Awareness and Acceptance of Malaria Vaccines by Caregivers of Under-five Children in Abia State, Nigeria: A Mixed Methods Study

ABSTRACT Introduction Malaria remains a leading cause of under-five mortality in Nigeria, with Abia State exemplifying hyperendemic transmission. The 2024 introduction of the R21/Matrix-M and RTS,S/AS01 vaccines offers promise, but evidence on caregiver awareness and acceptance in the non-pilot South-East region to inform equitable rollout is scarce. Methods We conducted a mixed-methods study from June to August 2025 among 618 caregivers of under-fives caregivers engaged with the routine immunization programme in Abia State. Quantitative cross-sectional surveys assessed awareness (knowledge of malaria vaccines) and acceptance (willingness on Likert scales), and inferential analysis was carried out using logistic regression. Qualitative in-depth interviews (n=28) and focus group discussions (n=6, 50 participants) explored perceptions using thematic analysis. Triangulation integrated findings. Results Awareness was low (38.2%; 95% CI: 34.5-42.0) and highest among urban educated caregivers (52.3%). However, acceptance was high (88.7%), driven by child protection (67.4%) and provider trust (59.8%). Barriers included fears of side effects (51.4%) and misinformation (18.7%). Significantly, education (AOR=3.28) and urban residence (AOR=1.78) predicted awareness, and income (AOR=2.05) and awareness status (AOR=6.92) influenced acceptance. Qualitative themes corroborated quantitative findings: “fragmented information” explained rural gaps, and “maternal instinct” amplified willingness to accept. Conclusion Based on our findings, caregivers demonstrated strong acceptance of malaria vaccines despite critically low awareness, a disparity fuelled by information gaps and sociodemographic inequities such as low education and rural residence that threaten vaccine rollout and malaria elimination goals. Based on our findings, this pioneering mixed-methods study recommends that specific channels that leverage PHC providers and community leaders for information dissemination should be utilised, given the high levels of trust, to ensure malaria vaccine uptake and accelerate progress in reducing under-five deaths. KEY MESSAGES What is already known on this topic Malaria vaccines (RTS,S/AS01 and R21/Matrix-M) were introduced in Nigeria in late 2024, with prior studies in northern regions reporting low caregiver awareness and high acceptance rates. However, evidence remains scarce in non-pilot South-East states like Abia, where hyperendemic transmission and urban-rural disparities necessitate localised data to guide equitable rollout and integration into routine immunisation. What this study adds This pioneering mixed-methods study in Abia State of Nigeria reveals critically low malaria vaccine awareness (38.2%) among 618 routine immunisation-engaged caregivers, contrasted by robust acceptance (88.7%), with education, urban residence, income, and awareness status as key predictors, corroborated by qualitative themes of “fragmented information” barriers and “maternal instinct” facilitators. It provides the first post-approval, pre-expansion insights from Abia State, rejecting the null hypothesis of no sociodemographic associations and highlighting resilience in acceptance despite informational gaps. How this study might affect research, practice or policy Policymakers should integrate these findings into Nigeria’s National Malaria Strategic Plan 2024-2028 with South-East-contextualised, Igbo-language awareness campaigns through church networks and media to bridge the 38.2% awareness gap and align with African Union vaccination targets. Programme managers can leverage high provider trust (59.8%) through community health worker-led dialogues and mobile clinics to dispel side-effect myths, targeting low-education rural caregivers and potentially elevating acceptance beyond 88.7% for improved under-five malaria prevention. GRAHICAL ABSTRACT