Perceived Barriers to Pregnancy Vaccination Plans in Chile: A Qualitative Analysis

doi:10.21203/rs.3.rs-7871693/v1

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Research Article

Perceived Barriers to Pregnancy Vaccination Plans in Chile: A Qualitative Analysis

https://doi.org/10.21203/rs.3.rs-7871693/v1

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Background

Vaccination is widely recognized as a cost-effective public health intervention. However, vaccination rates among pregnant women have been decreasing, especially in low and middle-income countries and in subgroups like migrant communities. Hence, the purpose of this study was to unveil experiences, barriers and facilitators to vaccination recommended by Chile’s National Immunization Program among pregnant women, both locals and international migrants, in three large cities in Chile.

Methods

A multiple Case Study was conducted. Through snowballing technique, local and migrant pregnant women or women with toddlers (i.e., recently pregnant) were invited to participate (n = 28, 14 Chileans and 14 international migrants). Semi-structured interviews were held online based on a pre-defined guide and lasted for 60–90 minutes. Interviews were audio recorded and transcribed verbatim and analyzed thematically. The project was approved by the Scientific Ethics Committee at UDD.

Results

There was general consensus that the country has a very strong immunization program, along with a well-established vaccination culture and compliance with the national immunization plan. Participants identified five main barriers to access vaccines: (i) problems related to vaccine information, (ii) barriers related to potential adverse effects, (iii) some cases of disrespectful or neglectful treatment, (iv) social vulnerability and lack of social support, and (v) unique barriers faced by migrant women. Perceived facilitators were the following three: (i) timely and comprehensive access to information, (ii) free provision of vaccines, and (iii) preferential care at health centers.

Conclusions

Findings highlight the need for strengthening access to quality and timely information about the vaccination plan during pregnancy, improving client-provider communication, ensuring dignified treatment, and training healthcare workers about health rights of migrant pregnant women in the country. Addressing these multifaceted barriers requires integrated strategies that combine culturally sensitive education, improved provider-patient interactions, and systemic reforms to ensure equitable, non-discriminatory access to maternal vaccines.

Vaccination

Pregnant Women

Emigrants and immigrants

Qualitative Research

Chile

Health Care Quality

Access

and Evaluation

There is a paucity of qualitative research exploring the experiences and perceptions surrounding maternal vaccination in settings characterized by high immunization coverage and publicly funded vaccination programs, particularly within Latin American contexts such as Chile.
This study offers novel empirical insights from Chile, elucidating the ways in which structural, relational, and cultural determinants shape decision-making processes regarding vaccination during pregnancy.
The findings underscore the impact of immigration status and experiences of discrimination on both access to and trust in immunization services—an area that remains insufficiently examined in countries with well-established national vaccination programs.
These results contribute to the global discourse by emphasizing the imperative for culturally responsive and rights-based approaches to ensure equitable access to maternal vaccination.
The findings enhance the global understanding of the necessity for culturally sensitive and rights-centred strategies to promote equitable vaccination for pregnant women.

Vaccination is widely recognized as one of the most cost-effective public health interventions. It plays a crucial role in reducing mortality and morbidity across the lifespan and in preventing and controlling outbreaks of infectious diseases (1). Between 2010 and 2015, it is estimated that immunization efforts helped prevent over 5 million deaths annually (2). In 2012, the World Health Organization (WHO) launched the Global Vaccine Action Plan with the aim of achieving and sustaining high and equitable vaccination coverage worldwide. Despite these efforts, significant disparities in vaccine access and coverage persist between high-income countries and those with middle and low incomes, as well as within these countries themselves. These inequities continue to pose a major challenge to global public health (3). Strengthening immunization systems is essential for achieving the Sustainable Development Goals (SDGs) (4).

