Perceptions of determinants for the provision and uptake of maternal influenza vaccination from the perspective of healthcare providers in Kuwait: a qualitative study

Abstract

Objectives

To explore the current context in which maternal influenza vaccination (MIV) is delivered in Kuwait and to identify determinants influencing its provision and uptake from the perspectives of preventive medicine professionals (PMPs), including policymakers.

Design

Qualitative semistructured interviews were conducted with purposely selected PMPs including policymakers. Interview questions were obtained from the Tailoring Immunization Programme for improving MIV in Europe.

Setting

PMPs from six governmental regions of Kuwait, including hospitals and associated polyclinics. Data collection was conducted between March and June 2022.

Participants

A total of 10 participants reflected diverse professional and population contexts, including Kuwaiti and non-Kuwaiti professionals working in rural and urban settings. Cell sampling was used to ensure representation across key roles involved in MIV delivery, including policymakers, vaccination campaign managers and campaign implementers.

Results

Thematic analysis identified four overarching themes: barriers, facilitators, influences on MIV uptake and suggested interventions. Key barriers included limited knowledge among pregnant women and healthcare providers (HCPs), lack of prioritisation of pregnant women within vaccination programmes, shortage of vaccine supply and the COVID-19 pandemic. Facilitators and influential factors included the presence of vaccination champions, targeted health promotion activities and the availability of a Ministry of Health (MoH) hotline for addressing concerns and system-level accessibility and digital facilitation of MIV uptake. Suggested interventions emphasised strengthening HCP education through continuous training aligned with clear national policies and guidelines.

Conclusion

This study highlights the need for clear national policies and clinical guidelines to support consistent MIV provision, alongside ongoing education for HCPs in Kuwait to strengthen MIV recommendation. Future research should include obstetricians, given their central role in antenatal care, to ensure MIV strategies are clinically grounded and integrated into routine maternity services.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• In contrast to prior research focused mainly on obstetric care providers, this study incorporated policymakers’ perspectives, offering a broader strategic understanding of organisational and societal influences on maternal influenza vaccination (MIV) and strengthening the policy relevance and applicability of the findings to public health practice.

• Data collection relied solely on semistructured interviews with preventive medicine professionals, limiting triangulation and potentially the transferability of findings; however, the use of the established Tailoring Immunization Programme framework, purposive and heterogeneous sampling, and achievement of data saturation enhanced the depth and trustworthiness of the data.

• The absence of obstetricians from the participant sample may be considered a limitation, as their inclusion could have offered important insights into clinical attitudes and behaviours regarding the recommendation of MIV.

• The study has a relatively small sample of 10 participants; although data collection continued until data saturation was achieved, the limited number may restrict the transferability of findings.

Introduction

The WHO recommends seasonal influenza vaccination for pregnant women;¹ the inactivated influenza vaccine has been reported to be effective in reducing laboratory-confirmed influenza rates for pregnant women.²,⁵ Kuwait conducts seasonal influenza vaccination campaigns targeting the general population; however, there is no dedicated or targeted influenza vaccination programme specifically for pregnant women. Influenza vaccines are provided free of charge through the public healthcare system and are delivered primarily via government primary healthcare centres and hospitals. In addition, mobile vaccination units are deployed in non-clinical settings, such as shopping malls and selected government ministries, to improve accessibility and facilitate uptake among the wider population. Preventive medicine professionals (PMPs) are responsible for managing, implementing and delivering influenza vaccination campaigns.

Despite these broader recommendations and delivery mechanisms, no specific policy or structured delivery pathway exists for maternal influenza vaccination (MIV), and there are currently no published data on MIV coverage in Kuwait.^{6 7}

The aim of this study is to understand the current landscape in which MIV is being delivered and determinants of its provision and uptake from the perspectives of PMPs, including policymakers.

Methods

Reporting of this study was guided by the Standards for Reporting Qualitative Research⁸ (online supplemental file 1).

Study site

The study was conducted among the six governorates in Kuwait, including Asmah, Farwaniya, Hawally, Jahra, Mubarak Alkabeer and Ahmadi (figure 1); however, due to the COVID-19 pandemic, Mubarak Alkabeer governorate’s maternity hospital transferred all their patients and healthcare providers (HCPs) to the maternity hospital in Asmah. Thus, maternity hospitals in the Asmah governate represented patients from the Asmah and Mubarak Alkabeer governates.

