*Article* **Vaccine Hesitancy in Women of Childbearing Age and Occupational Physicians: Results from a Cross-Sectional Study (Italy, 2022)**

**Matteo Riccò 1,\*, Antonio Baldassarre 2, Milena Pia Cerviere <sup>3</sup> and Federico Marchesi <sup>4</sup>**


**Abstract:** Italian occupational physicians (OPs) are instrumental in promoting vaccination practice in occupational settings, and this study aims to characterize their attitudes, knowledge, and practices (collectively, KAP) towards immunization practice in women of childbearing age. A convenience sample of 120 OPs (50.8% males, mean age of 48.2 ± 5.9 years old) completed a structured online questionnaire (potential recipients: 2034; response rate: 5.9%) assessing their understanding of official recommendations, their general knowledge of vaccine practice, their attitudes towards vaccines, and their risk perception about vaccine-preventable infectious diseases. The sampled OPs exhibited a good understanding of official recommendations, and they were largely favorable towards vaccination of pregnant women. Knowledge status was relatively good (potential range 0 to 100%, average score 22 74.5% ± 18.2), while risk perception towards sampled disorders was heterogenous: the greatest was the one for SARS-CoV-2 (52.7% ± 32.9), followed by seasonal influenza (45.3% ± 31.6), and pertussis (37.8% 24 ± 28.2). The main predictors for promoting vaccination were higher knowledge about seasonal influenza vaccine (SIV; adjusted Odds Ratio [aOR] 102.2, 95% Confidence Interval [95%CI] 9.68–1080.26), tetanus-diphtheria-acellular pertussis vaccine (Tdap; aOR 12.34, 95%CI 2.62; 58.22) 27 and SARS-CoV-2 vaccine (aOR 14.76, 95%CI 2.74–79.69). A better attitude towards SIV was positively associated with previous vaccination of the respondent (aOR 4.90, 95%CI 1.19–20.14), while higher risk perception towards SIV was characterized as a negative predictor (aOR 0.04, 95%CI 0.01–0.35), as was working as an OP in healthcare facilities (aOR 0.03, 95%CI 0.01–0.43). Tdap was positively associated with male gender of respondents (aOR 10.22, 95%CI 2.60 to 40.24) and higher risk perception about pertussis (aOR 10.38, 95%CI 1.47 to 73.47). Overall, our data suggest that improving the understanding of OPs about the health burden of frequently encountered pathogens could be instrumental in increasing their involvement in the promotion of vaccine practice. Because of the low rate of response to our survey, our conclusions remain tentative.

**Keywords:** pregnant women; vaccine-preventable diseases; knowledge; attitudes; practices; risk perception

#### **1. Introduction**

Where implemented by the national legal framework, occupational physicians (OPs; please refer to Table A1 for a full summary of acronyms) are the medical professionals responsible for health surveillance and promotion across the workplaces [1,2]. Well before the inception of the SARS-CoV-2 pandemic, Italian OPs were actively involved in the implementation of specifically tailored preventive measures against biological risk factors [3–5], including prescription and/or delivery of appropriate vaccinations [2,6]. Not coinciden-

**Citation:** Riccò, M.; Baldassarre, A.; Cerviere, M.P.; Marchesi, F. Vaccine Hesitancy in Women of Childbearing Age and Occupational Physicians: Results from a Cross-Sectional Study (Italy, 2022). *Women* **2023**, *3*, 237–262. https://doi.org/10.3390/ women3020019

Academic Editors: Claudio Costantino, Maiorana Antonio, Mary V. Seeman and Maria Grazia Porpora

Received: 31 December 2022 Revised: 8 April 2023 Accepted: 4 May 2023 Published: 6 May 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

tally, Italian OPs have been extensively involved in the implementation of SARS-CoV-2 vaccination campaigns [7].

Pregnant women may be exposed to various pathogens, including "conventional" ones such as seasonal and pandemic influenza, pertussis, measles, and rubella [8–10], and emerging ones such as Flaviviridae (e.g., Zika virus) [11–13], and most notably SARS-CoV-2 [14–20] not only as healthcare workers (HCWs) but also in settings such as forestry, zootechny, food, veterinary, biotechnology, treatment and waste disposal. Their exposure and contact with highly dangerous agents are associated with an increased risk of morbidity, mortality, and adverse pregnancy outcomes [21–24].

Consequently, the implementation of properly tailored immunization policies among female workers of childbearing age could represent a substantial duty for OPs [25–29]. Notably, since 2017, the Italian National Immunization Plan (NIP) recommends the vaccination of pregnant women with the pertussis vaccine, included in the trivalent formulation tetanus-diphtheria-acellular pertussis (Tdap) vaccine between the 27th and the 36th week of every pregnancy, regardless of prior Tdap history [30,31]. Similarly, Seasonal Influenza Vaccine (SIV) should be delivered at any stage of the gestational period as a preventive intervention targeting both the recipient and the offspring [30–33]. In both cases, the role of OPs in improving vaccination rates among female workers from high-risk settings (e.g., HCW) has been specifically stressed by official Italian guidelines [9,18,34–39]. Unfortunately, coverage rates for recommended vaccinations, including SIV and Tdap, among pregnant women remain very low [27,28,32,33,40–42].

Even SARS-CoV-2 vaccines have been recently addressed by official recommendations that support their delivery in pregnant women. While initially recommended for breastfeeding mothers and pregnant women at higher risk of exposure to the virus or at greater risk of developing a severe illness, since the second half of 2021, SARS-CoV-2 mRNA vaccines have been extended to all pregnant women in their second and third trimester who wish to be vaccinated [43–48]. More precisely, national vaccination guidelines prioritize women at greater risk of contracting SARS-CoV-2 infection because of their occupational exposures (e.g., HCWs) and/or at greater risk of developing severe COVID-19 disease (women with risk factors such as age >30 years, BMI >30, comorbidities, women from countries where the migration pressure is high) [43–45].

In such a setting, the role of OPs may be of particular interest, as they could contribute to the promotion of recommended vaccination in working age groups, which in women largely coincide with childbearing age. Unfortunately, previous studies have reported a high occurrence of false beliefs about vaccinations and a lack of knowledge about national vaccination policies among Italian OPs [2,6,46,47]. Interestingly, similar shortcomings have been reported also in other national settings [1,20,48].

As a consequence, the main endpoint of this study was to assess knowledge (how much the respondents understand a certain topic), attitudes (that is the feelings of sampled individuals towards the assessed subject, as well as any preconceived ideas they may have towards it), and practices (the ways in which they demonstrate their knowledge and attitude through their actions; collectively, KAP) of a sample of OPs about vaccinations and vaccination policies in women of childbearing age and pregnant women. The understanding of general and specific recommendations was specifically focused on, as well as how the KAP of sampled professionals related to these recommendations. Our results may contribute to identifying areas that may be potentially targeted by specific informative and educative campaigns dedicated to OPs.

#### **2. Results**

#### *2.1. Descriptive Analysis*

As reported in Figure 1, a total of 120 OPs (5.9% of the original population of 2034 OPs) participated in the inquiry.

Overall, 50.8% of the participants were of the male gender, and their mean age was 48.2 ± 5.9 years (30.0% aged 50 years old or more), with average seniority as OPs of 16.3 ± 10.1 years (75.0% of them, with a seniority of 10 years or more). Of these, the large majority had offspring (86.7%) and worked as OPs in healthcare facilities (71.7%) (Table 1).

