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Background/Rationale: Although influenza (flu) does not normally cause serious health consequences, pregnant women are at increased risk of flu, and consequences amongst this population can be more severe. Physiological and immunological changes that occur during pregnancy, make pregnant women five times more likely to be hospitalised as a result of flu. During 2009-2012, one in 11 maternal deaths were attributable to flu, making it a considerable public health concern. Despite the increased risk that flu poses to pregnant women, uptake of the flu vaccination is suboptimal. Since the recommendation in 2010 that all pregnant women receive free flu vaccination, uptake in the UK has not exceeded 45% despite a target uptake of 75%. Aims: This thesis has four main aims: 1.) To examine the influence that interventions that aim to change risk and efficacy appraisals have on the intentions and uptake of vaccination, 2.) To explore the beliefs that pregnant women hold about flu and the flu vaccination, 3.) To design and develop an appropriate intervention, aiming to increase the uptake of flu vaccination amongst pregnant women, and 4.) Explore the acceptability and potential impact of the intervention. Method: This thesis describes a systematic review involving a systematic search to identify randomised controlled trials of interventions presenting a risk message and measuring risk appraisal and intentions and uptake post-intervention. Random effects meta-analyses investigated the size of the effect that interventions had on vaccination risk appraisal, and on vaccination behaviour or intention to vaccinate, and the size of the relationship between vaccination risk appraisal and vaccination intentions. A qualitative study, involving semi-structured interviews was conducted to explore pregnant women’s beliefs about flu and the flu vaccination, and to explore how well the data fits the Illness Risk Representation framework. Data was analysed using thematic analysis. Findings of the qualitative study were used alongside relevant theory to inform the design of an animation, guided by Intervention Mapping, and shaped by collaboration with pregnant women, midwives, Public Health professionals and clinicians. A further qualitative study involved think aloud methods and semi-structured interviews with pregnant and recently pregnant women to explore the acceptability and potential impact of the animation, analysed using content analysis. Results: Searches for the systematic review resulted in 18 studies that met the inclusion criteria (16 of which were eligible for inclusion in the meta-analysis). Interventions overall had small significant effects on risk appraisal (d= 0.161, p= .047) and perceptions of susceptibility (d= 0.195, p= .025), but no effect on perceptions of severity (d= -0.036, p= .828). Interventions showed no effect on intention to vaccinate (d= 0.138, p= .195) and no effect on vaccination behaviour (d= 0.043, p= .826). The qualitative study highlighted a number of beliefs, based on incorrect knowledge, that may have been having an unhelpful effect on vaccination decisions. These included the belief that pregnancy did not increase the severity of flu, that flu would not have any severe consequences on either pregnant woman or their unborn baby, and that the vaccination involved the administering of a live vaccine. The Illness Risk Representation framework was an adequate fit to the data. Following the application of Intervention Mapping techniques, perceived severity, perceived susceptibility, self-efficacy and response-efficacy were selected as appropriate determinants for the animation to target. The Performance Objective (the aim of the animation) was defined as ‘decide to have the flu vaccination.’ The completed animation contained information about the risks and consequences of flu during pregnancy, how the vaccination works to protect both the pregnant woman and the unborn baby, and provided information about the ingredients of the flu vaccine. Results of the think aloud study showed that the majority of participants felt that the length and the level of information provided was appropriate, and felt happy to recommend the animation to other pregnant women, which was considered to be helpful in helping them make the decision whether to vaccinate or not. Discussion: The systematic review was not able to answer whether interventions that contain a risk message are successful in increasing risk appraisal and vaccination uptake. It did however, highlight a number of methodological shortcomings of experimental studies that currently exist on this topic. The qualitative study identified a number of areas of incorrect knowledge that pregnant women held about flu and the flu vaccination, that appeared to be influencing their beliefs. Providing accurate information may help to shape vaccination decisions favourably. The animation is the first known animation, based on theory that aims to increase pregnant women’s acceptable of the flu vaccination, by targeting a change in risk and efficacy appraisals. Initial testing suggests that it is an acceptable intervention that has the potential to be useful in providing information to pregnant women which may help them make an informed decision about vaccinating against flu. Local Public Health departments have agreed to include the animation in local seasonal flu campaigns in the 2018/19 flu season, potentially reaching a large number of pregnant women.

