Perceived safety and efficacy of the malaria vaccine, RTS,S/AS01 among vaccinated children in the South West Region of Cameroon: Mixed Study Approach

Perceived safety and efficacy of the malaria vaccine, RTS,S/AS01 among vaccinated children in the South West Region of Cameroon: Mixed Study Approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perceived safety and efficacy of the malaria vaccine, RTS,S/AS01 among vaccinated children in the South West Region of Cameroon: Mixed Study Approach Jude Che Anye, Loveline Lum Niba, Omarine Njimanted, Nicholas Tendongfor, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8293727/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Malaria remains a leading cause of morbidity and mortality among children under five in Cameroon. In 2024, the RTS,S/AS01 malaria vaccine was introduced into the Expanded Programme on Immunization (EPI), yet evidence on community perceptions, uptake, and real-world effectiveness remains limited. This study assessed caregivers’ and healthcare workers’ perceptions of the vaccine’s safety and efficacy, and examined factors influencing uptake among children in three high-burden districts of the South West Region (SWR) of Cameroon. Methods A mixed-methods study was conducted using a cross-sectional survey of caregivers of vaccinated children and qualitative interviews with mothers and healthcare workers. Quantitative data captured awareness, perceived safety, reported side effects, and vaccine effectiveness. Qualitative data also explored perceptions, communication gaps, cultural influences, and health-system challenges. Descriptive and inferential statistics, including logistic regression, were used for quantitative analysis, while thematic analysis guided qualitative interpretation. Results Among 418 surveyed caregivers, complete vaccine uptake was 62% (258) which is below the WHO recommended target. Lack of knowledge (33%, 109), fear of side effects (22%, 75), and low trust in the health system (14%, 47) were major barriers to full adherence. Perceived safety was generally high (55%, 195), with no serious adverse events reported. Children who completed all vaccine doses were significantly less likely to develop malaria (OR = 0.52; p = 0.037) and had markedly lower odds of severe malaria than those partially vaccinated (OR = 14.5; p < 0.01). Qualitative findings confirmed safety and effectiveness, but limited awareness, misconceptions, stock-outs, and the need for improved community sensitization. Conclusion The RTS,S/AS01 vaccine is perceived as safe and effective, but uptake is hindered by knowledge gaps, communication challenges, and supply constraints in the study area. Therefore, strengthening community awareness, improving health-worker training, and ensuring consistent vaccine availability are essential. Malaria vaccine RTS S/AS01 safety efficacy uptake caregivers mixed-methods SWR Cameroon Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION Malaria has always been a major public health problem in sub-Saharan Africa (SSA), leading to the highest morbidity and mortality rates globally. More than 90% of deaths associated with malaria are due to Plasmodium falciparum ( 1 , 2 ). In 2022, it was estimated that there were about 249 million cases and 619,000 deaths due to malaria worldwide. The African Region including Cameroon accounted for over 93% of the cases and about 95% of the deaths and most of these deaths were among children under five years old ( 3 , 4 ). Cameroon like the rest of SSA has a very high burden of malaria with more than 3 million confirmed cases recorded each year and thousands of deaths and malaria continue to be the leading cause of morbidity and mortality among children below five years in the country ( 3 , 5 , 6 , 7 , 8 ); thereby requiring serious control measures. Control measures against malaria in Cameroon have been mostly vector control through insecticide-treated nets and indoor residual spraying along with intermittent preventive treatment for pregnant women and children under five as well as seasonal chemo-prevention in epidemic-prone areas. Treatment has been available through the public health system since it was adopted by WHO ( 5 ). The fight against malaria has however stagnated because progress has been hindered by insecticide resistance, drug resistance, very high transmission intensity, and inequitable use of the available prevention tools ( 9 – 11 ). The RTS,S/AS01 vaccine introduced by the WHO following a recommendation in 2021 and prequalified in 2022 adds an important new dimension to malaria prevention. This vaccine showed moderate but significant efficacy against clinical and severe malaria, hospitalizations due to any cause, or mortality among young children in African countries ( 12 – 14 ). It is worth noting that the pilot implementation programs conducted in Ghana ( 13 ), Kenya ( 13 ), and Malawi ( 14 ) have demonstrated significant reductions in malaria morbidity and mortality even under conditions where bed nets and chemoprevention are already widely used against child deaths and severe malaria. Cameroon introduced RTS,S/AS01 into its EPI at the beginning of January 2024 after receiving the first shipment of vaccines in November 2023 ( 6 ). High-risk districts prioritized for initial rollout based on sub-national malaria burden analyses included Limbe, Tiko, and Mamfe all from South West Region of Cameroon. These were areas with historically high transmission and severe malaria burden among under-fives ( 6 , 8 , 15 ). The vaccination schedule comprises four doses at 6, 7 and 9 months, and a booster dose at 24 months ( 16 ). Public health impacts are generally paramount for uptake of new vaccines within SSA against the background of caregiver perceptions and sociocultural beliefs. Moreover, risk awareness and health system factors such as accessibility, communication plus worker capacity to deliver these interventions, perceived safety, side effects and effectiveness during early phases are very critical ( 17 – 20 ). Although global evidence affirms the safety of RTS,S/AS01 with most adverse events being mild and transient ( 21 – 23 ), many local perceptions within newly vaccinated communities in Cameroon are largely undocumented thereby necessitating this study. Caregivers’ and health workers’ perceptions about the safety, tolerability, and efficacy of the malaria vaccine are important in optimizing demand generation, strengthening adherence to the multi-dose schedule, and informing policy adaptations during rollout. This study therefore used a mixed-method approach to assess perceptions in relation to malaria vaccine safety and efficacy among caregivers of vaccinated children and key health personnel in selected districts of the South West Region of Cameroon. Findings from this study will be used to improve communication strategies, strengthen delivery strategies, and obviously increase overall uptake of the vaccine within an ongoing national program. METHODS Study Design A cross-sectional mixed-methods design was used to assess perceptions of RTS,S/AS01 malaria vaccine safety and efficacy among caregivers of vaccinated children and health care providers involved in vaccine delivery. Quantitative methods assessed awareness, perceived safety, side effects experienced by vaccinated children, perceived effectiveness, and uptake of doses, while qualitative methods explored deeper insights into experiences, attitudes, and contextual factors influencing perceptions and uptake. Study Setting This study was carried out in three high malaria burden health districts (Limbe, Tiko, and Mamfe) of the South West Region of Cameroon. These districts were selected as part of the national pilot rollout for RTS,S/AS01 due to consistently high morbidity and mortality from malaria among children under five ( 6 , 15 ). All participating health facilities were providing routine immunization services and delivering the malaria vaccine according to national EPI guidelines. Study Population A mixed population study involving caregivers of young children as well as frontline health personnel was used. The quantitative component included mothers/caregivers to children aged 11–30 months who by the time data was collected (October 2025) were eligible to receive at least three doses of RTS,S/AS01 vaccine. They were recruited from six randomly selected health areas across three health districts using probability proportionate to size followed by purposive sampling with support from community agents. Twenty female caregivers aged 20–53 years participated in two focus group discussions representing rural and urban settings for the qualitative component. Primary caregivers of children under five with varied educational backgrounds and livelihood activities were included. It also involved ten health care workers comprising nurses, midwives, psychosocial and community health workers, a laboratory technician having between 5–25 years’ experience and eight managers aged 39–52 holding senior district/regional leadership positions for malaria prevention/immunization services. Sample size calculation for quantitative aspect Using Cochrane’s formula to estimate proportion of children receiving vaccine (prior estimate of complete uptake = 41%) ( 16 ) with a margin of error of 5% assuming a normal distribution of the margin of error, the minimum sample size was calculated to be 372 participants. After adjustment for an 8% non-response rate and rounding the target sample size was 400. Participants were selected using purposive sampling proportionate to the population size of children 11–30 months of each of the six target health areas at the time of data collection. This method was used to avoid potential bias of the results considering equal numbers across all areas would have over represented smaller communities and under-represented larger ones potentially introducing a bias into the results. Table 1 shows the sample proportions. Table 1 Sample size of mothers of children between 11 to 30 months within health district/areas selected (Probability proportionate to size method) Health District Health Area Total births from June, 2023 to October, 2024 (Children 11–30 months) by October, 2025 Proportion Total sample size Limbe Bota 1872 0.2 80 Limbe Idenau 201 0.03 12 Mamfe Bachou-Akagbe 251 0.03 12 Mamfe Mamfe 1523 0.2 80 Tiko Tiko 326 0.04 16 Tiko Mutengene 3618 0.5 200 Total 6 7791 1 400 Sampling Procedure A multistage sampling technique was used in the selection of individual respondents for this study. The purposive sampling technique was first used to select districts that were piloting the implementation phase of the vaccine rollout program. Two health areas from each of the health districts were then selected using the simple random technique whereby names of all the health areas per district were wrapped in pieces of papers and two randomly picked by a neutral person. Thirdly, to ensure uptake was well determined and to avoid bias, healthcare workers with community agents moved around different localities within the health areas into homes of caregivers to purposively select those whose children fell under the eligibility criteria (11 to 30 months old). Those whose children were not within this age group were excluded from the study. For the qualitative part, participants were selected using purposive sampling to ensure representation across caregiver demographics and health worker cadres. FGDs with caregivers and healthcare workers were held as well as in-depth interviews (IDIs) with malaria and immunization focal persons. Data Collection Procedures Quantitative Data A structured questionnaire was administered through Kobo-collect tool to caregivers which sought information on their sociodemographic characteristics, awareness of malaria vaccine, perceived safety, reported side effects, perceived efficacy, and completion of vaccine doses. The questions were adopted from previous validated questionnaires used in Malaria Indicator surveys and Demographic and Health surveys ( 24 – 29 ). Qualitative Data Four FGDs and 2 IDIs were conducted using semi-structured guides tailored to each participant group. Discussions explored experiences with the vaccine, perceived safety and effectiveness, trust in the health system, communication received, challenges faced, and suggestions for improving uptake. Interviews and FGDs took place in quiet spaces within health facilities where they could be audio-recorded with consent plus field notes as a supplement. Data Analysis Responses to an electronic based questionnaire (kobo-collect tool) were downloaded by the researcher and study team into Microsoft Excel. A team member performed double data entry verification through comparison of questionnaires against what had been downloaded into Microsoft Excel. The cleaned data set was then imported into SPSS version 21 for analysis. Descriptive statistics were calculated for binary, categorical, and continuous variables. Logistic regression was used to evaluate association between independent variables (for example vaccine uptake) with efficacy as dependent variable. Frequencies, percentages mean plus confidence intervals summarized perceptions on safety as well as efficacy. Qualitative data were analyzed thematically with Nvivo 12 after being transcribed verbatim. A coding framework was created based on research objectives and themes that emerged inductively. Triangulation of data across FGDs and IDIs was done to increase validity and contextual interpretation. Ethical Considerations Ethical clearance was obtained from the Faculty of Health Sciences Institutional Review Board of the University of Bamenda (Ref. 2025/0002H/Uba/IRB) and the Regional Ethics Committee for Human Health Research in the South West Region of Cameroon (Ref. No771/CRERSH/SW/C/09/2025). Authorizations to carry out research were obtained from the South West Regional Delegation of Public Health, Cameroon and district health authorities. Written informed consent was obtained from all participants that took part in the study. Confidentiality, voluntary participation, and the right to withdraw at any time were fully ensured in line with ethical guidelines. RESULTS Quantitative Findings Sociodemographic Characteristics of the Study Population A total of 418 mothers/caregivers participated in the study across the three health districts of Mamfe, Tiko, and Limbe. The mean age of respondents was 30 ± 7.5 years, with age distributions relatively similar across the districts. Nearly half of all participants (49.3%, 206) were between 20–29 years, followed by 37.6% (157) aged 30–39 years. Only 3.6% ( 15 ) were younger than 20 years, while 9.6% (40) were aged 40 years and above. In terms of marital status, more than half of the respondents were married (56.9%, 238), while 37.8% (158) were single. A smaller proportion were divorced (2.6%, 11) or widowed (2.6%, 11). Distribution differed slightly by district, with Mamfe having the highest proportion of married respondents (56.5%, 61) and Limbe registering the highest proportion of single caregivers (53.2%, 50). Regarding their relationship with the child, the majority of participants were biological mothers (85.4%, 357), while 7.7% ( 32 ) were fathers and 6.9% ( 29 ) were primary caregivers such as grandparents or guardians. There was a slightly higher proportion of fathers and primary caregivers in Limbe compared to the other districts (Table 2). With respect to educational level, more than half of the participants (53.8%, 225) had secondary education, while 29.4% (123) had completed primary education. Only 10.8% (45) had attained tertiary-level education, and 6.0% ( 25 ) reported having no formal education. Limbe had the highest proportion of respondents with primary education (50%, 47), whereas Mamfe had a comparatively higher proportion of respondents with tertiary education (14.8%, 16). Concerning occupation, the majority of respondents were self-employed (54.5%, 228), followed by 34.0% (142) who were unemployed. Public and private sector workers accounted for 5.5% ( 23 ) and 6.0% ( 25 ), respectively. Tiko had the highest proportion of self-employed