Figure 1. The State of Kuwait and its different governorates (Kuwait presentation map: Vector world maps, 2023).

Recruitment

Purposive sampling was employed to capture a broad spectrum of experiences and perspectives related to the provision and uptake of the MIV in Kuwait. PMPs were recruited from various Kuwaiti governorates to ensure diverse viewpoints, reflecting the heterogeneous nature of the population, including Kuwaiti and non-Kuwaiti, and rural and urban working areas. Additionally, cell sampling was used to classify participants into key subgroups, including policymakers, campaign managers and implementers, as outlined by Miles and Huberman.⁹

35 potential participants were identified through maternity hospitals, where department secretaries distributed participant information sheets. Prior to participation, all interviewees were provided with detailed information about the study aims and procedures and written or electronic informed consent was obtained. Participation was voluntary and no incentives were used.¹⁰ Inclusion and exclusion criteria are summarised in table 1.

Table 1. Inclusion and exclusion criteria.

Inclusion	Exclusion
Policymakers working in MIV provision and vaccination campaigns	Health inspectors as they do not deal with recommending, discussing or administering vaccines
PMPs who are responsible for discussing vaccines, managing and implementing vaccination campaigns

MIV, maternal influenza vaccination; PMPs, preventive medicine professionals.

Data collection

Data were collected between March and June 2022 using semistructured interviews informed by the Tailoring Immunization Programme (TIP-FLU) framework¹¹ and adapted to the Kuwaiti context. Two interview protocols were used: a policymaker guide (21 questions) examining MIV governance, policy development, implementation and monitoring (online supplemental file 2); and a campaign manager and implementer guide (15 questions) exploring strategies to improve uptake, communication approaches, policy adherence, barriers to coverage and the transferability of lessons from other risk groups (online supplemental file 3).

Semistructured interviews

Recruitment and data collection occurred concurrently until data saturation was achieved. Female participants were offered audio-only or video-based interviews in accordance with local cultural norms. All interviews were conducted in English, which minimised translation-related bias and enabled authentic capture of participants’ perspectives. Participants received an information sheet and were assured of confidentiality and secure data handling. Interviews were audio-recorded, lasted 35–45 min and used qualitative techniques such as probing and paraphrasing to elicit rich data.^{12 13}

Data analysis

All interviews were audio-recorded, transcribed verbatim by the researcher, and checked against the original recordings for accuracy before analysis. Transcripts were imported into NVivo (QSR International, Melbourne, Australia) and analysed using Braun and Clarke’s thematic analysis framework,¹⁴ following an inductive approach.^{14 15}

Ethical considerations

Interviews were conducted via Skype, ensuring compliance with the UK General Data Protection Regulation.

Patient and public involvement

None.

Results

Participants

A total of 10 HCPs were interviewed. These interviews comprised a diverse group of participants:

1. Policymakers: Two PMPs who play a role in shaping healthcare policies related to influenza vaccination.

2. Hospital-level vaccine campaign managers: Four PMPs responsible for managing and overseeing influenza vaccination campaigns within healthcare institutions.

3. Community-level vaccine campaign implementers: Four PMPs responsible for implementing influenza vaccination campaigns at the community level, ensuring that the campaigns reach the intended target populations.

All participants were experienced public health professionals with specialised knowledge and responsibilities related to designing, developing and implementing influenza vaccination campaigns in Kuwait. Characteristics of participants are presented in table 2.

Table 2. Characteristics of PMPs who participated in semistructured interviews.

Participation number (P)	Expertise	Governate	Years of experience	Rural/urban areas
P1	Campaign implementer	Ahmedi	6	Rural
P2	Campaign manager	Asmah	15	Urban
P3	Campaign implementer	Asmah	9	Urban
P4	Campaign implementer	Hawally	8	Urban
P5	Campaign manager	Jahra	13	Rural
P6	Campaign manager	Asmah—maternity	20	Urban
P7	Campaign implementer	Farwaniya	9	Urban
P8	Campaign manager	Farwaniya	13	Urban
P9	Policymaker	MoH	30	Not applicable
P10	Policymaker	MoH	26	Not applicable

MoH, Ministry of Health; PMPs, preventive medicine professionals.