In the aftermath of the pandemic, two major types of gaps in vaccination coverage have emerged. First, access to and use of SARS-CoV-2 vaccines has been highly unequal. Alarmingly, in 2022 only 11% of the total population in low-income countries received the COVID-19 vaccine (5, 6). Second, the pandemic disrupted routine immunization efforts for other infectious diseases. Global coverage of national immunization programs declined from 86% in 2019 to 83% in 2020, the lowest number since 2009 (7). The regions most affected by these vaccination gaps include North Africa and the Middle East, South Asia, and Latin America and the Caribbean (8). There is the urgent need to understand the modifiable factors and mechanisms underlying vaccine inequalities, in addition to systemic challenges related to public policy, coordination, and health systems capacity to deliver vaccines (9). Other barriers have been identified—particularly the lack of trust in vaccines among socially vulnerable populations (10). Vaccine hesitancy is driven by a range of factors, including misinformation, perceived risks of adverse effects (2), and ideological opposition to vaccination (10). These concerns are often amplified in communities facing social exclusion, economic hardship, or historical marginalization (11). A sustained focus on health equity, national government commitment to immunization goals, affordable pricing, reliable supply chains, and targeted strategies to reach unvaccinated populations are all essential components of successful immunization programs (5, 6, 12).

Vaccine hesitancy among pregnant women is a persistent global challenge that undermines maternal and neonatal health outcomes. Globally, pregnant individuals exhibit lower vaccine uptake compared to the general population, primarily due to concerns about vaccine safety, lack of clinical trial data, and mistrust in health systems(13). A 2024 systematic review highlighted that misinformation—particularly via social media—has exacerbated fears about infertility, miscarriage, and congenital anomalies, especially in low- and middle-income countries (14). In Latin America, vaccine hesitancy is influenced by political instability, limited access to reliable health information, and historical distrust in public health institutions (15).

Chile, a high-income country with mixed public and private health systems, has a strong National Immunization Plan that was created in 1938. Chile’s Programa Nacional de Inmunizaciones (PNI), established in 1978, is a central component of the country’s public health strategy, offering universal and free access to vaccines for all residents, regardless of migratory or socioeconomic status(16, 17). The program has achieved significant public health milestones, including the eradication of smallpox and poliomyelitis, and the control of diseases such as measles and diphtheria (16, 17). One of the PNI’s key strengths lies in its high national coverage rates, supported by a robust logistical infrastructure and integration with maternal and child health services (18). The program is also characterized by strong institutional support and a clearly defined immunization schedule (16, 17). Despite these strengths, the PNI faces several challenges, including inequities in access among migrant populations and residents of rural or underserved urban areas (19). Vaccine hesitancy has emerged as a barrier to maintaining high coverage, especially among pregnant women (19). Additionally, gaps in communication strategies have been reported, with some users citing inconsistent or insufficient information from healthcare providers (18, 19).

Although maternal vaccine coverage is higher than in many neighboring countries, hesitancy persists due to complacency, misinformation, and inconsistent recommendations from healthcare providers (20). A qualitative review of maternal vaccine uptake in low- and middle-income countries, including Chile, emphasized the importance of health system factors such as provider trust, policy clarity, and access to antenatal care (21). A 2024 global synthesis identified that strong provider recommendations, culturally sensitive communication, and convenient access to vaccines are key facilitators of maternal immunization (22). We observed an evidence gap in knowledge related to perceived barriers to accessing vaccination among pregnant women in Chile and; hence, this unique secondary analysis of a larger study aimed to unveil experiences, barriers and facilitators to vaccination recommended by Chile’s National Immunization Program among pregnant women.

A multiple Case Study was conducted (23). This is a qualitative methodological design in which the researcher explores bounded systems through in-depth data collection. Case studies involve multiple sources of information to provide a detailed description of each case. We conducted this study in three large cities in Chile, Antofagasta (north of Chile, desertic climate with high density or migrant communities), Santiago (the largest city in the country, the capital, in the central area of the country, Mediterranean climate) and Osorno (south of Chile, marine west coast climate). The context of the study is detailed in the supplementary files. This secondary analysis if part of a larger study that aimed to understand vaccination hesitancy for multiple vaccination efforts deployed in the country, including COVID-19 and the national immunization plan strategy.

