com/linked/749716.Fig.1-_Ms.id__144710.png

If word limits allow it, it would be nice to see some more illustrative quotes throughout the results. For example, if the results state that multiple participants reported similar themes, including 2 or 3 three quotes would be great.
Response: We thank the reviewer for this comment.
We will add the following two quotes under:
Healthcare workload

[We need more nurses. Currently in this Maternal Child Health (MCH) clinic, you can see this room is closed - it's supposed to provide postnatal care, cervical cancer screening, and family planning services. But because we're understaffed, we've had to close it. Now just one nurse must provide all these services in a single room, which forces clients to wait extremely long hours. This situation ultimately discourages mothers from returning to the clinic. Key informant 2]

[Then another thing we should add our manpower because me as nurse X I cannot say I know this and this and it’s me only every day, Key Informant 4]

Under stockout we will also add the following quote
[Frequent stock outs so they will tell you every time we come, there are stock outs so better we remain at home, Key informant 5]

Reasons for not taking reasons for not taking maternal tetanus toxoid vaccine
Due to home delivery
[The other one is my sister you tell her to go to clinic, and she tells you I am okay, no need for me to go to clinic, I will deliver at home, is it a must I go to hospital? Expectant mother FGD 1]

[There are those who give birth at the hospital but there are others who are afraid like me, I have given birth three times at home but then I have been told that I must give birth at the hospital Expectant mother FGD 4]

These home deliveries are facilitated mostly by midwives or traditional birth attendant
[Then there are the midwives they have a habit of asking you to visit them so that they can check the child’s progress, Expectant mother FGD2]

[I once carried my pregnancy to the end, from the first to the ninth month and never visited the clinic even once … I did not come for clinic not even a single day. I was going to these midwives who massaged me and told me my baby was okay, Expectant mother FGD 4]

General vaccination knowledge and awareness
We will add the following statement
Most expectant women know that the vaccine is useful for protecting them and their unborn child
[That injection we were taught that it helps prevent tetanus and when a mother is pregnant, the foetus gets immunity against tetanus because of the injection given to the mother. Expectant mother FGD 3]

[I had been told it protects both the mother and the child, but it did not affect me. Expectant mother FGD 1]

Discussion
Try not to introduce new results within the discussion section.
We appreciate the reviewer’s valuable feedback, which strengthens the rigor of our discussion. As suggested, we have incorporated direct participant quotes in the revised manuscript to reinforce the consensus that the vaccine was perceived as beneficial for mothers, further validating our discussion point.

Please ensure citations are included if what is stated is not directly from your results.
We will include a citation for the following statements:

It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls https://www.afro.who.int/news/kenya-rolls-out-massive-measles-rubella-and-tetanus-campaign.

The majority of Kenyans identify themselves with a particular religion. We will rewrite this statement to read
According to the 2019 Kenya census majority of Kenyans identify themselves with a particular religion https://www.knbs.or.ke/2019-kenya-population-and-housing-census-results/.

It is worth noting that the government, through the Public Health Department, has put in place mechanisms to trace those missing out on vaccination and sometimes using the law (we will remove the word law with community lead interventions) to encourage vaccine uptake
https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/kenya/kenya_cmyp_2015-2019.pdf.

As guided by the reviewer we have added quotes in the results section to support this statement in the discussion section
We found that Traditional Birth Attendants (TBAs) remained important because mothers could access them easily and faster, especially if the dispensaries were far.

Acknowledgement
We thank the reviewer for their meticulous critique, which has strengthened the rigor and clarity of our work. All changes will be implemented in the revised manuscript.
This is an interesting manuscript exploring the reasons for hesitancy towards tetanus vaccination during pregnancy. I have a few comments/suggestions for the authors. We appreciate the reviewer’s kind words.

Methods:
Please revise for brevity and clarity. How many FGDs were conducted? What was the final sample for the FGDs? Were the 104 survey participants a sub-sample of the FGD sample or were these a separate sample?
Response: We thank the reviewer for this comment. Under the study population we will add, ‘We conducted four FGDs comprising of 10-12 participants.’ The final sample size of the FGDs was 45.
We apologize for the confusion. The 104 surveyed were not a sub-sample of the FGD, rather they were a randomly selected separate population.

Were there any data cleaning procedures that the authors feel it is appropriate to report? Did the authors deal with any missing data during analysis?
Response: We thank the reviewer for this comment. We will revise our qualitative and quantitative data section as follows: The qualitative data were audio-recorded, transcribed verbatim, and translated into English. We conducted thematic analysis following Braun and Clarke's (2006) approach, with a particular focus on latent themes. This analytical level moves beyond surface-level content to examine the underlying assumptions, conceptual frameworks, and ideologies shaping participants' responses (Braun & Clarke, 2006, p. 84). Our analysis sought to identify meaningful patterns that could inform our research questions, paying particular attention to the implicit meanings and theoretical constructs embedded in the data.
On missing data: for the qualitative data, participants were allowed to opt oout of answering any questions. Missing data for quantitative data in included in the figures as missing data as indicated in Table 1 and figure 2 as non-responders.

On revise for brevity and clarity
We will cut this section from the study design section
“Since study activities were conducted during the COVID-19 pandemic, the study team followed the infection control guidelines put in place by the County Department of Health Services to reduce SARS-CoV-2 infections such as social distancing; regular hand washing; use of personal protective equipment to protect oneself and participants; and measuring temperatures of study team before each field visits.”

We will revise the data collection section to read as follows:
Before data collection, the study team was trained on the study objectives, consent process, and data management. We then conducted:

Focus Group Discussions (FGDs): 10–12 expectant women per group, selected via convenience sampling from high-volume facilities to ensure urban-rural diversity. FGDs (60–90 min) took place during maternal health clinic days.

Surveys: Administered to 104 randomly selected men and women of reproductive age.

Key Informant (KI) Interviews: Six interviews (30–60 min) with healthcare workers and vaccine managers, conducted at their workplaces.

All FGDs and KIs were audio-recorded (encrypted) and noted by hand. Two researchers (PKK and ROM) conducted face-to-face interviews. Written consent was obtained from all participants. Data collection occurred between September and October 2020.