**Table 1.** Characteristics of the 120 Italian occupational physicians who participated in the present survey (Italy, 2022).


#### *2.2. Assessment of Knowledge Status*

Knowledge status was assessed by means of a series of 25 true–false questions, whose internal consistency was good (Cronbach's alpha = 0.873). After percent normalization, the corresponding cumulative score (general knowledge score, or GKS) was generally high (74.5% ± 18.2; actual range 28.6–100%; median 78.6%). A skewed distribution was identified at visual inspection (Figure 2), and the Gaussian distribution was rejected by the D'Agostino–Pearson test (K2 = 22.17, *p* < 0.001).

**Figure 2.** Density plots on general knowledge score (GKS) for participants fulfilling all inclusion criteria (No. 120, 5.9% of the original sample). Average GKS was estimated to be 74.5% ± 18.2 (actual range 28.6–100%; median 78.6%), with a non-Gaussian distribution as confirmed by D'Agostino– Pearson test (K2 = 22.17, *p* < 0.001).

Detailed results of the knowledge test are reported in Table A2. More precisely, substantial uncertainties were associated with items represented by Q19, as only 37.5% of respondents were aware that no RSV vaccine has been to date commercially made available; and Q23, as only 47.5% of participants had any understanding that mRNA vaccines against SARS-CoV-2 vaccines can be employed also in women with a previous history of deep vein thrombosis. Interestingly, even though a large share of participants had a proper understanding of official recommendations that allow the use of vaccines in pregnancy (Q16, 91.7%), similar knowledge gaps affected the recommendations for the delivery of the Tdap vaccine to all pregnant women (Q15, 54.2%) and for avoiding live-attenuated vaccines in pregnancy (Q17, 54.2%).

Moreover, a substantial share of participants exhibited some uncertainties regarding the role of vaccine additives in human health (Q01, 66.7% of correct answers) and the potential resurgence of secondary cases with epidemic potential after vaccinations with liveattenuated vaccines (Q21, 67.5%). Around a third of respondents also exhibited knowledge gaps about the potential vaccine-related induction of encephalitis lethargica (Q04, 66.7%), subacute sclerosing panencephalitis (Q03, 67.5%), and autoimmune Hashimoto's thyroiditis (Q06, 63.3%). Conversely, the large majority of participants properly acknowledged the efficacy of vaccines (Q11), understood the role of smallpox vaccination in the progressive eradication of the pathogen (Q10; 95.8% for both statements), and correctly reported that tetanus vaccination should be delivered in all adults every 10 years (Q18, 91.7%). The large majority of respondents also agreed on the lack of secondary effects of childhood immunization on their resistance to infectious diseases (Q12, 93.3%), and that vaccines do not increase the risk of developing autism (Q07, 91.7%), being of substantial value in promoting the control of infectious disease (Q09, 91.7%).

#### *2.3. Risk Perception*

Risk perception scores (RPS) for natural infections and vaccine-related side effects were calculated as the mathematical product of perceived severity (potential range 0 to 5) and perceived incidence (potential range 0 to 5) of the assessed condition (Figures A1 and A2). Briefly, the greatest RPS on natural infections was associated with SARS-CoV-2 (52.7% ± 32.9), followed by rubella (50.3% ± 26.7), varicella (49.4% ± 27.6), seasonal influenza (45.3% ± 31.6), measles (41% ± 26.3), parotitis (40.8% ± 27.5), pertussis (37.8% ± 28.3), hepatitis B (35.1% ± 22.0), diphtheria (27.6% ± 23.3), and tetanus (26.6% ± 22.3).

By arbitrarily assuming seasonal influenza as the reference group, the difference between reported RPS was significant only for tetanus (mean difference in favor of seasonal influenza, 18.71, 95%CI 9.31 to 28.11, *p* < 0.001), diphtheria (mean difference 17.71, 95%CI 8.31 to 27.11, *p* < 0.001), and hepatitis B (mean difference 10.21, 95%CI 8.11 to 19.61, *p* = 0.026) (Table A3). When dealing with reported side effects of vaccinations, the greatest RPS was associated with varicella (25.5% ± 25.7), followed by rubella (21.8% ± 22.4), SARS-CoV-2 immunizations with adenovirus carrier (19.9% ± 19.8), parotitis (19.5% ± 20.0), measles (18.4% ± 19.9), SARS-CoV-2 vaccines based on the mRNA technology (15.7% ± 19.4), hepatitis B vaccine (15.3% ± 16.2), and SARS-CoV-2 vaccines based on the subunit technology (15.2% ± 16.1), while lower estimates were associated with pertussis (13.0% ± 17.0), SIV (12.1% ± 15.0), diphtheria (12.1% ± 16.6), and tetanus (11.4% ± 15.3). When SIV was taken as the reference group, the difference was significant for parotitis (mean difference −7.39, 95%CI −14.09 to 0.70, *p* = 0.022), rubella (mean difference −9.67, 95%CI −16.36 to −2.97 *p* = 0.001), varicella (mean difference −13.33, 95%CI −20.03 to −6.64, *p* < 0.001), and SARS-CoV-2 performed through adenovirus carriers (mean difference −7.79, 95%CI −14.49 to 1.10, *p* = 0.013) (Table A4).

#### *2.4. Attitudes towards Vaccination*

When participants were asked about the perceived barriers towards vaccination of pregnant women (Table 2), the most frequently reported one was the inappropriate risk perception by pregnant women (83.3%), followed by their appropriate understanding of official recommendations (79.2%), the fear of side effects (70.8%), the inappropriate understanding of official recommendations by medical professionals (62.5%). Moreover, 45.9% of participants claimed that other medical professionals may not perceive maternal vaccinations as a priority and that vaccination services may be scarcely available given the specificities of pregnant women (37.5%). Only 12.5% of participants reported any complaints about the high costs of vaccines.

**Table 2.** Perceived barriers towards vaccinations of pregnant women as reported by 120 Italian occupational physicians (Italy, 2022).


Overall, the majority of participants recommended any of the SARS-CoV-2 vaccines (i.e., mRNA, subunit, or adenovirus-based formulates) in women of childbearing age (74.2%), followed by Tdap (70.8%), SIV (66.7%), and hepatitis B virus vaccine (54.2%) (Table 3). On the contrary, less than 50% of participants actively recommended MPR (45.8%), and varicella (41.7%) immunizations.


**Table 3.** Vaccinations actively recommended for women of childbearing age by 120 Italian occupational physicians (Italy, 2022).

When participants were asked about their vaccination status (Table 4), 91.7% of them had received a full course for SARS-CoV-2, while 71.7% of them had been reportedly vaccinated against HBV, 65.8% against SIV (at least one time in the previous 5 years). Moreover, 63.3% had received MPR, 61.7% Tdap, and only 16.7% varicella (either in a tetravalent immunization or as an individual vaccination).

**Table 4.** Vaccination status self-reported by 120 Italian occupational physicians (Italy, 2022).


Notes: (1) at least 1 time in the previous 5 years; (2) at least 1 vaccination shot in the previous 10 years; (3) at least 1 vaccination shot in the previous 10 years, or documented antibody titer as >10 UI/mL.