Based on theoretical and practical grounds, as well as similar to previous international studies (24, 25), the estimated initial sample size was 28. The study sample was constructed based on the priority groups defined by Chile’s National Immunization Program. We identified community leaders (n = 12) as sample seeds and from them we continued recruitment through snowballing technique. 58 pregnant women or women with toddlers (i.e., recently pregnant) were invited to participate in the study. Given the growing proportion of international migrants living in the country (around 12% of the total population (26)), we also included migrant women in the sample recruitment process. Once the sample size was achieved (n = 28, 14 Chileans and 14 international migrants), recruitment stopped. Those who declined to participate cited lack of time or interest. Field work took place between 01 January 2023 and 30 April 2024. Semi-structured interviews were held online based on a pre-defined guide and lasted for 60–90 minutes. Table 1 describes the study´s sample. Semi-structured interview guide appears in supplementary files.

Table 1
Description of study sample
Pregnant Woman / Woman with toddlers (0–18 months)	N	%
	28	100
City
Antofagasta	9	32%
Santiago	9	32%
Osorno	10	36%
Sex
Female	28	100%
Age
19–30	13	46%
31–40	13	46%
41–50	2	7%
Nacionality
chilean	14	50%
migrant	14	50%
Health System
Public Health System	21	75%
Private Health System	7	25%

Interviews were audio recorded and transcribed verbatim into a Word document and subsequently analyzed thematically, following the guiding categories outlined in the interview script, while also allowing for the emergence of new categories based on participants’ narratives. Random revisions were conducted by a second research team member to over a third of transcriptions to secure quality. Selected quotes were translated to English for publication aims and double-checked by an independent team member who was fluent in academic English writing. To ensure the credibility and reliability of the study, the following rigor criteria were applied: (i) Participant triangulation: findings were triangulated across different study participants to enhance the robustness of the analysis. (ii) Reflexivity: the research team engaged in continuous discussion and reflection on preliminary findings as data collection progressed, in order to deepen thematic insights and enrich the analysis and presentation of results. Data saturation was achieved at 30 interviews for the dimensions of: general perception of the immunization plan, barriers and facilitators.

This study was funded by the MSD Grant Global Health Equity Catalyst Fund. The project was approved by the Scientific Ethics Committee of the Faculty of Medicine Clinica Alemana, Universidad del Desarrollo (#2023-02).

General perceptions about the National Immunization Plan

There was consensus among interviewees that the country has a very strong immunization program. It is noted that there is broad coverage, without restrictions, with a “wide set” of vaccines available, and that the vaccination process is easily accessible and free of charge. This is further supported by the perception that Chile has an established “vaccination culture” and that people are generally “compliant” with the national immunization plan.

“I think it's easy to access vaccines in Chile. There's a super strict, controlled plan for which vaccines you should get throughout your life. And that information is readily available, and it's easy to access that vaccine” (Chilean Woman 14, Osorno, Public Health System).

The vast majority expressed that Chile has a very strong immunization program in comparison to other countries. International migrants considered that Chile’s vaccination plan is significantly more comprehensive and accessible than those in their countries of origin and other Latin American countries. Interviewees particularly highlighted the limited availability of vaccines in their home countries, often in the context of overwhelmed health systems.

“There [in Peru] almost no one has insurance, but here they do. Here they vaccinate everyone, whether Chilean or foreign, everyone, if they have to, even if you don't have a visa, even if you're illegal, it doesn't matter, we'll vaccinate you anyway, and that's good” (Migrant Woman 1, Antofagasta, Public Health System).

It is mentioned that the vaccination plan has evolved: new vaccines have been incorporated or some older ones have been “updated,” and booster doses for certain diseases have been added or increased. As part of this “updating” of components, several people mention that current vaccines cause fewer skin reactions and leave less scarring than those administered a few decades ago. In addition to the integration of new vaccines (including the COVID-19 vaccine), the administration of vaccines considered “seasonal,” such as the influenza vaccine, is perceived to have been “intensified.”

“I believe there are more vaccines, especially because there are more influenza vaccines, which are boosters, and also Covid vaccines, so there is more monitoring (…)” (Migrant Woman 5, Antofagasta, Public Health System).

Perceptions of the vaccination plan in pregnant women

Positive perceptions are identified, primarily stemming from trust in the effectiveness of vaccines and the belief that they provide protection against disease. The perceived importance of vaccination is often reinforced by personal experiences—or those of close acquaintances—with illnesses that are now preventable through immunization. Trust in vaccines is further supported by accounts of individuals close to the respondents who did not experience adverse effects following vaccination during pregnancy.