Results
Please aim to only present your study results in the results section. Compare and contrast with the literature in the discussion section.
Response: We thank the reviewer for this comment. We will remove the following statement below from the results section that suggests we are comparing or contrasting our results with other studies

Indeed, several studies have examined whether religion influences childhood immunisation uptake (Costa et al. 2020; Fournet et al. 2018), including the adolescent human papillomavirus
(Best et al. 2019).

The Wellcome Global Monitor Report 2018 the world’s largest study into how people around the world think and feel about science and major health challenges, estimates that globally, 73% of people highly trust healthcare workers for their sources of information.

Since 2013, the Kenyan government has introduced two policies to reduce maternal and neonatal deaths: the abolition of client user fees and the provision of free maternity services in public health facilities (Pyone, Smith, and Van Den Broek 2017).

In figure 2, it would be helpful if the x axis title was a bit more descriptive. For example: (Percentage of participants (N=104)).
Response: We thank the reviewer for this comment. We will relabel the axis as Percentage of participants (N=104) as shown below
for fig refer to following link: https://f1000research-files.f1000.com/linked/749716.Fig.1-_Ms.id__144710.png

If word limits allow it, it would be nice to see some more illustrative quotes throughout the results. For example, if the results state that multiple participants reported similar themes, including 2 or 3 three quotes would be great.
Response: We thank the reviewer for this comment.
We will add the following two quotes under:
Healthcare workload

[We need more nurses. Currently in this Maternal Child Health (MCH) clinic, you can see this room is closed - it's supposed to provide postnatal care, cervical cancer screening, and family planning services. But because we're understaffed, we've had to close it. Now just one nurse must provide all these services in a single room, which forces clients to wait extremely long hours. This situation ultimately discourages mothers from returning to the clinic. Key informant 2]

[Then another thing we should add our manpower because me as nurse X I cannot say I know this and this and it’s me only every day, Key Informant 4]

Under stockout we will also add the following quote
[Frequent stock outs so they will tell you every time we come, there are stock outs so better we remain at home, Key informant 5]

Reasons for not taking reasons for not taking maternal tetanus toxoid vaccine
Due to home delivery
[The other one is my sister you tell her to go to clinic, and she tells you I am okay, no need for me to go to clinic, I will deliver at home, is it a must I go to hospital? Expectant mother FGD 1]

[There are those who give birth at the hospital but there are others who are afraid like me, I have given birth three times at home but then I have been told that I must give birth at the hospital Expectant mother FGD 4]

These home deliveries are facilitated mostly by midwives or traditional birth attendant
[Then there are the midwives they have a habit of asking you to visit them so that they can check the child’s progress, Expectant mother FGD2]

[I once carried my pregnancy to the end, from the first to the ninth month and never visited the clinic even once … I did not come for clinic not even a single day. I was going to these midwives who massaged me and told me my baby was okay, Expectant mother FGD 4]

General vaccination knowledge and awareness
We will add the following statement
Most expectant women know that the vaccine is useful for protecting them and their unborn child
[That injection we were taught that it helps prevent tetanus and when a mother is pregnant, the foetus gets immunity against tetanus because of the injection given to the mother. Expectant mother FGD 3]

[I had been told it protects both the mother and the child, but it did not affect me. Expectant mother FGD 1]

Discussion
Try not to introduce new results within the discussion section.
We appreciate the reviewer’s valuable feedback, which strengthens the rigor of our discussion. As suggested, we have incorporated direct participant quotes in the revised manuscript to reinforce the consensus that the vaccine was perceived as beneficial for mothers, further validating our discussion point.

Please ensure citations are included if what is stated is not directly from your results.
We will include a citation for the following statements:

It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls https://www.afro.who.int/news/kenya-rolls-out-massive-measles-rubella-and-tetanus-campaign.

The majority of Kenyans identify themselves with a particular religion. We will rewrite this statement to read
According to the 2019 Kenya census majority of Kenyans identify themselves with a particular religion https://www.knbs.or.ke/2019-kenya-population-and-housing-census-results/.

It is worth noting that the government, through the Public Health Department, has put in place mechanisms to trace those missing out on vaccination and sometimes using the law (we will remove the word law with community lead interventions) to encourage vaccine uptake
https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/kenya/kenya_cmyp_2015-2019.pdf.

As guided by the reviewer we have added quotes in the results section to support this statement in the discussion section
We found that Traditional Birth Attendants (TBAs) remained important because mothers could access them easily and faster, especially if the dispensaries were far.

Acknowledgement
We thank the reviewer for their meticulous critique, which has strengthened the rigor and clarity of our work. All changes will be implemented in the revised manuscript.
Competing Interests: None Close
Report a concern

Views

Reviewer Report 23 Jul 2024

Nasir Yusuf, Department of Immunization, Vaccines, and Biologicals, World Health Organization, Geneva, Switzerland

Approved with Reservations

https://doi.org/10.5256/f1000research.158548.r291099

Your Report

Please provide a full report, expanding on your answers to the questions above. In particular, if you answered “no” or “partly” to any of the questions, please give constructive and specific details as to how the authors can address any criticisms. Please indicate clearly which points must be addressed to make the article scientifically sound. (50 words min.)

General comments:

The paper is quite timely and will add significantly to the wealth of knowledge on maternal and to some extent, adult immunization especially in the context of ongoing global efforts to immunize all along life-course.

Comments on specific sections
Introduction

“The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus toxoid vaccine” – As of 2019, nearly all countries, especially those that procure their vaccines through the UNICEF Supply Division had replaced tetanus toxoid vaccine (TT) with tetanus and diphtheria toxoid (Td) vaccines based on the recommendation of the WHO Strategic Advisory Group of Experts (SAGE). This latter vaccine provides protection both against tetanus and diphtheria. You may wish to mention this in the appropriate section of the paper

“Several factors that contribute to vaccine hesitancy have been reported. These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (Bukenya and Freeman 1991)” – You may wish to revisit the paper cited here as it refers to missed opportunities for immunization (MOI) which is influenced by factors beyond hesitancy. For example, it is unclear how vaccine logistical issues, which contributes to MOI will affect hesitancy.