caregivers (63%, 136), while the highest proportion of unemployed participants (52.8%, 57) was recorded in Mamfe. In terms of religion, most respondents identified as Christians (88.8%, 371), while 7.2% ( 30 ) were Muslims, and 4.1% ( 17 ) belonged to other religious groups. Mamfe and Limbe showed similar patterns, while Tiko had a slightly higher proportion of Muslims (11.6%, 25). Finally, most caregivers had one child aged 11–30 months (78.2%, 327), while 17.5% (73) had two children and 4.3% ( 18 ) had three. Mamfe and Tiko had a very high proportion of caregivers with only one eligible child (86.1%, 93) for Mamfe and 89.3% (194) for Tiko), whereas Limbe had a more even distribution, with 42.6% (40) having one child and 45.7% (43) having two children in the eligible age group (Table 2). Table 2 Socio-demographic characteristics of the study population (N = 418) Characteristic Category Mamfe % (n) Tiko % (n) Limbe % (n) Total % (n) Age (years) 31.5 ± 8.4 29 ± 6.4 30.8 ± 8.3 30 ± 7.5 < 20 1.9 ( 2 ) 4.2 ( 9 ) 4.3 ( 4 ) 3.6 ( 15 ) 20–29 45.4 (49) 51.9 (112) 47.9 (45) 49.3 (206) 30–39 36.1 (39) 38.0 (82) 38.3 ( 36 ) 37.6 (157) 40+ 16.7 ( 18 ) 6.0 ( 13 ) 9.6 ( 9 ) 9.6 (40) Marital Status Single 40.7 (44) 29.6 (64) 53.2 (50) 37.8 (158) Married 56.5 (61) 63.4 (137) 42.6 (40) 56.9 (238) Divorced 0.9 ( 1 ) 4.6 ( 10 ) 0.0 (0) 2.6 ( 11 ) Widowed 1.9 ( 2 ) 2.3 ( 5 ) 4.3 ( 4 ) 2.6 ( 11 ) Relationship with child Father 7.4 ( 8 ) 5.6 ( 12 ) 12.8 ( 12 ) 7.7 ( 32 ) Biological mother 83.3 (90) 91.2 (197) 74.5 (70) 85.4 (357) Primary caregiver 9.3 ( 10 ) 3.2 ( 7 ) 12.8 ( 12 ) 6.9 ( 29 ) Level of Education No formal education 3.7 ( 4 ) 6.0 ( 13 ) 8.5 ( 8 ) 6.0 ( 25 ) Primary education 30.6 ( 33 ) 19.9 (43) 50.0 (47) 29.4 (123) Secondary education 50.9 (55) 62.5 (135) 37.2 ( 35 ) 53.8 (225) Tertiary education 14.8 ( 16 ) 11.6 ( 25 ) 4.3 ( 4 ) 10.8 (45) Occupation Unemployed 52.8 (57) 25.5 (55) 31.9 ( 30 ) 34.0 (142) self-employed 34.3 ( 37 ) 63.0 (136) 58.5 (55) 54.5 (228) Public sector worker 8.3 ( 9 ) 4.2 ( 9 ) 5.3 ( 5 ) 5.5 ( 23 ) Private sector worker 4.6 ( 5 ) 7.4 ( 16 ) 4.3 ( 4 ) 6.0 ( 25 ) Religion Christian 88.9 (96) 88.4 (191) 89.4 (84) 88.8 (371) Muslim 2.8 ( 3 ) 11.6 ( 25 ) 2.1 ( 2 ) 7.2 ( 30 ) Others 8.3 ( 9 ) 0.0 (0) 8.5 ( 8 ) 4.1 ( 17 ) Number of Children aged 11–30 months per caregiver 1 86.1 (93) 89.3 (194) 42.6 (40) 78.2 (327) 2 9.3 ( 10 ) 9.3 ( 20 ) 45.7 (43) 17.5 (73) 3 4.6 ( 5 ) 0.9 ( 2 ) 11.7 ( 11 ) 4.3 ( 18 ) Exploration of mother’s/caregiver’s awareness, perception, and efficacy of malaria vaccine uptake Awareness of Mothers and Care Givers on the Malaria Vaccine An awareness index was constructed using three survey items designed to assess mothers’ knowledge of the malaria vaccine. The index had a maximum score of 5, and awareness levels were categorized as low (0–1), moderate ( 2 – 3 ), and high ( 4 – 5 ). Among the 418 mothers/caregivers who participated in the study, 327 (78.2%) demonstrated a high level of awareness regarding the malaria vaccine. Additionally, 59 (14.1%) respondents exhibited moderate awareness, while 32 (7.7%) showed a low level of awareness as shown in Table 3. Table 3 Awareness Level of Mothers/caregivers on the Malaria Vaccine Level of Awareness Frequency Percentage (%) High 327 78.2 Moderate 59 14.1 Low 32 7.7 Total 418 100 Source of Information on the Malaria Vaccine The primary source of information for individuals who had heard about the malaria vaccine was health facilities (52%, 388). Community health workers and the media accounted for 20% (147) and 19% (144) respectively. Sensitization through family/friends contributed the least to informing women about the newly introduced vaccine. Figure i: Information source of participants on malaria Vaccine Willingness of mothers/caregivers to vaccinate children against malaria The majority of mothers/caregivers, 377 out of 418 (90.2%), indicated that they were willing to vaccinate their children against malaria, reflecting a high level of trust and acceptance of the malaria vaccine. Conversely, 30 respondents (7.2%) reported unwillingness to vaccinate their children, suggesting potential non-uptake or incomplete uptake of the vaccine. Additionally, 11 participants (2.6%) expressed uncertainty regarding whether they would vaccinate their children, demonstrating that a small proportion of mothers still held reservations about the vaccine (Table 4). Table 4 Mothers’/Caregivers’ willingness to vaccinate children against Malaria Willingness to vaccinate child Frequency Percentage (%) Yes 377 90.2 May be 11 2.6 No 30 7.2 Total 418 100 Malaria vaccine Uptake amongst children under 5 years Children aged 11 to 30 months at the time of data collection were expected to have received at least three doses of the malaria vaccine, which was considered complete uptake for this study. According to WHO recommendations, three doses provide extended protection (greater than one year) against severe malaria, followed by a booster dose at 24 months as per WHO guideline. Crude uptake was assessed using vaccination card verification and caregiver recall at the community level. Overall, malaria vaccine uptake patterns were as follows: No uptake: 15% (n = 63), Initial uptake (1 dose): 85% (n = 355), Partial uptake (2 doses): 79% (329) and Complete uptake (3 to 4 doses): 62% (n = 258) as shown in Fig. 2. The complete uptake level observed in the study (61%) fell below the WHO-recommended target coverage of 80%. Possible barriers to non/incomplete uptake of the malaria vaccine Among the respondents with partial or no uptake at the time of the study, the most commonly reported barrier based on responses was lack of knowledge about the malaria vaccine (33%. 109 responses), consistent with the finding that fewer than 80% demonstrated a high level of awareness. Other notable barriers included fear of side effects (22%, 75), and lack of trust in the health-care system (14%, 47). Other factors that cumulatively represented 25% (104) of responses were (non-availability of vaccines, cultural/religious believes, distance from health facilities and lack of time/personal reasons). These factors were reported among mothers/caregivers whose children had no uptake or incomplete uptake of the vaccine as illustrated in Fig. 3. Malaria Vaccine Safety & Effectiveness Malaria vaccine safety a) Perceived side effects amongst vaccinated children Among the 355 children who had received at least one dose of the malaria vaccine, 160 (45%) mothers/caregivers reported believing that the vaccine could cause side effects. In contrast, a larger proportion of respondents (195, 55%) did not perceive any possibility of side or adverse effects associated with the malaria vaccine as shown in Fig. 4. b) Anticipated side effects amongst respondents who perceived possibility of side effects Among the 160 mothers/caregivers who believed that the malaria vaccine could cause side effects, the most commonly anticipated reactions were fever (52%, 136) and swelling at the injection site (29%, 77). Other anticipated effects (dizziness, vomiting, body weakness, and loss of appetite) cumulatively accounted for 19% (51) of side effects reported. No major side effects like convulsions were reported by any of the participants thus, indicating safety of the malaria vaccine (Fig. 5). Malaria Vaccine Effectiveness a) Comparison of malaria cases amongst vaccinated and unvaccinated children Analysis showed no statistically significant difference in malaria occurrence between children with partial vaccine uptake and those with no uptake (p = 0.50). However, a statistically significant difference was observed between children with complete uptake and those with no uptake (p = 0.037). Children who had received all three doses of the malaria vaccine were 0.52 times less likely to develop malaria compared to children with no uptake (OR = 0.52; 95% CI: 0.29–0.96). This shows effectiveness of vaccine with those with complete uptake when compared to other groups (Table 5). Table 5 Malaria cases amongst vaccinated and unvaccinated children Characteristic (Vaccine uptake) No of children infected with malaria (%) No of children not infected with malaria (%) Total No (%) Odds Ratio (OR) 95% CI P-Value No Uptake 45 (71.4) 18 (28.6) 63 (100) 1.00 - - Partial Uptake 82 (84.5) 15 (15.5) 97 (100) 2.18 1.0-4.74 0.05 Complete Uptake 147 (57) 111 (43) 258 (100) 0.52 0.29–0.96 0.037* Total 274 (65.6) 144 (34.4) 418 (100) b) Possibility of developing severe malaria among children with partial and complete vaccine uptake To assess the effectiveness of the malaria vaccine in reducing disease severity, malaria severity amongst those that had developed malaria was compared between children with partial vaccination and those with complete vaccine uptake. A statistically significant difference was observed: children with only partial vaccination were 14.5 times more likely to develop severe malaria when compared to those with complete vaccination (p < 0.01; OR = 14.5; 95% CI: 3.15–66.3) as shown in Table 6. Table 6 Severe malaria cases amongst children with partial and complete vaccine uptake Characteristic (Vaccine uptake) Severe Malaria in children No (%) Simple Malaria in children No (%) Total No (%) Odds Ratio (OR) 95% CI P-Value Partial Uptake 15 (26.8) 41 (73.2) 56 (100) 14.45 3.15–66.3 < 0.01 * Complete Uptake 02 (2.5) 79 (97.5) 81 (100) 1.00 - - Total 17 (65.6) 120 (34.4) 137 (100) c) Diagnosed malaria species amongst vaccinated children in the SWR Among the 137 vaccinated children who developed malaria, 133 (97%) caregivers had no knowledge of the Plasmodium species responsible. This suggests limited or no communication from healthcare workers regarding species-specific information, as well as a lack of emphasis on identifying the species targeted by the malaria vaccine (Fig. 6). Figure vi: Knowledge level of caregivers on Plasmodium species responsible for malaria amongst vaccinated children Qualitative Findings (Mothers/Caregivers) Theme 1. Awareness and Knowledge of the Malaria Vaccine A caregiver attempted to describe the vaccine schedule but inconsistently: The vaccine is given at 3 months, 5 months and 6 months to protect my child from malaria. This suggests that while caregivers encounter health services, health education has not been adequate or consistent. Some caregivers missed health talks because they were not conducted consistently or they were not present when talks were done. We have not even heard much about the vaccine because sometimes when we come to the clinic, they don't give health talks and some other times they give health talks when some of us might not be there. This suggests the need for more systematic and accessible health education within healthcare facilities. Social dynamics, particularly male household authority, also influenced decision-making as when the question was posed: Would you be willing to take the vaccine at the community if proposed to you by healthcare workers? Participant’s Response: “We cannot take it if our husbands have not approved where it's coming from at the community.” These perceptions highlight the influence of community narratives and patriarchal decision structures on vaccine uptake. Theme 3. Perceived Importance and Efficacy Some caregivers who had vaccinated their children reported observable reductions in malaria episodes, reinforcing trust in the vaccine. Since after the vaccine, my child has been having fever sometimes but when they test at the hospital, they say the child does not have malaria which was not the same before. Positive personal experience acted as a facilitator and could be leveraged in awareness efforts. Qualitative Findings (Health Care Workers) Theme 1: Knowledge About the Malaria Vaccine Healthcare workers demonstrated good foundational knowledge about the malaria vaccine particularly its preventive purpose and its role in reducing disease severity. Several participants recognized that the vaccine targets children aged 0–5 years, a group vulnerable due to their weak immunity and high malaria-related mortality. “The malaria vaccine is given to prevent frequent malaria infections in children. Even if a child still gets malaria, the vaccine helps reduce the severity of the disease”. While the participants understood the basic function of the vaccine, they expressed knowledge gaps regarding side effects and management of post-vaccination reactions. Sometimes a child receives a vaccine and then has a reaction, but we don’t always know how to explain it to the parents. This gap suggests a need for continuous professional development to strengthen Health Care Worker’s technical understanding and improve their communication with caregivers. Theme 2: Perceived Effectiveness and Experiences Most participants believed the vaccine was safe, effective, citing a decline in malaria cases among children since its introduction and just a case of a major side effect experienced. Before its introduction, we used to receive many malaria cases in children. But now, even when children come with fever, lab tests often show it’s not malaria. The malaria vaccine is relatively new; it was introduced into the childhood vaccination calendar less than four years ago. It is effective in preventing malaria, as we now see fewer children returning to the hospital with the disease. "The only serious side effect I have experienced is a situation in which a child was vaccinated and suddenly developed very high fever and when a lab test was conducted, we noticed that the child was positive for malaria. Thus, I will recommend that test should be provided for all children before vaccination. Nevertheless, some participants urged caution in attributing the decline solely to vaccination, noting possible seasonal fluctuations in malaria prevalence. Malaria is a seasonal disease, we should observe it over a longer period before drawing final conclusions. This balanced view indicates that while faith in the vaccine is strong, Health Care Workers (HCWs) also recognize the need for ongoing data monitoring to confirm long-term impact. Theme 3: Attitudes and Willingness to Recommend Overall, healthcare workers expressed positive attitudes toward the malaria vaccine and a high willingness to recommend it. They viewed it as a “strategic plan” by the government to reduce child morbidity and mortality. Since it was introduced, we’ve noticed that children are healthier, and we rarely see malaria cases among them. Nevertheless, some expressed frustration with parental hesitancy: Some parents refuse the vaccine because they believe injections cause pain. I have to spend time explaining the benefits and convincing them. Positive personal experiences with vaccine outcomes further reinforced trust: From my experience, it is very effective. I have not seen any vaccinated children return with malaria. Thus, attitudes of confidence and perceived success motivate health workers to actively recommend the vaccine. Theme 4: Barriers and Challenges The most significant barriers identified were fear and misinformation, often spread through social media or linked to previous COVID-19 vaccine skepticism. Many people compared it to the COVID-19 vaccine and said, ‘You’ve come again to kill our children. Healthcare workers reported that effective sensitization and reassurance about mild side effects were key to overcoming fear. When we explain properly that the malaria vaccine is like any other vaccine, the fear reduces. Facilitator: “Now, I have a question for the laboratory technicians here. How do you know whether the malaria vaccine is effective? Participant 2 (Lab Technician) “We can’t say for sure whether the vaccine is effective because we’re not directly involved in administering it to children. The people who can best judge its effectiveness are those who vaccinate children between zero and five years. However, we do contribute by collecting and reviewing data. We take laboratory statistics that show the number of malaria cases over time. From those statistics, we can make some observations about trends in malaria cases”. Facilitator (Follow-up): So, is there any way that laboratory data can help monitor vaccine effectiveness? “No, it is