#### *2.5. Univariate Analysis*

Overall, a positive correlation between GKS and RPS was identified for the majority of infections reported to the participants, and more precisely: seasonal influenza (r = 0.341, *p* < 0.001), pertussis (r = 0.200, *p* = 0.028), measles (r = 0.356, *p* < 0.001), parotitis (r = 0.238, *p* = 0.009), varicella (r = 0.196, *p* = 0.032), hepatitis B virus (r = 0.406, *p* < 001), and SARS-CoV-2 (r = 0.428, *p* < 0.001). In other words, a better understanding of vaccine-related issues was associated with a greater risk perception of the aforementioned disorders, and vice versa (Table A5).

Conversely, SIV (r = −0.352, *p* < 0.001), vaccines for diphtheria (r = −0.450, *p* < 0.001), tetanus (r = −0.367, *p* < 0.001), pertussis (r = −0.379, *p* < 0.001), hepatitis B virus (r = −0.191, *p* = 0.037), as well as SARS-CoV-2 vaccines based on mRNA (r = −0.354, *p* < 0.001), adenoviral carriers (r = −0.314, *p* < 0.001), and subunit technology (r = −0.314, *p* < 0.001), were negatively correlated with RPS, and a positive correlation between GKS and RPS was only reported for SARS-CoV-2 vaccines based on adenovirus carriers (r = 0.239, *p* < 0.009). Therefore, a better GKS meant a reduced risk perception of side effects following the delivery of SIV, and vaccinations against diphtheria, tetanus, pertussis, hepatitis B virus, and SARS-CoV-2 based on mRNA and subunit technology, while individuals exhibiting a better knowledge status were more frequently concerned about SARS-CoV-2 vaccines based on adenovirus carriers. Moreover, as shown in Figure 3, participants recommending the uptake of SIV, Tdap, and SARS-CoV-2 vaccines consistently had greater GKS compared to those who did not (i.e., SIV 81.7% ± 12.4 vs. 60.1% ± 19.5, Mann–Whitney [M-W] U = 2725.0, *p* < 0.001; Tdap 80.0% ± 14.4 vs. 61.3% ± 19.9, M-W U = 2458.0, *p* < 0.001; SARS-CoV-2 79.4% ± 14.3 vs. 60.6% ± 21.1, M-W U = 2194.5, *p* < 0.001).

**Figure 3.** Density plots on General Knowledge Score (GKS). Estimates were broken down by the reported attitude towards the following vaccinations: (**a**) SIV (Seasonal Influenza Virus), (**b**) Tdap, and (**c**) SARS-CoV-2. Briefly, estimates were substantially greater among individuals reporting a positive attitude than among those not recommending the assessed vaccination (i.e., SIV 81.7% ± 12.4 vs. 60.1% ± 19.5, Mann–Whitney [M-W] U = 2725.0, *p* < 0.001; Tdap 80.0% ± 14.4 vs. 61.3% ± 19.9, M-W U = 2458.0, *p* < 0.001; SARS-CoV-2 79.4% ± 14.3 vs. 60.6% ± 21.1, M-W U = 2194.5, *p* < 0.001).

When the outcome variables of actively promoting SIV, Tdap, and SARS-CoV-2 vaccines were compared to the individual characteristics of respondents (Table 5), a positive attitude towards SIV was positively associated with a better knowledge status (55.0% of individuals reporting a favorable attitude versus 7.5% among those not favorable to the reported vaccine, *p* < 0.001), having been previously vaccinated against seasonal influenza (82.5% vs. 32.5%, *p* < 0.001), and reporting higher RPS on influenza (62.5% vs. 25.0%, *p* < 0.001). On the contrary, working as an occupational physician in healthcare facilities (63.7% vs. 87.5%, *p* = 0.012) and reporting higher RPS on the vaccine (25.0% vs. 75.0%, *p* < 0.001) were more frequently reported among individuals not favorable to the vaccine than among those promoting the intervention.

**Table 5.** Association between the individual attitude towards seasonal influenza vaccine (SIV), diphtheria, tetanus, and pertussis formulate (Tdap), and SARS-CoV-2 vaccination among 120 Italian occupational physicians (Italy, 2022). Note: RPS = risk perception score.




Similarly, a positive attitude toward the Tdap vaccine was positively associated with male gender (58.8% vs. 31.4%, *p* = 0.011), reporting a higher knowledge status (51.8% vs. 8.6%, *p* < 0.001), and having a higher RPS on diphtheria (52.9% vs. 14.3%, *p* < 0.001) and pertussis (64.7% vs. 14.3%, *p* < 0.001), while it was negatively associated with higher RPS on tetanus vaccine (17.6% vs. 42.9%, *p* = 0.008).

A favorable attitude towards SARS-CoV-2 vaccine was negatively associated with belonging to older age groups (22.5% among respondents of 50 years or more vs. 51.6% of respondents not favorable to SARS-CoV-2 vaccines) and reporting higher RPS on mRNA (38.2% vs. 67.7%, *p* = 0.008) and adenoviral (43.8% vs. 67.7%, *p* = 0.037) SARS-CoV-2 vaccines. Conversely, having a better knowledge status (50.6% vs. 6.5%, *p* < 0.001), and having been vaccinated against SARS-CoV-2 were positively associated with a favorable attitude (98.9% vs. 71.0%, *p* < 0.001).

#### *2.6. Multivariable Analysis*

Multivariable analysis was modeled including the variables that in univariate analysis were significantly associated (*p* < 0.05) with the active promotion among female workers of childbearing age of SIV (Model 1), Tdap (Model 2), and SARS-CoV-2 vaccines (Model 3), and more precisely (Table A6):


As shown in Table 6, a favorable attitude towards SIV was more frequently reported among participants exhibiting a better knowledge status (adjusted Odds Ratios [aOR] 102.24, 95% Confidence Interval [95%CI] 9.68 to 1080.26), and having been vaccinated against SIV (aOR 4.90, 95%CI 1.19 to 20.14). On the contrary, it was less frequently reported by participants who reportedly worked as OPs in healthcare facilities (aOR 0.03, 95%CI 0.01 to 0.43) and who reported higher RPS on the vaccine (aOR 0.04, 95%CI 0.01 to 0.35).

**Table 6.** Multivariable analysis of factors associated with a better individual attitude towards seasonal influenza vaccine (SIV), diphtheria, tetanus, and pertussis formulate (Tdap), and SARS-CoV-2 vaccination among 120 occupational physicians participating in the survey. The assessed models included the favorable attitude towards the individual vaccine as the outcome variable, and assessed as explanatory variables all factors that in univariate analysis were associated (*p* < 0.05) with the corresponding outcomes.


Similarly, a better knowledge status was associated with a favorable attitude towards SARS-CoV-2 vaccine (aOR 14.76, 95%CI 2.74 to 79.69), while male gender of respondents (aOR 10.22, 95%CI 2.60 to 40.24), scoring a GKS > median value (aOR 12.34, 95%CI 2.62 to 58.22), and higher risk perception of pertussis (aOR 10.38, 95%CI 1.47 to 73.47) were characterized as explanatory variables for a positive attitude towards Tdap.