“At no time was I afraid, let's say, about the vaccines, because I always did everything the gynecologist told me, the tests and everything, so I didn't feel like it was something that could put me or the baby at risk, because from the moment they told me it was a vaccine that I had to receive while I was pregnant, I said 'everyone does it, I mean, everyone, I'm not going to be the first,' and then talking to pregnant friends, of course, they were receiving them, they already had them and nothing had happened to them, so I was kind of calm about that” (Chilean Woman 1, Antofagasta, Private Health System).

Individuals who exhibit a more passive adherence to vaccination generally perceive vaccination during pregnancy as a procedural requirement, rather than an emotionally significant experience. They tend not to associate the process with strong feelings. Conversely, those who express concerns about potential adverse effects of vaccines report experiencing fear.

“I got vaccinated without thinking too much about it. What I do remember is that throughout the vaccination process during pregnancy, I felt a bit of fear. I wasn’t sufficiently informed to understand why I was getting vaccinated. The doctor didn’t guide me much through the process. And when I started to do my own research, it was like, ‘What am I doing?’ But I thought, ‘I have to do it,’ and I didn’t question it much. Still, I got vaccinated during pregnancy with a lot of fear” (Chilean Woman 13, Osorno, Public Health System).

Among pregnant or recently pregnant women who identified themselves as adherent to vaccination, the vaccines most frequently mentioned were Influenza, COVID-19, and Tdap. Although the Tdap vaccine protects against diphtheria, tetanus, and pertussis, it is most commonly recalled simply as the “pertussis” or “whooping cough” vaccine. The vast majority of participants reported being unaware of the Tdap vaccine prior to pregnancy. It was primarily during prenatal care visits—both in public and private healthcare settings—that they learned about its existence and importance.

“I mean, if the midwife hadn't told me, I think it was in a good way, just like last time, I would have never had any idea that I had to get vaccinated against whooping cough. No... I didn't even know that whooping cough existed.” (Migrant Woman 8, Santiago, Public Health System)

Cases in which women reported not having been vaccinated during pregnancy correspond to those who initiated antenatal care late or were in transit between countries during their pregnancy. The vast majority mentioned public or private health centers or vaccination clinics, with one reference to mobile health campaigns in Antofagasta.

Barriers, facilitators and recommendations for improvement

Participants mentioned five types of barriers to accessing vaccination in Chile. First, they referred to problems related to vaccine information. The public health system is perceived as delivering incomplete information, with a sense that there is no interest in providing information. In contrast, the private healthcare system is generally trusted to provide all the necessary information.

“If it's not through your gynecologist, I think that if... There is no other area, or there is no other channel that informs you that you have to get the vaccine (...) I have not seen other channels, other than, if it is a person who is interested and to look it up through the Ministry, or to look for the calendar, but I don't know if the entire population is very attentive to vaccines and when each person's turn comes” (Chilean Woman 5, Santiago, Private Health System).

Second, barriers related to potential adverse effects were identified as a barrier to attending prenatal health check-ups. Third, some women reported negative experiences and reported some cases of disrespectful or neglectful treatment when attending to antenatal controls.

“It has happened to me that they see you and everything is quick and then they weigh you, measure you and everything. It's like you feel vulnerable. Well, that's how I felt when I went to the doctor's office and I felt like that, like... I didn't like how they treated me. It's like they push you around... You know, we're people, but they don't see that... Because, yes, they have more education, they have studies, but they should be humbler. Especially with pregnant women, who are more, uh... prone to crying, we get more sentimental... But they don't care about that" (Chilean Woman 8, Santiago, Public Health System).

The fourth perceived barrier to accessing vaccination plans are related to social vulnerability and lack of social support. Economic constraints were identified as a barrier to attending health check-ups, along with the lack of support networks for childcare and the inability to take time off work. The fifth and final barrier had to do with participants reporting unique barriers faced by migrant women in the country, mostly related to (i) lack of familiarity with the Chilean healthcare system, (ii) limited information about vaccines administered in the country of origin or during transit, (iii) delayed initiation of antenatal care, (iv) administrative barriers to accessing healthcare services, (v) experiences of discrimination and xenophobia, and (vi) transitions to the private healthcare system in search of respectful treatment

“When I was pregnant, it depended on the person I was assigned to see whether I was treated. Sometimes they would see me, but other times I would get a person who would say no, ask for my papers, and put up a thousand obstacles to not accepting me while I was pregnant, feeling unwell (…)” (Migrant Woman 7, Santiago, Public Health System).