through regular statistical analysis. The people who collect and record malaria test results can help show whether malaria cases are decreasing. Right now, statisticians handle most of that data, so they’re the ones who can best determine if there’s been improvement”. Logistical and Infrastructure Barriers Health care managers identified cold chain limitations, transport delays, and damaged infrastructure as key bottlenecks. “Normally, the quality of vaccine is very important. If the vaccines are not properly conserved, you can imagine the impact it can have when it comes to its potency and ability of the children to be immunized which we might not be sure of. Imagine the impact. Some centers like Kajifu health area lack electricity or solar fridges. Cold boxes are used but limited for long-term storage.” Participant quote Monitoring, Evaluation, and Data Management Monitoring enables timely interventions such as PIRI (Periodic Intensification of Routine Immunization) to address missed children. “We usually carry out regular monitoring to check progress but so far we have not been able to access the prevalence during discussion session/meetings.” - Respondent. Interpretation: This might indicate limited interest or concern when it comes to evaluation of effectiveness by health care managers. Theme 5: Enablers and Recommendations Participants highlighted several strategies to improve vaccine rollout: “We should be given more detailed information about possible side effects to explain them better to parents.” (Participant 5) These suggestions reflect a proactive approach among HCWs toward improving implementation and maintaining public trust. Community Engagement and Education “Inform the population about the dangers of malaria and the importance of vaccination.” Participant quote Improved Logistics and Infrastructure “Provide solar-powered fridges, training materials, and posters to improve vaccination coverage.” Participant quote DISCUSSION This mixed-methods study assessed caregiver and healthcare worker perceptions regarding the safety, efficacy, and uptake of the RTS,S/AS01 malaria vaccine in three high-burden districts of the South West Region of Cameroon. The discussion synthesizes quantitative and qualitative findings and places them within existing literature. The willingness to vaccinate children was high (> 90%) but complete uptake (three doses or more) fell to 62% and this is below the WHO-recommended target of 80%. This gap between willingness and full adherence could possibly reflect systemic and informational barriers over caregiver motivation. The most frequently reported obstacles were lack of knowledge (33%), fear of side effects (22%), low trust in the health system (14%) and practical constraints such as vaccine stock-outs as well as distance to facilities. This is consistent with earlier evidence that limited awareness and concerns about vaccine safety commonly hinder uptake for newly introduced vaccines in sub-Saharan Africa ( 18 – 19 , 30 ). A study carried out by Dimala et al. (31.) in SSA also highlights that vaccine acceptance is strongly influenced by perception of disease severity, trust in the health system, and communication from health authorities perceived as clear. The knowledge gap observed herein supports prior findings that many caregivers lack essential vaccination information ( 31 ) and this can negatively influence follow-up visits required for multi-dose vaccines ( 32 ). Qualitative insights from mothers further confirmed this pattern as many caregivers had only heard about the vaccine during facility visits, had misconceptions about its purpose, or expressed confusion about the number of doses. These perceptions echo the broader finding of Zavala ( 30 ) in a study conducted in 11 SSA countries which reported that inadequate messaging during early vaccine rollout contributed to inconsistent uptake. With regards to vaccine safety, 55% (195) of caregivers reported no concerns about side effects while 45% (160) expected some adverse outcomes. Among those expecting side effects common concerns included fever and injection site swelling. However, major adverse reactions such as convulsions were not reported. This aligns with global trial findings where RTS,S/AS01 had an acceptable safety profile with predominantly mild transient side effects as reported by Ali et al. in African children ( 12 ). The hesitation observed in a subset of caregivers is consistent with documented patterns that uncertainty about vaccine side effects contributes significantly to refusal or hesitancy in many contexts including earlier malaria vaccine trials such as the SPf66 study. Chaufan et al. reported that 26.7% of caregivers described themselves as “unsure” about the spf66 vaccine safety in a systematic review involving several countries in Africa ( 32 ). Healthcare workers had similar mixed feelings. Most were in favour of the vaccine, but some said they had not been trained adequately or still had questions about how it worked and which age groups it was meant for. Evidence has shown that healthcare worker confidence is strongly related to their willingness to recommend vaccines ( 33 ) and that gaps in training make them less effective as trusted sources of information ( 34 ). The study found a very significant protective effect among children who completed the full vaccination schedule as those with complete uptake were 0.52 times less likely to develop malaria when compared to those with no uptake (p = 0.037). Partially vaccinated children as well were 14.5 times more likely to develop severe malaria than those with complete uptake (p < 0.01). These findings are consistent with global RTS,S evidence on moderate but substantial reductions in clinical and severe malaria, particularly when the full dose schedule is completed ( 12 – 14 ). The results also reinforce increasing real-world evidence from early implementation programmes demonstrating reductions in severe malaria, hospital admissions, and malaria-related mortality ( 13 , 14 ) from previous findings reported by Datoo et al. , in Africa. Qualitative feedback from caregivers supports this quantitative trend as several mothers noted a marked decrease in malaria episodes among vaccinated children. This is consistent with long-standing community-level acceptance of preventive health interventions ( 33 ) and validation that perceived benefits increase trust in vaccines. The study’s qualitative findings highlighted communication gaps as a critical factor influencing uptake. Caregivers frequently mentioned that they received insufficient explanation regarding dosage schedules, expected side effects, or the vaccine’s purpose. This resonates with previous findings by Munir et al. , in Pakistain emphasizing the role of clear, continuous communication and community engagement in improving vaccine adoption ( 31 , 35 ). Healthcare workers also identified stock-outs of vaccines as challenges affecting promotion along with cultural resistance and parental hesitancy toward vaccination. These issues are similar to earlier studies that reported how inconsistency in the supply chain and cultural beliefs can undermine confidence in programs for malaria vaccines ( 36 ). Participants expressed a need for government-led campaigns, frequent reminders, community-based sensitization supporting the notion that multichannel communication significantly enhances vaccine uptake including digital nudges and stakeholder collaboration ( 35 , 37 ). Limitations of the study The study’s design limited the ability to establish causal relationships between vaccination uptake and malaria outcomes. Caregiver-reporting of malaria episodes, vaccine side effects, and vaccination history may be inaccurate, affecting data reliability. Recruitment from pilot districts in the South West Region may not fully represent caregivers in other regions or those less engaged with health services. Most caregivers did not know the Plasmodium species responsible for their child’s malaria, limiting precise assessment of vaccine effectiveness against P. falciparum , the targeted species. CONCLUSIONS This mixed-methods study shows that early community acceptance of the RTS,S/AS01 malaria vaccine is a good sign and that caregivers mostly see it as safe and effective. However, there are major gaps in awareness, communication from the health system, and reliability of the supply chain. The vaccine proved very effective among children with complete uptake by reducing both malaria occurrence and severity, but incomplete uptake due to lack of knowledge, fear of side effects, and structural challenges keep the full public health potential out of reach for this vaccine. Therefore, strengthening communication strategies, ensuring consistent availability of the vaccine, and empowering healthcare workers through comprehensive training will be necessary steps toward improving uptake in order to achieve expected population-level benefits from malaria vaccination in the South West Region of Cameroon. It is therefore recommended that targeted community sensitization campaigns should be implemented by health authorities. The use of digital reminders and culturally relevant information tools should be encouraged to improve adherence and standardized messages on safety, dose schedule, and expected mild side effects should be encouraged Declarations Declaration of conflict of Interest: The authors declare no potential conflict of interest with respect to the research, authorship and/or publication of this article Funding: The author(s) received no financial support for the research, authorship and/or publication of this article. Consent for Publication: Not applicable considering we are not publishing any identifiable participant information. N.B Considering some health areas went slightly above the minimum sample size, we ended up having an overall 418 caregiver sampled. Author Contribution J.C.A: Conceived and designed the study, developed the research protocol and data collection tools, supervised the fieldwork, conducted and validated the qualitative data analysis, interpreted the findings, drafted the manuscript, and coordinated all revisions until submission.L.L.N., N.T.: Provided academic supervision during study design, contributed to the development of the methodological approach, reviewed the protocol and analysis framework, and critically revised the manuscript.O.N.: Contributed to the study design and qualitative methodology, reviewed data analysis outputs, provided supervisory guidance, and critically reviewed and approved the final manuscript.M.Y.N.: Contributed to the design of the data collection instruments, supported training of field data collectors, participated in data collection, assisted in organizing data, and contributed to preliminary analysis.J.E.A.: Contributed to transcription, coding, and initial thematic analysis, and provided input during interpretation of findings, assisted in refining the data collection tools, contributed to data analysis and management, participated in data cleaning and initial coding, and reviewed the methods and results sections of the manuscript.H.K.K.: Provided overall academic supervision, guided the study design and methodological decisions, contributed to the interpretation of results, critically reviewed multiple manuscript drafts, and approved the final version for submission. Acknowledgement The authors are grateful to Ewi-kang Georges Hermann, Dr Adeline Green, Eyong Herdis Nsoh, Fang Eugene, Ibrahim Usmanu Tata, Abunaw Rebecca, Akamandu Anye Daniel, Nsuh Gladys Chi, Anye Fru Godlove, Vakunta John, Melvis Chembopouh and Constance Tamungang for assisting in the realisation of this work Data Availability Data can be made available on request (restricted access due to confidentiality): Considering the study used a mixed approach, with respondents clearly assured of their confidentiality, especially during FGD and Indebt interviews, the datasets generated and analyzed during the current study are not publicly available due to ethical/confidentiality restrictions but can be made available by the corresponding author on reasonable request. References Allison AC. Protection afforded by sickle-cell trait against subtertian malarial infection. Br Med J. 1954;1(4857):290–4. Snow RW. Global malaria eradication and the importance of Plasmodium falciparum epidemiology in Africa. Volume 13. BMC Medicine. BioMed Central Ltd.; 2015. World Health Organization. World malaria report 2022 [Internet]. 2023. Available from: https://www.wipo.int/amc/en/mediation World Health Organization. World malaria report 2022 [Internet]. 2023. Available from: https://www.wipo.int/amc/en/mediation World Health Organization. Global Malaria Programme operational strategy 2024–2030. Chiabi A, Djimafo ANM, Nguefack S, Mah E, Nguefack F, Angwafo F. Severe malaria in Cameroon: Pattern of disease in children at the Yaounde Gynaeco-Obstetric and Pediatric hospital. J Infect Public Health. 2020;13(10):1469–72. PMI. U.S. President’s Malaria Initiative Cameroon Malaria Operational Plan FY 2022 [Internet]. 2022. Available from: www.pmi.gov. World Health Organization. World malaria report 2023. Geneva: World Health Organization; 2023. Kevin Baird J. Evidence and implications of mortality associated with acute plasmodium vivax malaria. Clin Microbiol Rev. 2013;26(1):36–57. Ndip RN, Sumbele I. Trends of Malaria in the South West Region of Cameroon: Overview, Challenges and Perspectives (SDG3). 2022. Strategy to respond to antimalarial drug resistance in Africa. Ali T, Sumbal A, Haque MA. The fight against malaria: a new hope with the R21 vaccine. Int J Surgery: Global Health. 2024;7(2). The Lancet. Malaria vaccines: a test for global health. Vol. 403, The Lancet. Elsevier B.V.; 2024. p. 503. Datoo MS, Dicko A, Tinto H, Ouédraogo JB, Hamaluba M, Olotu A, et al. Safety and efficacy of malaria vaccine candidate R21/Matrix-M in African children: a multi-center, double-blind, randomized, phase 3 trial. Lancet. 2024;403(10426):533–44. Ndoula ST, Mboussou F, Njoh AA, Nembot R, Baonga SF, Njinkeu A et al. Malaria Vaccine Introduction in Cameroon: Early Results 30 Days into Rollout. Vaccines (Basel) [Internet]. 2024;12(4):346. Available from: https://www.mdpi.com/2076-393X/12/4/346 Simbeye AJ, Kumwenda S, Cohee LM, Omondi D, Masibo PK, Wao H et al. Factors associated with malaria vaccine uptake in Nsanje district, Malawi. Malar J. 2024;23(1). Galadima AN, Zulkefli NAM, Said SM, Ahmad N. Factors influencing childhood immunisation uptake in Africa: a systematic review. BMC Public Health. 2021;21(1). Bangura JB, Xiao S, Qiu D, Ouyang F, Chen L. Barriers to childhood immunization in sub-Saharan Africa: A systematic review. Volume 20. BMC Public Health. BioMed Central; 2020. Ojakaa DI, Ofware P, Machira YW, Yamo E, Collymore Y, Ba-Nguz A et al. Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya. Malar J. 2011;10. Yeboah D, Owusu-Marfo J, Agyeman YN. Predictors of malaria vaccine uptake among children 6–24 months in the Kassena Nankana Municipality in the Upper East Region of Ghana. Malar J. 2022;21(1). Zhao B, Zhao L. Mining adverse events in large frequency tables with ontology, with an application to the vaccine adverse event reporting system. Stat Med. 2023;42(10):1512–24. Mahmud MS, Kamrujjaman M, Adan MMIY, Hossain MA, Rahman MM, Islam MS, et al. Vaccine efficacy and SARS-CoV-2 control in California and U.S. during the session 2020–2026: A modeling study. Infect Dis Model. 2022;7(1):62–81. Withers MR, McKinney D, Ogutu BR, Waitumbi JN, Milman JB, Apollo OJ et al. Safety and Reactogenicity of an MSP-1 Malaria Vaccine Candidate: A Randomized Phase Ib Dose-Escalation Trial in Kenyan Children. PLoS Clin Trials [Internet]. 2006;1(7):e32. Available from: https://dx.plos.org/10.1371/journal.pctr.0010032 Balgovind P, Mohammadnezhad M. Perceptions of Healthcare Workers (HCWs) towards childhood immunization and immunization services in Fiji: a qualitative study. BMC Pediatr. 