Introduction

Epidemiological data on the recent monkeypox (MPOX) outbreak indicate that as of August 2023, 989,308 people contracted the disease, which resulted in 152 deaths across the six World Health Organization (WHO) regions [1]. The WHO African region accounts for 2.1% (1,902) of confirmed cases and 13% of deaths globally [1]. Although low, the disproportionally high mortality rate of MPOX in Africa reflects the region’s vulnerability to the disease and, indeed, to several other infectious diseases, underscoring the need for public health programs to curtail infections. In the specific case of Ghana, although MPOX infection is relatively low (127 confirmed cases), it is labelled as a high-risk country, hence the need for evidence-informed public health interventions [1, 2].

Vaccinations are recommended to prevent and reduce the spread of MPOX, especially for at-risk populations such as health workers, people with multiple sex partners, sex workers, and men who have sex with men [3, 4]. Vaccinations may also help reduce hospitalizations from the disease and lessen the burden on health infrastructure. Yet, in Ghana and most countries in sub-Saharan Africa, vaccine apathy and hesitancy are high, which can have adverse public health implications [4, 5]. This is particularly concerning as these contexts are characterized by weak health systems and socio-cultural practices such as elaborate funerals and weddings, which tend to facilitate the spread of infectious diseases such as MPOX [6, 7].

According to current research, people’s self-rated health may impact their vaccine uptake [8]. Research has mixed results examining the association between self-rated health and vaccine acceptance. For instance, in Ethiopia, it was observed that government healthcare workers with no known chronic health condition were more likely to receive the COVID-19 vaccine [9]. Individuals with poor self-rated health in Canada were less likely to be vaccinated against COVID-19 [10]. The authors argue that individuals with poor self-rated health may be concerned about the safety of available vaccines and, hence, less likely to accept them. On the contrary, O’Halloran et al. [11], in a study on influenza vaccination among high-risk populations in the United States, showed that individuals who perceive themselves as “healthy” are less likely to participate in preventive health activities, including influenza immunization [11].

Individual’s vaccination history may also impact their willingness to receive vaccines [5, 12, 13]. For example, in China, the history of influenza vaccination was associated with women’s acceptance of the influenza vaccine during the COVID-19 pandemic [14]. Beyond these factors, the literature also links people’s willingness to accept vaccines to sociodemographic and economic factors such as level of education, age, gender, and place of residence [5, 10, 13]. Likewise, knowledge of infectious diseases can also influence vaccine uptake reactions as it empowers them to make (un)informed health decisions [13–15].

Notwithstanding these studies’ usefulness in knowledge enhancement and public health programming, little is known about the relationships between self-rated health, vaccine uptake history, and people’s willingness to take the MPOX vaccine in Ghana [2, 5]. A critical study by Ghazy and colleagues [5] drew on cross-sectional data from social media platforms to examine MPOX vaccine acceptance among people in Ghana [5]. Their study used a snowball sampling technique and was limited to people (n = 550) with access to the internet and smartphones, which has implications for their findings.

Building on this earlier study, we examine the associations between self-rated health, history of vaccine uptake, and people’s willingness to accept the MPOX vaccine in Ghana using cross-sectional data from four major cities in Ghana. Understanding the relationship between self-rated health, vaccination history, and willingness to accept MPOX vaccinations can help develop appropriate interventions to improve vaccine uptake, especially for people in low- and middle-income countries.

Materials and methods

Measures

Results

Characteristics of the study sample

Characteristics of the 2059 study sample are presented in Table 1. Women made up 40.18% of the total sample. About 36.96% of the sample were educated, and 63.04% were married. Most (53.67%) of the participants were employed, and 63.42% were insured. Most (91.26%) participants rated their health as “excellent.” Regarding vaccination history, 41.75% were vaccinated in the past year, 65.75% were not, and 3.83% were hesitant to answer. Furthermore, 31.93% of participants said they were willing to receive the MPOX vaccine.

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Table 1. Descriptive statistics of the study sample.

https://doi.org/10.1371/journal.pgph.0003564.t001

Adjusted and unadjusted logistic regression models with odd ratios and confidence intervals

Table 2 below presents three models. Models 1 and 2 present unadjusted odds ratios (UOR). Model 1 examines the relationship between self-rated health and willingness to accept the MPOX vaccine. Model 2 examines previous vaccine uptake and willingness to accept the MPOX vaccine. On the other hand, the third model (model 3) provides the adjusted odd ratios (AOR) of models 1 and 2. The adjusted variables are gender, age, employment status, health insurance status, and MPOX virus and vaccine knowledge.