In the introduction section of the paper, it will be useful to provide and/or cite literatures on the importance and influence on immunization uptake by males, especially the heads of the households. This will allow for a better understanding of why males were also interviewed

Methods – Study populations

It will be useful to give a bit of an insight into the random sampling method of the expectant women attending ANC and men and women of reproductive age at the community level in four different locations/wards

Any reason why the coverage of the first dose of TT was used rather than at least two doses (TT2+)? One dose TT is not known to confer any level of immunity against tetanus, while a child born to a mother who receives at least two well-spaced doses is considered to be protected at birth (PAB) against tetanus.

Methods – data collection

How many FGDs were conducted?

Results
General vaccination knowledge and awareness

It will be useful to disaggregate this data by sex, to assess the knowledge about maternal immunization between males and females.

Discussion
“Rumors and misinformation around the tetanus vaccine within the community caused fears among expectant mothers. It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls. The fact that boys were excluded from the campaign made the community suspicious that the vaccine was to control fertility among young women” - It will be useful to know if the same perception holds for tetanus vaccines given through the routine immunization system, during ANC visits. The delivery of tetanus and diphtheria toxoid-containing vaccines along life-course: 3 primary series of DTP during infancy, 1st booster dose at 2nd year of life, 2nd booster dose during school entry (4 - 7 years) and 3rd booster during early adolescence (9 - 15 years) does not have gender discrimination and may help to dispel the existing rumor

Overall comments
The paper may require some minor changes to address the queries raised
While I am not familiar with the journal’s policies, I strongly suggest that a sub-heading be included on the limitations to the research as there appears to be a handful
Final recommendation
The paper should be indexed after the minor changes in line with the queries/comments/suggestions made above and those that might be made by the other reviewers

I have also attached a copy of the paper with my comments and queries highlighted for the different sections.
https://f1000research.s3.amazonaws.com/linked/665275.Assessing_risk_perceptions_that_contribute_to_tetanus_toxoid_maternal_vaccine_hesitancy_in_Kilifi_County%2C_Kenya--_Nasir_Yusuf..pdf

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

No source data required
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

CITE

Report a concern

Respond or Comment

Comments on this article Comments (1)

Version 2

VERSION 2 PUBLISHED 24 Jul 2025

Revised

Comment

Version 1

VERSION 1 PUBLISHED 02 Apr 2024

Discussion is closed on this version, please comment on the latest version above.

Author Response 20 Sep 2024

Patience Kiyuka, CGMR-C, Kenya Medical Research Institute, Kilifi, 80108, Kenya

20 Sep 2024

Author Response

“The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus toxoid vaccine” – As of 2019, nearly all countries, especially those that procure their vaccines through the UNICEF ... Continue reading “The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus toxoid vaccine” – As of 2019, nearly all countries, especially those that procure their vaccines through the UNICEF Supply Division had replaced tetanus toxoid vaccine (TT) with tetanus and diphtheria toxoid (Td) vaccines based on the recommendation of the WHO Strategic Advisory Group of Experts (SAGE). This latter vaccine provides protection both against tetanus and diphtheria. You may wish to mention this in the appropriate section of the paper

Response: We thank the reviewer for bringing this crucial update to our attention. We will rephrase the statement to read: The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus-diphtheria (Td) vaccine.

“Several factors that contribute to vaccine hesitancy have been reported. These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (Bukenya and Freeman 1991)” – You may wish to revisit the paper cited here as it refers to missed opportunities for immunization (MOI) which is influenced by factors beyond hesitancy. For example, it is unclear how vaccine logistical issues, which contributes to MOI will affect hesitancy.
Response: We have revised the statement with a correct citation
These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (R. J. Wilson et al. 2015)…

In the introduction section of the paper, it will be useful to provide and/or cite literatures on the importance and influence on immunization uptake by males, especially the heads of the households. This will allow for a better understanding of why males were also interviewed
Response: We will add the following paragraph to the introduction
Other factors that influence motivation for maternal vaccine uptake include the views of the people around the expectant women. It has been shown that husbands and mothers-in-law play a role in the expectant women's decision-making process during pregnancy, including whether to take or not take a vaccine, coupled with the fact of the woman’s limited autonomy within the family setting, especially so within the African context (Johm et al. 2021). In other settings, expectant women seek advice on whether to be vaccinated or not from their female family members such as sisters who already have children, mothers and aunts but less so from their male partners (R. Wilson, Paterson, and Larson 2019)

Methods – Study populations
It will be useful to give a bit of an insight into the random sampling method of the expectant women attending ANC and men and women of reproductive age at the community level in four different locations/wards
Response: We thank the reviewer for pointing this out and apologize for any confusion this statement might have caused. We will revise to ensure consistency throughout the text.
We used convenient sampling for expectant women attending the ANC clinic at select participating health care facilities of Kilifi County Hospital (KCH), Mnarani and Ngeranya dispensaries. We identified women and men of reproductive age at the community level through the assistance of Community Health Extension Officers, who have good knowledge of their communities and also served as study facilitators. Other studies have also used this approach (Watson-Jones et al. 2015).

Any reason why the coverage of the first dose of TT was used rather than at least two doses (TT2+)? One dose TT is not known to confer any level of immunity against tetanus, while a child born to a mother who receives at least two well-spaced doses is considered to be protected at birth (PAB) against tetanus.
Response: In general, in Kenya, tetanus-diphtheria (Td) vaccine uptake remains low (Otieno et al. 2021, 2017–2018). We used the first dose of vaccine as indicative of coverage to guide us to select study sites and not to directly link it to immunity accorded by the vaccine per se.

Methods – data collection
How many FGDs were conducted?
Response: Our study used the triangulation method to understand factors contributing to maternal vaccine uptake within the rural setting of Kilifi, Kenya. We conducted four focus group discussions with expectant women. The FGDs took place at the participating health care centers. Furthermore key informant interviews and survey questionnaires were also used to help us understand the contextual factors for maternal vaccine uptake.

