ABSTRACT
Respiratory syncytial virus (RSV) is a leading cause of pediatric lower respiratory tract infections, yet evidence on vaccine acceptance among Chinese pregnant and postpartum women remains limited. This study examines the willingness, preference and factors influencing neonatal RSV immunization among this population in Lanzhou City, China. The study used a convergent mixed-methods approach, including cross-sectional questionnaires and in-depth interviews, and data were processed through multiple regression analysis and thematic analysis. The results showed that the respondents’ knowledge of RSV was generally low, with 56.5% indicating that they had never heard of the virus, and only 40.1% expressing willingness to be vaccinated, with most of them preferring monoclonal antibody after the birth of infants to maternal vaccination during pregnancy. The key factors influencing immunization willingness included education level, occupation, experience of vaccine side effects, health status during pregnancy, previous vaccination history during pregnancy, and RSV knowledge level, while the factors influencing immunization preference included annual per capita household income, RSV understanding level and RSV knowledge level. Qualitative interviews further revealed participants’ general concerns about the safety and efficacy of vaccination during pregnancy, with national immunization policy and vaccine cost also being important influencing factors. Pregnant and postpartum women demonstrated limited RSV awareness and generally low willingness for immunization, with a clear preference for infant monoclonal antibody administration over maternal vaccination. Comprehensive interventions in terms of health education, service accessibility, financial subsidies and precise communication are recommended to increase immunization rates and reduce the burden of RSV-related diseases.
KEYWORDS: Maternal and child health, RSV immunization, willingness, preference, western China
Introduction
Respiratory syncytial virus (RSV) represents one of the most frequent causes of respiratory infection among infants and young children, and is a leading viral etiology of acute lower respiratory tract infections (ALRTIs) in children under five years of age.1–4 According to the World Health Organization (WHO), ALRTIs constitute the fourth leading cause of mortality worldwide, particularly in low- and middle-income countries, where pneumonia and bronchiolitis are major drivers of hospitalization and in-hospital death in this vulnerable population.5 Epidemiological estimates from 2019 indicate that RSV-associated ALRTIs resulted in approximately 33 million cases, 3.6 million hospital admissions, and 26,300 in-hospital fatalities globally among children under five, with an overall RSV-attributable mortality burden of 101,400.2 Currently, clinical management of RSV infection primarily relies on supportive care, with a relative scarcity of specific therapeutic agents.6 Furthermore, natural RSV infection fails to induce durable immunity, and reinfections are common. Thus, effective immunoprophylaxis is essential to reduce the substantial disease burden associated with RSV.7–10
Currently, two main immunization strategies exist for the prevention of RSV-associated lower respiratory tract infections in infants and young children. The first is maternal immunization, in which pregnant individuals receive an approved RSV vaccine during the late stages of pregnancy. This elicits the production of specific neutralizing antibodies that are transferred transplacentally to the fetus, thereby conferring protection against RSV-related illness in early infancy. The second strategy involves the administration of long-acting monoclonal antibody directly to infants, providing passive immunoprotection during a critical window of vulnerability in early life.11,12 Critically for China, one such monoclonal antibody, nirsevimab, was approved by the National Medical Products Administration (NMPA) in December 2023, marking significant advancement for specific passive immunoprophylaxis during seasonal RSV epidemics.
However, the successful implementation of this promising preventive tool hinges on its acceptance by the target population, where vaccine hesitancy poses a significant challenge. This challenge is encapsulated by the concept of vaccine hesitancy, a major global health threat by the Strategic Advisory Group of Experts (SAGE) as a “delay in acceptance or refusal of vaccines despite availability of vaccination services.”13 To better understand this complex phenomenon, the 5C psychological antecedents model was developed, building upon the WHO’s initial 3C framework, to assess the degree of vaccine hesitancy.14 The 5C model consists of five dimensions: (1) confidence: an individual’s degree of trust in the efficacy and safety of vaccination, the healthcare system, and the motives of decision-makers determining which vaccines to recommend; (2) complacency: an individual’s perception of disease risk, reflecting the degree to which one feels vulnerable and considers vaccination necessary; (3) constraint: structural barriers affecting immunization, including accessibility, affordability, and comprehensibility of immunization services; (4) calculation: the capacity and extent of an individual’s participation in extensive information searches; (5) collective responsibility: the degree of prosocial motivation to receive vaccination for the protection of others.15,16
To enhance the coverage and effectiveness of RSV immunization, it is imperative to gain an in-depth understanding of the knowledge and attitudes of women during pregnancy and childbirth toward RSV vaccination. Currently, empirical research on maternal acceptance of different RSV immunization strategies in China remains limited. In response, this study employs a convergent mixed-methods approach to systematically evaluate the willingness and preference of pregnant and postpartum women regarding both maternal RSV vaccination during pregnancy and monoclonal antibody immunization for neonates, and identify key determinants of their decisions. The findings will provide a scientific basis for the development of targeted promotion strategies and evidence-based public health interventions, thereby contributing to a reduction in the burden of RSV-related diseases, improved public health outcomes, and enhanced maternal and child health.
Materials and methods
Participants and survey procedures
This study used a convergent mixed-methods research approach, integrating a cross-sectional survey and personal interviews, to investigate maternal willingness and preference regarding RSV immunization. Data collection was conducted from January to May 2025 in Lanzhou city, Gansu province, western China. Using a convenience sampling strategy, two Grade A tertiary hospitals and two community health centers were selected as study sites. Eligible participants were required to meet the following criteria: (1) currently pregnant at any gestational stages (early: 0–12 weeks; middle: 13–27 weeks; late: 28–40 weeks) or within 6 weeks postpartum17; (2) aged 18 y or older; (3) free from any severe physical diseases or psychological disorders, and (4) able to provide informed consent and possess adequate communication skills. The exclusion criteria were as follows: (1) age below 18 y; (2) presence of severe physical illness or mental disorder; (3) limited communication or comprehension ability; (4) unwillingness to participate in the study or failure to provide written informed consent.
Cross-sectional survey
This study utilized a self-administered questionnaire, developed and validated through two rounds of Delphi expert consultation, to collect baseline information from participants. Data were collected on-site by uniformly trained interviewers and included the following domains: (1) socio-demographic characteristics: age, type of birthplace, type of residence, educational level, occupation, and annual household income per capita; (2) pregnancy-related information: pregnancy and postpartum period, number of pregnancies, health status during pregnancy, and vaccination history during pregnancy; (3) RSV awareness: level of understanding of RSV, level of knowledge of RSV (comprising 10 items, each item scored 1 point, total score 10 points. A median score of 6 points serves as the threshold; a total score ≥ 6 indicates high knowledge level, while < 6 indicates low knowledge level)18; (4) immunization willingness: willingness toward RSV immunization was assessed using a single item: “Are you willing to receive RSV immunization to protect your child from infection? (including maternal vaccination during pregnancy or monoclonal antibody administration for the child).” Responses were categorized as “Yes,” “No,” or “Undecided.” Participants selecting “No” or “Undecided” were classified as vaccine hesitancy13; (5) immunization preference: respondents evaluated their acceptance of two RSV immunization strategies, using a 0–10 scale, where 0 indicated ‘completely unwilling’ and 10 indicated ‘completely willing’ (6); 5C psychological scale15,16: assesses psychological antecedents for both RSV immunization strategies across five dimensions: confidence, complacency, constraint, calculation, and collective responsibility. Each dimension comprises three items, totaling 15 items. Scoring employs a 5-point Likert scale, where 1 denotes ‘strongly disagree’ and 5 denotes ‘strongly agree.’
Individual interviews
Using purposive sampling, this study recruited interview participants from among pregnant and postpartum women who had taken part in the field survey and consented to follow-up interviews. According to grounded theory principles, a larger sample size theoretically yields greater saturation; however, in practice, an excessively large sample may introduce information redundancy and reduce analytical efficiency. Thus, guided by the principle of data saturation and informed by feasibility considerations, this study ultimately included 10 participants, with whom one-on-one, personalized semi-structured interviews were conducted. Prior to each interview, researchers explained the study’s purpose, procedures, significance, and anticipated duration, and obtained written informed consent. All sessions were audio-recorded and transcribed verbatim. Transcripts were reviewed and organized by the interviewers. The interview guide covered the following domains: (1) awareness of RSV and immunization options, including sources of information; (2) acceptance, trust, preference, and recommendation intent related to maternal RSV vaccination and monoclonal antibody immunization; (3) perceived influence of social, cultural, economic, and policy-related factors on immunization decisions; and (4) participant-identified needs and suggestions concerning education, service accessibility, and financial support for immunization.