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Table 2. Bivariate and multivariate logistic regression of self-rated health and previous vaccine uptake on willingness to accept MPOX vaccine.

https://doi.org/10.1371/journal.pgph.0003564.t002

The results from model 1 indicate that self-rated health is significantly associated with the willingness to receive the MPOX vaccine. Compared to those who reported their health status as “Excellent,” individuals who reported their health status as “poor” (UOR 2.07; 95% CI: 1:.43–2.98) were significantly more willing to receive an MPOX vaccine. Similarly, model 2 shows a statistically significant association between previous vaccine uptake and the willingness to accept the MPOX vaccine. Compared to individuals who have previously accepted a vaccine, those who said no to previous vaccines (UOR .48; 95% CI: .39–.60) and those who prefer not to say (UOR .10; 95% CI: .04–.25) were significantly less likely to accept the MPOX vaccine.

Even after adjusting for covariates in model 3, there is still a significant link between vaccine uptake history and willingness to get the MPOX vaccine. Thus, people who have not been vaccinated in the past are much less likely to get the vaccine (AOR .29; 95% CI: .19–.44). In model 3, although there is a relationship between poor health and the willingness to accept the MPOX vaccine (AOR 1.65; 95% CI: .87–3.11), the relationship is not significant. Meaning there is an interaction between self-rated health and the covariates presented in model 3.

A significant association was found between gender and the willingness to accept the vaccine. Females were significantly more willing to accept the vaccine (AOR 1.65; 95% CI: 1.13–2.40) than their male counterparts. The results further indicate that compared to those less than 30 years old, those above 40 are significantly more willing (AOR 2.55; 95% CI: 1.40–3.62) to accept the MPOX vaccine. Interestingly, we found that compared to the employed, the unemployed are more willing to accept the vaccine (AOR 1.60; 95% CI:1.07–2.41). In addition, we found that compared to the unmarried, those married are more willing to accept the MPOX vaccine (AOR 1.59; 95% CI: 1.06–2.39). We also found that compared to those who earn less than GHC 2000 (the “poor”), those who earn more than GHC 4000 (the “rich”) are significantly (AOR .25; 95% CI: .14–.45) less willing to accept the MPOX vaccine. Regarding knowledge of the MPOX disease and vaccine, albeit not significant, we found that those with high vaccine knowledge are less willing to receive the MPOX vaccine.

Discussion and conclusions

On July 23, 2022, MPOX was declared a Public Health Emergency of International Concern by the World Health Organization (WHO). Even though the vast majority of reported cases are outside of the WHO African region, the poor health systems in this context underscore the urgent need for research on the factors influencing MPOX vaccine uptake [20, 21]. The emergence and re-emergence of infectious diseases, many of which tend to be public health threats, further demonstrate the essential need for evidence-informed public health policies and measures to enhance vaccine uptake. In this study, we examine the associations between self-rated health, vaccine uptake history, and the willingness to accept the MPOX vaccine by adults in Ghana during a public health emergency. At the bivariate level, we observed that individuals who rated their health as poor were significantly more willing to receive the MPOX vaccine than their counterparts who rated their health as excellent. However, after adjusting for sociodemographic and economic variables and participants’ knowledge, this relationship disappeared, suggesting the critical role of these variables in mediating the relationship between self-rated health and the uptake of the MPOX vaccine [15, 22]. For example, sociodemographic factors such as age and gender are found to be associated with MPOX vaccine acceptance in Ghana [5] and Ethiopia [23].

Findings from this study are consistent with previous studies establishing that previous uptake of vaccines is critical to their future acceptance [5, 12, 13]. For instance, Ghazy and colleagues, using data obtained from individuals on social media platforms, observed among Ghanaians that those vaccinated against COVID-19 had higher MPOX vaccine acceptance than their counterparts who did not [5]. Winter and colleagues made similar observations in the United States [24]. The authors found the receipt of COVID-19 vaccine to predict MPOX vaccine acceptance strongly. Previous vaccination history was also significantly associated with MPOX vaccine acceptance among healthcare workers in Jordan [25]. In Shenzhen, China, past influenza vaccine receipt was significantly associated with MPOX vaccine acceptance among adults [26]. An earlier systematic review of the literature on the factors associated with vaccination against pandemic influenza found that individuals vaccinated earlier against seasonal influenza were more likely to be vaccinated against pandemic influenza [12]. Raut et al. [13] drew similar conclusions in a recent review. The acceptance of vaccines in the past suggests that these individuals acknowledge the critical role of vaccines in reducing mortality and hospitalization rates and are, hence, inclined to accept the MPOX vaccine [26, 27]. Moreover, it is plausible that individuals vaccinated in the past generally trust vaccines and their overall efficacy and safety and, hence, are likely to accept the MPOX vaccine [5, 25, 28]. Having people who previously received vaccines testify to the efficacy and safety of vaccines through public health communication and messaging will be helpful in promoting vaccine uptake.

