Iran Journal of Nursing

Introduction
The COVID-19 pandemic caused high damages to the health of people and the economy of many countries. Vaccination is the most successful method to control the COVID-19 pandemic. Although vaccination is an effective method to reduce infected cases, its use depends on the willingness of people to receive the vaccine. Vaccine hesitancy may relate to several factors, including lack of information about COVID-19 and distrust in vaccine or healthcare providers and policy makers. Pregnant women are at higher risk of complications associated with COVID-19 infection including admission to the intensive care unit, invasive ventilation, preterm birth, hypertensive disorders of pregnancy, and maternal and neonatal morbidity and mortality.
It was first recommended that women should not receive the COVID-19 vaccine during pregnancy or lactation; however, with increasing evidence for the substantial risks of COVID-19 during pregnancy, pregnant women were later considered to be high priority for vaccination. The health belief model (HBM) is one of the most widely used models for examining the relationship between health-related behaviors and the use of health services. HBM has been widely used in the context of vaccination, especially the influenza vaccination. According to this model, individuals’ beliefs about health play a role in determining health-related behaviors. The HBM was used in the present study to predict the factors affecting the acceptance of COVID-19 vaccines among pregnant or lactating women referring to comprehensive health service centers in Zahedan, Iran.

Methods
This is a cross-sectional study that was conducted from July to September 2022. The statistical population included all pregnant and lactating women referring to comprehensive health service centers in Zahedan city. Using the Cochran formula and based on the previous studies, the sample size was determined 230. By considering a 10% sample dropout, 260 women were selected by convenience sampling method. The city of Zahedan was divided into four regions of North, South, East and West. Then, two comprehensive health service centers were selected from each region. The entry criteria were pregnancy or lactation and declaring informed consent. To collect data, a researcher-made questionnaire based on the HBM constructs was used. 
The reliability of the questionnaire was evaluated using Cronbach’s alpha coefficient, which was obtained 0.7. Moreover, the content validity index value was 0.81 and the content validity ratio was 0.77. After collecting, the questionnaires, to analyze the data, descriptive statistics including mean, standard deviation, frequency, and percentage were used. Due to non-normality of data distribution based on the Kolmogorov-Smirnov test results, non-parametric Mann-Whitney U test and Kruskal-Wallis test and regression analysis were used. The significance level was set at 0.05 and data analysis was done in SPSS software, version 22.

Results
Among the participants. 61% were in the age group of 20-30 years, and most of participants had middle school education or higher (47.7%) and were housekeeper (93.8%). Based on the age factor, the difference between women in the HBM domains was significant (P<0.05) except for perceived sensitivity and perceived barriers (P>0.05). There was a bivariate correlation between HBM domains and vaccine acceptance behavior in women. The demographic variables could predict 12.6% of the variance in the vaccine acceptance behavior, where only the variables of age and education level were found to be significant, such that younger age and higher educational level had a positive effect on the vaccine acceptance behavior (P<0.05). Moreover, the HBM constructs predicted 26.3% of the variance in vaccine acceptance behavior, where only self-efficacy and perceived benefits had a significant effect on the behavior (P<0.05).

Conclusion
The results of this research showed that younger age and high educational level are factors that the can predict the COVID-19 vaccine acceptance behavior of pregnant or lactating women in the south of Iran. The self-efficacy and perceived benefits as two constructs of the HBM can also predict the acceptance of vaccination. These findings can help policymakers and health care providers to use this model in designing programs for improving vaccination acceptance behaviors of these high-risk groups. In addition, it is necessary to use methods to increase the acceptance of vaccination for COVID-19, in pregnant or lactating women with low educational level.

Ethical Considerations
Compliance with ethical guidelines
Informed consent was obtained from the participants. The present study was approved by the Ethics Committee of Zahedan University of Medical Sciences (Code: IR.ZAUMS.REC.1401.087).

Funding
The present study was extracted from a research project (Grand No.: 10637), funded by Zahedan University of Medical Sciences.

Authors' contributions
Sara Moghimi: preparing the initial draft, collecting data, writing, and editing the article; Maryam Seraji: supervision, design; Zahra Arab Borzu: data analysis.

Conflict of interest
The authors declare no conflict of interest. 

Acknowledgments
The authors would like to thank the staff of comprehensive health centers in Zahedan and all the women participated in this research for their cooperation. 
 

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