Background: In Oman, 33.3% of women attended late for publicly funded antenatal care in 2015 and 24% did not attend for the recommended 4-6 visits during their pregnancy. This low attendance suggests a need to explore attendance for antenatal care for low-risk pregnant women in Oman. Methodology: An exploratory qualitative design informed by constructivist grounded theory methodology was used in this research. Methods: In-depth semi-structured interviews were conducted with an initial purposive sample of nine pregnant women. The initial analysis enabled theoretical sampling of thirteen non-participant observations during women's appointments, interviews with ten care providers, and six women who booked late after 12 weeks of gestation. A constructivist grounded theory analytical framework of initial, focused and theoretical coding was followed to analyse all the data collected. Findings: The core category consists of five interrelated sub-categories: perceived benefits and value of antenatal care; timing of the first antenatal visit; woman-carer interactions during antenatal care; experiences with antenatal care delivery; and supplementary use of private healthcare. The integral categories explain the social processes and issues surrounding antenatal care. The emergent core category, Navigating antenatal care, reflects the views of the women and their care providers. The women were unhappy with the organisation and physical environment of care but attended their appointments to ensure optimal pregnancy outcome and to alleviate their fears of developing complications. Thus, they used both private and public healthcare and sourced online information in response to their feelings of obligation to protect their fetus. Conclusion: The women appeared disempowered and to lack control over the care they received. Thus, they accepted conditions such as long waiting times in an uncomfortable environment and the disrespect they encountered during their visits. There was a discrepancy between what the women expected and needed from their antenatal care and the actual care and information they received, which did not satisfy their needs. This could be due to a lack of woman-centred care and limited involvement in the plan of care. Thus, women sought further reassurance by accessing private clinics, using online information, and networking with others, which also resulted in a late booking for public antenatal care.

Objectives: The purpose of this study was to examine rural women s access to maternal health information and its impact on levels of skilled healthcare utilization. Method: A qualitative study involving twenty five (25) pregnant women,five (5) Skilled healthcare providers and five (5) Traditional Birth Attendants (TBAs) was conducted in Chamwino District in Dodoma Region, Tanzania for a period of six months. Due to time and resource limitation the researcher selected two (2) of the 32 wards in the district where the problem of maternal mortality and non-utilization of skilled healthcare was most prominent. The two selected wards were Msanga and Buigiri wards. The researcher used The Health Belief Model and Theory of Planned Behaviour to develop interview questions and focus group guides as well as the interpretation of the findings. The researcher examined how variable factors e.g. maternal health literacy, individual perceptions, local knowledge and care provider-related factors affect pregnant women s health behaviours and utilization of skilled maternal services. The Data was analysed thematically using the 6-stage guide to thematic data analysis with the help of NVIvo Software. Results: The inadequate conditions of the health facilities and the poor working conditions of the care providers affected the provision of quality of maternal services and health information to pregnant women in the study area. The limited access to skilled maternal health information from skilled healthcare providers and lack of alternative sources of reliable health information led pregnant women to seek health information from their Mothers-in-laws, TBAs and other women in the society. However, there was a shortcoming of information inaccuracy as their health advice was not based on previous expert advice but rather on the personal opinion and attitude towards skilled maternal services. The limited access to maternal health information caused majority of pregnant women to underestimate the risks of pregnancy related complications and how they responded to pregnancy danger signs and other ill-health conditions that raised during pregnancy. The majority of pregnant women reported not to seek and kind of care when experienced a health problem. It was also found that during labour some would go to the TBA for childbirth and later go to the dispensary when the TBA failed while others would just go for TBAs opinion and confirmation that it was real labour then go to the health facility. This delayed women s timely access to obstetric care which is essential for positive outcome when a pregnant woman experiences a pregnancy or childbirth complications. Conclusion: The improvement of the quality of skilled healthcare services in rural areas is a prerequisite for achieving desired outcomes in maternal mortality reduction efforts in Tanzania. However, improvement of quality itself is not a panacea if pregnant women are not aware of the services, hence the healthcare providers should also focus in increasing provision of maternal health information to pregnant women. The findings show that the limited access to skilled maternal health information from healthcare providers and lack of alternative sources for reliable health information has constrained majority of these women from becoming maternal health literate hence affecting their levels of utilization of skilled maternal services. The healthcare providers and policy makers should focus on meeting the health information needs of general rural populations and enable them to become well-informed and knowledgeable to make better and well-informed maternal health decisions.