A cross-sectional survey of 334 pregnant women in Ghana’s Sekondi-Takoradi metropolis has found that protection motivation theory constructs—perceived vulnerability, perceived severity, self-efficacy, and response efficacy—predict acceptance of COVID-19 vaccination, with the number of children a woman has emerging as a significant correlate of her risk perceptions. The study, published in Discover Health Systems, examined women who were pregnant before Ghana recorded its first COVID-19 case and offers insights for designing epidemic risk communication in the country.
The research, led by Leander Achageba Allou, was grounded in the observation that the World Health Organization recommends COVID-19 vaccination as one of the most effective measures for preventing severe COVID-19 outcomes, but that the success of vaccine use depends on its acceptability. The study set out to explore the motivating factors for COVID-19 vaccination acceptance among pregnant women in the Western Region of Ghana during the outbreak of the pandemic.
Evidence cited in the study shows that COVID-19 infection during pregnancy has caused increased maternal morbidity, and comparative research between pregnant and puerperal women and non-pregnant women found that infection during pregnancy led to an increased risk of admission to intensive care units or invasive ventilation. The authors attribute this to altered respiratory function during pregnancy, driven by increased oxygen consumption, physiologic elevation of the diaphragm that restricts lung expansion, and hormone-induced swelling of the upper respiratory tract mucosa. Pregnant women who contract COVID-19 also face an increased risk of death compared with non-pregnant women, and the risk of preterm delivery or delivery by Caesarean section rises as well. One cited study reported that pregnant women infected with COVID-19 are most likely to have underweight children. Some studies, however, have reported that severe COVID-19 outcomes among pregnant women are not directly linked to COVID-19 itself but to underlying conditions such as advanced age, high body mass index, chronic hypertension, and pre-existing diabetes.
Against this backdrop, the WHO Strategic Advisory Group of Experts on Immunization recommended COVID-19 vaccination for pregnant and lactating mothers even though there were no studies on the effectiveness of the vaccine during pregnancy at the time, advising that pregnant women should be vaccinated when the benefits outweigh the potential risks. Pregnant women at high risk of exposure and those with comorbidities were considered a high-risk group for severe COVID-19. Vaccines were described as the most effective safeguard against severe illness, hospitalization, and death, and research by de Gier and colleagues and Yi and colleagues indicated that vaccination also significantly helps reduce transmission to other individuals.
The study applied Protection Motivation Theory, first propounded in 1975, which explains how cognitive processes affect the development of protective behaviour. The theory relies on a fear appeal to stimulate behaviour and assesses both threat appraisal—perceived severity of a disease and perceived susceptibility to contracting it—and coping appraisal, which covers how individuals rate the efficacy of preventive options (response efficacy) and how confident they feel in practicing those options (self-efficacy). Prior cross-sectional studies had used PMT to explain COVID-19 vaccination intentions: Ansari-Moghaddam and colleagues found that perceived severity, perceived self-efficacy, and perceived response efficacy significantly predicted vaccination intention, while Eberhardt and Ling identified maladaptive response rewards and self-efficacy as predictors. The authors acknowledge a limitation of PMT, namely its failure to consider normative influences on behaviour; Lueck and Spiers reported that injunctive and descriptive norms predicted vaccination intentions, and Scholz and Freund found that perceived social disapproval explained additional variance beyond PMT variables.
Methodologically, the survey targeted women who had registered for and were receiving antenatal care services in the Sekondi-Takoradi metropolis before Ghana’s first COVID-19 case was reported. The region was chosen for its high infection rates and because women there were not affected by a lockdown, while the metropolis itself was selected as the most cosmopolitan town in the Western Region, with a diverse mix of social, economic, religious, and cultural backgrounds. From an estimated 2,400 pregnant women recorded in the sub-district antenatal registers as of March 2020, the researchers used systematic random sampling, selecting every fifth woman on the registers, with the sixth woman serving as a replacement when the fifth did not meet the inclusion criteria. Eligible participants had registered for antenatal care, had a live birth, and had resided in the study area throughout their pregnancy and still resided there; women who had a stillbirth, abortion, or miscarriage, or whose babies died before ten weeks of age, were excluded because the study formed part of a larger investigation of maternal and child health service access.
Data were collected over three months, from February to April 2022, using a structured questionnaire on the KoBoCollect platform, adapted in part from a 2020 risk perception questionnaire by Prasetyo and colleagues and pre-tested in the neighbouring Ahanta West Municipal Assembly. The questionnaire measured perceived vulnerability with five items (Cronbach’s alpha 0.81), perceived severity with seven items (alpha 0.767), a further construct with four items (alpha 0.725), and response efficacy with seven items (alpha 0.763), all on five-point Likert scales from strongly disagree to strongly agree. Vaccine acceptance was operationalised as actually receiving the COVID-19 vaccination and coded dichotomously. Analysis in STATA employed Pearson’s Chi-Square tests and logistic regression at a 5% significance level. Most respondents were aged 26 to 30 years (34.8 percent), had one previous child (32.6 percent), were married (72.8 percent), had reached JHS or middle school as their highest education level, were Christian (89.8 percent), self-employed (72.5 percent), and earned between 0 and 4,999 Ghanaian cedis annually (89.5 percent).