Data analysis
Descriptive statistics were used to summarize participant characteristics. Categorical data were described using frequencies and percentages [n (%)], and the chi-square test was used to compare groups. Normality tests were performed on the scores for each dimension of the 5C scale and preference scores. The results indicated that all data were skewed; therefore, they were described using the median and interquartile range [M (P25, P75)], and intergroup comparisons were performed using the Mann-Whitney U test or the Kruskal-Wallis H rank-sum test. Spearman correlation analysis was used to evaluate associations between 5C dimensions and preference scores. To identify determinants of outcome, multivariate logistic regression was applied to identify factors associated with immunization willingness, with “Yes” as the reference category, and multivariate linear regression to identify determinants of immunization preference, with categorical variables included as dummy variables. We initially included all variables with P < .05 in univariate analysis as candidate predictors for multivariate regression. To mitigate confounding, we developed separate regression models for each statistically significant variable from the univariate analysis, with tailored confounder adjustment to ensure reliable estimates.19 All quantitative data were analyzed using SPSS 27.0, and graphics were created using Origin 2025b. A significance level of α = 0.05 was adopted, with P < .05 considered statistically significant.
Qualitative data were organized and analyzed using NVivo 15.0. Following a grounded theory approach, interview transcripts were independently coded by two researchers through a three-stage process: open coding, axial coding, and selective coding. Recurring and convergent concepts were iteratively refined. Thematic analysis was then applied to integrate the coded materials and identify salient themes, thereby systematically elucidating participants’ core perceptions, attitudes, and behavioral intentions toward RSV immunization.
This study used a convergent mixed-methods design, collecting quantitative and qualitative data concurrently and integrating them during interpretation. Integration was achieved via two complementary strategies: a joint display, where qualitative themes were cross-tabulated with quantitative findings for side-by-side comparison; and meta-inference, using qualitative insights to explain, contextualize, or challenge quantitative patterns. This approach enabled finding triangulation and offered a more comprehensive understanding of RSV immunization decision-making than either method alone.
Results
Comparison of socio-demographic characteristics under different immunization willingness and preference
A total of 759 questionnaires were collected in this study, and 695 valid questionnaires were finally obtained after excluding invalid questionnaires, with a validity rate of 91.57%. Among the 695 pregnant and postpartum women included in the study, according to the stage of pregnancy and childbirth, 114 (16.4%) cases were in the early stage of pregnancy, 194 (27.9%) cases were in the middle stage of pregnancy, 227 (32.7%) cases were in the late stage of pregnancy, and 160 (23.0%) cases were in the first 6 weeks of postpartum. Among all participants, 56.5% reported no prior awareness of RSV, while 52.1% demonstrated a high level of RSV knowledge. Regarding immunization, 40.1% expressed willingness to receive RSV vaccination, whereas 59.9% exhibited vaccine hesitancy. Using RSV immunization willingness as the dependent variable, statistical analyses revealed significant differences across groups based on education level (P = .002), occupation (P < .001), medical insurance coverage (P = .022), experience of vaccine side effects (P = .027), health status during pregnancy (P = .028), vaccination history during pregnancy (P < .001), RSV understanding level (P = .004), and RSV knowledge level (P < .001), as detailed in Table 1.
Table 1.
Comparison of socio-demographic characteristics under different immunization willingness.
| Characteristics | N | RSV immunization willingness (n, %) |
|||
|---|---|---|---|---|---|
| Yes (n = 279, 40.1) |
No (n = 97, 14.0) |
Undecided (n = 319, 45.9) |
P | ||
| Age group | .723 | ||||
| 20–24 y | 21 (3.0) | 11 (52.4) | 3 (14.3) | 7 (33.3) | |
| 25–29 y | 239 (34.4) | 91 (38.1) | 33 (13.8) | 115 (48.1) | |
| 30–34 y | 331 (47.6) | 140 (42.3) | 46 (13.9) | 145 (43.8) | |
| ≥35 y | 104 (15.0) | 37 (35.6) | 15 (14.4) | 52 (50.0) | |
| Pregnancy and postpartum period | .632 | ||||
| Early pregnancy | 114 (16.4) | 49 (43.0) | 15 (13.2) | 50 (43.9) | |
| Mid-pregnancy | 194 (27.9) | 72 (37.1) | 22 (11.3) | 100 (51.5) | |
| Late pregnancy | 227 (32.7) | 94 (41.4) | 35 (15.4) | 98 (43.2) | |
| Within 6 weeks postpartum | 160 (23.0) | 64 (40.0) | 25 (15.6) | 71 (44.4) | |
| Type of birthplace | .676 | ||||
| Urban | 214 (30.8) | 89 (41.6) | 32 (15.0) | 93 (43.5) | |
| Rural | 481 (69.2) | 190 (39.5) | 65 (13.5) | 226 (47.0) | |
| Type of residence | .513 | ||||
| Urban | 536 (77.1) | 221 (41.2) | 75 (14.0) | 240 (44.8) | |
| Rural | 159 (22.9) | 58 (36.5) | 22 (13.8) | 79 (49.7) | |
| Level of education | .002 | ||||
| Junior high school and below | 68 (9.8) | 15 (22.1) | 10 (14.7) | 43 (63.2) | |
| High school | 93 (13.4) | 37 (39.8) | 8 (8.6) | 48 (51.6) | |
| College or undergraduate | 469 (67.5) | 200 (42.6) | 75 (16.0) | 194 (41.4) | |
| Postgraduate | 65 (9.4) | 27 (41.5) | 4 (6.2) | 34 (52.3) | |
| Occupation | <.001 | ||||
| Healthcare workers | 75 (10.8) | 26 (34.7) | 18 (24.0) | 31 (41.3) | |
| Public sector employees | 246 (35.4) | 123 (50.0) | 30 (12.2) | 93 (37.8) | |
| Self-employed | 192 (27.6) | 85 (44.3) | 19 (9.9) | 88 (45.8) | |
| Peasant | 33 (4.7) | 7 (21.2) | 7 (21.2) | 19 (57.6) | |
| Unemployed | 116 (16.7) | 29 (25.0) | 20 (17.2) | 67 (57.8) | |
| Other | 33 (4.7) | 9 (27.3) | 3 (9.1) | 21 (63.6) | |
| Annual household income per capita | .453 | ||||
| 10,000 RMB or less | 166 (23.9) | 55 (33.1) | 22 (13.3) | 89 (53.6) | |
| 10,000–30,000 RMB | 97 (14.0) | 43 (44.3) | 13 (13.4) | 41 (42.3) | |
| 30,000–50,000 RMB | 120 (17.3) | 43 (35.8) | 18 (15.0) | 59 (49.2) | |
| 50,000–100,000 RMB | 184 (26.5) | 81 (44.0) | 26 (14.1) | 77 (41.8) | |
| 100,000–150,000 RMB | 79 (11.4) | 36 (45.6) | 13 (16.5) | 30 (38.0) | |
| Over 150,000 RMB | 49 (7.1) | 21 (42.9) | 5 (10.2) | 23 (46.9) | |
| Medical insurance coverage status | .022 | ||||
| Yes | 658 (94.7) | 271 (41.2) | 93 (14.1) | 294 (44.7) | |
| No | 37 (5.3) | 8 (21.6) | 4 (10.8) | 25 (67.6) | |
| Experience of vaccine side effects | .027 | ||||
| Yes | 139 (20.0) | 64 (46.0) | 25 (18.0) | 50 (36.0) | |
| No | 556 (80.0) | 215 (38.7) | 72 (12.9) | 269 (48.4) | |
| Health status during pregnancy | .028 | ||||
| Rather poor | 260 (37.4) | 115 (44.2) | 29 (11.2) | 116 (44.6) | |
| More healthy | 132 (19.0) | 61 (46.2) | 21 (15.9) | 50 (37.9) | |
| Senseless | 303 (43.6) | 103 (34.0) | 47 (15.5) | 153 (50.5) | |
| Number of pregnancies excluding the current one | .301 | ||||
| 0 | 375 (54.0) | 154 (41.1) | 47 (12.5) | 174 (46.4) | |
| 1 | 193 (27.8) | 83 (43.0) | 24 (12.4) | 86 (44.6) | |
| 2 | 74 (10.6) | 26 (35.1) | 15 (20.3) | 33 (44.6) | |
| 3 or more | 53 (7.6) | 16 (30.2) | 11 (20.8) | 26 (49.1) | |
| Vaccination history during pregnancy | <.001 | ||||
| Yes | 132 (19.0) | 73 (55.3) | 11 (8.3) | 48 (36.4) | |
| No | 563 (81.0) | 206 (36.6) | 86 (15.3) | 271 (48.1) | |
| Level of understanding of RSV | .004 | ||||
| Never heard | 393 (56.5) | 140 (35.6) | 53 (13.5) | 200 (50.9) | |
| Heard of it | 225 (32.4) | 97 (43.1) | 29 (12.9) | 99 (44.0) | |
| Learn a little | 64 (9.2) | 36 (56.3) | 11 (17.2) | 17 (26.6) | |
| Deep understanding | 13 (1.9) | 6 (46.2) | 4 (30.8) | 3 (23.1) | |
| Level of knowledge of RSV | <.001 | ||||
| High | 362 (52.1) | 188 (51.9) | 47 (13.0) | 127 (35.1) | |
| Low | 333 (47.9) | 91 (27.3) | 50 (15.0) | 192 (57.7) | |
In the comparison of socio-demographic characteristics across different immunization preference, the preference score for maternal vaccine was 5.00 (2.00, 6.00) and for monoclonal antibody was 5.00 (2.00, 7.00), while the central tendency was identical, the upper quartile was higher for the monoclonal antibody than for the maternal vaccine, suggesting that the top 25% of preference scores were systematically higher for monoclonal antibody administration. For maternal vaccination, preference scores differed significantly according to gestational and postpartum stage (P = .027), type of birthplace (P = .036), type of residence (P = .018), annual household income per capita (P = .012), medical insurance coverage (P = .007), RSV understanding level (P = .032), and RSV knowledge level (P < .001). For monoclonal antibody, significant differences were observed in type of birthplace (P = .009), type of residence (P = .001), education level P = .008), annual household income per capita (P = .001), medical insurance coverage (P = .014), RSV understanding level (P = .033), and RSV knowledge level (P < .001), as presented in Table 2.
