A socio-ecological exploration to identify factors influencing the COVID-19 vaccine decision-making process among pregnant and lactating women: Findings from Kenya

Rupali J. Limaye, Alicia Paul, Rachel Gur-Arie, Eleonor Zavala, Clarice Lee, Berhaun Fesshaye, Prachi Singh, Wincate Njagi, Paul Odila, Paul Munyao, Rosemary Njogu, Stephen Mutwiwa, Lisa Noguchi, Christopher Morgan, Ruth Karron

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


The vaccine decision-making process of pregnant and lactating women is complex. Regarding COVID-19, pregnant women are at increased risk for severe disease and poor health outcomes. While pregnant and lactating women were excluded from COVID-19 vaccine trials, available evidence suggests that COVID-19 vaccines are safe and protective during pregnancy. In this study, we used a socio-ecological approach to explore factors influencing the decision-making process for COVID-19 vaccines in pregnant and lactating women in Kenya, for the purpose of informing demand generation strategies. As pregnant and lactating women are influenced by many factors, we conducted 84 in-depth interviews with a variety of stakeholders, including 31 pregnant or lactating women, 20 healthcare workers such as nurses, midwives, doctors, and frontline workers, 25 male family members of pregnant or lactating women, and 8 gatekeepers such as community leaders and faith-based leaders. These individuals were recruited from six communities in Kenya: three urban, and three rural. We applied a grounded theory approach to identify emerging themes and organized emerging themes using the SAGE Vaccine Hesitancy model, which includes three categories of determinants of vaccine acceptance, including contextual influences, individual and group influences, and vaccine and vaccination specific issues. Myths, interpersonal norms, and religion emerged as themes related to contextual influences. Safety, risk perception, and the role of the healthcare worker emerged as themes related to individual and group influences. For vaccine and vaccination specific issues, emerging themes included availability, accessibility, and eligibility. While maternal immunization can substantially reduce the effect of infectious diseases in mothers and infants, vaccine acceptance is critical. However, vaccines do not save lives; vaccination does. We hope the results of this study can be used to tailor communication efforts to increase vaccine demand among pregnant and lactating women.

Original languageEnglish
Pages (from-to)7305-7311
Number of pages7
Issue number50
StatePublished - 28 Nov 2022
Externally publishedYes


  • COVID-19
  • Communication
  • Maternal immunization
  • Pregnant women
  • Vaccine acceptance

ASJC Scopus subject areas

  • General Veterinary
  • Public Health, Environmental and Occupational Health
  • Infectious Diseases
  • Molecular Medicine
  • General Immunology and Microbiology


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