2022;22(1). Jenna H, George O, Jenny H, Teresa B. RTS,S/AS01 malaria vaccine pilot implementation in western Kenya: a qualitative longitudinal study to understand immunization barriers and optimize uptake. BMC. 2023;23(1). Kuhangana C. Health workers’ knowledge, attitudes, and practices on the RTS,S malaria vaccine: A qualitative study in Kenya. Malar J. 2022;21. Simbeye AJ, Kumwenda S, Cohee LM, Omondi D, Masibo PK, Wao H et al. Factors associated with malaria vaccine uptake in Nsanje district, Malawi. Malar J. 2024;23(1). Mtenga S, Kimweri A, Romore I, Ali A, Exavery A, Sicuri E et al. Stakeholders’ opinions and questions regarding the anticipated malaria vaccine in Tanzania. Malar J. 2016;15(1). Saaka SA, Mohammed K, Pienaah CKA, Luginaah I. Child malaria vaccine uptake in Ghana: Factors influencing parents’ willingness to allow vaccination of their children under five (5) years. PLoS ONE. 2024;19(1 January). Zavala F. RTS,S: the first malaria vaccine. Vol. 132, Journal of Clinical Investigation. American Society for Clinical Investigation; 2022. Dimala CA, Kika BT, Kadia BM, Blencowe H. Current challenges and proposed solutions to the effective implementation of the RTS, S/ AS01 Malaria Vaccine Program in sub-Saharan Africa: A systematic review. Volume 13. PLoS ONE. Public Library of Science; 2018. Chaufan C, Heredia C, Mcdonald J, Hemsing N. Title Page The balance of risks and benefits in the COVID-19 vaccine hesitancy literature: An umbrella review. Sulaiman SK, Musa MS, Tsiga-Ahmed FI, Dayyab FM, Sulaiman AK, Bako AT. A systematic review and meta-analysis of the prevalence of caregiver acceptance of malaria vaccine for under-five children in low-income and middle-income countries (LMICs). PLoS ONE. 2022;17(12 December). Khatiwada M, Nugraha RR, Dochez C, Harapan H, Mutyara K, Rahayuwati L et al. Understanding COVID-19 Vaccine Acceptance among Healthcare Workers in Indonesia: Lessons from Multi-Site Survey. Vaccines (Basel). 2024;12(6). Munir S, Said F, Taj U, Zafar M. Digital nudges to increase childhood vaccination compliance: Evidence from Pakistan. Mahmud S, Mohsin M, Khan IA, Mian AU, Zaman MA. Knowledge, beliefs, attitudes and perceived risk about COVID-19 vaccine and determinants of COVID-19 vaccine acceptance in Bangladesh. PLoS ONE. 2021;16(9 September). Periáñez Á, Trister A, Nekkar M, del Río AF, Alonso PL. Adaptive Interventions for Global Health: A Case Study of Malaria. 2023; Available from: http://arxiv.org/abs/2303.02075 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 16 Mar, 2026 Reviews received at journal 21 Jan, 2026 Reviews received at journal 15 Jan, 2026 Reviewers agreed at journal 14 Jan, 2026 Reviewers agreed at journal 12 Jan, 2026 Reviewers invited by journal 06 Jan, 2026 Editor invited by journal 12 Dec, 2025 Editor assigned by journal 08 Dec, 2025 Submission checks completed at journal 08 Dec, 2025 First submitted to journal 06 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8293727","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":570245209,"identity":"3f02c22d-a15c-4da6-95a4-9ce945595e0c","order_by":0,"name":"Jude Che Anye","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYLACxgYGZgaGBMYHQDYPHylamA1AWtiI1QIECWwSIIqgFv7ZPYYPfu6wYTc4nnys8muOnQwbA/PDRzfwaJG4c8bYsPdMGrPBmWdpt2W3JQMdxmZsnIPPmhs5ZtKMbYeZDYCM25LbmIFaeNik8WmRv5Fj/pux7T9QS/63Yslt9YS1gAxnZmw7ALKFjfHjtsOEtRjeSCuW7G1LZpY888xYmnHbcR42ZgJ+kbuRvPHDzza7ZL7jyQ8//txWbc/P3vzwMV7vM3CAIpAhGUQw84BJvMpBgP0BiLQDEYw/CKoeBaNgFIyCkQgATyhH5UvsA0sAAAAASUVORK5CYII=","orcid":"","institution":"University of Bamenda","correspondingAuthor":true,"prefix":"","firstName":"Jude","middleName":"Che","lastName":"Anye","suffix":""},{"id":570245211,"identity":"1b1ac54d-8e53-4f9f-b33a-82ca1ad6bbef","order_by":1,"name":"Loveline Lum Niba","email":"","orcid":"","institution":"University of Bamenda","correspondingAuthor":false,"prefix":"","firstName":"Loveline","middleName":"Lum","lastName":"Niba","suffix":""},{"id":570245212,"identity":"62aef8eb-759c-4040-9a6d-d355d28d2a8e","order_by":2,"name":"Omarine Njimanted","email":"","orcid":"","institution":"University of Bamenda","correspondingAuthor":false,"prefix":"","firstName":"Omarine","middleName":"","lastName":"Njimanted","suffix":""},{"id":570245213,"identity":"72fd9f18-f0a5-44f0-8d95-2ba5ac48590f","order_by":3,"name":"Nicholas Tendongfor","email":"","orcid":"","institution":"University of Buea","correspondingAuthor":false,"prefix":"","firstName":"Nicholas","middleName":"","lastName":"Tendongfor","suffix":""},{"id":570245214,"identity":"21b352b3-570a-4b57-8306-dfe740d0df2d","order_by":4,"name":"Mark Yuyun Nyuykonge","email":"","orcid":"","institution":"UN International Organization for Migration","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"Yuyun","lastName":"Nyuykonge","suffix":""},{"id":570245215,"identity":"1ba296db-e458-44d3-b972-fe0f8077f10b","order_by":5,"name":"Ewane Etah Junior","email":"","orcid":"","institution":"Canadian College of Business, Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Ewane","middleName":"Etah","lastName":"Junior","suffix":""},{"id":570245217,"identity":"f4f96564-6fc2-4b5a-99f6-11943c869548","order_by":6,"name":"Helen Kuokuo Kimbi","email":"","orcid":"","institution":"University of Bamenda","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"Kuokuo","lastName":"Kimbi","suffix":""}],"badges":[],"createdAt":"2025-12-06 09:53:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8293727/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8293727/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100357351,"identity":"42deae6c-b73b-44eb-ba6d-8496d05349a7","added_by":"auto","created_at":"2026-01-16 07:19:44","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1090005,"visible":true,"origin":"","legend":"","description":"","filename":"VaccineSafetyEfficacyCompleteManuscriptedited1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/2e1905455d0a70258051c729.docx"},{"id":99859209,"identity":"957bdb3b-274f-4341-8290-d41580f91663","added_by":"auto","created_at":"2026-01-09 06:38:05","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10619,"visible":true,"origin":"","legend":"","description":"","filename":"51a7f57eeee240999178f54e16fefb96.json","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/74280472c5ffc3d6bcc7b1d5.json"},{"id":99859211,"identity":"b1b60752-bad6-46ab-b0ab-b17e6c468550","added_by":"auto","created_at":"2026-01-09 06:38:05","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":133965,"visible":true,"origin":"","legend":"","description":"","filename":"51a7f57eeee240999178f54e16fefb961enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/d6056c15b34354892b0c38b0.xml"},{"id":99859213,"identity":"d7059855-ae00-4c56-a56d-6cae9d070c79","added_by":"auto","created_at":"2026-01-09 06:38:05","extension":"eps","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":624,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage3.eps","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/fe78b309c1b561eef34a1721.eps"},{"id":99859214,"identity":"51903f20-c2b3-4a64-a96d-667c3556b7fd","added_by":"auto","created_at":"2026-01-09 06:38:05","extension":"xml","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":130371,"visible":true,"origin":"","legend":"","description":"","filename":"51a7f57eeee240999178f54e16fefb961structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/e0c9bec5c16788c7630da856.xml"},{"id":100358267,"identity":"82db0e75-0cdf-4d10-bc7d-6eddd98edab9","added_by":"auto","created_at":"2026-01-16 07:20:49","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":150429,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/a753fc1c4a4bdda598b1afee.html"},{"id":99859203,"identity":"8b11ceb9-c683-49e3-beb2-57c559f38baf","added_by":"auto","created_at":"2026-01-09 06:38:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130389,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eInformation source of participants on malaria Vaccine\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/5f350e755d01404446e6e1b8.jpg"},{"id":99859204,"identity":"4d4ddb87-0b05-4170-8b6f-8e08f58bf7bf","added_by":"auto","created_at":"2026-01-09 06:38:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":130985,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eLevel of vaccine uptake amongst children in the SWR\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/889888a4281e0f1472d5bd7e.jpg"},{"id":99859208,"identity":"126282d7-324c-4810-8a22-5ace17ed89b1","added_by":"auto","created_at":"2026-01-09 06:38:05","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":174619,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBarriers responsible for non/incomplete vaccine uptake in the SWR\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/0073a98a126d78592f519463.jpg"},{"id":100357169,"identity":"dcd96cdd-2308-423c-b401-70933f65b9cf","added_by":"auto","created_at":"2026-01-16 07:19:10","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":107430,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePerceived Vaccine side effects amongst vaccinated children\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/feee974f8927cd8ef2bbdf72.jpg"},{"id":100358246,"identity":"49d12cc7-0a5b-4b95-be60-4ab125661c6f","added_by":"auto","created_at":"2026-01-16 07:20:47","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":102409,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eReported side effects amongst those who perceived the presence\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/00a58e40ed3884b67c9d13df.jpg"},{"id":100358005,"identity":"0ccc045d-17ad-430f-8448-acbb0923614f","added_by":"auto","created_at":"2026-01-16 07:20:34","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":82641,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eKnowledge level of caregivers on Plasmodium species responsible for malaria amongst vaccinated children\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/cf57b2baa5fe55b4c1b63bfb.jpg"},{"id":100421595,"identity":"89497c95-9a7d-42e0-85c3-bb7de85b7fe7","added_by":"auto","created_at":"2026-01-16 13:36:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3750764,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8293727/v1/4e7c9db3-0127-40ac-b3cc-b2c1a5ee1279.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perceived safety and efficacy of the malaria vaccine, RTS,S/AS01 among vaccinated children in the South West Region of Cameroon: Mixed Study Approach","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMalaria has always been a major public health problem in sub-Saharan Africa (SSA), leading to the highest morbidity and mortality rates globally. More than 90% of deaths associated with malaria are due to \u003cem\u003ePlasmodium falciparum\u003c/em\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In 2022, it was estimated that there were about 249\u0026nbsp;million cases and 619,000 deaths due to malaria worldwide. The African Region including Cameroon accounted for over 93% of the cases and about 95% of the deaths and most of these deaths were among children under five years old (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Cameroon like the rest of SSA has a very high burden of malaria with more than 3\u0026nbsp;million confirmed cases recorded each year and thousands of deaths and malaria continue to be the leading cause of morbidity and mortality among children below five years in the country (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e); thereby requiring serious control measures.\u003c/p\u003e \u003cp\u003eControl measures against malaria in Cameroon have been mostly vector control through insecticide-treated nets and indoor residual spraying along with intermittent preventive treatment for pregnant women and children under five as well as seasonal chemo-prevention in epidemic-prone areas. Treatment has been available through the public health system since it was adopted by WHO (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The fight against malaria has however stagnated because progress has been hindered by insecticide resistance, drug resistance, very high transmission intensity, and inequitable use of the available prevention tools (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe RTS,S/AS01 vaccine introduced by the WHO following a recommendation in 2021 and prequalified in 2022 adds an important new dimension to malaria prevention. This vaccine showed moderate but significant efficacy against clinical and severe malaria, hospitalizations due to any cause, or mortality among young children in African countries (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It is worth noting that the pilot implementation programs conducted in Ghana (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), Kenya (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and Malawi (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) have demonstrated significant reductions in malaria morbidity and mortality even under conditions where bed nets and chemoprevention are already widely used against child deaths and severe malaria.\u003c/p\u003e \u003cp\u003eCameroon introduced RTS,S/AS01 into its EPI at the beginning of January 2024 after receiving the first shipment of vaccines in November 2023 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). High-risk districts prioritized for initial rollout based on sub-national malaria burden analyses included Limbe, Tiko, and Mamfe all from South West Region of Cameroon. These were areas with historically high transmission and severe malaria burden among under-fives (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The vaccination schedule comprises four doses at 6, 7 and 9 months, and a booster dose at 24 months (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePublic health impacts are generally paramount for uptake of new vaccines within SSA against the background of caregiver perceptions and sociocultural beliefs. Moreover, risk awareness and health system factors such as accessibility, communication plus worker capacity to deliver these interventions, perceived safety, side effects and effectiveness during early phases are very critical (\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Although global evidence affirms the safety of RTS,S/AS01 with most adverse events being mild and transient (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), many local perceptions within newly vaccinated communities in Cameroon are largely undocumented thereby necessitating this study.\u003c/p\u003e \u003cp\u003eCaregivers\u0026rsquo; and health workers\u0026rsquo; perceptions about the safety, tolerability, and efficacy of the malaria vaccine are important in optimizing demand generation, strengthening adherence to the multi-dose schedule, and informing policy adaptations during rollout. This study therefore used a mixed-method approach to assess perceptions in relation to malaria vaccine safety and efficacy among caregivers of vaccinated children and key health personnel in selected districts of the South West Region of Cameroon. Findings from this study will be used to improve communication strategies, strengthen delivery strategies, and obviously increase overall uptake of the vaccine within an ongoing national program.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA cross-sectional mixed-methods design was used to assess perceptions of RTS,S/AS01 malaria vaccine safety and efficacy among caregivers of vaccinated children and health care providers involved in vaccine delivery. Quantitative methods assessed awareness, perceived safety, side effects experienced by vaccinated children, perceived effectiveness, and uptake of doses, while qualitative methods explored deeper insights into experiences, attitudes, and contextual factors influencing perceptions and uptake.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThis study was carried out in three high malaria burden health districts (Limbe, Tiko, and Mamfe) of the South West Region of Cameroon. These districts were selected as part of the national pilot rollout for RTS,S/AS01 due to consistently high morbidity and mortality from malaria among children under five (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). All participating health facilities were providing routine immunization services and delivering the malaria vaccine according to national EPI guidelines.