Table 2.
Comparison of socio-demographic characteristics under different immunization preference.
| Characteristics | RSV immunization preference [M (P25, P75)] |
|||
|---|---|---|---|---|
| Maternal vaccine 5.00 (2.00, 6.00) | P | Monoclonal antibody 5.00 (2.00, 7.00) | P | |
| Age group | .704 | .804 | ||
| 20–24 y | 5.00 (3.50, 7.00) | 5.00 (2.00, 7.00) | ||
| 25–29 y | 5.00 (2.00, 6.00) | 5.00 (2.00, 8.00) | ||
| 30–34 y | 5.00 (2.00, 6.00) | 5.00 (2.00, 6.00) | ||
| ≥35 y | 5.00 (2.25, 6.00) | 5.00 (2.00, 6.00) | ||
| Pregnancy and postpartum period | .027 | .080 | ||
| Early pregnancy | 5.00 (3.00, 7.00) | 5.00 (2.00, 6.00) | ||
| Mid-pregnancy | 5.00 (3.00, 7.00) | 5.00 (2.00, 6.00) | ||
| Late pregnancy | 5.00 (3.00, 7.00) | 5.00 (2.00, 6.00) | ||
| Within 6 weeks postpartum | 5.00 (3.00, 7.00) | 5.00 (2.00, 6.00) | ||
| Type of birthplace | .036 | .009 | ||
| Urban | 4.00 (2.00, 6.00) | 4.00 (2.00, 6.00) | ||
| Rural | 4.00 (2.00, 6.00) | 4.00 (2.00, 6.00) | ||
| Type of residence | .018 | .001 | ||
| Urban | 4.00 (2.00, 6.00) | 4.00 (2.00, 6.00) | ||
| Rural | 4.00 (2.00, 6.00) | 4.00 (2.00, 6.00) | ||
| Level of education | .066 | .008 | ||
| Junior high school and below | 4.00 (2.00, 5.75) | 3.00 (2.00, 5.00) | ||
| High school | 4.00 (3.00, 7.00) | 5.00 (2.00, 7.50) | ||
| College or undergraduate | 5.00 (2.00, 6.00) | 5.00 (2.00, 7.00) | ||
| Postgraduate | 4.00 (2.00, 6.00) | 5.00 (2.00, 8.00) | ||
| Occupation | .187 | .093 | ||
| Healthcare workers | 5.00 (1.50, 8.00) | 5.00 (2.50, 7.00) | ||
| Public sector employees | 5.00 (1.50, 8.00) | 5.00 (2.50, 7.00) | ||
| Self-employed | 5.00 (1.50, 8.00) | 5.00 (2.50, 7.00) | ||
| Peasant | 5.00 (1.50, 8.00) | 5.00 (2.50, 7.00) | ||
| Unemployed | 5.00 (1.50, 8.00) | 5.00 (2.50, 7.00) | ||
| Other | 5.00 (1.50, 8.00) | 5.00 (2.50, 7.00) | ||
| Annual household income per capita | .012 | .001 | ||
| 10,000 RMB or less | 5.00 (2.00, 7.50) | 6.00 (4.00, 8.00) | ||
| 10,000–30,000 RMB | 5.00 (2.00, 7.50) | 6.00 (4.00, 8.00) | ||
| 30,000–50,000 RMB | 5.00 (2.00, 7.50) | 6.00 (4.00, 8.00) | ||
| 50,000–100,000 RMB | 5.00 (2.00, 7.50) | 6.00 (4.00, 8.00) | ||
| 100,000–150,000 RMB | 5.00 (2.00, 7.50) | 6.00 (4.00, 8.00) | ||
| Over 150,000 RMB | 5.00 (2.00, 7.50) | 6.00 (4.00, 8.00) | ||
| Medical insurance coverage status | .007 | .014 | ||
| Yes | 2.00 (1.00, 5.00) | 3.00 (1.00, 5.50) | ||
| No | 2.00 (1.00, 5.00) | 3.00 (1.00, 5.50) | ||
| Experience of vaccine side effects | .621 | .767 | ||
| Yes | 5.00 (2.00, 6.00) | 5.00 (2.00, 6.75) | ||
| No | 5.00 (2.00, 6.00) | 5.00 (2.00, 6.75) | ||
| Health status during pregnancy | .107 | .919 | ||
| Rather poor | 5.00 (2.00, 6.00) | 5.00 (2.00, 6.00) | ||
| More healthy | 5.00 (2.00, 6.00) | 5.00 (2.00, 6.00) | ||
| Senseless | 5.00 (2.00, 6.00) | 5.00 (2.00, 6.00) | ||
| Number of pregnancies excluding the current one | .303 | .177 | ||
| 0 | 5.00 (2.00, 7.00) | 5.00 (2.00, 7.00) | ||
| 1 | 5.00 (2.00, 6.00) | 5.00 (2.00, 7.00) | ||
| 2 | 4.00 (2.00, 6.00) | 5.00 (2.00, 6.00) | ||
| 3 or more | 4.00 (1.50, 6.00) | 4.00 (1.00, 6.00) | ||
| Vaccination history during pregnancy | .441 | .292 | ||
| Yes | 5.00 (2.00, 6.00) | 5.00 (2.00, 6.00) | ||
| No | 5.00 (2.00, 6.00) | 5.00 (2.00, 6.00) | ||
| Level of understanding of RSV | .032 | .033 | ||
| Never heard | 6.00 (3.00, 8.00) | 5.00 (4.00, 8.50) | ||
| Heard of it | 6.00 (3.00, 8.00) | 5.00 (4.00, 8.50) | ||
| Learn a little | 6.00 (3.00, 8.00) | 5.00 (4.00, 8.50) | ||
| Deep understanding | 6.00 (3.00, 8.00) | 5.00 (4.00, 8.50) | ||
| Level of knowledge of RSV | <.001 | <.001 | ||
| High | 4.00 (2.00, 6.00) | 4.00 (2.00, 6.00) | ||
| Low | 4.00 (2.00, 6.00) | 4.00 (2.00, 6.00) | ||
Psychological antecedents analysis of the 5C model
Univariate analysis of maternal vaccination willingness revealed that, compared to other groups, the accepting group demonstrated significantly higher confidence (P < .001), lower complacency (P < .001), fewer constraint (P = .002), and greater calculation behavior (P = .001). However, no statistically significant difference was observed among the three groups in the collective responsibility dimension (P = .419). In contrast, analysis of monoclonal antibody immunization willingness indicated that the accepting group exhibited higher confidence (P < .001), lower complacency (P = .001), fewer constraint (P < .001), greater calculation (P = .004), and stronger collective responsibility (P = .048) relative to other groups, as detailed in Table 3.