Results
General vaccination knowledge and awareness
It will be useful to disaggregate this data by sex, to assess the knowledge about maternal immunization between males and females.
Response: We thank the reviewer for this comment. We will insert a table breakdown of the responses by sex, below is those who responded yes to the general vaccination knowledge and awareness.

Question
Males N (%)
Females N(%)

Have you ever heard of a vaccine?
38 (95)
63 (100)

Do you know which vaccine women get when expectant?
22 (55)
50 (79.4)

Have you ever heard of tetanus vaccine
36 (93.2)
60 (95.2)

Discussion
“Rumors and misinformation around the tetanus vaccine within the community caused fears among expectant mothers. It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls. The fact that boys were excluded from the campaign made the community suspicious that the vaccine was to control fertility among young women” - It will be useful to know if the same perception holds for tetanus vaccines given through the routine immunization system, during ANC visits. The delivery of tetanus and diphtheria toxoid-containing vaccines along life-course: 3 primary series of DTP during infancy, 1st booster dose at 2nd year of life, 2nd booster dose during school entry (4 - 7 years) and 3rd booster during early adolescence (9 - 15 years) does not have gender discrimination and may help to dispel the existing rumor
Response: We thank the reviewer for this comment. We agree that rolling out the DTP life course vaccine to both girls and boys may perhaps dispel the rumours. Future studies will be needed to monitor community perceptions as the vaccine is rolled out and careful risk communication strategies implemented.

References
Johm, Penda, Nicole Nkoum, Amie Ceesay, El Hadji Mbaye, Heidi Larson, and Beate Kampmann. 2021. ‘Factors Influencing Acceptance of Vaccination during Pregnancy in The Gambia and Senegal’. Vaccine 39 (29): 3926–34. https://doi.org/10.1016/j.vaccine.2021.05.068.
Otieno, Nancy A., Fauzia A. Malik, Stacy W. Nganga, Winnie N. Wairimu, Dominic O. Ouma, Godfrey M. Bigogo, Sandra S. Chaves, et al. 2021. ‘Decision-Making Process for Introduction of Maternal Vaccines in Kenya, 2017–2018’. Implementation Science 16 (1): 39. https://doi.org/10.1186/s13012-021-01101-7.
Watson-Jones, Deborah, Nelly Mugo, Shelley Lees, Muthoni Mathai, Sophie Vusha, Gathari Ndirangu, and David A. Ross. 2015. ‘Access and Attitudes to HPV Vaccination amongst Hard-To-Reach Populations in Kenya’. PLoS ONE 10 (6): e0123701. https://doi.org/10.1371/journal.pone.0123701.
Wilson, R., P. Paterson, and H. J. Larson. 2019. ‘Strategies to Improve Maternal Vaccination Acceptance’. BMC Public Health 19 (1): 342. https://doi.org/10.1186/s12889-019-6655-y.
Wilson, Rose J., Pauline Paterson, Caitlin Jarrett, and Heidi J. Larson. 2015. ‘Understanding Factors Influencing Vaccination Acceptance during Pregnancy Globally: A Literature Review’. Vaccine, Advancing Maternal Immunization Programs through Research in Low and Medium Income Countries, 33 (47): 6420–29. https://doi.org/10.1016/j.vaccine.2015.08.046.
“The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus toxoid vaccine” – As of 2019, nearly all countries, especially those that procure their vaccines through the UNICEF Supply Division had replaced tetanus toxoid vaccine (TT) with tetanus and diphtheria toxoid (Td) vaccines based on the recommendation of the WHO Strategic Advisory Group of Experts (SAGE). This latter vaccine provides protection both against tetanus and diphtheria. You may wish to mention this in the appropriate section of the paper

Response: We thank the reviewer for bringing this crucial update to our attention. We will rephrase the statement to read: The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus-diphtheria (Td) vaccine.

“Several factors that contribute to vaccine hesitancy have been reported. These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (Bukenya and Freeman 1991)” – You may wish to revisit the paper cited here as it refers to missed opportunities for immunization (MOI) which is influenced by factors beyond hesitancy. For example, it is unclear how vaccine logistical issues, which contributes to MOI will affect hesitancy.
Response: We have revised the statement with a correct citation
These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (R. J. Wilson et al. 2015)…

In the introduction section of the paper, it will be useful to provide and/or cite literatures on the importance and influence on immunization uptake by males, especially the heads of the households. This will allow for a better understanding of why males were also interviewed
Response: We will add the following paragraph to the introduction
Other factors that influence motivation for maternal vaccine uptake include the views of the people around the expectant women. It has been shown that husbands and mothers-in-law play a role in the expectant women's decision-making process during pregnancy, including whether to take or not take a vaccine, coupled with the fact of the woman’s limited autonomy within the family setting, especially so within the African context (Johm et al. 2021). In other settings, expectant women seek advice on whether to be vaccinated or not from their female family members such as sisters who already have children, mothers and aunts but less so from their male partners (R. Wilson, Paterson, and Larson 2019)

Methods – Study populations
It will be useful to give a bit of an insight into the random sampling method of the expectant women attending ANC and men and women of reproductive age at the community level in four different locations/wards
Response: We thank the reviewer for pointing this out and apologize for any confusion this statement might have caused. We will revise to ensure consistency throughout the text.
We used convenient sampling for expectant women attending the ANC clinic at select participating health care facilities of Kilifi County Hospital (KCH), Mnarani and Ngeranya dispensaries. We identified women and men of reproductive age at the community level through the assistance of Community Health Extension Officers, who have good knowledge of their communities and also served as study facilitators. Other studies have also used this approach (Watson-Jones et al. 2015).

Any reason why the coverage of the first dose of TT was used rather than at least two doses (TT2+)? One dose TT is not known to confer any level of immunity against tetanus, while a child born to a mother who receives at least two well-spaced doses is considered to be protected at birth (PAB) against tetanus.
Response: In general, in Kenya, tetanus-diphtheria (Td) vaccine uptake remains low (Otieno et al. 2021, 2017–2018). We used the first dose of vaccine as indicative of coverage to guide us to select study sites and not to directly link it to immunity accorded by the vaccine per se.