The logistic regression model was statistically significant (chi-square (6) = 150.37, p < 0.001) and explained approximately 52 percent of the variance in COVID-19 vaccine acceptance (Nagelkerke R2 = 0.52), with the Hosmer-Lemeshow test indicating adequate fit. Respondents with higher perceived vulnerability were approximately eight times more likely to accept COVID-19 vaccination (OR = 7.671, 95% CI 2.395 to 24.572), those with higher self-efficacy approximately two times more likely (OR = 2.042, 95% CI 1.277 to 3.264), and those with higher response efficacy approximately four times more likely (OR = 4.310, 95% CI 2.410 to 7.706). Notably, respondents with higher perceived severity were approximately only one third as likely to accept vaccination (OR = 0.385, 95% CI 0.214 to 0.693). The Chi-Square tests showed that the number of children a respondent had was significantly related to the PMT constructs of vulnerability (p = 0.015), severity (p = 0.001), self-efficacy (p = 0.001), and response efficacy (p = 0.045). The authors suggest that higher risk perception among women with more children may be explained by caregiving responsibilities that keep them close to their children, noting that women are primary caregivers of children during epidemics, increasing the likelihood of physical contact at home, while children are generally less prone to severe COVID-19 symptoms except those with underlying health conditions.
In the discussion, the authors report that perceived vulnerability acted as a primary, positive driver of protective behaviour, consistent with previous findings, and that perceived severity is the most important variable in threat appraisal apart from vulnerability, though higher perceived severity is usually linked to adopting preventive behaviour. They describe self-efficacy as an important component of coping appraisal, directly linked to intention to act, and found response efficacy to be a strong predictor of acceptance. The study, they write, supports the applicability of PMT in predicting preventive behaviour such as COVID-19 vaccine acceptance, and the pattern of effects is consistent with the theory. The conclusion emphasises that fear appeal in women and the likelihood of receiving the COVID-19 vaccine is influenced by the number of children they have, and recommends that risk communication efforts focus on women with fewer or no children, that epidemic risk communication tools be designed on the basis of protection motivation, and that the ministry in charge of communication and the National Commission for Civic Education implement measures ensuring that only accurate information is provided during epidemics. The Ministry of Health and the Ghana Health Service are urged to provide comprehensive epidemic information that appropriately shapes perceived vulnerability, severity, self-efficacy, and response efficacy, and to emphasise vaccine effectiveness. The authors also caution that risk perception is a double-edged sword: risk communication can foster protective behaviours that contain the spread of viruses, yet perceptions of risk may also lead to protective behaviours detrimental to delivering health services.
The study’s limitations are explicit. Because the design was cross-sectional, causality could not be determined, and the associations reported here should be read as correlations rather than causal effects. Generalisability was limited because the sample was drawn only from women who had registered for and accessed antenatal care services at the time of the COVID-19 outbreak in Ghana, and the researchers found it difficult to obtain a list of pregnant women at the study site who did not access antenatal services. The findings also reflect experiences and perceptions relating to the early phase of the pandemic, gathered in interviews conducted in 2022. Within those boundaries, the work adds a theory-driven, regionally specific account of what motivated vaccine acceptance among pregnant women in western Ghana, and provides a template for PMT-based risk communication in future epidemic responses.
Subject of Research: Predictors of COVID-19 vaccination acceptance among pregnant women in western Ghana, analysed through protection motivation theory
Article Title: Assessing the predictors of COVID-19 vaccination acceptance among pregnant women in the Sekondi Takoradi metropolis of Western Ghana using protection motivation theory
Article References: Allou, L. A. (2026). Assessing the predictors of COVID-19 vaccination acceptance among pregnant women in the Sekondi Takoradi metropolis of Western Ghana using protection motivation theory. Discover Health Systems, 5(1), Article 84. https://doi.org/10.1007/s44250-026-00427-7
Image Credits: AI Generated
DOI: 10.1007/s44250-026-00427-7
Keywords: COVID-19, vaccination acceptance, pregnant women, Ghana, protection motivation theory, risk perception, cross-sectional study, antenatal care, health communication, self-efficacy, vaccine hesitancy, Western Region
News Source: Harold Sullivan. (October 28, 2026). Research report: Assessing the predictors of COVID-19 vaccination acceptance among pregnant women in the Sekondi Takoradi metropolis of Western Ghana using protection motivation theory. Scienmag.