Table 3.
Immunization willingness for RSV maternal vaccine and monoclonal antibody based on the 5C model.
| Types | Dimension | RSV immunization willingness [M (P25, P75)] |
P | ||
|---|---|---|---|---|---|
| Yes | No | Undecided | |||
| Maternal vaccine | Confidence | 3.33 (3.00, 4.00) | 3.00 (2.00, 3.00) | 3.00 (3.00, 3.00) | <.001 |
| Complacency | 3.00 (2.00, 3.00) | 3.00 (2.33, 3.33) | 3.00 (2.67, 3.00) | <.001 | |
| Constraint | 3.00 (2.00, 3.00) | 3.00 (2.33, 3.00) | 3.00 (2.67, 3.00) | .002 | |
| Calculation | 3.67 (3.00, 4.00) | 3.00 (3.00, 4.00) | 3.00 (3.00, 4.00) | .001 | |
| Collective responsibility | 3.00 (2.67, 3.33) | 3.00 (2.67, 3.33) | 3.00 (3.00, 3.00) | .419 | |
| Monoclonal antibody | Confidence | 3.00 (3.00, 4.00) | 3.00 (2.50, 3.00) | 3.00 (3.00, 3.00) | <.001 |
| Complacency | 3.00 (2.00, 3.00) | 3.00 (2.33, 3.00) | 3.00 (2.67, 3.00) | .001 | |
| Constraint | 3.00 (2.00, 3.00) | 3.00 (2.33, 3.00) | 3.00 (3.00, 3.00) | <.001 | |
| Calculation | 3.33 (3.00, 4.00) | 3.00 (3.00, 4.00) | 3.00 (3.00, 4.00) | .004 | |
| Collective responsibility | 3.00 (3.00, 3.33) | 3.00 (2.67, 3.00) | 3.00 (3.00, 3.00) | .048 | |
Correlation analysis for maternal vaccination preference indicated significant associations among all dimensions of the 5C model. Confidence, calculation, and collective responsibility were significantly positively correlated with preference scores, whereas complacency and constraint showed significant negative correlations. Similarly, for monoclonal antibody immunization preference, significant correlations were also observed among the 5C dimensions. Confidence, calculation, and collective responsibility were positively associated with preference scores, while complacency was negatively correlated, as summarized in Figure 1.
Figure 1.
Immunization preference for RSV maternal vaccine and monoclonal antibody based on the 5C model.
Multifactorial regression analysis of factors influencing willingness and preference for RSV immunization
Multivariate logistic regression was performed to identify factors associated with RSV immunization willingness. The results indicated that the following factors were associated with immunization willingness: level of education (aOR = 4.38, 95% CI: 1.12–17.15), occupation (aOR = 0.31, 95% CI: 0.14–0.68), experience of vaccine side effects (aOR = 0.64, 95% CI: 0.42–0.96), health status during pregnancy (aOR = 0.53, 95% CI: 0.31–0.93), vaccination history during pregnancy (aOR = 0.43, 95% CI: 0.22–0.88), and level of knowledge of RSV (aOR = 0.40, 95% CI: 0.24–0.66). Specifically, after adjusting for confounding factors, participants with a higher level of RSV knowledge had 0.40 times the odds of vaccine refusal compared to those with a lower level of knowledge, corresponding to a 60% reduction in the odds of refusal. Further analysis based on the 5C psychological antecedents of vaccination model revealed that higher confidence (maternal vaccine: aOR = 0.32, 95% CI: 0.21–0.49; monoclonal antibody: aOR = 0.74, 95% CI: 0.56–0.99) was associated with a reduced risk of vaccine hesitancy, whereas greater complacency (maternal vaccine: aOR = 2.43, 95% CI: 1.28–4.60; monoclonal antibody: aOR = 1.64, 95% CI: 1.10–2.44) was associated with an increased risk, as detailed in Table 4.
Table 4.
Regression analysis of factors influencing RSV immunization willingness.
| Variables | RSV immunization willingness aOR (95%CI) |
|
|---|---|---|
| No | Undecided | |
| Level of education (ref = Postgraduate) | ||
| Junior high school and below | 4.38* (1.12–17.15) | 2.13 (0.94–4.80) |
| High school | 1.46 (0.39–5.49) | 1.01 (0.50–2.01) |
| College or undergraduate | 2.52 (0.85–7.53) | 0.74 (0.43–1.29) |
| Occupation (ref = Unemployed) | ||
| Healthcare workers | 0.93 (0.38–2.24) | 0.54 (0.26–1.10) |
| Public sector employees | 0.31** (0.14–0.68) | 0.31*** (0.17–0.56) |
| Self-employed | 0.31** (0.14–0.68) | 0.44** (0.25–0.77) |
| Peasant | 1.52 (0.43–5.35) | 0.99 (0.36–2.73) |
| Other | 0.42 (0.10–1.79) | 0.99 (0.39–2.47) |
| Medical insurance coverage status (ref = No) | ||
| Yes | 1.03 (0.29–3.62) | 0.49 (0.21–1.15) |
| Experience of vaccine side effects (ref = No) | ||
| Yes | 1.22 (0.71–2.09) | 0.64* (0.42–0.96) |
| Health status during pregnancy (ref = Senseless) | ||
| Rather poor | 0.53* (0.31–0.93) | 0.66* (0.45–0.97) |
| More healthy | 0.75 (0.40–1.41) | 0.57* (0.35–0.91) |
| Vaccination history during pregnancy (ref = No) | ||
| Yes | 0.43* (0.22–0.88) | 0.54** (0.35–0.83) |
| Level of understanding of RSV (ref = Deep understanding) | ||
| Never heard | 0.76 (0.18–3.13) | 3.12 (0.73–13.28) |
| Heard of it | 0.50 (0.12–2.08) | 1.95 (0.45–8.34) |
| Learn a little | 0.37 (0.08–1.70) | 0.82 (0.18–3.86) |
| Level of knowledge of RSV (ref = Low) | ||
| High | 0.40*** (0.24–0.66) | 0.31*** (0.22–0.45) |
| The 5C model of maternal vaccine | ||
| Confidence | 0.32*** (0.21–0.49) | 0.58* (0.36–0.95) |
| Complacency | 2.43** (1.28–4.60) | 1.00 (0.54–1.87) |
| Constraint | 0.95 (0.50–1.79) | 1.03 (0.55–1.91) |
| Calculation | 1.25 (0.80–1.97) | 0.79 (0.50–1.25) |
| Collective responsibility | 1.12 (0.64–1.96) | 1.39 (0.73–2.66) |
| The 5C model of monoclonal antibody | ||
| Confidence | 0.74* (0.56–0.99) | 0.58** (0.41–0.83) |
| Complacency | 1.64* (1.10–2.44) | 0.87 (0.58–1.30) |
| Constraint | 1.02 (0.66–1.59) | 1.66* (1.10–2.52) |
| Calculation | 0.82 (0.60–1.13) | 1.17 (0.86–1.59) |
| Collective responsibility | 1.10 (0.75–1.60) | 0.81 (0.55–1.21) |
Based on causal inference theory and established literature, we constructed tailored confounder adjustment sets for each exposure variable to enhance the accuracy of association estimates. For details of the specific adjustment plan, please refer to Appendix 4.
aOR denotes adjusted Odds Ratio, 95% CI denotes 95% Confidence Interval, ref denotes reference category.