Themes

Four themes were identified in the analysis: barriers, facilitators, influences towards MIV uptake and interventions. Determinants of the provision and uptake of MIV in the state of Kuwait were interpreted in 11 subthemes within these themes.

The first theme explored perceived barriers to MIV provision and uptake as reported by participants. The second theme examined MoH services that were viewed as facilitating MIV delivery. The third theme addressed the range of influences affecting pregnant women’s decisions regarding MIV, encompassing both factors that encouraged and those that discouraged vaccine acceptance. The final theme focused on interventions proposed by participants to strengthen MIV provision and increase uptake in Kuwait. The themes and their subthemes are provided in table 3.

Table 3. Generated themes and corresponding subthemes.

Themes	Subthemes
Barriers	Pregnant women’s and HCPs’ knowledge Lack of prioritisation of pregnant women and shortage of influenza vaccine supply COVID-19 pandemic
Facilitators	Vaccination champion Health promotion and MoH hotline for concerns and emergency System-level accessibility and digital facilitation of MIV uptake
Influences	HCPs’ influences Social and cultural influences Media influences
Suggested interventions	Education for HCPs Policy and guidelines

HCP, healthcare provider; MIV, maternal influenza vaccination; MoH, Ministry of Health.

Theme 1: barriers

Three subthemes were generated, including pregnant women’s and HCPs’ knowledge, lack of prioritisation of pregnant women and shortage of influenza vaccine and the impact of the COVID-19 pandemic.

Pregnant women’s and HCPs’ knowledge

PMPs consistently perceived insufficient knowledge among both pregnant women and HCPs as a key barrier to MIV uptake. Participants reported that many pregnant women lacked adequate understanding of the safety and importance of MIV, which contributed to vaccine refusal. Concerns regarding potential harm to the fetus were described as a reason for non-uptake:

There are many barriers toward the uptake of influenza vaccine, such as women’s knowledge, lack of knowledge about the safety and importance of influenza vaccine among pregnant women. P9

Another participant highlighted widespread misconceptions, stating:

They all misunderstand that influenza vaccine is harmful to the baby. P5

PMPs also emphasised that HCPs’ knowledge played a critical role in shaping pregnant women’s acceptance of MIV. HCPs who were perceived as knowledgeable and confident were more likely to recommend MIV:

Knowledgeable healthcare provider who holds a positive attitude toward the vaccine will recommend it to their patients because they know the significance of being vaccinated. P10

PMPs attributed gaps in HCP knowledge to limited engagement with MoH training due to heavy workloads and time constraints and perceived that more experienced HCPs were less likely to recommend or discuss MIV because they underestimated the risk of influenza during pregnancy.

Lack of prioritisation of pregnant women and shortage of the influenza vaccine

PMPs identified the lack of prioritisation of pregnant women, combined with early vaccine supply shortages, as a key barrier to MIV uptake. Although pregnant women were classified as a high-risk group, PMPs reported that older adults were often prioritised in practice due to limited vaccine availability at the start of the seasonal influenza vaccine campaign:

The ministry is prioritising this for the risk group, including pregnant women, but this is not usually the situation; we have to keep it for older people. P2

Vaccine shortages were particularly evident early in the campaign:

when there are limited quantities of influenza vaccines available. P2

Despite strong public readiness at campaign launch, PMPs highlighted challenges in sustaining momentum and ensuring equitable access for pregnant women throughout the season (P1, P8).

COVID-19 pandemic

PMPs perceived the COVID-19 pandemic as temporarily shifting attention away from MIV. Although PMPs reported steady improvements in MIV uptake since 2016, when pregnant women were classified as a high-risk group, they believed that the pandemic disrupted this progress by redirecting resources and focus towards COVID-19 vaccination:

Before the pandemic, we were having steady improvement in planning and uptake of influenza vaccine… however now we are focusing on the pandemic. P10

PMPs further suggested that the rapid roll-out of COVID-19 vaccines intensified vaccine hesitancy and contributed to ‘vaccine fatigue’ among pregnant women and HCPs. This was compounded by reduced vaccine recommendations from HCPs, who were primarily focused on COVID-19 prevention:

Influenza vaccine uptake was improving before COVID-19, but after the pandemic, people are not encouraged to take influenza vaccine. P3

Theme 2: facilitators

This theme discussed facilitators from the perspective of study participants. Three subthemes were generated, including vaccination champion, health promotion and MoH hotline for concerns and emergencies and system-level accessibility and digital facilitation of MIV uptake.