#### **3. Discussion**

In our cross-sectional study, we assessed the KAP of a small sample of Italian OPs (120 respondents in total) about vaccinations and vaccination policies in female workers of childbearing age. As HCWs, OPs can reasonably represent a model for the general population, but because of their exclusive role in the occupational settings, they are also potentially instrumental in overcoming vaccine hesitancy (delay in acceptance or refusal of vaccines irrespective of their actual availability) [49–51] across workplaces and in high-risk occupational groups [52]. Consequently, when OPs improperly share

false beliefs among the workers they care for, they may even become detrimental to the global efforts to achieve and maintain high vaccination rates, not only for "new" vaccines such as SARS-CoV-2 [1,2,36,53] but also for more conventional ones such ad Tdap and SIV [36,48,54,55]. In our study, the majority of respondents exhibited a relatively good performance on the knowledge test (74.5% ± 18.2) and a somehow discrete positive attitude towards SIV (66.7%), Tdap (70.8%), and SARS-CoV-2 (74.2%). It is often believed that the attitudes towards vaccines of medical professionals (including OPs) should not be negative and that they cannot be affected by substantial vaccine hesitancy. Even though these results are obviously desirable, they cannot be taken for granted [17,56–58].

In our study, the aforementioned vaccinations were associated with quite distinctive predictive variables. On the one hand, a better knowledge status was consistently characterized as a predictive variable (aOR 12.34, 95%CI 2.62 to 58.22 for Tdap, aOR 14.76, 95%CI 2.74 to 79.69 for SARS-CoV-2), particularly for promoting SIV (aOR 102.24, 95%CI 9.68 to 1080.26). On the other hand, the promotion of assessed vaccines was associated with the self-reported immunization of the respondents only for SIV (aOR 4.90, 95%CI 1.19 to 20.14). In this regard, participants working as OPs for healthcare facilities and reporting higher RPS towards the vaccine exhibited a negative attitude towards the promotion of SIV among female workers of childbearing age (aOR 0.03, 95%CI 0.01 to 0.43 and aOR 0.04, 95%CI 0.01 to 0.35, respectively). On the contrary, a positive attitude to Tdap was positively associated with male gender (aOR 10.22, 95%CI 2.60 to 40.24) and higher risk perception of pertussis infection (aOR 10.38, 95%CI 1.47 to 73.47).

Our estimates are therefore somewhat consistent with most of the available KAP studies on immunizations [2,6,7,29,33,53,59–66], where the domain of knowledge has been often acknowledged as a main predictor for attitudes and practices of medical professionals. It should be stressed that similar results have been repetitively but not consistently reported in occupational studies, particularly in those performed on OPs [1,2,6,7,36,53]. Particularly when dealing with KAP studies on biological risk in occupational settings, knowledge represents a key factor that should be specifically addressed. As previously stressed by Betsch et al. in a sample of German professionals [1], OPs are not spared by substantial knowledge gaps and misunderstanding of biological risk agents. Similar estimates were reported from several Italian studies [2,7,53,67], and a likely explanation for these knowledge gaps may be tentatively identified in the core curriculum of OPs. Until recently, despite the underlying legal framework, and the substantial burden represented by pathogens such as HBV, HCV, and HIV, the formal education and the medical training of Italian OPs have often prioritized other topics (e.g., work-related musculoskeletal diseases, occupational pulmonary diseases, occupational neoplasia) over biological risk [15,37,39,68]. In other words, despite their professional role, scientific background, and medical training, not only may OPs fail to overcome the gaps between official recommendations and vaccine objectors [1,2,7,67,69], but their knowledge gaps could even lead to a certain degree of vaccine hesitancy [2,6,7,53,59].

In addition, the negative attitude towards the promotion of SIV among female workers of childbearing age could be explained in terms of potential false beliefs, particularly on the actual efficacy and safety profile of the available vaccines [29,32,70,71]. During the previous decade, the reporting of three deaths within 48 h of vaccination with the Fluad® vaccine led to a sustained reduction in vaccination rates between 2014 and 2017 [72,73], also among medical professionals [72,74], with a sustained lack of trust in this preventive intervention [29,53]. Even in our study, SIV was associated with an RPS that exceeded other immunizations, notably including varicella and rubella immunizations. Both vaccines are represented by live-attenuated pathogens: even though reactivation of vaccine strains is usually acknowledged as somewhat unusual for both varicella and rubella, for the safety of mother and children, their delivery is usually avoided in pregnant women [19,75–79]. Moreover, the reported mismatch between antigens contained in the SIV and the circulating pathogens in several winter seasons has presumptively led to the diffuse underscoring of the actual preventive role of SIV [46,80,81]. Nonetheless, we cannot rule out that a certain disregard for SIV could be associated with the misunderstanding of the actual

aims of this intervention. While vaccines included in Tdap are aimed to avoid the clinical syndromes associated with the natural infection of the primary pathogens, the primary aim of SIV is avoiding complications of the natural infection, likewise with SARS-CoV-2 immunization [24,74,82,83]. Interestingly, the effectiveness of SIV in avoiding sick leave in certain settings, such as healthcare facilities, although proven [84], has been inconsistently reported in several Italian studies [53,83,84]. In other words, some professionals may have failed to properly appreciate the actual cost-benefit ratio of this medical intervention, particularly in individuals such as pregnant women, where the clinician should not only target the health and safety of the patient (i.e., the pregnant woman) but care also for the unborn child. Not coincidentally, being an occupational physician in medical facilities was a negative predictor for a positive attitude towards SIV [26,33,85–88].

The inappropriate attitude of participating OPs towards SIV is particularly unsatisfactory when keeping in mind that vaccination of pregnant women remains globally low [85], and that there is a certain base of evidence that the failure of HCW to recommend, offer, promote, and perform influenza vaccination represents a substantial barrier to antenatal influenza vaccination [85–87]. A more effective contribution of OPs in overcoming usual barriers to maternal vaccination would be therefore both appreciable and necessary, as previously recommended for other medical professionals interacting with pregnant women [26,33,85,88–91].

In our study, the eventual promotion of the SARS-CoV-2 vaccine among pregnant women was remarkable (74.2%) and quite similar to the overall acceptance of mRNA formulates in a precedent report on Italian OPs (89.8% of 166 professionals) [7]. Moreover, the overall risk perception for these vaccines was comparable to other assessed immunizations, with the notable exception of adenovirus-based formulates. In this regard, a worse acceptance of these formulates was reported even in the aforementioned preliminary report (i.e., 51.2% vs. 89.8%) [7]. In fact, participating OPs appeared to be up-to-date in terms of general recommendations towards SARS-CoV-2 vaccines, with the notable exception of the exemption for women previously reporting cases of deep vein thrombosis. During the first SARS-CoV-2 vaccination campaign, several claims of an increased risk of deep vein thrombosis after SARS-CoV-2 vaccination shots urged for a critical reappraisal of these vaccines in groups potentially at high-risk, including individuals with previous episodes of deep vein thrombosis, women using birth control pills or hormone replacement therapy, and pregnant women [92–96]. Still, most of the reported cases were actually associated with adenovirus-based formulates [92,93,97], while mRNA vaccines and subunit vaccines have shown a safer profile [92,95,96]. Even though SARS-CoV-2 immunizations performed by means of an adenovirus carrier were discontinued during 2021, the overall attitude towards this immunization was actually associated with a quite higher RPS than that reported for mRNA formulates (19.9% ± 19.8 vs. 15.7% ± 19.4) and for SARS-CoV-2 vaccines based on the subunit technology (15.2% ± 16.1). The similar appraisal of mRNA and subunit vaccines—at least in this specific sample—may contribute to our understanding of the unsatisfying uptake of subunit formulates during vaccination campaigns in 2021 and 2022. Even though substantial vaccine hesitancy had previously affected similarly designed vaccines targeting hepatitis B and *Neisseria meningitidis* ACWY [31,98–101], subunit formulates have been initially welcome as "more conventional" drugs that could contribute to overcoming most of the concerns about the innovative mRNA technology [102]. However, according to an official report from the Italian National Health Service, by 26 September 2022, a total of 140,689,960 doses of SARS-CoV-2 vaccines had been delivered among Italian residents; of these, only 0.03% were represented by subunit formulates [103]. In other terms, our results seemingly suggest that interventions improving the understanding of actual guidelines among OPs may also improve their acceptance and proactive attitude towards SARS-CoV-2 vaccines even in pregnant women.