* denotes P < .05, ** denotes P < .01, *** denotes P < .001.
Multivariate linear regression was employed to identify factors associated with RSV immunization preference. The results indicated that gross annual household income per capita (β = 0.76, 95% CI: 0.05–1.46), medical insurance status (β = −1.07, 95% CI: −2.06–0.08), level of understanding of RSV (β = 0.56, 95% CI: 0.07–1.05) and level of knowledge of RSV (β = −0.85, 95% CI: −1.29–0.41) were significant factors associated with maternal vaccination preference. For monoclonal antibody immunization preference, significant factors included type of birthplace (β = −0.62, 95% CI: −1.11–0.14), level of education (β = 1.01, 95% CI: 0.09–1.93), gross annual household income per capita (β = 0.82, 95% CI: 0.16–1.49), level of understanding of RSV (β = 1.30, 95% CI: 0.48–2.12) and level of knowledge of RSV (β = −1.11, 95% CI: −1.55–0.66), Analysis based on the 5C psychological antecedents of vaccination showed that confidence (maternal vaccine: β = 0.56, 95% CI: 0.24–0.88; monoclonal antibody: β = 0.87, 95% CI: 0.48–1.25), constraint (monoclonal antibody: β = −0.48, 95% CI: −0.95–0.01), and calculation (monoclonal antibody: β = 0.39, 95% CI: 0.03–0.74) were associated with immunization preferences, as presented in Table 5.
Table 5.
Regression analysis of factors influencing RSV immunization preference.
| Variables | RSV immunization preference β (95%CI) |
|
|---|---|---|
| Maternal vaccine | Monoclonal antibody | |
| Pregnancy and postpartum period (ref = Early pregnancy) | ||
| Mid-pregnancy | −0.41 (−1.09–0.27) | |
| Late pregnancy | 0.20 (−0.46–0.86) | |
| Within 6 weeks postpartum | 0.35 (−0.36–1.06) | |
| Type of birthplace (ref = Urban) | ||
| Rural | −0.43 (−0.91–0.04) | −0.62* (−1.11–0.14) |
| Type of residence (ref = Urban) | ||
| Rural | −0.15 (−0.75–0.46) | −0.25 (−0.87–0.36) |
| Level of education (ref = Junior high school and below) | ||
| High school | 1.01* (0.09–1.93) | |
| College or undergraduate | 0.75 (−0.03–1.53) | |
| Postgraduate | 0.48 (−0.56–1.53) | |
| Annual household income per capita (ref = 10,000 RMB or less) | ||
| 10,000–30,000 RMB | 0.70 (−0.04–1.44) | 0.65 (−0.11–1.40) |
| 30,000–50,000 RMB | 0.76* (0.05–1.46) | 0.71 (−0.01–1.43) |
| 50,000–100,000 RMB | 0.80* (0.15–1.46) | 0.82* (0.16–1.49) |
| 100,000–150,000 RMB | 1.01* (0.18–1.84) | 0.96* (0.11–1.80) |
| Over 150,000 RMB | 0.81 (−0.21–1.82) | 1.42** (0.39–2.46) |
| Medical insurance coverage status (ref = Yes) | ||
| No | −1.07* (−2.06–0.08) | −0.95 (−1.96–0.06) |
| Level of understanding of RSV (ref = Never heard) | ||
| Heard of it | 0.56* (0.07–1.05) | 0.44 (−0.06–0.94) |
| Learn a little | 1.06* (0.26–1.87) | 1.30** (0.48–2.12) |
| Deep understanding | 1.32 (−0.31–2.95) | 1.27 (−0.39–2.93) |
| Level of knowledge of RSV (ref = High) | ||
| Low | −0.85*** (−1.29–0.41) | −1.11*** (−1.55–0.66) |
| 5C model | ||
| Confidence | 0.56*** (0.24–0.88) | 0.87*** (0.48–1.25) |
| Complacency | −0.33 (−0.79–0.12) | 0.16 (−0.30–0.62) |
| Constraint | −0.49 (−0.9–0.00) | −0.48* (−0.95–0.01) |
| Calculation | −0.34 (−0.71–0.02) | 0.39* (0.03–0.74) |
| Collective responsibility | 0.18 (−0.26–0.61) | 0.27 (−0.19–0.72) |
Based on causal inference theory and established literature, we constructed tailored confounder adjustment sets for each exposure variable to enhance the accuracy of association estimates. For details of the specific adjustment plan, please refer to Appendix 5.
β denotes adjusted regression coefficient, 95% CI denotes 95% Confidence Interval, ref denotes reference category.
* denotes P < .05, ** denotes P < .01, *** denotes P < .001.
Integrated findings
A total of 10 pregnant and postpartum women participated in the in-depth interviews, including 1 in the first trimester, 2 in the second trimester, 3 in the third trimester, and 4 within 6 weeks postpartum. Among them, 3 expressed willingness to receive RSV immunization, 2 explicitly declined, and 5 remained undecided.
To achieve a comprehensive understanding of RSV immunization decision-making, we integrated quantitative and qualitative data through joint display. Table 6 presents the four core themes identified through this integration, mapping qualitative insights onto quantitative findings.
Table 6.
Joint display of integrated findings on RSV immunization decision-making.
| Theme | Quantitative findings | Qualitative insights | Meta-inference |
|---|---|---|---|
| Limited awareness as a prerequisite for hesitancy | 56.5% never heard of RSV; high knowledge level associated with 60% lower hesitancy risk (aOR = 0.40, 95%CI: 0.24–0.66) | “I’ve only heard of RSV and don’t know much about it…” (R1); “Need to understand the vaccine information first before making a decision.” (R8) | Cognitive deficit is the starting point of hesitancy; however, information framing (disease severity and vaccine safety) determines whether knowledge translates into acceptance. |
| Safety concerns as the core psychological barrier | Low confidence was the strongest hesitancy predictor (maternal vaccine: aOR = 0.32, 95%CI: 0.21–0.49; monoclonal antibody: aOR = 0.74, 95%CI: 0.56–0.99) | “Worried about side effects, especially the impact on the baby during pregnancy.” (R1); “Reluctant to be vaccinated during pregnancy due to concerns about fetal harm.” (R3) | Quantitative “low confidence” is qualitatively manifested as specific fears about fetal harm and unknown reactions; trust-building must directly address these concrete concerns. |
| Preference for infant monoclonal antibody driven by harm avoidance | Preference score higher for monoclonal antibody than maternal vaccine | “Prefer baby vaccination after birth, because vaccination during pregnancy cannot predict fetal response.” (R3); “Would consider if many children are vaccinated after birth.” (R3) | The preference pattern reflects a “harm avoidance first” logic; participants rationally choose the strategy perceived as lower risk to the infant, even if both are clinically safe. |
| Financial barriers and demand for policy support | Constraint dimension significantly associated with monoclonal antibody preference (β = −0.48, 95%CI: −0.95–0.01) | “Cost is a factor (2000–4000 RMB).” (R6); “Hope to include in medical insurance reimbursement.” (R1, R5, R7, et al.) | Economic burden is a structural barrier; insurance coverage serves dual functions, reducing financial strain and providing government endorsement that enhances confidence. |
Theme 1: Limited awareness as a prerequisite for vaccine hesitancy. Quantitative data revealed that 56.5% of participants had never heard of RSV, and RSV knowledge level was strongly associated with immunization willingness. Multivariate regression further confirmed that a high knowledge level reduced the odds of refusal by 60% (aOR = 0.40, 95% CI: 0.24–0.66). Qualitative interviews provided contextual understanding of this statistical pattern, with seven of ten interviewees explicitly stating they had “no understanding” or “very little understanding” of RSV. More importantly, the interviews revealed the psychological pathway from ignorance to hesitancy: one participant described a transformative experience after receiving information (“I don’t know much about this virus, but after seeing the leaflet mentioning that many babies are prone to pneumonia… it seems necessary to get vaccinated,” Respondent 5), while another articulated a cautious stance typical of those who remain undecided (“I need to understand the vaccine information first before making a decision,” Respondent 8). The meta-inference suggests that while cognitive deficit serves as a prerequisite for vaccine hesitancy, the finding that information can rapidly shift attitudes indicates that knowledge alone is insufficient; rather, the framing of information, particularly the balance between emphasizing disease severity and addressing safety concerns, critically determines whether knowledge translates into acceptance or continued hesitation.