Vaccination champion

PMPs showed awareness of vaccination champions in the Kuwaiti healthcare system to provide ongoing support for HCPs and patients. PMPs agreed that preventive medicine doctors were vaccination champions who offered support for patients and HCPs, by providing information, answering questions and addressing concerns about vaccinations, including the MIV:

Preventive medicine doctors who are in hospitals and polyclinics are the one who is responsible for answering and discussing concerns about vaccinations as a whole, including influenza vaccine for both healthcare providers and the population. P9

Furthermore, vaccination champions are responsible for educating HCPs about the importance of vaccinations, providing guidelines for vaccine administration and best practices for discussing vaccines with patients. PMPs discussed that training, in the form of lectures, helped HCPs become more confident in discussing and recommending MIV:

As for health care providers, it is our job as preventive medicine doctors to provide education such as workshops and lectures about vaccines and answer any question related to vaccines… this will provide confidence to HCPs to discuss and recommend MIV for pregnant women. P2

Health promotion and MoH hot line for concerns and emergency

PMPs perceived the MoH in Kuwait as actively promoting MIV through seasonal health promotion activities. Multiple communication tools, including social media, posters and printed materials, were used to inform pregnant women and support informed decision-making:

There are many tools providing information to pregnant women such as social media pages, posters, leaflets and brochures. P2

PMPs also identified the MoH hot line as a key facilitator:

a hotline created by the Ministry of Health to answer all medical questions or report an adverse event. P3

Its accessibility and credibility were perceived to enhance confidence and support MIV uptake (P1).

System-level accessibility and digital facilitation of MIV uptake

PMPs reported that MIV was widely available through preventive medicine and antenatal care clinics, as well as mobile units, and was provided free of charge without appointment requirements:

All vaccines, including influenza vaccine, are provided in preventive medicine clinics. P2.

Digital registration was perceived to improve efficiency by reducing waiting times and overcrowding:

electronic registration… regulate[s] the uptake of vaccinations. P1

However, PMPs highlighted a limitation in monitoring, as MIV uptake among pregnant women was not recorded separately (P10).

Theme 3: Influences towards the uptake of MIV

PMPs perceived that pregnant women face multiple influences that have the potential to impact their decisions regarding the uptake of MIV significantly. Such influences played a crucial role in shaping pregnant women’s decisions, either positively or negatively, about the acceptance and administration of the MIV. Three subthemes were generated: HCPs’, social and media influences.

HCPs’ influences

PMPs reported that pregnant women frequently sought guidance from HCPs regarding the benefits and risks of MIV, specifically obstetricians. Obstetricians were identified as particularly influential due to their regular contact with pregnant women and the high level of trust placed in their specialised knowledge:

It is well known that obstetricians have the biggest influence on pregnant mothers’ decision toward maternal vaccines including influenza vaccine. P10

In my opinion, the obstetrician-gynaecologists have a major role as pregnant ladies trust them the most, and they got to visit them regularly during their pregnancy, so their influence on pregnant women is big. P7

Social influences

PMPs perceived social associations, particularly family members, as influential in shaping pregnant women’s attitudes towards MIV. Family advice could either encourage acceptance or reinforce hesitancy, especially where trust and close relationships were central:

Family members or friends influence pregnant women’s uptake of influenza vaccine… either to the favour of getting the vaccine or reject it. P1

Mothers were described as particularly influential:

If the mother asks her daughter, she will respond and take the vaccine. P3

PMPs further reported that pregnant women often relied on family guidance due to limited vaccine knowledge, which could increase confusion and fear (P7). In more rural areas, such as Jahra, cultural beliefs and preferences for traditional remedies were perceived to further shape vaccine decisions, sometimes outweighing HCPs’ recommendations:

…in Jahra, people are more like following traditional and natural remedies in treating many diseases, so they refuse to take influenza vaccine. P5

Media influences

PMPs perceived media, particularly social media, as a significant influence on pregnant women’s attitudes towards MIV:

The media has a big influence on women’s decisions toward their vaccines. P6

Although some PMPs reported increased antivaccine content on social media, they believed its impact in Kuwait was limited due to pregnant women’s strong trust in HCPs:

There are campaigns against vaccinations in social media, but they are not effective here in Kuwait; people here always trust their doctors. P8

Theme 4: Interventions

In this theme, the perceived interventions from the PMPs’ perspective on enhancing the uptake of MIV among pregnant women in Kuwait were discussed. Interventions aimed at improving the uptake of MIV encompassed the subthemes of multifaceted strategies that include educating HCPs and establishing policies and guidelines for MIV provision and uptake.

HCPs’ education

PMPs emphasised that increasing MIV uptake required targeted educational interventions for HCPs caring for pregnant women. PMPs reported that workshops and educational lectures improved HCP knowledge and attitudes towards MIV, thereby enhancing vaccine recommendation and uptake:

We need to provide workshops and education lectures for all HCPs dealing with pregnant women to improve their attitude toward the vaccine. P7

PMPs further noted that such initiatives had measurable impact:

We noticed a double of vaccinations uptake number after these seminars. P3

Policy and guidelines

PMPs believed that establishing clear clinical guidelines for MIV in Kuwait would strengthen the prioritisation of pregnant women and support the integration of MIV into routine practice, thereby improving uptake:

Set a clear guideline to prioritise pregnant women in practice. P1

Furthermore, PMPs emphasised the need for a dedicated MIV policy:

a national policy regarding maternal immunisation programme. P8

Conceptual framework

A comprehensive conceptual framework was developed to illustrate the interplay of various factors that can influence the provision and uptake of MIV in Kuwait (figure 2). This framework considered many influences that had the potential to act as either barriers or

Figure 2. Conceptual framework of determinants to the provision and uptake of MIV in Kuwait. MIV, maternal influenza vaccination.

facilitators, subsequently either supporting or hindering the acceptance of MIV. It accentuated the necessity for precisely targeted interventions to amplify MIV provision and uptake.

Discussion

We believe this is the first study that provides a qualitative exploration of barriers, facilitators, influences and interventions shaping MIV provision in Kuwait from the perspectives of PMPs, including policymakers. The findings demonstrate that MIV uptake is influenced by a complex interaction of knowledge-related barriers, structural and policy gaps, social and professional influences, system-level facilitators and disruptions caused by the COVID-19 pandemic. Although the MoH has implemented several measures to improve vaccine accessibility, the results suggest that access alone is insufficient to achieve optimal uptake without coordinated educational, policy and system-level strategies.

A major barrier identified was insufficient knowledge among both pregnant women and HCPs. Misconceptions regarding vaccine safety, particularly concerns about fetal harm, were perceived to contribute to vaccine refusal and hesitancy. Addressing vaccine hesitancy and increasing knowledge have been shown to improve uptake, as has making vaccines compulsory.¹⁶,¹⁸ HCPs’ knowledge and confidence were viewed as critical determinants of MIV recommendation, with knowledgeable HCPs more likely to promote vaccination. Gaps in HCP knowledge were attributed to limited engagement with MoH training due to workload pressures and time constraints. In addition, practitioners with more than 15 years of experience were perceived as less likely to recommend MIV, often underestimating influenza-related risks during pregnancy. These findings align with international evidence showing that inadequate HCP knowledge and low risk perception reduce vaccine recommendation and uptake.¹⁹,²⁵

Structural barriers limited MIV uptake, as early vaccine shortages and unclear prioritisation led to preferential vaccination of older adults despite pregnant women being classified as high-risk, making sustained and equitable access difficult.²⁰ These challenges were exacerbated during the COVID-19 pandemic, which diverted resources and contributed to vaccine fatigue, anxiety, confusion between vaccines and reduced routine MIV recommendation by HCPs.^{26 27}