Methods – data collection
How many FGDs were conducted?
Response: Our study used the triangulation method to understand factors contributing to maternal vaccine uptake within the rural setting of Kilifi, Kenya. We conducted four focus group discussions with expectant women. The FGDs took place at the participating health care centers. Furthermore key informant interviews and survey questionnaires were also used to help us understand the contextual factors for maternal vaccine uptake.

Results
General vaccination knowledge and awareness
It will be useful to disaggregate this data by sex, to assess the knowledge about maternal immunization between males and females.
Response: We thank the reviewer for this comment. We will insert a table breakdown of the responses by sex, below is those who responded yes to the general vaccination knowledge and awareness.

Question
Males N (%)
Females N(%)

Have you ever heard of a vaccine?
38 (95)
63 (100)

Do you know which vaccine women get when expectant?
22 (55)
50 (79.4)

Have you ever heard of tetanus vaccine
36 (93.2)
60 (95.2)

Discussion
“Rumors and misinformation around the tetanus vaccine within the community caused fears among expectant mothers. It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls. The fact that boys were excluded from the campaign made the community suspicious that the vaccine was to control fertility among young women” - It will be useful to know if the same perception holds for tetanus vaccines given through the routine immunization system, during ANC visits. The delivery of tetanus and diphtheria toxoid-containing vaccines along life-course: 3 primary series of DTP during infancy, 1st booster dose at 2nd year of life, 2nd booster dose during school entry (4 - 7 years) and 3rd booster during early adolescence (9 - 15 years) does not have gender discrimination and may help to dispel the existing rumor
Response: We thank the reviewer for this comment. We agree that rolling out the DTP life course vaccine to both girls and boys may perhaps dispel the rumours. Future studies will be needed to monitor community perceptions as the vaccine is rolled out and careful risk communication strategies implemented.

References
Johm, Penda, Nicole Nkoum, Amie Ceesay, El Hadji Mbaye, Heidi Larson, and Beate Kampmann. 2021. ‘Factors Influencing Acceptance of Vaccination during Pregnancy in The Gambia and Senegal’. Vaccine 39 (29): 3926–34. https://doi.org/10.1016/j.vaccine.2021.05.068.
Otieno, Nancy A., Fauzia A. Malik, Stacy W. Nganga, Winnie N. Wairimu, Dominic O. Ouma, Godfrey M. Bigogo, Sandra S. Chaves, et al. 2021. ‘Decision-Making Process for Introduction of Maternal Vaccines in Kenya, 2017–2018’. Implementation Science 16 (1): 39. https://doi.org/10.1186/s13012-021-01101-7.
Watson-Jones, Deborah, Nelly Mugo, Shelley Lees, Muthoni Mathai, Sophie Vusha, Gathari Ndirangu, and David A. Ross. 2015. ‘Access and Attitudes to HPV Vaccination amongst Hard-To-Reach Populations in Kenya’. PLoS ONE 10 (6): e0123701. https://doi.org/10.1371/journal.pone.0123701.
Wilson, R., P. Paterson, and H. J. Larson. 2019. ‘Strategies to Improve Maternal Vaccination Acceptance’. BMC Public Health 19 (1): 342. https://doi.org/10.1186/s12889-019-6655-y.
Wilson, Rose J., Pauline Paterson, Caitlin Jarrett, and Heidi J. Larson. 2015. ‘Understanding Factors Influencing Vaccination Acceptance during Pregnancy Globally: A Literature Review’. Vaccine, Advancing Maternal Immunization Programs through Research in Low and Medium Income Countries, 33 (47): 6420–29. https://doi.org/10.1016/j.vaccine.2015.08.046.
Competing Interests: NA Close
Report a concern
Discussion is closed on this version, please comment on the latest version above.

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2
Version 2 (revision) 24 Jul 25
Version 1 02 Apr 24	read	read

Nasir Yusuf, World Health Organization, Geneva, Switzerland
Berhaun Fesshaye, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

Comments on this article

All Comments(1)

Add a comment

Browse by related subjects

Back to all reports

Reviewer Report

11 Views

26 May 2025 | for Version 1

Berhaun Fesshaye, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

11 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Maternal immunization; vaccine acceptance

Respond to this report

Responses (1)

Author Response

10 Sep 2025

Patience Kiyuka, CGMR-C, Kenya Medical Research Institute, Kilifi, 80108, Kenya

This is an interesting manuscript exploring the reasons for hesitancy towards tetanus vaccination during pregnancy. I have a few comments/suggestions for the authors. We appreciate the reviewer’s kind words.

Methods:
Please revise for brevity and clarity. How many FGDs were conducted? What was the final sample for the FGDs? Were the 104 survey participants a sub-sample of the FGD sample or were these a separate sample?
Response: We thank the reviewer for this comment. Under the study population we will add, ‘We conducted four FGDs comprising of 10-12 participants.’ The final sample size of the FGDs was 45.
We apologize for the confusion. The 104 surveyed were not a sub-sample of the FGD, rather they were a randomly selected separate population.

Were there any data cleaning procedures that the authors feel it is appropriate to report? Did the authors deal with any missing data during analysis?
Response: We thank the reviewer for this comment. We will revise our qualitative and quantitative data section as follows: The qualitative data were audio-recorded, transcribed verbatim, and translated into English. We conducted thematic analysis following Braun and Clarke's (2006) approach, with a particular focus on latent themes. This analytical level moves beyond surface-level content to examine the underlying assumptions, conceptual frameworks, and ideologies shaping participants' responses (Braun & Clarke, 2006, p. 84). Our analysis sought to identify meaningful patterns that could inform our research questions, paying particular attention to the implicit meanings and theoretical constructs embedded in the data.
On missing data: for the qualitative data, participants were allowed to opt oout of answering any questions. Missing data for quantitative data in included in the figures as missing data as indicated in Table 1 and figure 2 as non-responders.

On revise for brevity and clarity
We will cut this section from the study design section
“Since study activities were conducted during the COVID-19 pandemic, the study team followed the infection control guidelines put in place by the County Department of Health Services to reduce SARS-CoV-2 infections such as social distancing; regular hand washing; use of personal protective equipment to protect oneself and participants; and measuring temperatures of study team before each field visits.”