\u003c/p\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eA mixed population study involving caregivers of young children as well as frontline health personnel was used. The quantitative component included mothers/caregivers to children aged 11\u0026ndash;30 months who by the time data was collected (October 2025) were eligible to receive at least three doses of RTS,S/AS01 vaccine. They were recruited from six randomly selected health areas across three health districts using probability proportionate to size followed by purposive sampling with support from community agents.\u003c/p\u003e \u003cp\u003eTwenty female caregivers aged 20\u0026ndash;53 years participated in two focus group discussions representing rural and urban settings for the qualitative component. Primary caregivers of children under five with varied educational backgrounds and livelihood activities were included. It also involved ten health care workers comprising nurses, midwives, psychosocial and community health workers, a laboratory technician having between 5\u0026ndash;25 years\u0026rsquo; experience and eight managers aged 39\u0026ndash;52 holding senior district/regional leadership positions for malaria prevention/immunization services.\u003c/p\u003e\n\u003ch3\u003eSample size calculation for quantitative aspect\u003c/h3\u003e\n\u003cp\u003eUsing Cochrane\u0026rsquo;s formula to estimate proportion of children receiving vaccine (prior estimate of complete uptake\u0026thinsp;=\u0026thinsp;41%) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) with a margin of error of 5% assuming a normal distribution of the margin of error, the minimum sample size was calculated to be 372 participants. After adjustment for an 8% non-response rate and rounding the target sample size was 400. Participants were selected using purposive sampling proportionate to the population size of children 11\u0026ndash;30 months of each of the six target health areas at the time of data collection. This method was used to avoid potential bias of the results considering equal numbers across all areas would have over represented smaller communities and under-represented larger ones potentially introducing a bias into the results. Table\u0026nbsp;1 shows the sample proportions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample size of mothers of children between 11 to 30 months within health district/areas selected (Probability proportionate to size method)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth District\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Area\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal births from June, 2023 to October, 2024 (Children 11\u0026ndash;30 months) by October, 2025\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProportion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal sample size\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimbe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBota\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimbe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdenau\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMamfe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachou-Akagbe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMamfe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMamfe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1523\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTiko\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTiko\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTiko\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMutengene\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e7791\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e400\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eSampling Procedure\u003c/h3\u003e\n\u003cp\u003eA multistage sampling technique was used in the selection of individual respondents for this study. The purposive sampling technique was first used to select districts that were piloting the implementation phase of the vaccine rollout program. Two health areas from each of the health districts were then selected using the simple random technique whereby names of all the health areas per district were wrapped in pieces of papers and two randomly picked by a neutral person. Thirdly, to ensure uptake was well determined and to avoid bias, healthcare workers with community agents moved around different localities within the health areas into homes of caregivers to purposively select those whose children fell under the eligibility criteria (11 to 30 months old). Those whose children were not within this age group were excluded from the study.\u003c/p\u003e \u003cp\u003eFor the qualitative part, participants were selected using purposive sampling to ensure representation across caregiver demographics and health worker cadres. FGDs with caregivers and healthcare workers were held as well as in-depth interviews (IDIs) with malaria and immunization focal persons.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Procedures\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eQuantitative Data\u003c/h2\u003e \u003cp\u003eA structured questionnaire was administered through Kobo-collect tool to caregivers which sought information on their sociodemographic characteristics, awareness of malaria vaccine, perceived safety, reported side effects, perceived efficacy, and completion of vaccine doses. The questions were adopted from previous validated questionnaires used in Malaria Indicator surveys and Demographic and Health surveys (\u003cspan additionalcitationids=\"CR25 CR26 CR27 CR28\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Data\u003c/h3\u003e\n\u003cp\u003eFour FGDs and 2 IDIs were conducted using semi-structured guides tailored to each participant group. Discussions explored experiences with the vaccine, perceived safety and effectiveness, trust in the health system, communication received, challenges faced, and suggestions for improving uptake. Interviews and FGDs took place in quiet spaces within health facilities where they could be audio-recorded with consent plus field notes as a supplement.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eResponses to an electronic based questionnaire (kobo-collect tool) were downloaded by the researcher and study team into Microsoft Excel. A team member performed double data entry verification through comparison of questionnaires against what had been downloaded into Microsoft Excel. The cleaned data set was then imported into SPSS version 21 for analysis. Descriptive statistics were calculated for binary, categorical, and continuous variables. Logistic regression was used to evaluate association between independent variables (for example vaccine uptake) with efficacy as dependent variable. Frequencies, percentages mean plus confidence intervals summarized perceptions on safety as well as efficacy.\u003c/p\u003e \u003cp\u003eQualitative data were analyzed thematically with Nvivo 12 after being transcribed verbatim. A coding framework was created based on research objectives and themes that emerged inductively. Triangulation of data across FGDs and IDIs was done to increase validity and contextual interpretation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e Ethical clearance was obtained from the Faculty of Health Sciences Institutional Review Board of the University of Bamenda (Ref. 2025/0002H/Uba/IRB) and the Regional Ethics Committee for Human Health Research in the South West Region of Cameroon (Ref. No771/CRERSH/SW/C/09/2025). Authorizations to carry out research were obtained from the South West Regional Delegation of Public Health, Cameroon and district health authorities. Written informed consent was obtained from all participants that took part in the study. Confidentiality, voluntary participation, and the right to withdraw at any time were fully ensured in line with ethical guidelines.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Findings\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eSociodemographic Characteristics of the Study Population\u003c/h2\u003e \u003cp\u003e A total of 418 mothers/caregivers participated in the study across the three health districts of Mamfe, Tiko, and Limbe. The mean age of respondents was 30\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5 years, with age distributions relatively similar across the districts. Nearly half of all participants (49.3%, 206) were between 20\u0026ndash;29 years, followed by 37.6% (157) aged 30\u0026ndash;39 years. Only 3.6% (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) were younger than 20 years, while 9.6% (40) were aged 40 years and above.\u003c/p\u003e \u003cp\u003eIn terms of marital status, more than half of the respondents were married (56.9%, 238), while 37.8% (158) were single. A smaller proportion were divorced (2.6%, 11) or widowed (2.6%, 11). Distribution differed slightly by district, with Mamfe having the highest proportion of married respondents (56.5%, 61) and Limbe registering the highest proportion of single caregivers (53.2%, 50).\u003c/p\u003e \u003cp\u003eRegarding their relationship with the child, the majority of participants were biological mothers (85.4%, 357), while 7.7% (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) were fathers and 6.9% (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) were primary caregivers such as grandparents or guardians. There was a slightly higher proportion of fathers and primary caregivers in Limbe compared to the other districts (Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eWith respect to educational level, more than half of the participants (53.8%, 225) had secondary education, while 29.4% (123) had completed primary education. Only 10.8% (45) had attained tertiary-level education, and 6.0% (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) reported having no formal education. Limbe had the highest proportion of respondents with primary education (50%, 47), whereas Mamfe had a comparatively higher proportion of respondents with tertiary education (14.8%, 16).\u003c/p\u003e \u003cp\u003eConcerning occupation, the majority of respondents were self-employed (54.5%, 228), followed by 34.0% (142) who were unemployed. Public and private sector workers accounted for 5.5% (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and 6.0% (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), respectively. Tiko had the highest proportion of self-employed caregivers (63%, 136), while the highest proportion of unemployed participants (52.8%, 57) was recorded in Mamfe.\u003c/p\u003e \u003cp\u003eIn terms of religion, most respondents identified as Christians (88.8%, 371), while 7.2% (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) were Muslims, and 4.1% (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) belonged to other religious groups. Mamfe and Limbe showed similar patterns, while Tiko had a slightly higher proportion of Muslims (11.6%, 25).\u003c/p\u003e \u003cp\u003eFinally, most caregivers had one child aged 11\u0026ndash;30 months (78.2%, 327), while 17.5% (73) had two children and 4.3% (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) had three. Mamfe and Tiko had a very high proportion of caregivers with only one eligible child (86.1%, 93) for Mamfe and 89.3% (194) for Tiko), whereas Limbe had a more even distribution, with 42.6% (40) having one child and 45.7% (43) having two children in the eligible age group (Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eSocio-demographic characteristics of the study population\u003c/b\u003e (N\u0026thinsp;=\u0026thinsp;418)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMamfe\u003c/p\u003e \u003cp\u003e% (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTiko\u003c/p\u003e \u003cp\u003e% (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLimbe\u003c/p\u003e \u003cp\u003e% (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e% (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.3 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.6 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.4 (49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.9 (112)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.9 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49.3 (206)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.1 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.0 (82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.3 (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37.6 (157)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.0 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.6 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.6 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.7 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.6 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.2 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37.8 (158)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.5 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63.4 (137)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.6 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56.9 (238)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.9 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.6 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.6 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.3 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.3 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.6 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRelationship with child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFather\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.4 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.6 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.8 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.7 (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBiological mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.3 (90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.2 (197)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.5 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85.4 (357)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary caregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.3 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.2 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.8 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.9 (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLevel of Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.7 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.0 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.5 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.0 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.6 (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.9 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.4 (123)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.9 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.5 (135)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.2 (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e53.8 (225)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.8 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.6 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.3 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.8 (45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.8 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.5 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.9 (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.0 (142)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eself-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.3 (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63.0 (136)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58.5 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54.5 (228)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic sector worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.3 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.5 