Facilitators of vaccination access in Chile, as reported by participants, include timely and comprehensive access to information, free provision of vaccines, and preferential care at health centers. The availability of vaccines was particularly emphasized by women. Additional facilitators include workplace permissions and accommodations, with some participants affirming that “vaccination is a right.” For migrant women included in this study, universal access to healthcare—without the need for a provisional national ID number (RUT)—was highlighted as a key enabler of vaccination during pregnancy.

"The speed, the attention, and the availability of vaccines. There are times when other places don't have them, but here I really can't complain, because during my pregnancy, all the vaccines were available. You arrive, get the number, and they'll see you immediately." (Migrant Woman 7, Santiago, Public Health System)

“I arrived pregnant, I registered, and they already gave me my RUT number. But even before they gave me my RUT number, they had already seen me because it was due to the pregnancy (…)” (Migrant Woman 9, Santiago, Public Health System).

Finally, three main recommendations appeared from participants: (i) to strengthen access to quality and timely information about the vaccination plan in Chile, especially during pregnancy, (ii) improve patient-provider interactions and communication and the way pregnant women are treated, and (ii) train healthcare workers about health rights of migrant pregnant women in the country, including translated information packs for this population residing in the country.

"I think for pregnant women, more information, because I had no idea what I could access or what my health rights were. And for those of us who have breastfeeding children and are pregnant, I insist on having information in other languages, like Creole for Haitians" (Migrant Woman 8, Santiago, Public Health System).

Our study aimed to unravel experiences and perceptions from the perspective of pregnant women, both Chileans and international migrants, about vaccination schemes during pregnancy in Chile. Our findings suggest that there is an established vaccination culture and that people are generally compliant with the national immunization plan. We also found a number of perceived barriers and facilitators to accessing vaccines, which are from the provider and the demand sides, as well as the interaction between the two parts. Our findings are consistent with the international evidence. Low compliance with maternal vaccination schedules remains a significant public health concern both globally and in Latin America. Research indicates that vaccine hesitancy—often rooted in misinformation, fear of adverse effects, and concerns about fetal safety—is a primary barrier to uptake among pregnant women (27, 28). These fears are frequently exacerbated by limited access to reliable health information, particularly in underserved populations such as migrants and rural communities (29). In Latin America, structural challenges including fragmented health systems, inconsistent communication from healthcare providers, and logistical barriers to accessing prenatal care further hinder vaccination adherence (30). Socioeconomic factors, such as unstable employment, lack of childcare support, and transportation difficulties, also contribute to missed opportunities for immunization (31). Addressing these multifaceted barriers requires integrated strategies that combine culturally sensitive education, improved provider-patient communication, and systemic reforms to ensure equitable access to maternal vaccines.

This study contributes to existing public health research and policy. In Chile, qualitative research on vaccine hesitancy among pregnant women remains limited, despite growing global evidence highlighting the complexity of maternal decision-making regarding immunization (32). However, in the Chilean context, there is a notable gap in understanding how factors like migration status and regional disparities shape vaccine perceptions and behaviors during pregnancy (33). Addressing these gaps requires investment in locally grounded, interdisciplinary research that engages pregnant women as co-creators of knowledge and policy solutions. Policy implications of this study are related to the lack of culturally and contextually grounded research calls for the integration of participatory approaches in health policy design, ensuring that interventions reflect the lived experiences of diverse populations, including indigenous and migrant women (33). Also, policies should strengthen the role of primary care providers as trusted sources of vaccine information, supported by training in culturally sensitive communication and shared decision-making (34).