We will revise the data collection section to read as follows:
Before data collection, the study team was trained on the study objectives, consent process, and data management. We then conducted:

Focus Group Discussions (FGDs): 10–12 expectant women per group, selected via convenience sampling from high-volume facilities to ensure urban-rural diversity. FGDs (60–90 min) took place during maternal health clinic days.
Surveys: Administered to 104 randomly selected men and women of reproductive age.
Key Informant (KI) Interviews: Six interviews (30–60 min) with healthcare workers and vaccine managers, conducted at their workplaces.

All FGDs and KIs were audio-recorded (encrypted) and noted by hand. Two researchers (PKK and ROM) conducted face-to-face interviews. Written consent was obtained from all participants. Data collection occurred between September and October 2020.

Results
Please aim to only present your study results in the results section. Compare and contrast with the literature in the discussion section.
Response: We thank the reviewer for this comment. We will remove the following statement below from the results section that suggests we are comparing or contrasting our results with other studies

Indeed, several studies have examined whether religion influences childhood immunisation uptake (Costa et al. 2020; Fournet et al. 2018), including the adolescent human papillomavirus
(Best et al. 2019).

The Wellcome Global Monitor Report 2018 the world’s largest study into how people around the world think and feel about science and major health challenges, estimates that globally, 73% of people highly trust healthcare workers for their sources of information.

Since 2013, the Kenyan government has introduced two policies to reduce maternal and neonatal deaths: the abolition of client user fees and the provision of free maternity services in public health facilities (Pyone, Smith, and Van Den Broek 2017).

In figure 2, it would be helpful if the x axis title was a bit more descriptive. For example: (Percentage of participants (N=104)).
Response: We thank the reviewer for this comment. We will relabel the axis as Percentage of participants (N=104) as shown below
for fig refer to following link: https://f1000research-files.f1000.com/linked/749716.Fig.1-_Ms.id__144710.png

If word limits allow it, it would be nice to see some more illustrative quotes throughout the results. For example, if the results state that multiple participants reported similar themes, including 2 or 3 three quotes would be great.
Response: We thank the reviewer for this comment.
We will add the following two quotes under:
Healthcare workload

[We need more nurses. Currently in this Maternal Child Health (MCH) clinic, you can see this room is closed - it's supposed to provide postnatal care, cervical cancer screening, and family planning services. But because we're understaffed, we've had to close it. Now just one nurse must provide all these services in a single room, which forces clients to wait extremely long hours. This situation ultimately discourages mothers from returning to the clinic. Key informant 2]

[Then another thing we should add our manpower because me as nurse X I cannot say I know this and this and it’s me only every day, Key Informant 4]

Under stockout we will also add the following quote
[Frequent stock outs so they will tell you every time we come, there are stock outs so better we remain at home, Key informant 5]

Reasons for not taking reasons for not taking maternal tetanus toxoid vaccine
Due to home delivery
[The other one is my sister you tell her to go to clinic, and she tells you I am okay, no need for me to go to clinic, I will deliver at home, is it a must I go to hospital? Expectant mother FGD 1]

[There are those who give birth at the hospital but there are others who are afraid like me, I have given birth three times at home but then I have been told that I must give birth at the hospital Expectant mother FGD 4]

These home deliveries are facilitated mostly by midwives or traditional birth attendant
[Then there are the midwives they have a habit of asking you to visit them so that they can check the child’s progress, Expectant mother FGD2]

[I once carried my pregnancy to the end, from the first to the ninth month and never visited the clinic even once … I did not come for clinic not even a single day. I was going to these midwives who massaged me and told me my baby was okay, Expectant mother FGD 4]

General vaccination knowledge and awareness
We will add the following statement
Most expectant women know that the vaccine is useful for protecting them and their unborn child
[That injection we were taught that it helps prevent tetanus and when a mother is pregnant, the foetus gets immunity against tetanus because of the injection given to the mother. Expectant mother FGD 3]

[I had been told it protects both the mother and the child, but it did not affect me. Expectant mother FGD 1]

Discussion
Try not to introduce new results within the discussion section.
We appreciate the reviewer’s valuable feedback, which strengthens the rigor of our discussion. As suggested, we have incorporated direct participant quotes in the revised manuscript to reinforce the consensus that the vaccine was perceived as beneficial for mothers, further validating our discussion point.

Please ensure citations are included if what is stated is not directly from your results.
We will include a citation for the following statements:

It was perceived that the tetanus vaccine was a family planning method, a message reinformed when the Kenyan government rolled out a tetanus vaccination campaign among school-going girls https://www.afro.who.int/news/kenya-rolls-out-massive-measles-rubella-and-tetanus-campaign.

The majority of Kenyans identify themselves with a particular religion. We will rewrite this statement to read
According to the 2019 Kenya census majority of Kenyans identify themselves with a particular religion https://www.knbs.or.ke/2019-kenya-population-and-housing-census-results/.

It is worth noting that the government, through the Public Health Department, has put in place mechanisms to trace those missing out on vaccination and sometimes using the law (we will remove the word law with community lead interventions) to encourage vaccine uptake
https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/kenya/kenya_cmyp_2015-2019.pdf.

As guided by the reviewer we have added quotes in the results section to support this statement in the discussion section
We found that Traditional Birth Attendants (TBAs) remained important because mothers could access them easily and faster, especially if the dispensaries were far.

Acknowledgement
We thank the reviewer for their meticulous critique, which has strengthened the rigor and clarity of our work. All changes will be implemented in the revised manuscript.

View more View less

Competing Interests

None

Back to all reports

Reviewer Report

16 Views

23 Jul 2024 | for Version 1

Nasir Yusuf, Department of Immunization, Vaccines, and Biologicals, World Health Organization, Geneva, Switzerland

16 Views Cite this report Responses(0)

Approved With Reservations

The paper is quite timely and will add significantly to the wealth of knowledge on maternal and to some extent, adult immunization especially in the context of ongoing global efforts to immunize all along life-course.