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate sector worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.6 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.4 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.3 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.0 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChristian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.9 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.4 (191)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89.4 (84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88.8 (371)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.6 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.1 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.2 (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.5 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.1 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Children aged 11\u0026ndash;30 months per caregiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.1 (93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89.3 (194)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.6 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78.2 (327)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.3 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.3 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.7 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.5 (73)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.6 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.7 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.3 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eExploration of mother\u0026rsquo;s/caregiver\u0026rsquo;s awareness, perception, and efficacy of malaria vaccine uptake\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eAwareness of Mothers and Care Givers on the Malaria Vaccine\u003c/h2\u003e \u003cp\u003eAn awareness index was constructed using three survey items designed to assess mothers\u0026rsquo; knowledge of the malaria vaccine. The index had a maximum score of 5, and awareness levels were categorized as low (0\u0026ndash;1), moderate (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and high (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Among the 418 mothers/caregivers who participated in the study, 327 (78.2%) demonstrated a high level of awareness regarding the malaria vaccine. Additionally, 59 (14.1%) respondents exhibited moderate awareness, while 32 (7.7%) showed a low level of awareness as shown in Table\u0026nbsp;3.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAwareness Level of Mothers/caregivers on the Malaria Vaccine\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of Awareness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e418\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSource of Information on the Malaria Vaccine\u003c/h2\u003e \u003cp\u003eThe primary source of information for individuals who had heard about the malaria vaccine was health facilities (52%, 388). Community health workers and the media accounted for 20% (147) and 19% (144) respectively. Sensitization through family/friends contributed the least to informing women about the newly introduced vaccine.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure i: Information source of participants on malaria Vaccine\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eWillingness of mothers/caregivers to vaccinate children against malaria\u003c/h2\u003e \u003cp\u003eThe majority of mothers/caregivers, 377 out of 418 (90.2%), indicated that they were willing to vaccinate their children against malaria, reflecting a high level of trust and acceptance of the malaria vaccine. Conversely, 30 respondents (7.2%) reported unwillingness to vaccinate their children, suggesting potential non-uptake or incomplete uptake of the vaccine. Additionally, 11 participants (2.6%) expressed uncertainty regarding whether they would vaccinate their children, demonstrating that a small proportion of mothers still held reservations about the vaccine (Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMothers\u0026rsquo;/Caregivers\u0026rsquo; willingness to vaccinate children against Malaria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWillingness to vaccinate child\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e377\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMay be\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e418\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMalaria vaccine Uptake amongst children under 5 years\u003c/h2\u003e \u003cp\u003eChildren aged 11 to 30 months at the time of data collection were expected to have received at least three doses of the malaria vaccine, which was considered \u003cem\u003ecomplete uptake\u003c/em\u003e for this study. According to WHO recommendations, three doses provide extended protection (greater than one year) against severe malaria, followed by a booster dose at 24 months as per WHO guideline.\u003c/p\u003e \u003cp\u003eCrude uptake was assessed using vaccination card verification and caregiver recall at the community level. Overall, malaria vaccine uptake patterns were as follows: No uptake: 15% (n\u0026thinsp;=\u0026thinsp;63), Initial uptake (1 dose): 85% (n\u0026thinsp;=\u0026thinsp;355), Partial uptake (2 doses): 79% (329) and Complete uptake (3 to 4 doses): 62% (n\u0026thinsp;=\u0026thinsp;258) as shown in Fig.\u0026nbsp;2. The complete uptake level observed in the study (61%) fell below the WHO-recommended target coverage of 80%.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePossible barriers to non/incomplete uptake of the malaria vaccine\u003c/h2\u003e \u003cp\u003eAmong the respondents with partial or no uptake at the time of the study, the most commonly reported barrier based on responses was lack of knowledge about the malaria vaccine (33%. 109 responses), consistent with the finding that fewer than 80% demonstrated a high level of awareness. Other notable barriers included fear of side effects (22%, 75), and lack of trust in the health-care system (14%, 47). Other factors that cumulatively represented 25% (104) of responses were (non-availability of vaccines, cultural/religious believes, distance from health facilities and lack of time/personal reasons). These factors were reported among mothers/caregivers whose children had no uptake or incomplete uptake of the vaccine as illustrated in Fig.\u0026nbsp;3.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eMalaria Vaccine Safety \u0026amp; Effectiveness\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eMalaria vaccine safety\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ea) Perceived side effects amongst vaccinated children\u003c/h2\u003e \u003cp\u003eAmong the 355 children who had received at least one dose of the malaria vaccine, 160 (45%) mothers/caregivers reported believing that the vaccine could cause side effects. In contrast, a larger proportion of respondents (195, 55%) did not perceive any possibility of side or adverse effects associated with the malaria vaccine as shown in Fig.\u0026nbsp;4.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eb) Anticipated side effects amongst respondents who perceived possibility of side effects\u003c/h2\u003e \u003cp\u003eAmong the 160 mothers/caregivers who believed that the malaria vaccine could cause side effects, the most commonly anticipated reactions were fever (52%, 136) and swelling at the injection site (29%, 77). Other anticipated effects (dizziness, vomiting, body weakness, and loss of appetite) cumulatively accounted for 19% (51) of side effects reported. No major side effects like convulsions were reported by any of the participants thus, indicating safety of the malaria vaccine (Fig.\u0026nbsp;5).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003col start=\"2\"\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eMalaria Vaccine Effectiveness\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003ea) Comparison of malaria cases amongst vaccinated and unvaccinated children\u003c/h2\u003e \u003cp\u003eAnalysis showed no statistically significant difference in malaria occurrence between children with partial vaccine uptake and those with no uptake (p\u0026thinsp;=\u0026thinsp;0.50). However, a statistically significant difference was observed between children with complete uptake and those with no uptake (p\u0026thinsp;=\u0026thinsp;0.037). Children who had received all three doses of the malaria vaccine were 0.52 times less likely to develop malaria compared to children with no uptake (OR\u0026thinsp;=\u0026thinsp;0.52; 95% CI: 0.29\u0026ndash;0.96). This shows effectiveness of vaccine with those with complete uptake when compared to other groups (Table\u0026nbsp;5).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMalaria cases amongst vaccinated and unvaccinated children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003cp\u003e(Vaccine uptake)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo of children infected with malaria (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo of children not infected with malaria (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal No (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOdds Ratio (OR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82 (84.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0-4.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e258 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.52\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.29\u0026ndash;0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.037*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e274 (65.6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e144 (34.4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e418 (100)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eb) Possibility of developing severe malaria among children with partial and complete vaccine uptake\u003c/h2\u003e \u003cp\u003eTo assess the effectiveness of the malaria vaccine in reducing disease severity, malaria severity amongst those that had developed malaria was compared between children with partial vaccination and those with complete vaccine uptake. A statistically significant difference was observed: children with only partial vaccination were 14.5 times more likely to develop severe malaria when compared to those with complete vaccination (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; OR\u0026thinsp;=\u0026thinsp;14.5; 95% CI: 3.15\u0026ndash;66.3) as shown in Table\u0026nbsp;6.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSevere malaria cases amongst children with partial and complete vaccine uptake\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003cp\u003e(Vaccine uptake)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere Malaria in children\u003c/p\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSimple Malaria in children No (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal No (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOdds Ratio (OR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (73.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e14.45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.15\u0026ndash;66.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e02 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79 (97.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e1.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e17 (65.6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e120 (34.4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e137 (100)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003ec) Diagnosed malaria species amongst vaccinated children in the SWR\u003c/h2\u003e \u003cp\u003eAmong the 137 vaccinated children who developed malaria, 133 (97%) caregivers had no knowledge of the \u003cem\u003ePlasmodium\u003c/em\u003e species responsible. This suggests limited or no communication from healthcare workers regarding species-specific information, as well as a lack of emphasis on identifying the species targeted by the malaria vaccine (Fig.\u0026nbsp;6).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure vi: Knowledge level of caregivers on Plasmodium species responsible for malaria amongst vaccinated children\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eQualitative Findings (Mothers/Caregivers)\u003c/h2\u003e \u003cdiv id=\"Sec28\" class=\"Section4\"\u003e \u003ch2\u003eTheme 1. Awareness and Knowledge of the Malaria Vaccine\u003c/h2\u003e \u003cp\u003eA caregiver attempted to describe the vaccine schedule but inconsistently:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe vaccine is given at 3 months, 5 months and 6 months to protect my child from malaria.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis suggests that while caregivers encounter health services, health education has not been adequate or consistent.\u003c/p\u003e \u003cp\u003eSome caregivers missed health talks because they were not conducted consistently or they were not present when talks were done.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe have not even heard much about the vaccine because sometimes when we come to the clinic, they don't give health talks and some other times they give health talks when some of us might not be there.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis suggests the need for more systematic and accessible health education within healthcare facilities.\u003c/p\u003e \u003cp\u003eSocial dynamics, particularly male household authority, also influenced decision-making as when the question was posed: Would you be willing to take the vaccine at the community if proposed to you by healthcare workers?\u003c/p\u003e \u003cp\u003e \u003cb\u003eParticipant\u0026rsquo;s Response: \u0026ldquo;We cannot take it if our husbands have not approved where it's coming from at the community.\u0026rdquo;\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThese perceptions highlight the influence of community narratives and patriarchal decision structures on vaccine uptake.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3. Perceived Importance and Efficacy\u003c/h2\u003e \u003cp\u003eSome caregivers who had vaccinated their children reported observable reductions in malaria episodes, reinforcing trust in the vaccine.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSince after the vaccine, my child has been having fever sometimes but when they test at the hospital, they say the child does not have malaria which was not the same before.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePositive personal experience acted as a facilitator and could be leveraged in awareness efforts.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Findings (Health Care Workers)\u003c/h3\u003e\n\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Knowledge About the Malaria Vaccine\u003c/h2\u003e \u003cp\u003eHealthcare workers demonstrated good foundational knowledge about the malaria vaccine particularly its preventive purpose and its role in reducing disease severity. Several participants recognized that the vaccine targets children aged 0\u0026ndash;5 years, a group vulnerable due to their weak immunity and high malaria-related mortality.\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;The malaria vaccine is given to prevent frequent malaria infections in children. Even if a child still gets malaria, the vaccine helps reduce the severity of the disease\u0026rdquo;.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhile the participants understood the basic function of the vaccine, they expressed knowledge gaps regarding side effects and management of post-vaccination reactions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSometimes a child receives a vaccine and then has a reaction, but we don\u0026rsquo;t always know how to explain it to the parents.