This qualitative study offers valuable insights into the complex and context-specific factors influencing pregnant women's hesitancy toward vaccination, particularly by capturing personal narratives, cultural beliefs, and emotional responses that quantitative methods may overlook. Through in-depth interviews and thematic analyses, we could explore nuanced perceptions of risk and trust in healthcare systems (20). However, this study has a relatively small sample size, facing limitations in generalizability and may not adequately represent the diversity of experiences across different socioeconomic, ethnic, or geographic groups of pregnant women that reside in the three cities included in this study (35). Additionally, findings may be influenced by selection bias, as these women were recruited through snowballing technique. Despite these constraints, this qualitative study shed light on current understanding of vaccination perceptions and barriers among pregnant women in Chile, hence remaining essential for hypothesis generation and for informing culturally sensitive interventions, especially in under-researched populations (20). Moreover, this analysis fills a gap in the pressing need for qualitative research that incorporates the voice of pregnant women, especially among some marginalized groups such as migrants, who often face compounded barriers to vaccine access and acceptance (20). Future research should prioritize longitudinal designs, participatory methodologies, and culturally tailored interventions to better inform practice and policy.

This study demonstrates that, despite widespread recognition of Chile’s immunization program as robust and internationally acclaimed, a closer examination of maternal vaccination reveals persistent barriers and challenges in access. Although the national system offers broad coverage, free provision, and nominal accessibility, low adherence among pregnant women is primarily driven by structural and relational factors. These include insufficient and untimely information, concerns about adverse effects, inadequate interpersonal treatment within healthcare settings, and socioeconomic vulnerability. For migrant women, additional barriers emerge, such as limited knowledge of the healthcare system, administrative obstacles, experiences of discrimination, and delayed initiation of prenatal care. Nevertheless, the policy of universal access to vaccination—without requiring a tax identification number—serves as a significant facilitator.

Our findings highlight the urgent need for structural reforms and integrated strategies aimed at enhancing information dissemination, strengthening communication between healthcare providers and users, and fostering culturally sensitive care. This research provides critical qualitative evidence to inform the development of more equitable and inclusive maternal vaccination policies.

WHO

World Health Organization

SDGs

Sustainable Development Goals

PNI

Chile´s National Immunization Plan

Tdap

Diphtheria, Tetanus, and Pertussis Vaccine

Ethics approval and consent to participate

This study was conducted in accordance with the appropriate guidelines and regulations for research involving human beings, including the Declaration of Helsinki. It received approval from the Scientific Ethics Committee at Universidad del Desarrollo (#2023-02) before its execution. All participants read and signed an online informed consent.

Consent for publication

Not applicable.

Availability of data and materials

The data supporting this study's findings are available on request from the corresponding author, A.O. However, the data are not publicly available due to participants confidentiality.

Competing interests

The authors declare that they have no competing interests. The entire study was conducted independently by the research team at UDD.

Funding

This study was funded by MSD Equity grant, which has applied to and granted by an external reviewing committee.

Author contributions

All authors contributed to the investigation, validation, visualization, and editing of the manuscript. Authors BC, AO, and AC were responsible for the conceptualization. Authors BC, AO, MS, and AB contributed to the methodology. Formal analysis was conducted by Authors BC, AO, and MS, while data curation was managed by Authors AO, PM, MS, and SB. Project administration was overseen by Authors BC, AO, PM, AC, and SB, with supervision provided by Authors BC, AO, AC, and SB. Funding acquisition and resource management were handled by Authors BC and AO, and the original draft was prepared by Authors BC, AO, and PM.I certify that this manuscript represents an original work and that it, or another work with substantially similar content by me, has not been published, in parts or completely, nor is it being considered for publication by another journal, be it in print or digital publications.

Acknowledgements

We acknowledge all study participants for their time and generosity.

The final version of the manuscript went through final grammar revision and editing in Grammarly software.

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No competing interests reported.

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Perceived Barriers to Pregnancy Vaccination Plans in Chile: A Qualitative Analysis

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Version 1

Abstract

Background

Methods

Results

Conclusions

CONTRIBUTION TO THE LITERATURE

BACKGROUND

METHODS

RESULTS

General perceptions about the National Immunization Plan

Perceptions of the vaccination plan in pregnant women

Barriers, facilitators and recommendations for improvement

DISCUSSION

CONCLUSIONS

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1