Comments on specific sections
Introduction

“The Kenya Expanded Programme on Immunization recommends that expectant women receive tetanus toxoid vaccine” – As of 2019, nearly all countries, especially those that procure their vaccines through the UNICEF Supply Division had replaced tetanus toxoid vaccine (TT) with tetanus and diphtheria toxoid (Td) vaccines based on the recommendation of the WHO Strategic Advisory Group of Experts (SAGE). This latter vaccine provides protection both against tetanus and diphtheria. You may wish to mention this in the appropriate section of the paper

“Several factors that contribute to vaccine hesitancy have been reported. These include expectant women’s levels of knowledge and attitude towards the safety and efficacy of the vaccine (Bushar et al. 2017; Eppes et al. 2013), how the healthcare worker interacts with mothers (Bukenya and Freeman 1991)” – You may wish to revisit the paper cited here as it refers to missed opportunities for immunization (MOI) which is influenced by factors beyond hesitancy. For example, it is unclear how vaccine logistical issues, which contributes to MOI will affect hesitancy.

In the introduction section of the paper, it will be useful to provide and/or cite literatures on the importance and influence on immunization uptake by males, especially the heads of the households. This will allow for a better understanding of why males were also interviewed

Methods – Study populations

It will be useful to give a bit of an insight into the random sampling method of the expectant women attending ANC and men and women of reproductive age at the community level in four different locations/wards

Any reason why the coverage of the first dose of TT was used rather than at least two doses (TT2+)? One dose TT is not known to confer any level of immunity against tetanus, while a child born to a mother who receives at least two well-spaced doses is considered to be protected at birth (PAB) against tetanus.

Methods – data collection

How many FGDs were conducted?

Results
General vaccination knowledge and awareness

It will be useful to disaggregate this data by sex, to assess the knowledge about maternal immunization between males and females.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

No source data required
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Respond to this report

Responses (0)

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] Afulani PA, Buback L, Essandoh F, et al.: Quality of Antenatal Care and Associated Factors in a Rural County in Kenya: An Assessment of Service Provision and Experience Dimensions. BMC Health Serv. Res. 2019; 19(1): 684. PubMed Abstract | Publisher Full Text | Free Full Text

[2] Arunda M, Emmelin A, Asamoah BO: Effectiveness of Antenatal Care Services in Reducing Neonatal Mortality in Kenya: Analysis of National Survey Data. Glob. Health Action. 2017; 10(1): 1328796. PubMed Abstract | Publisher Full Text | Free Full Text

[3] Best AL, Thompson EL, Adamu AM, et al.: Examining the Influence of Religious and Spiritual Beliefs on HPV Vaccine Uptake Among College Women. J. Relig. Health. 2019; 58(6): 2196–2207. PubMed Abstract | Publisher Full Text | Free Full Text

[4] Blencowe H, Lawn J, Vandelaer J, et al.: Tetanus Toxoid Immunization to Reduce Mortality from Neonatal Tetanus. Int. J. Epidemiol. 2010; 39(SUPPL. 1): i102–i109. PubMed Abstract | Publisher Full Text | Free Full Text

[5] Brewer NT, Chapman GB, Rothman AJ, et al.: Increasing Vaccination: Putting Psychological Science Into Action. Psychol. Sci. Public Interest. 2017; 18(3): 149–207. PubMed Abstract | Publisher Full Text

[6] Bukenya GB, Freeman PA: Possible Reasons for Non-Completion of Immunization in an Urban Settlement of Papua New Guinea. P. N. G. Med. J. 1991; 34(1): 22–25. PubMed Abstract

[7] Bushar JA, Kendrick JS, Ding H, et al.: Text4baby Influenza Messaging and Influenza Vaccination Among Pregnant Women. Am. J. Prev. Med. 2017; 53(6): 845–853. PubMed Abstract | Publisher Full Text | Free Full Text

[8] Cornwall W: Officials Gird for a War on Vaccine Misinformation Fears of a Rushed COVID-19 Vaccine and Rise of Social Media Demand New Messaging Strategy. Science. 2020; 369: 14–15. American Association for the Advancement of Science. PubMed Abstract | Publisher Full Text

[9] Costa JC, Weber AM, Darmstadt GL, et al.: Religious Affiliation and Immunization Coverage in 15 Countries in Sub-Saharan Africa. Vaccine. 2020; 38(5): 1160–1169. PubMed Abstract | Publisher Full Text | Free Full Text

[10] Das S, Mia MN, Hanifi SMA, et al.: Health Literacy in a Community with Low Levels of Education: Findings from Chakaria, a Rural Area of Bangladesh. BMC Public Health. 2017; 17(1): 203. PubMed Abstract | Publisher Full Text | Free Full Text

[11] Dawa J, Chaves SS, Nguz AB, et al.: Developing a Seasonal Influenza Vaccine Recommendation in Kenya: Process and Challenges Faced by the National Immunization Technical Advisory Group (NITAG). Vaccine. 2019; 37(3): 464–472. PubMed Abstract | Publisher Full Text

[12] Enserink M: Fact-Checking Judy Mikovits, the Controversial Virologist Attacking Anthony Fauci in a Viral Conspiracy Video. Science. 2020 May. Publisher Full Text

[13] Eppes C, Alison W, Whitney You KA, et al.: Barriers to Influenza Vaccination among Pregnant Women. Vaccine. 2013; 31(27): 2874–2878. Publisher Full Text

[14] Fournet N, Mollema L, Ruijs WL, et al.: Under Vaccinated Groups in Europe and Their Beliefs, Attitudes and Reasons for Non Vaccination Two Systematic Reviews. BMC Public Health. 2018; 18(1): 196. PubMed Abstract | Publisher Full Text | Free Full Text

[15] Gebremichael MW, Worku A, Medhanyie AA, et al.: Women Suffer More from Disrespectful and Abusive Care than from the Labour Pain Itself: A Qualitative Study from Women’s Perspective. BMC Pregnancy Childbirth. 2018; 18: 392. BioMed Central Ltd. PubMed Abstract | Publisher Full Text | Free Full Text