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis gap suggests a need for continuous professional development to strengthen Health Care Worker\u0026rsquo;s technical understanding and improve their communication with caregivers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Perceived Effectiveness and Experiences\u003c/h2\u003e \u003cp\u003eMost participants believed the vaccine was safe, effective, citing a decline in malaria cases among children since its introduction and just a case of a major side effect experienced.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBefore its introduction, we used to receive many malaria cases in children. But now, even when children come with fever, lab tests often show it\u0026rsquo;s not malaria.\u003c/p\u003e\u003cp\u003eThe malaria vaccine is relatively new; it was introduced into the childhood vaccination calendar less than four years ago. It is effective in preventing malaria, as we now see fewer children returning to the hospital with the disease.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e\"The only serious side effect I have experienced is a situation in which a child was vaccinated and suddenly developed very high fever and when a lab test was conducted, we noticed that the child was positive for malaria. Thus, I will recommend that test should be provided for all children before vaccination.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNevertheless, some participants urged caution in attributing the decline solely to vaccination, noting possible seasonal fluctuations in malaria prevalence.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMalaria is a seasonal disease, we should observe it over a longer period before drawing final conclusions.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis balanced view indicates that while faith in the vaccine is strong, Health Care Workers (HCWs) also recognize the need for ongoing data monitoring to confirm long-term impact.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eTheme 3: Attitudes and Willingness to Recommend\u003c/h2\u003e \u003cp\u003eOverall, healthcare workers expressed positive attitudes toward the malaria vaccine and a high willingness to recommend it. They viewed it as a \u0026ldquo;strategic plan\u0026rdquo; by the government to reduce child morbidity and mortality.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSince it was introduced, we\u0026rsquo;ve noticed that children are healthier, and we rarely see malaria cases among them.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNevertheless, some expressed frustration with parental hesitancy:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSome parents refuse the vaccine because they believe injections cause pain. I have to spend time explaining the benefits and convincing them.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePositive personal experiences with vaccine outcomes further reinforced trust:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFrom my experience, it is very effective. I have not seen any vaccinated children return with malaria.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThus, attitudes of confidence and perceived success motivate health workers to actively recommend the vaccine.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eTheme 4: Barriers and Challenges\u003c/h2\u003e \u003cp\u003eThe most significant barriers identified were fear and misinformation, often spread through social media or linked to previous COVID-19 vaccine skepticism.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMany people compared it to the COVID-19 vaccine and said, \u0026lsquo;You\u0026rsquo;ve come again to kill our children.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHealthcare workers reported that effective sensitization and reassurance about mild side effects were key to overcoming fear.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen we explain properly that the malaria vaccine is like any other vaccine, the fear reduces.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eFacilitator:\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003e\u0026ldquo;Now, I have a question for the laboratory technicians here. How do you know whether the malaria vaccine is effective?\u003c/b\u003e \u003c/p\u003e\n\u003ch3\u003eParticipant 2 (Lab Technician)\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003e\u0026ldquo;We can\u0026rsquo;t say for sure whether the vaccine is effective because we\u0026rsquo;re not directly involved in administering it to children. The people who can best judge its effectiveness are those who vaccinate children between zero and five years. However, we do contribute by collecting and reviewing data. We take laboratory statistics that show the number of malaria cases over time. From those statistics, we can make some observations about trends in malaria cases\u0026rdquo;.\u003c/b\u003e \u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eFacilitator (Follow-up):\u003c/h2\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eSo, is there any way that laboratory data can help monitor vaccine effectiveness?\u003c/h2\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;No, it is through regular statistical analysis. The people who collect and record malaria test results can help show whether malaria cases are decreasing. Right now, statisticians handle most of that data, so they\u0026rsquo;re the ones who can best determine if there\u0026rsquo;s been improvement\u0026rdquo;.\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section2\"\u003e \u003ch2\u003eLogistical and Infrastructure Barriers\u003c/h2\u003e \u003cp\u003eHealth care managers identified cold chain limitations, transport delays, and damaged infrastructure as key bottlenecks.\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;Normally, the quality of vaccine is very important. If the vaccines are not properly conserved, you can imagine the impact it can have when it comes to its potency and ability of the children to be immunized which we might not be sure of. Imagine the impact. Some centers like Kajifu health area lack electricity or solar fridges. Cold boxes are used but limited for long-term storage.\u0026rdquo; Participant quote\u003c/b\u003e \u003c/p\u003e \u003cdiv id=\"Sec40\" class=\"Section3\"\u003e \u003ch2\u003eMonitoring, Evaluation, and Data Management\u003c/h2\u003e \u003cp\u003eMonitoring enables timely interventions such as PIRI (Periodic Intensification of Routine Immunization) to address missed children.\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;We usually carry out regular monitoring to check progress but so far we have not been able to access the prevalence during discussion session/meetings.\u0026rdquo; - Respondent.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eInterpretation: This might indicate limited interest or concern when it comes to evaluation of effectiveness by health care managers.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 5: Enablers and Recommendations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants highlighted several strategies to improve vaccine rollout:\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;We should be given more detailed information about possible side effects to explain them better to parents.\u0026rdquo; (Participant 5)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThese suggestions reflect a proactive approach among HCWs toward improving implementation and maintaining public trust.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCommunity Engagement and Education\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Inform the population about the dangers of malaria and the importance of vaccination.\u0026rdquo; Participant quote\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eImproved Logistics and Infrastructure\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Provide solar-powered fridges, training materials, and posters to improve vaccination coverage.\u0026rdquo; Participant quote\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis mixed-methods study assessed caregiver and healthcare worker perceptions regarding the safety, efficacy, and uptake of the RTS,S/AS01 malaria vaccine in three high-burden districts of the South West Region of Cameroon. The discussion synthesizes quantitative and qualitative findings and places them within existing literature.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe\u003c/b\u003e willingness to vaccinate children was high (\u0026gt;\u0026thinsp;90%) but complete uptake (three doses or more) fell to 62% and this is below the WHO-recommended target of 80%. This gap between willingness and full adherence could possibly reflect systemic and informational barriers over caregiver motivation. The most frequently reported obstacles were lack of knowledge (33%), fear of side effects (22%), low trust in the health system (14%) and practical constraints such as vaccine stock-outs as well as distance to facilities. This is consistent with earlier evidence that limited awareness and concerns about vaccine safety commonly hinder uptake for newly introduced vaccines in sub-Saharan Africa (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study carried out by Dimala \u003cem\u003eet al.\u003c/em\u003e (31.) in SSA also highlights that vaccine acceptance is strongly influenced by perception of disease severity, trust in the health system, and communication from health authorities perceived as clear. The knowledge gap observed herein supports prior findings that many caregivers lack essential vaccination information (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and this can negatively influence follow-up visits required for multi-dose vaccines (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eQualitative insights from mothers further confirmed this pattern as many caregivers had only heard about the vaccine during facility visits, had misconceptions about its purpose, or expressed confusion about the number of doses. These perceptions echo the broader finding of Zavala (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) in a study conducted in 11 SSA countries which reported that inadequate messaging during early vaccine rollout contributed to inconsistent uptake.\u003c/p\u003e \u003cp\u003eWith regards to vaccine safety, 55% (195) of caregivers reported no concerns about side effects while 45% (160) expected some adverse outcomes. Among those expecting side effects common concerns included fever and injection site swelling. However, major adverse reactions such as convulsions were not reported. This aligns with global trial findings where RTS,S/AS01 had an acceptable safety profile with predominantly mild transient side effects as reported by Ali \u003cem\u003eet al.\u003c/em\u003e in African children (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe hesitation observed in a subset of caregivers is consistent with documented patterns that uncertainty about vaccine side effects contributes significantly to refusal or hesitancy in many contexts including earlier malaria vaccine trials such as the SPf66 study. Chaufan et al. reported that 26.7% of caregivers described themselves as \u0026ldquo;unsure\u0026rdquo; about the spf66 vaccine safety in a systematic review involving several countries in Africa (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealthcare workers had similar mixed feelings. Most were in favour of the vaccine, but some said they had not been trained adequately or still had questions about how it worked and which age groups it was meant for. Evidence has shown that healthcare worker confidence is strongly related to their willingness to recommend vaccines (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and that gaps in training make them less effective as trusted sources of information (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study found a very significant protective effect among children who completed the full vaccination schedule as those with complete uptake were 0.52 times less likely to develop malaria when compared to those with no uptake (p\u0026thinsp;=\u0026thinsp;0.037). Partially vaccinated children as well were 14.5 times more likely to develop severe malaria than those with complete uptake (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). These findings are consistent with global RTS,S evidence on moderate but substantial reductions in clinical and severe malaria, particularly when the full dose schedule is completed (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The results also reinforce increasing real-world evidence from early implementation programmes demonstrating reductions in severe malaria, hospital admissions, and malaria-related mortality (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) from previous findings reported by Datoo \u003cem\u003eet al.\u003c/em\u003e, in Africa. Qualitative feedback from caregivers supports this quantitative trend as several mothers noted a marked decrease in malaria episodes among vaccinated children. This is consistent with long-standing community-level acceptance of preventive health interventions (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and validation that perceived benefits increase trust in vaccines.\u003c/p\u003e \u003cp\u003eThe study\u0026rsquo;s qualitative findings highlighted communication gaps as a critical factor influencing uptake. Caregivers frequently mentioned that they received insufficient explanation regarding dosage schedules, expected side effects, or the vaccine\u0026rsquo;s purpose. This resonates with previous findings by Munir \u003cem\u003eet al.\u003c/em\u003e, in Pakistain emphasizing the role of clear, continuous communication and community engagement in improving vaccine adoption (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealthcare workers also identified stock-outs of vaccines as challenges affecting promotion along with cultural resistance and parental hesitancy toward vaccination. These issues are similar to earlier studies that reported how inconsistency in the supply chain and cultural beliefs can undermine confidence in programs for malaria vaccines (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants expressed a need for government-led campaigns, frequent reminders, community-based sensitization supporting the notion that multichannel communication significantly enhances vaccine uptake including digital nudges and stakeholder collaboration (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations of the study\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study\u0026rsquo;s design limited the ability to establish causal relationships between vaccination uptake and malaria outcomes.\u003c/p\u003e \u003cp\u003eCaregiver-reporting of malaria episodes, vaccine side effects, and vaccination history may be inaccurate, affecting data reliability.\u003c/p\u003e \u003cp\u003eRecruitment from pilot districts in the South West Region may not fully represent caregivers in other regions or those less engaged with health services.\u003c/p\u003e \u003cp\u003eMost caregivers did not know the \u003cem\u003ePlasmodium\u003c/em\u003e species responsible for their child\u0026rsquo;s malaria, limiting precise assessment of vaccine effectiveness against \u003cem\u003eP. falciparum\u003c/em\u003e, the targeted species.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis mixed-methods study shows that early community acceptance of the RTS,S/AS01 malaria vaccine is a good sign and that caregivers mostly see it as safe and effective. However, there are major gaps in awareness, communication from the health system, and reliability of the supply chain. The vaccine proved very effective among children with complete uptake by reducing both malaria occurrence and severity, but incomplete uptake due to lack of knowledge, fear of side effects, and structural challenges keep the full public health potential out of reach for this vaccine.\u003c/p\u003e \u003cp\u003eTherefore, strengthening communication strategies, ensuring consistent availability of the vaccine, and empowering healthcare workers through comprehensive training will be necessary steps toward improving uptake in order to achieve expected population-level benefits from malaria vaccination in the South West Region of Cameroon.