Theme 2: Safety concerns as the core psychological barrier. The 5C model analysis identified confidence, defined as trust in vaccine safety, efficacy, and the healthcare system, as one of the strongest predictors of immunization willingness. Higher confidence was significantly associated with greater immunization willingness, reducing the odds of refusal for maternal vaccination by 68% (aOR = 0.32, 95% CI: 0.21–0.49) and for monoclonal antibody administration by 26% (aOR = 0.74, 95% CI: 0.56–0.99). Qualitative interviews provided rich explanatory context, as all ten participants expressed specific safety concerns. These concerns manifested as generalized fear of side effects (“I’m worried about possible side effects from the vaccine, especially how vaccination during pregnancy could affect the baby,” Respondent 1), specific fear of maternal vaccination (“I am reluctant to be vaccinated during pregnancy due to concerns about fetal harm,” Respondent 3), and anxiety rooted in negative prior experiences (“I worry about side effects because I had adverse reactions to other vaccines before,” Respondent 2). The meta-inference suggests that low confidence is qualitatively manifested as concrete, emotionally charged fears, particularly regarding fetal harm from maternal vaccination and unpredictable reactions in the newborn. These specific concerns indicate that trust-building interventions cannot rely solely on general messages about vaccine efficacy; rather, they must directly address and mitigate these articulated fears.
Theme 3: Preference for infant monoclonal antibody driven by harm avoidance logic. Quantitative preference scores revealed that participants were more accepting of monoclonal antibody administration for infants than maternal vaccination during pregnancy, a difference that, while modest in central tendency, was consistently reflected in the upper quartile distribution. Qualitative interviews elucidated the reasoning behind this preference pattern, revealing a systematic “harm avoidance” logic: participants expressed preferences for postnatal infant vaccination due to the unpredictability of fetal response (“I prefer baby vaccination after birth, because vaccination during pregnancy cannot predict the fetal response,” Respondent 3; “I tend to choose baby vaccination, as the effect of maternal vaccination on the fetus is unpredictable,” Respondent 3), with one participant indicating she would consider vaccination if many children were immunized after birth (“I would consider vaccinating my baby if many children are vaccinated after birth,” Respondent 3). Notably, even the participant who favored maternal vaccination framed her choice within the same protective logic (“Adults have stronger immunity than newborns and are exposed to more environments,” Respondent 5). The meta-inference suggests that the quantitative preference pattern reflects a rational “harm avoidance first” decision-making model: participants do not simply reject immunization but actively choose the strategy perceived as posing lower risk to the infant.
Theme 4: Financial barriers and demand for policy support. Multivariate regression demonstrated that the constraint dimension, measuring affordability and accessibility barriers, was significantly associated with monoclonal antibody preference (β = −0.48, 95% CI: −0.95–0.01), indicating that higher perceived constraints reduced preference scores. Qualitative interviews uniformly identified cost as a critical barrier, with participants spontaneously articulating both price sensitivity (“Cost is a factor [2000–4000 RMB],” Respondent 6; “I would find it acceptable if under 1000 RMB,” Respondent 7) and a universal demand for insurance coverage, nine of ten participants explicitly mentioned inclusion in medical insurance reimbursement when asked about their needs (“I hope it can be covered by medical insurance reimbursement, convenient and cost-saving,” Respondent 1; “I hope for widespread promotion, cost reduction, insurance coverage, and safety assurance,” Respondent 5). The meta-inference suggests that financial burden constitutes a structural barrier to RSV immunization, second only to safety concerns in importance. Insurance coverage serves a dual function: directly reducing the constraint dimension by improving affordability while indirectly enhancing confidence through government endorsement. Participants’ spontaneous emphasis on policy support indicates that national-level promotion and community education are perceived as essential external drivers to bridge the cognitive-practical gap.
Discussion
This study employed a convergent mixed-methods approach to systematically investigate the willingness and preference for RSV immunization among pregnant and postpartum women, as well as the factors influencing their immunization decisions. Quantitative and qualitative results complemented each other, offering a comprehensive understanding of the cognitive characteristics, psychological mechanisms, and practical barriers affecting RSV immunization decision-making in this population.
The findings revealed generally low levels of awareness regarding RSV and its immunization strategies among participants, with 56.5% reporting no prior knowledge of RSV. Additionally, a pronounced level of vaccine hesitancy was observed, with only 40.1% of respondents expressing willingness to vaccinate. These results differ significantly from those reported by Wang et al. in studies involving the general Chinese population18 and parent groups,20 underscoring that although RSV is a major pathogen responsible for lower respiratory tract infections in infants and young children, awareness and acceptance of immunization among pregnant and postpartum women remain suboptimal and warrant further attention.21,22 Qualitative interviews further elucidated that limited knowledge often coexists with concerns regarding vaccine safety and efficacy, which emerged as a salient factor contributing to hesitancy or refusal of vaccination.23,24
Based on the 5C psychological antecedents model, this study revealed significant psychological influences on RSV immunization willingness and preference. Results indicated that confidence was positively associated with immunization acceptance, suggesting that enhancing trust in vaccine safety, effectiveness, and the healthcare system may improve uptake among pregnant and postpartum women.25,26 In contrast, complacency showed a negative correlation with acceptance, reflecting insufficient perception of RSV severity and personal susceptibility among some pregnant women,27,28 thereby reducing their motivation to vaccinate. Constraint, particularly financial burden, as frequently indicated in both quantitative and qualitative findings, proved to be another critical barrier. Notably, higher calculation was associated with lower vaccine hesitancy, a finding that contrasts with reports by Machida29 and Wismans30 in studies of COVID-19 vaccination intent. This may be explained by the fact that individuals with higher calculation are more capable of actively seeking and evaluating evidence on newly available vaccines, allowing them to perform personal risk-benefit assessments and arrive at more informed decisions. Furthermore, collective responsibility emerged as a positive predictor of monoclonal antibody immunization willingness, indicating that altruistic motives, such as protecting others through immunization, may also influence decision-making. This insight could inform the design of public health messaging and promotion strategies in the future.
Multivariable regression analyses indicated that several socio-demographic factors were significantly associated with immunization willingness. For instance, occupation as public sector employees, having experienced vaccine side effects, previous vaccination during pregnancy, and higher levels of RSV knowledge were positively correlated with greater immunization willingness. These findings suggest that educational background, occupational context, and prior vaccination experiences (even with side effects) may contribute to more favorable attitudes toward immunization.31 The association between prior side effect experience and higher acceptance may reflect a perception among some women that transient side effects are an expected part of the immune response, potentially indicating vaccine activity and efficacy, rather than deterring future vaccination. This aligns with health behavior theories suggesting that individuals who have successfully navigated minor adverse events may develop greater self-efficacy in managing post-vaccination symptoms,32 thereby reducing hesitation toward subsequent immunization. Furthermore, engagement in standard perinatal health management practices, such as registration of a maternal health record and completion of systematic antenatal examinations, was also associated with increased immunization willingness, indicating that better access to and utilization of healthcare services may facilitate vaccine acceptance.33,34
Notably, despite the availability of both maternal and monoclonal antibody-based immunization strategies, this study found that pregnant women exhibited a stronger preference for postnatal monoclonal antibody administration for their infants rather than maternal vaccination during pregnancy, a finding that contrasts with reports by Gagnon23 and Wang35 et al. Qualitative insights revealed that this preference was primarily driven by concerns regarding the safety of vaccination during pregnancy, uncertainties about the efficacy of maternally derived antibodies, and the perception of heightened susceptibility of newborns to RSV infection. These results highlight the importance of tailoring immunization promotion strategies to specific audience segments and developing targeted health education that addresses the particular concerns and information gaps among pregnant and postpartum women.
