Vaccine hesitancy and uptake during pregnancy: investigating the role of emotional mental imagery

Background Vaccine hesitancy and suboptimal vaccine uptake pose significant threats to public health, but modifiable psychological factors underpinning them are under-investigated. We examined the prevalence of spontaneous emotional mental imagery relating to infectious diseases and perinatal vaccines and its unique associations with vaccine hesitancy and uptake behaviour. Methods In a two-part longitudinal study, a sample of 411 English-speaking pregnant women attending a large public maternity hospital in Western Australia completed a baseline survey assessing levels of vaccine hesitancy and vaccine uptake (status and timing) during pregnancy for influenza, pertussis, and COVID-19. Vaccine uptake data were collected through official immunisation records. Spontaneous mental imagery was assessed using a novel paradigm comprised of risk-perception questions, after which participants were asked to indicate whether they experienced disease and vaccine-related mental imagery when completing risk-perception question. Results Vaccine hesitancy was lowest for pertussis and highest for COVID-19. Participants (38%) reported primarily negative mental images formulated from personal experiences, the news and social media. Over and above maternal vaccination intention and anticipated regret, the presence of negative vaccine imagery was associated with higher vaccine hesitancy for those not yet vaccinated for pertussis and influenza. The presence of positive vaccine imagery was independently associated with higher uptake likelihood and earlier uptake timing for pertussis only. Mental imagery was not associated with COVID-19 vaccine hesitancy or uptake. Conclusions Vaccine-related mental imagery represents a potential cognitive marker and modifiable intervention target for vaccine hesitancy. Findings should be interpreted considering limitations associated with real-world field research and the unique Western Australian pandemic context.