\u003c/p\u003e \u003cp\u003eIt is therefore recommended that targeted community sensitization campaigns should be implemented by health authorities. The use of digital reminders and culturally relevant information tools should be encouraged to improve adherence and standardized messages on safety, dose schedule, and expected mild side effects should be encouraged\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of conflict of Interest:\u003c/strong\u003e The authors declare no potential conflict of interest with respect to the research, authorship and/or publication of this article\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The author(s) received no financial support for the research, authorship and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable considering we are not publishing any identifiable participant information.\u003c/p\u003e\u003cp\u003e \u003ch2\u003eN.B\u003c/h2\u003e \u003cp\u003e Considering some health areas went slightly above the minimum sample size, we ended up having an overall 418 caregiver sampled.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.C.A: Conceived and designed the study, developed the research protocol and data collection tools, supervised the fieldwork, conducted and validated the qualitative data analysis, interpreted the findings, drafted the manuscript, and coordinated all revisions until submission.L.L.N., N.T.: Provided academic supervision during study design, contributed to the development of the methodological approach, reviewed the protocol and analysis framework, and critically revised the manuscript.O.N.: Contributed to the study design and qualitative methodology, reviewed data analysis outputs, provided supervisory guidance, and critically reviewed and approved the final manuscript.M.Y.N.: Contributed to the design of the data collection instruments, supported training of field data collectors, participated in data collection, assisted in organizing data, and contributed to preliminary analysis.J.E.A.: Contributed to transcription, coding, and initial thematic analysis, and provided input during interpretation of findings, assisted in refining the data collection tools, contributed to data analysis and management, participated in data cleaning and initial coding, and reviewed the methods and results sections of the manuscript.H.K.K.: Provided overall academic supervision, guided the study design and methodological decisions, contributed to the interpretation of results, critically reviewed multiple manuscript drafts, and approved the final version for submission.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors are grateful to Ewi-kang Georges Hermann, Dr Adeline Green, Eyong Herdis Nsoh, Fang Eugene, Ibrahim Usmanu Tata, Abunaw Rebecca, Akamandu Anye Daniel, Nsuh Gladys Chi, Anye Fru Godlove, Vakunta John, Melvis Chembopouh and Constance Tamungang for assisting in the realisation of this work\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData can be made available on request (restricted access due to confidentiality): Considering the study used a mixed approach, with respondents clearly assured of their confidentiality, especially during FGD and Indebt interviews, the datasets generated and analyzed during the current study are not publicly available due to ethical/confidentiality restrictions but can be made available by the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAllison AC. Protection afforded by sickle-cell trait against subtertian malarial infection. Br Med J. 1954;1(4857):290\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSnow RW. Global malaria eradication and the importance of Plasmodium falciparum epidemiology in Africa. Volume 13. BMC Medicine. BioMed Central Ltd.; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. World malaria report 2022 [Internet]. 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wipo.int/amc/en/mediation\u003c/span\u003e\u003cspan address=\"https://www.wipo.int/amc/en/mediation\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. World malaria report 2022 [Internet]. 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wipo.int/amc/en/mediation\u003c/span\u003e\u003cspan address=\"https://www.wipo.int/amc/en/mediation\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global Malaria Programme operational strategy 2024\u0026ndash;2030.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiabi A, Djimafo ANM, Nguefack S, Mah E, Nguefack F, Angwafo F. Severe malaria in Cameroon: Pattern of disease in children at the Yaounde Gynaeco-Obstetric and Pediatric hospital. J Infect Public Health. 2020;13(10):1469\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePMI. U.S. President\u0026rsquo;s Malaria Initiative Cameroon Malaria Operational Plan FY 2022 [Internet]. 2022. Available from: www.pmi.gov.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. World malaria report 2023. Geneva: World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKevin Baird J. Evidence and implications of mortality associated with acute plasmodium vivax malaria. Clin Microbiol Rev. 2013;26(1):36\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNdip RN, Sumbele I. Trends of Malaria in the South West Region of Cameroon: Overview, Challenges and Perspectives (SDG3). 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrategy to respond to antimalarial drug resistance in Africa.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli T, Sumbal A, Haque MA. The fight against malaria: a new hope with the R21 vaccine. Int J Surgery: Global Health. 2024;7(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe Lancet. Malaria vaccines: a test for global health. Vol. 403, The Lancet. Elsevier B.V.; 2024. p. 503.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDatoo MS, Dicko A, Tinto H, Ou\u0026eacute;draogo JB, Hamaluba M, Olotu A, et al. Safety and efficacy of malaria vaccine candidate R21/Matrix-M in African children: a multi-center, double-blind, randomized, phase 3 trial. Lancet. 2024;403(10426):533\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNdoula ST, Mboussou F, Njoh AA, Nembot R, Baonga SF, Njinkeu A et al. Malaria Vaccine Introduction in Cameroon: Early Results 30 Days into Rollout. Vaccines (Basel) [Internet]. 2024;12(4):346. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mdpi.com/2076-393X/12/4/346\u003c/span\u003e\u003cspan address=\"https://www.mdpi.com/2076-393X/12/4/346\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimbeye AJ, Kumwenda S, Cohee LM, Omondi D, Masibo PK, Wao H et al. Factors associated with malaria vaccine uptake in Nsanje district, Malawi. Malar J. 2024;23(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaladima AN, Zulkefli NAM, Said SM, Ahmad N. Factors influencing childhood immunisation uptake in Africa: a systematic review. BMC Public Health. 2021;21(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBangura JB, Xiao S, Qiu D, Ouyang F, Chen L. Barriers to childhood immunization in sub-Saharan Africa: A systematic review. Volume 20. BMC Public Health. BioMed Central; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOjakaa DI, Ofware P, Machira YW, Yamo E, Collymore Y, Ba-Nguz A et al. Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya. Malar J. 2011;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYeboah D, Owusu-Marfo J, Agyeman YN. Predictors of malaria vaccine uptake among children 6\u0026ndash;24 months in the Kassena Nankana Municipality in the Upper East Region of Ghana. Malar J. 2022;21(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao B, Zhao L. Mining adverse events in large frequency tables with ontology, with an application to the vaccine adverse event reporting system. Stat Med. 2023;42(10):1512\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahmud MS, Kamrujjaman M, Adan MMIY, Hossain MA, Rahman MM, Islam MS, et al. Vaccine efficacy and SARS-CoV-2 control in California and U.S. during the session 2020\u0026ndash;2026: A modeling study. Infect Dis Model. 2022;7(1):62\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWithers MR, McKinney D, Ogutu BR, Waitumbi JN, Milman JB, Apollo OJ et al. Safety and Reactogenicity of an MSP-1 Malaria Vaccine Candidate: A Randomized Phase Ib Dose-Escalation Trial in Kenyan Children. PLoS Clin Trials [Internet]. 2006;1(7):e32. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dx.plos.org/10.1371/journal.pctr.0010032\u003c/span\u003e\u003cspan address=\"https://dx.plos.10.1371/journal.pctr.0010032\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalgovind P, Mohammadnezhad M. Perceptions of Healthcare Workers (HCWs) towards childhood immunization and immunization services in Fiji: a qualitative study. BMC Pediatr. 2022;22(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJenna H, George O, Jenny H, Teresa B. RTS,S/AS01 malaria vaccine pilot implementation in western Kenya: a qualitative longitudinal study to understand immunization barriers and optimize uptake. BMC. 2023;23(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuhangana C. Health workers\u0026rsquo; knowledge, attitudes, and practices on the RTS,S malaria vaccine: A qualitative study in Kenya. Malar J. 2022;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimbeye AJ, Kumwenda S, Cohee LM, Omondi D, Masibo PK, Wao H et al. Factors associated with malaria vaccine uptake in Nsanje district, Malawi. Malar J. 2024;23(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMtenga S, Kimweri A, Romore I, Ali A, Exavery A, Sicuri E et al. Stakeholders\u0026rsquo; opinions and questions regarding the anticipated malaria vaccine in Tanzania. Malar J. 2016;15(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaaka SA, Mohammed K, Pienaah CKA, Luginaah I. Child malaria vaccine uptake in Ghana: Factors influencing parents\u0026rsquo; willingness to allow vaccination of their children under five (5) years. PLoS ONE. 2024;19(1 January).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZavala F. RTS,S: the first malaria vaccine. Vol. 132, Journal of Clinical Investigation. American Society for Clinical Investigation; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDimala CA, Kika BT, Kadia BM, Blencowe H. Current challenges and proposed solutions to the effective implementation of the RTS, S/ AS01 Malaria Vaccine Program in sub-Saharan Africa: A systematic review. Volume 13. PLoS ONE. Public Library of Science; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaufan C, Heredia C, Mcdonald J, Hemsing N. Title Page The balance of risks and benefits in the COVID-19 vaccine hesitancy literature: An umbrella review.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSulaiman SK, Musa MS, Tsiga-Ahmed FI, Dayyab FM, Sulaiman AK, Bako AT. A systematic review and meta-analysis of the prevalence of caregiver acceptance of malaria vaccine for under-five children in low-income and middle-income countries (LMICs). PLoS ONE. 2022;17(12 December).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhatiwada M, Nugraha RR, Dochez C, Harapan H, Mutyara K, Rahayuwati L et al. Understanding COVID-19 Vaccine Acceptance among Healthcare Workers in Indonesia: Lessons from Multi-Site Survey. Vaccines (Basel). 2024;12(6).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunir S, Said F, Taj U, Zafar M. Digital nudges to increase childhood vaccination compliance: Evidence from Pakistan.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahmud S, Mohsin M, Khan IA, Mian AU, Zaman MA. Knowledge, beliefs, attitudes and perceived risk about COVID-19 vaccine and determinants of COVID-19 vaccine acceptance in Bangladesh. PLoS ONE. 2021;16(9 September).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeri\u0026aacute;\u0026ntilde;ez \u0026Aacute;, Trister A, Nekkar M, del R\u0026iacute;o AF, Alonso PL. Adaptive Interventions for Global Health: A Case Study of Malaria. 2023; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://arxiv.org/abs/2303.02075\u003c/span\u003e\u003cspan address=\"http://arxiv.org/abs/2303.02075\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Malaria vaccine, RTS, S/AS01, safety, efficacy, uptake, caregivers, mixed-methods, SWR Cameroon","lastPublishedDoi":"10.21203/rs.3.rs-8293727/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8293727/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMalaria remains a leading cause of morbidity and mortality among children under five in Cameroon. In 2024, the RTS,S/AS01 malaria vaccine was introduced into the Expanded Programme on Immunization (EPI), yet evidence on community perceptions, uptake, and real-world effectiveness remains limited. This study assessed caregivers\u0026rsquo; and healthcare workers\u0026rsquo; perceptions of the vaccine\u0026rsquo;s safety and efficacy, and examined factors influencing uptake among children in three high-burden districts of the South West Region (SWR) of Cameroon.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods study was conducted using a cross-sectional survey of caregivers of vaccinated children and qualitative interviews with mothers and healthcare workers. Quantitative data captured awareness, perceived safety, reported side effects, and vaccine effectiveness. Qualitative data also explored perceptions, communication gaps, cultural influences, and health-system challenges. Descriptive and inferential statistics, including logistic regression, were used for quantitative analysis, while thematic analysis guided qualitative interpretation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 418 surveyed caregivers, complete vaccine uptake was 62% (258) which is below the WHO recommended target. Lack of knowledge (33%, 109), fear of side effects (22%, 75), and low trust in the health system (14%, 47) were major barriers to full adherence. Perceived safety was generally high (55%, 195), with no serious adverse events reported. Children who completed all vaccine doses were significantly less likely to develop malaria (OR\u0026thinsp;=\u0026thinsp;0.52; p\u0026thinsp;=\u0026thinsp;0.037) and had markedly lower odds of severe malaria than those partially vaccinated (OR\u0026thinsp;=\u0026thinsp;14.5; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Qualitative findings confirmed safety and effectiveness, but limited awareness, misconceptions, stock-outs, and the need for improved community sensitization.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe RTS,S/AS01 vaccine is perceived as safe and effective, but uptake is hindered by knowledge gaps, communication challenges, and supply constraints in the study area. Therefore, strengthening community awareness, improving health-worker training, and ensuring consistent vaccine availability are essential.\u003c/p\u003e","manuscriptTitle":"Perceived safety and efficacy of the malaria vaccine, RTS,S/AS01 among vaccinated children in the South West Region of Cameroon: Mixed Study Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-09 06:38:00","doi":"10.21203/rs.3.rs-8293727/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-16T07:50:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T04:57:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-15T12:13:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227850075051404731836177456648812530126","date":"2026-01-15T03:25:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"292400807372813991727164562689429497618","date":"2026-01-12T13:34:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-06T13:36:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-12T07:24:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-09T01:04:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-09T01:02:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-12-06T09:46:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5629e129-e164-49dc-ad49-3f20b86bd760","owner":[],"postedDate":"January 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T10:54:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-09 06:38:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8293727","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8293727","identity":"rs-8293727","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}