At the policy and service levels, this study identifies cost as a critical barrier to immunization willingness.36,37 A majority of respondents indicated that their willingness to vaccinate would increase significantly if vaccines were covered by medical insurance or otherwise subsidized. In addition, national-level publicity campaigns, community-based health education initiatives, and recommendations from healthcare professionals were widely perceived as effective measures to enhance confidence in vaccination.38,39
This study has several limitations. First, the use of convenience sampling within healthcare facilities in Lanzhou may restrict the representativeness of the sample and limit the generalizability of the findings to other regions. Future research should involve multi-center studies across diverse geographical settings to enhance external validity. Second, as a cross-sectional design was employed, causal inferences cannot be drawn. Longitudinal studies are needed to track the evolution of immunization decisions over time. Third, self-reported data are subject to social desirability bias, which may persist despite anonymous data collection. Fourth, no single analytical model can account for all potential biases. Despite constructing separate regression models for each exposure variable and applying tailored adjustment strategies, it remains impossible to measure and adjust for all potential confounders. Finally, the cultural adaptation and psychometric properties of the 5C scale require further validation and refinement within Chinese pregnant and postpartum populations.
In summary, this study identifies key factors influencing RSV immunization decision-making among pregnant and postpartum women across multiple levels, including cognitive, psychological, behavioral, and socio-environmental dimensions. Future strategies to promote RSV immunization should prioritize: enhancing maternal health education to improve knowledge of RSV and immunization options; increasing transparency of the healthcare system and accessibility of professional guidance to strengthen trust in vaccine safety and efficacy; reducing financial barriers through insurance coverage or subsidies to improve service affordability and access; and developing differentiated, stage-appropriate communication and implementation pathways aligned with both immunization strategy characteristics and population preference. It is anticipated that such multi-level, multi-strategy interventions will increase RSV immunization acceptance among pregnant and postpartum women, thereby reducing the burden of RSV-related disease in infants and children and improving maternal and child health outcomes.
Supplementary Material
Acknowledgments
The authors would like to thank all the healthcare workers who collected and participants who contributed the original data at the involved hospitals. The authors would also like to thank all members of the LAN LAB@LZU at the School of Public Health, Lanzhou University, for their support and collaboration.
Biography
Guanlan Zhao, Professor (Associate) at the School of Public Health, Lanzhou University (China). He holds a Bachelor degree of Medicine in Havana Medical University (Cuba), Master of Public Health in University of Alcalá (Spain) and Cum-Laude Ph.D degree in Health Sciences from the University of Alicante (Spain) and completed postdoctoral training at Zhejiang University (China). He was visiting scholar at the Centre for International Health in University of Bergen (Norway). His research focuses on child-maternal health, primary health care and global health governance. He has led several national and international projects and published over 20 papers in SCI/SSCI-indexed journals. Dr. Zhao serves as Former Co-Chair of the Spanish Young Epidemiologists Association and holds editorial roles in several public health journals. He has been recognized with awards including the Extraordinary Doctoral Award from the University of Alicante (Spain).
Funding Statement
His study was supported by MSD China Holding Co., Ltd. MISP Program [Grant No. IIS #102659] and the Gansu Provincial Department of Science and Technology Key R&D Program, China [Grant No. 25YFWA002]. The funding institution had no role in the study design, the collection, analysis and interpretation of the data, and the decision to publish or preparation of the manuscript.
Disclosure statement
No potential conflict of interest was reported by the author(s).
In the preparation of this work, the authors used DeepSeek strictly for grammatical corrections under close oversight. Following its use, the authors carefully reviewed and edited the content as necessary and assume full responsibility for the final publication.
Data availability statement
Data may be available from the corresponding author on reasonable request depending on the policy and procedures of the institutions that participate in the consortiums.
Ethical approval
This study received ethical approval from the Medical Ethics Committee of the School of Public Health, Zhejiang University, on October 1, 2024 (approval number: ZGL202410-1). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments ethical standards. All participants were informed of the study’s content and provided written informed consent prior to participating in the study.
Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2026.2681942.
References
- 1.Wang X, Li Y, Shi T, Bont LJ, Chu HY, Zar HJ, Wahi-Singh B, Ma Y, Cong B, Sharland E, et al. Global disease burden of and risk factors for acute lower respiratory infections caused by respiratory syncytial virus in preterm infants and young children in 2019: a systematic review and meta-analysis of aggregated and individual participant data. Lancet. 2024;403(10433):1241–15. doi: 10.1016/S0140-6736(24)00138-7. [DOI] [PubMed] [Google Scholar]
- 2.Li Y, Wang X, Blau DM, Caballero MT, Feikin DR, Gill CJ, Madhi SA, Omer SB, Simões EAF, Campbell H, et al. Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in children younger than 5 years in 2019: a systematic analysis. Lancet. 2022;399(10340):2047–2064. doi: 10.1016/S0140-6736(22)00478-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Srisingh K, Khongthongprasert S, Jaturabundit T, Soponwaree N, Klangsombat K, Sriwad C, Oilmungmool N, Phuaksaman C, Lawanaskol S.. Risk factors for respiratory syncytial virus (RSV) infection in children under 5 years old with acute lower respiratory tract infection. J Thorac Dis. 2025;17(7):4565–4575. doi: 10.21037/jtd-2024-2170. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Wang Y, Xiang Y, Jin R, Li B, Feng X, Han Q, Deng X, Lu Y, Zhang C, Xiao S. Risk factors for severe lower respiratory tract infection among children under 5 years of age hospitalized with respiratory syncytial virus. Eur J Clin Microbiol Infect Dis. 2025;44(9):2239–2251. doi: 10.1007/s10096-025-05191-9. [DOI] [PubMed] [Google Scholar]
- 5.Frigati L, Greybe L, Andronikou S, Eber E, Venkatakrishna S, Goussard P. Respiratory infections in low and middle-income countries. Paediatr Respir Rev. 2025;54:43–51. doi: 10.1016/j.prrv.2024.08.002. [DOI] [PubMed] [Google Scholar]
- 6.Gatt D, Martin I, Alfouzan R, Moraes TJ. Prevention and treatment strategies for respiratory syncytial virus (RSV). Pathogens. 2023;12(2):154. doi: 10.3390/pathogens12020154. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Georgakopoulou VE, Pitiriga VC. Immunomodulation in respiratory syncytial virus infection: mechanisms, therapeutic targets, and clinical implications. Microorganisms. 2025;13(8):1876. doi: 10.3390/microorganisms13081876. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Hu M, Bogoyevitch MA, Jans DA. Impact of respiratory syncytial virus infection on host functions: implications for antiviral strategies. Physiol Rev. 2020;100(4):1527–1594. doi: 10.1152/physrev.00030.2019. [DOI] [PubMed] [Google Scholar]
- 9.Langedijk AC, Bont LJ. Respiratory syncytial virus infection and novel interventions. Nat Rev Microbiol. 2023;21(11):734–749. doi: 10.1038/s41579-023-00919-w. [DOI] [PubMed] [Google Scholar]
- 10.Ruckwardt TJ, Morabito KM, Graham BS. Immunological lessons from respiratory syncytial virus vaccine development. Immunity. 2019;51(3):429–442. doi: 10.1016/j.immuni.2019.08.007. [DOI] [PubMed] [Google Scholar]
- 11.Esposito S, Abu RB, Baraldi E, Flanagan K, Martinon Torres F, Tsolia M, Zielen S. RSV prevention in all infants: which is the most preferable strategy? Front Immunol. 2022;13:880368. doi: 10.3389/fimmu.2022.880368. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Messina A, Germano C, Avellis V, Tavella E, Dodaro V, Massaro A, Vitale R, Masturzo B, Manzoni P. New strategies for the prevention of respiratory syncytial virus (RSV). Early Hum Dev. 2022;174:105666. doi: 10.1016/j.earlhumdev.2022.105666. [DOI] [PubMed] [Google Scholar]