We observed that individuals’ sociodemographic and economic status also influence their willingness to take the MPOX vaccine. Specifically, females were found to be more likely to accept the vaccine compared to their male counterparts. This finding is consistent with earlier studies on COVID-19, influenza, and MPOX [12, 22, 28–30]. For instance, Braimah et al. [29] argue that women tend to take less risk and are more health conscious than their male counterparts and, hence, may be more willing to accept the MPOX vaccine. However, this finding contrasts with earlier studies, contending that females are less likely to take MPOX and influenza vaccines in Ghana [5] and Hungary [31]. Participants’ age was also significantly associated with their willingness to accept the MPOX vaccine, with individuals over forty more likely to accept the vaccine than their counterparts under thirty. This finding is consistent with previous studies linking age to health-seeking behaviors, including the willingness to accept vaccines [15, 31]. Evidence shows that age is a risk factor for diseases [14, 22, 32], including infectious diseases, and hence, older individuals may be willing to accept vaccines to minimize these risks, possibly explaining our findings. Furthermore, we found unemployed people more willing to accept the vaccine than employed people. This finding is surprising as employed individuals tend to be more exposed to the virus, especially in the workplace. A qualitative exploration of how employment influences behaviors toward vaccination will be beneficial. Earlier studies suggest that married individuals are more likely to act against infectious diseases to protect their families [29, 33]. In line with these studies, married individuals are more likely to accept the MPOX vaccine than their unmarried counterparts.

Besides sociodemographic and economic factors, knowledge of the cause and transmission mode of MPOX was observed to influence people’s willingness to vaccinate against it. This finding is not surprising and aligns with earlier studies [14, 29, 31]. Knowledge of the source of infection for the MPOX disease will enhance people’s trust and confidence, which can positively influence their attitudes towards the vaccine and its acceptance [15, 26]. Accurate knowledge about diseases’ causes and transmission modes will also aid in better assessing their risks and associated behaviors. Thus, public health promotion measures for MPOX disease will also need to be tailored to enhance people’s knowledge about its causes, transmission, and risks.

This study is among the first to examine how self-rated health and vaccine uptake history influence people’s willingness to receive the MPOX vaccine during a public health emergency, drawing from a nationally representative sample. Thus, our findings are generalizable to similar contexts. The findings are instrumental in enhancing knowledge of vaccine hesitancy and providing policy directions for public health promotion. Nonetheless, several limitations exist that are worth noting. Firstly, the data for the study is cross-sectional, limiting the interpretation of our findings to statistical associations. Thus, longitudinal and qualitative studies will be useful in addressing this limitation. Furthermore, answers to our questions may be influenced by participants’ experiences with COVID-19 as our data were collected immediately after the height of the pandemic, subjecting our findings to potential bias. Finally, although we accounted for the role of sociodemographic factors in influencing the relationship between self-rated health and willingness to take the MPOX vaccine in model 3, we did not perform further interaction analysis, as that is beyond the scope of this paper. Thus, future studies could benefit from mediation/interaction analysis to unveil the specific sociodemographic and economic variables mediating the relationships between self-rated health, vaccine acceptance history, and willingness to receive the MPOX vaccine.

Notwithstanding these limitations, our findings demonstrate that people’s willingness to accept the MPOX vaccine may depend on multiple factors, including their vaccine uptake history, age, gender, income, and knowledge of the etiology of the disease. Based on these, we make some policy recommendations. First, we recommend a multi-pronged public health approach in addressing vaccine rejection or apathy in the Ghanaian context and perhaps other low- and middle-income countries. Thus, public health measures to enhance vaccine uptake should pay particular attention to people’s vaccine histories, given its association with the willingness to accept the MPOX vaccine. Second, we propose gender-sensitive public health policies and programs focusing on men with relatively higher vaccine hesitancy levels. Finally, we recommended involving community members with up-to-date vaccination history in vaccine-related public health education and programming. The educational programs should particularly focus on clarifying MPOX vaccine safety concerns.

Supporting information

Acknowledgments

We would like to thank our research participants for sharing their perspectives with us. We also thank the reviewers for taking time off their busy schedules to review this manuscript.