[16] Kajungu D, Muhoozi M, Stark J, et al.: Vaccines Safety and Maternal Knowledge for Enhanced Maternal Immunization Acceptability in Rural Uganda: A Qualitative Study Approach. PLoS One. 2020; 15(12 December): e0243834. PubMed Abstract | Publisher Full Text | Free Full Text

[17] Kiyuka P: Replication Data for: Assessing Risk Perceptions That Contribute to Tetanus Toxoid Maternal Vaccine Hesitancy in Kilifi County, Kenya. Harvard Dataverse. 2024. Publisher Full Text

[18] Larson HJ, Brocard P, Garnett G: The India HPV-Vaccine Suspension. Lancet. 2010; 376: 572–573. Elsevier. PubMed Abstract | Publisher Full Text

[19] Larson HJ, Jarrett C, Eckersberger E, et al.: Understanding Vaccine Hesitancy around Vaccines and Vaccination from a Global Perspective: A Systematic Review of Published Literature, 2007-2012. Vaccine. 2014; 32: 2150–2159. Elsevier BV. PubMed Abstract | Publisher Full Text

[20] Larson HJ, Jarrett C, Schulz WS, et al.: Measuring Vaccine Hesitancy: The Development of a Survey Tool. Vaccine. 2015; 33(34): 4165–4175. Publisher Full Text

[21] Williams L, Anna RM, Mwananyanda L, et al.: Maternal Vaccine Knowledge in Low- and Middle-Income Countries—and Why It Matters. Hum. Vaccin. Immunother. 2019; 15: 283–286. Taylor and Francis Inc. PubMed Abstract | Publisher Full Text | Free Full Text

[22] Lorini C, Santomauro F, Donzellini M, et al.: Health Literacy and Vaccination: A Systematic Review. Hum. Vaccin. Immunother. 2018; 14(2): 478–488. PubMed Abstract | Publisher Full Text | Free Full Text

[23] Maluka SO, Joseph C, Fitzgerald S, et al.: Why Do Pregnant Women in Iringa Region in Tanzania Start Antenatal Care Late? A Qualitative Analysis. BMC Pregnancy Childbirth. 2020; 20(1): 126. PubMed Abstract | Publisher Full Text | Free Full Text

[24] Marshall H, McMillan M, Andrews RM, et al.: Vaccines in Pregnancy: The Dual Benefit for Pregnant Women and Infants. Hum. Vaccin. Immunother. 2016; 12: 848–856. Taylor and Francis Inc. PubMed Abstract | Publisher Full Text | Free Full Text

[25] McMorrow ML, Emukule GO, Obor D, et al.: ‘Maternal Influenza Vaccine Strategies in Kenya: Which Approach Would Have the Greatest Impact on Disease Burden in Pregnant Women and Young Infants?’ Edited by David L. Swerdlow. PLoS One. 2017; 12(12): e0189623. PubMed Abstract | Publisher Full Text | Free Full Text

[26] Moindi RO, Ngari MM, Nyambati VCS, et al.: Why Mothers Still Deliver at Home: Understanding Factors Associated with Home Deliveries and Cultural Practices in Rural Coastal Kenya, a Cross-Section Study Global Health. BMC Public Health. 2016; 16(1): 114. PubMed Abstract | Publisher Full Text | Free Full Text

[27] Muinga N, Magare S, Monda J, et al.: Digital Health Systems in Kenyan Public Hospitals: A Mixed-Methods Survey. BMC Med. Inform. Decis. Mak. 2020; 20: 2. BioMed Central Ltd. PubMed Abstract | Publisher Full Text | Free Full Text

[28] Omer SB, Salmon DA, Orenstein WA, et al.: Vaccine Refusal, Mandatory Immunization, and the Risks of Vaccine-Preventable Diseases. N. Engl. J. Med. 2009; 360(19): 1981–1988. PubMed Abstract | Publisher Full Text

[29] Pyone T, Smith H, Van Den Broek N: Implementation of the Free Maternity Services Policy and Its Implications for Health System Governance in Kenya. BMJ Glob. Health. 2017; 2(4): e000249. PubMed Abstract | Publisher Full Text | Free Full Text

[30] Schaetti C, Hutubessy R, Ali SM, et al.: Oral Cholera Vaccine Use in Zanzibar: Socioeconomic and Behavioural Features Affecting Demand and Acceptance. BMC Public Health. 2009; 9(1): 99. PubMed Abstract | Publisher Full Text | Free Full Text

[31] Sridhar S, Maleq N, Guillermet E, et al.: A Systematic Literature Review of Missed Opportunities for Immunization in Low- and Middle-Income Countries. Vaccine. 2014; 32: 6870–6879. Elsevier Ltd. PubMed Abstract | Publisher Full Text

[32] Usman S, Bologna L, Stamidis KV: The Core Group Partners Project in North East Nigeria: Community Engagement Strategies to Combat Skepticism and Build Trust for Vaccine Acceptance. Am. J. Trop. Med. Hyg. 2019; 101(4): 68–73. PubMed Abstract | Publisher Full Text | Free Full Text

[33] WHO: Newborns: Improving Survival and Well-Being’. 2020.2020. Reference Source

Assessing risk perceptions that contribute to tetanus toxoid maternal vaccine hesitancy in Kilifi County, Kenya

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Methods

Ethics statement

Study design

Study location

Study population

Behavioral and social drivers of vaccination framework

Figure 1. The WHO behavioural and social drivers of the vaccination framework, available at https://www.who.int/teams/immunization-vaccines-and-biologicals/essential-programme-on-immunization/demand.

Questionnaire and question guide design

Data collection

Data analysis

Results

Table 1. Baseline characteristics for the study participants.

General vaccination knowledge and awareness

Reasons for not taking maternal tetanus toxoid vaccine

Role of decision-makers within the household

Trust in healthcare workers and the government

Health systems factors

Figure 2. Factors affecting maternal vaccine uptake.

Discussion

Conclusion

Data availability

Underlying data

Acknowledgement

References

Comments on this article Comments (1)

Open Peer Review

Comments on this article Comments (1)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Browse by related subjects

Competing Interests Policy

Stay Updated