*Limits and Strengths.* Despite its potential significance, our study is affected by several limitations and is not generalizable because of shortcomings affecting the sampling strategy and generalizability of the sample.

In the first place, our sample was quite small, as it included a total of 120 OPs, which is around 1.5% of all Italian occupational physicians at the time of the survey (n = 7826), and only 5.9% of the potential recipients. Therefore, the sample is not likely to be representative of all OPs. Moreover, because of the limited number of sampled professionals, and the similarly limited response rate across the targeted and invited OPs, the present study was also affected by reduced statistical power, urging for a very cautious appraisal of the results we were able to collect. More precisely, assuming as a reference the acceptance of influenza (68.5%), Tdap (52.7%), and SARS-CoV-2 (90.4%) by Italian OPs from some similarly designed studies [7,36,53], a Type I error of 5% (0.05), and a power of 95%, a minimum sample size ranging between 133 for SARS-CoV-2, 332 for SIV, and 383 for Tdap could be calculated [7]. In other words, the present study only collected one-third of the sample size it would have required in order to gather sufficient statistical power. Still, as the specific topic of immunization of childbearing-age women in occupational settings has been assessed in only a limited fashion, particularly in Italy, and available evidence has been mostly collected from healthcare workers [7,29,104–107], our preliminary results could provide some insight for potential interventions aimed to improve the overall delivery of vaccines by OPs.

Second, our research was designed as an internet-based survey, whose implicit limits have been previously addressed [108–110]. Similarly designed studies are acknowledged as reliable and cost-effective, but they are also affected by an extensive double "self-selection" of participating individuals. On the one hand, as participating individuals are recruited through social media platforms, the sample will only include individuals familiar with new media [36,109,111–113]. In turn, this could lead to the oversampling of individuals more accustomed to sharing personal information through internet access, usually more frequently reported among younger age groups. In effect, our sample included a reduced share of respondents aged 50 years or older (30.0% of the total sample), and these figures are quite inconsistent with the Italian medical workforce [114,115]. On the other hand, this sampling strategy would lead to the oversampling of subjects having greater knowledge and/or interest in the assessed topic [29,32,116,117], while not participating could be understood as a negative attitude or a lack of knowledge about the targeted topic [109], and that may impair the overall reliability and generalizability of collected results. Nonetheless, our study deliberately targeted a relatively homogenous subgroup of medical professionals (i.e., OPs) in order to mitigate as much as possible the potential self-selection of the participants and minimize or even rule out the eventual effect of individual factors such as occupational background and educational level.

Thirdly, we cannot rule out that some of the respondents did not fully adhere to our selection criteria, further compromising the actual representativity of the sample. In order to cope with this potential shortcoming, our study only included participants that were drawn from discussion groups, whose participation was limited to individuals having previously received a specific invitation from the manager and answered specific "selection" questions [118]. Moreover, we do not know how often sampled participants are usually requested to contribute to workers' vaccinations, and more specifically to the vaccination practice of pregnant women [7,29,36,53,104–107].

Fourth, even though the core of this study, i.e., the knowledge test, was based on a reliable model and characterized by a high degree of internal consistency [1,119], we cannot rule out that some of the items assessed might have been affected by some degree of social desirability bias, whereby some participants reported some answers in terms of "common sense", prioritizing more "socially appropriate" answers over their true understanding of certain topics. Interestingly, such potential bias has been repeatedly identified in previous KAP studies on OPs [1,2,36,53,108], including some surveys performed with a quite similar sample. Therefore, we cannot rule out that our results could have ultimately overstated the share of individuals having an effective understanding of vaccine-associated issues, but also actually acknowledging the reported and assessed vaccinations as recommended and promoted in pregnant women and women of childbearing age. In order to attempt a

certain quantification of participants affected by social desirability bias, the knowledge test specifically reported the still commercially unavailable maternal RSV vaccination [118,120]. Interestingly, only 37.5% of participants correctly ruled out this option, suggesting the need for a critical appraisal of overall results from the knowledge test and individual attitudes towards reported vaccines.

Finally, our study deliberately assessed the KAP of recruited participants on a selected set of immunizations, but women of childbearing age could be targeted by other interventions of some occupational interest, including but not limited to vaccines for *Neisseria meningitidis* and *Mycobacterium tuberculosis* (i.e., BCG) for healthcare workers, Hepatitis A virus, typhoid vaccines, and tick-borne encephalitis vaccine for workers traveling to parts of the world where these pathologies are common, and even rabies vaccines for professionals involved in laboratory and veterinary practice [30,31,121–127]. Moreover, workplaces may represent an appropriate setting for improving the acceptance of immunizations with a more limited occupational interest, such as pneumococcus, and mostly human papillomavirus (HPV) vaccines. In effect, the pneumococcal vaccine is currently indicated only for individuals having certain chronic medical conditions or other risk factors, and routine medical surveillance by OPs may provide an ideal opportunity for reaching potential recipients and/or addressing their vaccine hesitancy [128,129]. Similarly, OPs could contribute to the shared effort for improving HPV vaccination rates. HPV is not only the current most common sexually transmitted disease in the world but it is also acknowledged as the main risk factor for cervical cancer in women with an estimated 570,000 new cases per year [130–133]. According to the current guidelines, the HPV vaccine is currently recommended for everyone through age 26 years if not adequately vaccinated when younger, and OPs, during medical surveillance, could properly identify and address women that can potentially benefit from catch-up vaccination [134]. According to the total worker health approach, future interventions should be therefore tailored in order to include a more extensive list of assessed vaccinations, not strictly limited to the interventions associated with occupational settings [135,136].

#### **4. Materials and Methods**

#### *4.1. Study Design*

The present study was designed as a cross-sectional questionnaire-based study according to the STROBE statement (see STROBE checklist as Supplementary File S1) and performed between 1 April 2022 and 30 April 2022. The study was delivered across seven private Facebook group pages and four closed forums focusing on occupational medicine, whose applications were officially limited to OPs. According to the built-in statistics of the parent social media, by 1 April 2022, the group pages had a total of 2034 members. Still, no information could be retrieved about cross-membership and the number of actual, active users.

In order to share the study with the group members, the chief researcher (MR) preventively contacted the administrators of the groups, requesting preventive authorization for posting an invitation link to the questionnaire. Users who clicked on the invitation texts were then provided with a page reporting (a) the full study information; (b) the informed consent (authors' translation of the informed consent is available as Supplementary File S2); and (c) a web link to the first page of the survey (Google Forms; Google LLC; Menlo Park, California, CA, USA).