Vaccination champions were identified by PMPs as key facilitators of MIV uptake, providing education, addressing concerns and supporting both HCPs and the public. Training initiatives, such as workshops and lectures, increased HCP confidence and were associated with improved vaccination uptake, reinforcing evidence that empowered vaccination champions strengthen immunisation programmes.^{19 28} However, the limited and informal implementation of this role indicates a need for more systematic integration. In parallel, the MoH enhanced MIV accessibility through free, walk-in vaccination across polyclinics, hospitals and mobile units; nevertheless, international evidence suggests that integrating vaccination into point-of-care models may be more effective in increasing uptake.²⁹

Interpersonal influences strongly shaped vaccination decisions. Trust in HCPs, particularly obstetricians, was central. That helped reflect pregnant women’s reliance on professional guidance during antenatal care.¹⁹³⁰,³⁴ Family members, especially mothers and husbands, also played an influential role, sometimes outweighing professional advice. In rural areas, cultural preferences for traditional remedies further shaped decisions. Similar trends have been observed in other contexts, though Kuwait’s unique sociocultural composition may limit direct comparisons.^{31 35 36} Islamic principles generally promote preventive healthcare, including vaccination, as part of well-being and several Islamic religious authorities have issued rulings supporting the permissibility of vaccines for the protection of public health.³⁷,³⁹ Although concerns regarding animal-derived gelatine, particularly porcine gelatine, have previously contributed to vaccine hesitancy in some predominantly Islamic contexts,^{39 40} these were not identified as barriers in this study. In Kuwait, seasonal influenza vaccines are provided exclusively as injectable formulations that do not contain animal-derived gelatine. These findings indicate that religion was not a major barrier to MIV acceptance in this setting.

The study further revealed that media coverage, particularly on social media, influenced pregnant women’s decisions regarding MIV. While inaccurate messaging could contribute to vaccine hesitancy,⁴¹ its impact in Kuwait appeared limited, likely due to the trust pregnant women placed in HCPs. In the absence of professional guidance, women often sought reassurance and information from other mothers on social media platforms.⁴²

Although situated within the Kuwaiti healthcare context, these findings reflect determinants of maternal vaccination uptake reported internationally. Provider recommendation, trust, social influence, system accessibility and supportive policy frameworks remain central drivers of MIV provision and uptake across settings.¹⁹³⁰,³⁴ While implementation strategies must be locally adapted, these shared mechanisms suggest broad relevance beyond Kuwait.

A key strength of this study is the inclusion of policymakers’ perspectives, which contrasts with much of the existing literature that has focused primarily on obstetric care providers, particularly obstetricians and midwives. Incorporating policymakers enabled a broader and more strategic understanding of the organisational, governance and societal factors influencing MIV provision and uptake. This approach enhanced the policy relevance of the findings and supported the translation of research evidence into practical, contextually appropriate public health interventions.

However, several limitations should be acknowledged. Some participants reported limited familiarity with national or international guidelines on influenza vaccination during pregnancy and requested additional time to prepare for the interview, which may have affected the spontaneity of responses. Data collection relied solely on semistructured interviews with PMPs, limiting opportunities for triangulation and potentially restricting the transferability of the findings. Nevertheless, the use of the established TIP-FLU framework, purposive and heterogeneous sampling, and achievement of data saturation strengthened the depth and trustworthiness of the data. The absence of obstetricians from the participant sample represents a further limitation, as their inclusion could have provided valuable insights into clinical attitudes and practices related to MIV recommendation. Finally, the relatively small sample size of 10 participants, although sufficient to achieve data saturation, may limit the wider transferability of the findings.

Conclusion

This study highlights the need for the establishment of clearly defined national policies and clinical guidelines to ensure consistent provision of MIV. In parallel, structured and ongoing education for HCPs in Kuwait is essential to enhance their knowledge, confidence and capacity to effectively discuss and recommend MIV to pregnant women. Future research would benefit from the inclusion of obstetricians, given their crucial role in antenatal care and their substantial influence on pregnant women’s vaccination decision-making. Actively engaging obstetricians in future research and policy discussions is essential to ensure that MIV strategies are clinically grounded, integrated into routine maternity services and capable of supporting improvements in vaccination uptake.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.