- 13.Macdonald NE. Vaccine hesitancy: definition, scope and determinants. Vaccine. 2015;33(34):4161–4164. doi: 10.1016/j.vaccine.2015.04.036. [DOI] [PubMed] [Google Scholar]
- 14.Aggarwal S, Singh L, Alam U, Sharma S, Saroj SK, Zaman K, Usman M, Kant R, Chaturvedi HK. COVID-19 vaccine hesitancy among adults in India: a primary study based on health behavior theories and 5C psychological antecedents model. PLOS ONE. 2024;19(5):e0294480. doi: 10.1371/journal.pone.0294480. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Betsch C, Bach HK, Deshevoi S, Heinemeier D, Briko N, Kostenko N, Kocik J, Böhm R, Zettler I, Wiysonge CS, et al. Sample study protocol for adapting and translating the 5c scale to assess the psychological antecedents of vaccination. BMJ Open. 2020;10(3):e034869. doi: 10.1136/bmjopen-2019-034869. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Betsch C, Schmid P, Heinemeier D, Korn L, Holtmann C, Böhm R. Beyond confidence: development of a measure assessing the 5C psychological antecedents of vaccination. PLOS ONE. 2018;13(12):e0208601. doi: 10.1371/journal.pone.0208601. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Wojcieszek AM, Bonet M, Portela A, Althabe F, Bahl R, Chowdhary N, Dua T, Edmond K, Gupta S, Rogers LM, et al. Who recommendations on maternal and newborn care for a positive postnatal experience: strengthening the maternal and newborn care continuum. BMJ Glob Health. 2023;8(Suppl 2):e010992. doi: 10.1136/bmjgh-2022-010992. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Wang Q, Xiu S, Yang L, Li L, Yang M, Wang X, Shen Y, Wang W, Lin L. Perceptions about respiratory syncytial virus (RSV) and attitudes toward the RSV vaccine among the general public in China: a cross-sectional survey. Hum Vaccin Immunother. 2024;20(1):2310916. doi: 10.1080/21645515.2024.2310916. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Gao Y, Xiang L, Yi H, Song J, Sun D, Xu B, Zhang G, Wu IX. Confounder adjustment in observational studies investigating multiple risk factors: a methodological study. BMC Med. 2025;23(1):132. doi: 10.1186/s12916-025-03957-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Wang Q, Yang L, Li L, Xiu S, Yang M, Wang X, Shen Y, Wang W, Lin L. Investigating parental perceptions of respiratory syncytial virus (RSV) and attitudes to RSV vaccine in Jiangsu, China: insights from a cross-section study. Vaccine. 2025;44:126570. doi: 10.1016/j.vaccine.2024.126570. [DOI] [PubMed] [Google Scholar]
- 21.Limaye RJ, Fesshaye B, Singh P, Karron RA. RSV awareness, risk perception, causes, and terms: perspectives of pregnant and lactating women in Kenya to inform demand generation efforts for maternal RSV vaccines. Hum Vaccin Immunother. 2023;19(2):2258580. doi: 10.1080/21645515.2023.2258580. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Mccormack S, Thompson C, Nolan M, Imcha M, Dee A, Saunders J, Philip RK. Maternal awareness, acceptability and willingness towards respiratory syncytial virus (RSV) vaccination during pregnancy in Ireland. Immun Inflamm Dis. 2024;12(4):e1257. doi: 10.1002/iid3.1257. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Gagnon D, Gubany C, Ouakki M, Malo B, Paquette M, Brousseau N, Papenburg J, Dubé E. Factors influencing acceptance of RSV immunization for newborns among pregnant individuals: a mixed-methods study. Vaccine. 2025;55:127062. doi: 10.1016/j.vaccine.2025.127062. [DOI] [PubMed] [Google Scholar]
- 24.Nuzhath T, Khobragade N, Regan AK, Pinkney JA, Wise L, Callaghan T. Pregnant women’s perceptions of RSVpreF vaccine and nirsevimab for infant RSV prevention. Vaccine. 2025;62:127590. doi: 10.1016/j.vaccine.2025.127590. [DOI] [PubMed] [Google Scholar]
- 25.Sallam M, Kherfan T, Al-Farajat A, Nemrawi L, Atawneh N, Fram R, Al-Tammemi AB, Barakat M, Fram K. Attitude to RSV vaccination among a cohort of pregnant women in Jordan: a cross-sectional survey study. Health Sci Rep. 2025;8(1):e70319. doi: 10.1002/hsr2.70319. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Treston B, Geoghegan S. Exploring parental perspectives: maternal RSV vaccination versus infant RSV monoclonal antibody. Hum Vaccin Immunother. 2024;20(1):2341505. doi: 10.1080/21645515.2024.2341505. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Kim N, Seo J, Yoon D, Kim JN. Understanding RSV vaccine hesitancy: exploring decision-making pathways. Health Commun. 2025;40(14):3247–3262. doi: 10.1080/10410236.2025.2504109. [DOI] [PubMed] [Google Scholar]
- 28.Singh P, Fesshaye B, Lee C, Njogu RN, Karron RA, Limaye RJ. Maternal immunization decision-making among pregnant and lactating people in Kenya: a qualitative exploration of peer influences on vaccine decision-making for a future RSV vaccine. Matern Child Health J. 2024;28(10):1822–1832. doi: 10.1007/s10995-024-03982-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Machida M, Nakamura I, Kojima T, Saito R, Nakaya T, Hanibuchi T, Takamiya T, Odagiri Y, Fukushima N, Kikuchi H, et al. Trends in COVID-19 vaccination intent from pre- to post-COVID-19 vaccine distribution and their associations with the 5C psychological antecedents of vaccination by sex and age in Japan. Hum Vaccin Immunother. 2021;17(11):3954–3962. doi: 10.1080/21645515.2021.1968217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Wismans A, Thurik R, Baptista R, Dejardin M, Janssen F, Franken I. Psychological characteristics and the mediating role of the 5C model in explaining students’ COVID-19 vaccination intention. PLOS ONE. 2021;16(8):e0255382. doi: 10.1371/journal.pone.0255382. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Langer S, Holzapfel S, August L, Badura A, Wellmann S, Mack I. Parental knowledge and attitudes to infant immunization in the context of RSV: all about confidence? Vaccine. 2024;42(23):126050. doi: 10.1016/j.vaccine.2024.06.018. [DOI] [PubMed] [Google Scholar]
- 32.Inam A, Mushtaq A, Zaman S, Wasif S, Noor M, Khan HA. Vaccine hesitancy and post-vaccination adherence to safety measures: a mixed-method study. Front Public Health. 2023;11:1072740. doi: 10.3389/fpubh.2023.1072740. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Maggi S, Launay O, Dawson R. Respiratory virus vaccines: pathways to recommendations and enhanced coverage for at-risk populations. Infect Dis Ther. 2025;14(Suppl 1):99–114. doi: 10.1007/s40121-024-01082-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Treskova M, Pozo-Martin F, Scholz S, Schönfeld V, Wichmann O, Harder T. Assessment of the effects of active immunisation against respiratory syncytial virus (RSV) using decision-analytic models: a systematic review with a focus on vaccination strategies, modelling methods and input data. Pharmacoeconomics. 2021;39(3):287–315. doi: 10.1007/s40273-020-00991-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Wang B, Lassi Z, Andraweera P, Chen G, Ong JJ, McMillian M, Marshall H. Pregnant women’s choices for preventing respiratory syncytial virus (RSV). Vaccine. 2025;48:126790. doi: 10.1016/j.vaccine.2025.126790. [DOI] [PubMed] [Google Scholar]
- 36.Li X, Bilcke J, Beutels P. Pricey or priceless: cost-effectiveness of respiratory syncytial virus (RSV) prevention in infants. Lancet Reg Health Am. 2024;29:100657. doi: 10.1016/j.lana.2023.100657. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Li X, Willem L, Antillon M, Bilcke J, Jit M, Beutels P. Health and economic burden of respiratory syncytial virus (RSV) disease and the cost-effectiveness of potential interventions against RSV among children under 5 years in 72 Gavi-eligible countries. BMC Med. 2020;18(1):82. doi: 10.1186/s12916-020-01537-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Papagiannis D, Tiganis N, Kotsiou OS, Lampropoulos IC, Fradelos EC, Malli F, Gourgoulianis KI. Assessment of knowledge, attitudes, and vaccination practices regarding the new RSV vaccine among health professionals in Greece. Healthcare (Basel). 2024;12(15):1536. doi: 10.3390/healthcare12151536. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Ponticelli D, Losa L, Antonazzo IC, Zampella A, Di Marino F, Mottola G, Fede MN, Gallucci F, Magliuolo R, Rainone A, et al. Respiratory syncytial virus (RSV) and intention to recommend RSV vaccination: a cross-sectional survey of cardiologists and cardiac nurses in southern Italy. Infect Dis Rep. 2024;16(1):128–141. doi: 10.3390/idr16010010. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data may be available from the corresponding author on reasonable request depending on the policy and procedures of the institutions that participate in the consortiums.