On the first page of the survey, participants were initially asked whether they (a) were or not living and working in Italy and (b) were working as an OP at the time of the survey. Only participants sharing two positive answers to these checkpoint items received the full questionnaire, while in all other cases, the survey was closed, and no further data were retained. The questionnaire was compiled anonymously: personal data (e.g., name, IP address, email address), and all personal information unnecessary to the survey were not requested, saved, or tracked.

#### *4.2. Questionnaire and Availability of Data and Material*

The questionnaire was originally formulated in Italian, being designed as a followup to an instrument originally validated in obstetrics and gynecology [29]. The final questionnaire included the following sections:


As previously suggested by Yates, a quantitative estimate of perceived risk can be defined as the mathematical product of the perceived probability of an event and its expected consequences [1,139], and the corresponding RPS for vaccines and natural infection was therefore calculated as:

### RPS = I × C

4. Attitudes and practices: we initially inquired of participants whether they had previously received any of the following vaccinations: seasonal influenza virus, Tdap or dT, MPR, varicella (either as a single formulate or within an MPR-V vaccine), hepatitis B virus, SARS-CoV-2 (any). Similarly, participants were asked whether, during the last 12 months, they had recommended any of the aforementioned vaccines in women of childbearing age. Finally, we reported a series of potential barriers towards vaccinations in women of childbearing age (i.e., fear of side effects; costs of vaccinations; not being perceived as a priority by other medical professionals; inappropriate risk perception by pregnant women; vaccination services are scarcely available; inappropriate understanding of official recommendations by pregnant women; inappropriate understanding of official recommendations by medical professionals), and participants were asked to rate their perceived significance through a 5-point Likert scale ranging from 1 (not agreeing at all) to 5 (totally agreeing).

All questions were self-reported and not externally validated. The internal consistency or reliability of each of the sections of the questionnaire was assessed with the Cronbach alpha test, the results of which were interpreted in accordance with the literature. An English translation of the questionnaire is available on request to the study Authors.

#### *4.3. Ethical Approval*

Before giving their consent to the survey, participants were briefed that the principles and guidelines of the Helsinki Declaration would be followed across all steps of this study. More precisely, data were gathered anonymously and handled confidentially, being stored for a limited timeframe, in order to only allow aggregate data analysis. Participation was

strictly voluntary, and no monetary or other compensation was offered to the participants. Moreover, only subjects who had expressed consent for study participation were able to provide the questionnaire for data analysis. As individuals cannot be identified based on the presented material, this study caused no plausible harm or stigma to participants. The study was deliberately designed with an anonymous, observational approach, and it did not include clinical data. Moreover, demographic data were deliberately limited to very generic items (i.e., age, seniority, and gender). According to Italian law (Gazzetta Ufficiale no. 76, dated 31 March 2008; Supplementary File S3), a preliminary evaluation by an ethical committee was not required.

#### *4.4. Data Analysis*

Cumulative scores (RPS, GKS) were initially normalized to percent value, being then dichotomized by median value as "high" (i.e., >median) and "low" (≤median) groups. All continuous variables were reported as mean ± standard deviation. After visual inspection, their distributions were assessed by means of the D'Agostino–Pearson K2 test and compared through the Student's t-test for unpaired data or ANOVA for K2 test *p* value > 0.100 (i.e., normally distributed variable), or through the Mann–Whitney or Kruskal–Wallis test for K2 test *p* value < 0.100 (i.e., not normally distributed variable). According to the distribution of variables, their correlation was then assessed by Pearson's correlation coefficient (i.e., normally distributed variables) or through Spearman's ranks test (i.e., not normally distributed variable).

In order to properly characterize explanatory variables of the outcome variables represented by a somewhat positive attitude towards recommending SIV, Tdap, and SARS-CoV-2 vaccine, a multivariable analysis was modeled as follows. Firstly, univariate analysis of all of the categorical variables was performed in respect of the aforementioned outcome variables through a chi-squared test in order to test variables to be included in the multivariable analysis. All variables that at univariate analysis were significantly (*p* < 0.05) associated with a somewhat positive attitude towards recommending SIV, Tdap, and SARS-CoV-2 vaccines were then included in a stepwise binary logistic regression analysis model in order to calculate multivariate odds ratios (aOR) and their respective 95% confidence intervals (95%CI). We opted for a more restrictive stepwise approach over an a priori modeling as in a small dataset the latter could find many false associations that happen only by chance [140]. All statistical analyses were performed by means of IBM SPSS Statistics 26.0 for Macintosh (IBM Corp. Armonk, NY, USA).

#### **5. Conclusions**

OPs are called upon to play a dual key role, i.e., reconciling the right to work and protecting and promoting workers' health at the same time. Despite a generally favorable attitude towards vaccines among our OP respondents, the results of our study suggest substantial knowledge gaps and a need for better training in the area of immunization of pregnant women. Because of the low response to the survey, however, these results remain preliminary.

**Supplementary Materials:** The following supporting information can be downloaded at: https:// www.mdpi.com/article/10.3390/women3020019/s1, File S1: STROBE checklist; File S2: Authors' translation of the informed consent; File S3: Author's translation of the Gazzetta Ufficiale no. 76, dated 31 March 2008.

**Author Contributions:** Conceptualization, M.R., A.B., and F.M; Data curation, M.R.; Formal analysis, M.R. and A.B.; Funding acquisition, M.P.C.; Investigation, M.R. and F.M.; Methodology, M.R.; Project administration, F.M.; Resources, A.B.; Software, M.R. and A.B.; Validation, M.R. and F.M.; Writing—original draft, A.B., M.P.C., and F.M.; Writing—review and editing, A.B: and M.P.C. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki. A preventive ethical review and approval were waived for this study because of its anonymous, observational design and due to the lack of clinical data about patients that could configure the present research as a clinical trial. Participants were also guaranteed that retrieved data would be stored only for the time required by data analysis. The study, therefore, did not configure itself as a clinical trial, and a preliminary evaluation by an ethical committee was not required, according to Italian law (Gazzetta Ufficiale no. 76, dated 31 March 2008).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** Data are available on request.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **Appendix A**

**Figure A1.** Risk Perception Score (RPS) towards a selected series of vaccine-preventable diseases in pregnant women. Notes: Diph. = diphtheria; HBV = hepatitis B virus; Pert. = pertussis; SIV = Seasonal influenza vaccine; Var. = varicella.

**Figure A2.** Risk Perception Score (RPS) towards a selected series of vaccines to be performed in pregnant women. Notes: AdV = adenoviral vector; mRNA = mRNA-based vaccine; Diph. = diphtheria; HBV = hepatitis B virus; Pert. = pertussis; SIV = Seasonal influenza vaccine; Var. = varicella.


**Table A1.** Summary of shortcuts and acronyms employed across the manuscript.

**Table A2.** Knowledge Test in 120 occupational physicians participating in a survey on vaccinations in pregnant women (Italy, 2022).




**Table A3.** Comparison between perceived Risk Perception Score (RPS, potential range 0 to 100) on natural infections in pregnant women for selected pathogens as reported by 120 occupational physicians participating in the present survey (Italy, 2022) (Note: 95%CI = 95% confidence interval; ANOVA = analysis of the variance).


**Table A4.** Comparison between perceived Risk Perception Score (RPS, potential range 0 to 100) on vaccinations for pregnant women as reported by 120 occupational physicians participating in the present survey (Italy, 2022) (Note: 95%CI = 95% confidence interval; ANOVA = analysis of the variance).


**Table A5.** Correlation of Risk Perception Score (RPS) on diseases and corresponding vaccinations, and General Knowledge Score in 120 Italian occupational physicians participating in the survey on vaccines in pregnant women. The correlation was assessed by means of Spearman's rank test.


**Table A5.** *Cont.*


**Table A6.** Summary of the categorical variables that were included as explanatory ones in the logistic regression models (Model 1: outcome variable, somehow positive attitude towards Seasonal Influenza Vaccine, SIV; Model 2: outcome variable, somehow positive attitude towards tetanus-diphtheriapertussis [Tdap] vaccine; Model 3: outcome variable, somehow positive attitude towards SARS-CoV-2 vaccines) (Note: RPS = risk perception score).


#### **References**


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## *Article* **Determinants of Antenatal Education and Breastfeeding Uptake in Refugee-Background and Australian-Born Women**

**Tam Anh Nguyen 1, Mohammed Mohsin 2,3, Batool Moussa 2, Jane Fisher 4, Nawal Nadar 2, Fatima Hassoun 2, Batoul Khalil 2, Mariam Youssef 2, Yalini Krishna 2, Megan Kalucy <sup>2</sup> and Susan Rees 2,\***


**Abstract:** Despite the well-established benefits of antenatal education (ANE) and breastfeeding for mothers, there is a paucity of evidence about the uptake of ANE and breastfeeding amongst women from refugee backgrounds or its associations with sociodemographic factors. The current study is a cross-sectional survey at two time points examining the prevalence of ANE attendance, breastfeeding, and intimate partner violence (IPV) amongst 583 women refugees resettled in Australia and a control group of 528 Australian-born women. Multi-logistic regression was used to explore bivariate associations between ANE attendance, breastfeeding, IPV, and sociodemographic characteristics (parity, maternal employment, and education). Refugee-background women compared to Australianborn women have lower ANE utilization (20.4% vs. 24.1%), higher rates of breastfeeding on hospital discharge (89.3% vs. 81.7%), and more IPV reports (43.4% vs. 25.9%). Factors such as nulliparity, higher level of education, and employment predict higher rates of ANE and breastfeeding adoption. In contrast, IPV is a risk factor for ANE underutilization. Further, of the women from refugee backgrounds who accessed ANE services, 70% attended clinics designed for women from non-English-speaking backgrounds. These findings support the need to ensure effective screening and interventions for IPV during antenatal care and to better understand the role of culture as a protective or risk factor for breastfeeding initiation.

**Keywords:** antenatal education; intimate partner violence; breastfeeding; refugee; employment; women

#### **1. Introduction**

In Australia, antenatal education (ANE) is considered an important component of antenatal care. ANE is offered in group classes to women at most public and many private hospitals [1]. These educational programs typically focus on education to develop knowledge, skills, and confidence in understanding pregnancy, the birth process, and the hospital setting. The broad goal is to prepare the woman, her partner, and her family, if appropriate, for childbirth and early parenting [1]. Women who attend ANE classes are associated with better adjustment to parenthood [2], lower rates of negative birth outcomes, reduced maternal stress, and use of interventions (including cesarean section and epidural anesthesia) [3,4]. Furthermore, it has been identified that to improve health outcomes, culture- or languagespecific ANE programs should be offered for women from mainly non-English-speaking or immigrant backgrounds [5]. Multicultural health workers play a vital role in facilitating referrals to these specialized services and promoting community development [6].

**Citation:** Nguyen, T.A.; Mohsin, M.; Moussa, B.; Fisher, J.; Nadar, N.; Hassoun, F.; Khalil, B.; Youssef, M.; Krishna, Y.; Kalucy, M.; et al. Determinants of Antenatal Education and Breastfeeding Uptake in Refugee-Background and Australian-Born Women. *Women* **2023**, *3*, 263–280. https:// doi.org/10.3390/women3020020

Academic Editors: Claudio Costantino and Maiorana Antonio

Received: 11 April 2023 Revised: 5 May 2023 Accepted: 8 May 2023 Published: 11 May 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

Despite better health equity and universal healthcare coverage provision in highincome countries (HICs)*,* such as Medicare in Australia, which provides free antenatal care amongst other health services [6], women who arrive as migrants (both forced and economic) have lower rates of participation in antenatal care, where pregnancy-related screening and monitoring occur and social factors relevant to the pregnancy are discussed [7–11]. Poor, late, or lack of antenatal appointment attendance has been linked to negative birth outcomes in both groups of women [7,10]. While being of refugee background poses a risk factor for both adverse post-partum health outcomes and antenatal services underutilization [7], there exists a scarcity of empirical research on the impact and outcomes of ANE, as distinct from the general antenatal services participation, among refugee-background women in comparison to women born in HICs. In addition to immigration status, data from North America, Australia, and Europe have revealed that low income, low socioeconomic status (SES), and limited educational attainment contribute to lower antenatal services utilization and engender maternal health inequity [12,13]. Given this well-established association between socioeconomic factors and health outcomes, as well as the fact that women from refugee backgrounds often have lower SES compared to their native-born counterparts [14,15], it is imperative to explore the disparities between these two cohorts and factors contributing to their health trajectories.

As part of routine antenatal care, intimate partner violence (IPV) screening is typically conducted as an essential component of risk assessment [6]. In the antenatal setting, IPV often remains inadequately acknowledged, despite its higher prevalence than other obstetric risks such as pre-eclampsia or gestational diabetes [16]. Intimate partner violence is defined as any behavior by a current or former intimate partner that involves physical, sexual, financial, or psychological harm [17,18]. According to the World Health Organization (WHO), one-third of women worldwide have been subjected to IPV in their lifetime [19], with the highest rate observed in regions of Oceania and Sub-Saharan Africa (29–32%) and the lowest reported in central Europe (16%) [20]. IPV during pregnancy increases the risk of miscarriage, stillbirth, pre-term labor, and low-birth-weight neonates [16,21]. The evidence also suggests that IPV perpetrated primarily against the mother has has developmental effects on the child, such as increased risk of insulin resistance, psychiatric disorders, low intellectual capability, and cognitive impairment [22]. Predisposing factors include IPVrelated prenatal insults such as stress, substance abuse, inadequate nutritional intake, poor antenatal services utilization, and infective agents. During infancy, witnessing IPV and associated parental stress can have negative effects on socio-emotional development [22–26]. Women from refugee backgrounds experience higher rates of psychological and/or physical IPV during pregnancy compared to women born in the host country, with reported prevalence of 44.4% and 25.8%, respectively [27]. Whilst general perinatal care routinely includes IPV screening in most Australian jurisdictions, refugee-background women are more likely to experience barriers and challenges accessing that care. Furthermore, lack of trust and differences in expectations and communication styles from those of healthcare providers, may result in the underreporting of IPV [27,28].

Promoting early and exclusive breastfeeding is a central feature of ANE. Early and long-term breastfeeding, including exclusive breastfeeding for six months and non-exclusive continuation for two years, is recommended due to its numerous health benefits for both babies and mothers [29]. Early initiation of breastfeeding has been linked to a two-fold reduction in the mortality of infants across countries [30]. Breastfed babies demonstrate greater immunity, with lower odds of infectious morbidities such as gastrointestinal diseases, respiratory infections, otitis media, and urinary tract infections [31]. With respect to the child's long-term outcomes, breastfeeding improves cognitive function and performance on intelligence tests [32], and it protects against type 2 diabetes [29,33]. For mothers, breastfeeding is associated with decreased risk of maternal depression, breast and ovarian cancer [29], endometrial cancer, osteoporosis [34], and strokes amongst postmenopausal women [35]. Additionally, there is strong evidence of positive maternal–infant bonding associated with breastfeeding [34]. The current evidence shows that while breastfeeding

is initiated in 98% of infants soon after birth [36], the duration of exclusive breastfeeding at 6 months can drop to lower than 20% in HICs, with a critically low 1% reported in an Australian national survey [33,36,37]. In comparison, low/middle-income countries (LMICs) reported slightly higher rates of exclusive breastfeeding at 6 months (36%) [33,37]. In conflict-affected countries, the median prevalence of exclusive breastfeeding has been reported to be 25% across 56 studies [37]. However, one study found that although breastfeeding rates are low when refugee-background women initially settle in HICs, those rates increase for each additional year living in the host country [38].

A variety of maternal sociodemographic factors, including age, socioeconomic status, education, and employment, have been shown to exert a notable influence on the likelihood of breastfeeding [39–41]. However, the individual effects and levels of significance of these determinants vary across HICs [42–45], suggesting the presence of country-specific confounders intertwined with cultural nuances, economic circumstances, and social infrastructure. Since SES is linked to employment status and educational attainment to the disadvantages of those with lower SES [46,47], future social interventions should have a special focus on women from low SES backgrounds. There is also a need to consider culturally specific programs for refugee-background populations, as they are often subject to discriminatory practices in both education and the workplace [15]. The literature provides mixed findings about the association between IPV and breastfeeding. IPV during pregnancy may affect breastfeeding directly, through physical stress hindering breastmilk release, or indirectly, via psychological barriers such as self-doubt, body negativity, male partner coercion, and depression [48]. While studies from Spain and the United States found an association between IPV and lower rates of breastfeeding [38,49,50], studies from Australia and Sweden reported no association [51,52]. On the other hand, almost all studies from LMICs, particularly in Asia and Africa, report associations between IPV and reduced rates of breastfeeding [26,53,54], as well as shortened duration of breastfeeding [55].

#### *Aim*

To inform future analyses, this study aimed to present preliminary findings on the effects of intimate partner violence and sociodemographic factors on ANE attendance and early breastfeeding in two cohorts: refugee-background women resettled in Australia and Australian-born women. These findings will provide valuable insights for policymakers and healthcare providers in developing comprehensive strategies to enhance the health and well-being of refugee mothers and children. The study proposed the following hypotheses: (1) refugee-background women would have lower ANE attendance rates and higher prevalence of IPV; and (2) individuals who were exposed to IPV and did not attend any ANE classes would have lower rates of breastfeeding on discharge from hospital. These hypotheses were formulated to guide the analysis and interpretation of the study's findings.

#### **2. Results**

#### *2.1. Participants*

A total of 1111 eligible women were interviewed at both T1 and T2, including 528 (47.6%) women born in Australia and 583 (52.5%) women who migrated from conflictaffected countries, referred to as refugee-background women in this paper (Table 1). The mean age of Australian-born women in our study was 29.1 (SD, 5.4) years, and the mean age of refugee-background women was 29.8 (SD, 5.4) years (Table 1). In total, 57% of the Australian-born women had completed a university degree or other post-school qualification, compared to 50.8% of women from refugee backgrounds. It can be assumed that some women from the latter group may have gained their qualifications from their country of origin. While the levels of education were similar between the two groups, there was a substantial disparity in the rates of employment. At T1, 60.0% of the Australian-born women were employed, while the employment rate was only 26.8% for refugee-background women. Among the Australian-born women, 34.2% were categorized as nulliparous, and this rate was 30.2% for refugee-background women.


**Table 1.** Sociodemographic characteristics, intimate partner violence, and antenatal education visits for women born in Australia and women born in conflict-affected countries.

SD: Standard deviation. NA: Not applicable to Australian-born women. *N*: Total number of interview answers. # Designated classes: This question was directed to women born in conflict-affected countries only.

Refugee-background women reported higher rates of any IPV compared to Australianborn women at both time points. At T1, 25.9% of Australian-born women reported experiences of IPV in the past 12 months, whilst amongst women of refugee backgrounds, the rate of IPV experience was 43.4% (Table 1). Moreover, these rates increased slightly from T1 to T2 in both groups, with an additional 1.2% of Australian-born women reporting IPV at T2 (27.1%) and an additional 0.5% of refugee-background women reporting IPV (43.9%) at T2.

Australian-born women had higher ANE utilization compared to refugee-background women when measured by whether they had attended any ANE class (24.1% vs. 20.4%) (Table 1). Of the 119 refugee-background women who reported having attended ANE, up to 70.6% (84 out of 119) visited designated culture-specific or multicultural ANE classes.

Women from refugee backgrounds had higher breastfeeding rates compared to Australianborn women (89.3% vs. 81.7%, respectively). Both groups reported similar breastfeeding patterns: 34.9% of refugee-background women did not breastfeed or did for less than 1 month vs. 36.9% of Australian-born women; 65.1% of refugee-background women breastfed for more than 1 month vs. 63.1% of Australian-born women (Table 1).

#### *2.2. Factors Associated with Antenatal Education Engagement*

Results from bivariate analyses, presented in Table 2, show that the prevalence of ANE visits amongst Australian-born women was significantly higher for those who obtained post-school qualification (*p* = 0.001), were employed (*p* = 0.001), were nulliparous (*p* = 0.001), and reported no experiences of IPV during the perinatal period (*p* = 0.006). A similar trend between these factors and ANE attendance rates was also observed in refugee-background women. However, only higher educational attainment was statistically significant (*p* = 0.003).

**Table 2.** Association of sociodemographic characteristics and intimate partner violence with antenatal education (ANE) visits for women born in Australia and women born in conflict-affected countries.


Adjusting for age, employment status, and other sociodemographic factors, adjusted odd ratios (AORs) from multiple logistic analyses, presented in Table 3, further predicted that for both groups, women with a post-school level of education were twice as likely to attend ANE classes (University degree—Australian-born, AOR: 2.69, 95% CI, 1.45–5.00, *p* < 0.01. Refugee-background, AOR: 2.61, 95% CI, 1.43–4.74, *p* < 0.01). Furthermore, nulliparous women in both groups were more likely to attend ANE classes (Australianborn, AOR: 14.57, 95% CI, 8.67–24.55, *p* < 0.01. Refugee-background, AOR: 6.45, 95% CI, 4.13–10.09, *p* < 0.01). Employment status and IPV exposure were not found to be significantly associated with ANE visits for any group of women (Table 3).

**Table 3.** Associations of sociodemographic characteristics and intimate partner Violence (IPV) with Antenatal Education attendance: Adjusted odds ratios (AORs) with 95% confidence interval (95% CI) from logistic regression analysis for women born in Australia and women born in conflict-affected countries.

