A
Acceptability of the RTS, S malaria vaccine and associated factors among caregivers of children under 25 months in Soa Health District, Cameroon: a community-based cross-sectional study
Ludrique
Dang
1✉,2
Emaildangludrique237@gmail.com
Fabien
Fouda
Ombogo
1,2
Brenda
Bime
Burinyuy
3
Gilles
Tounsi
Kamdem
4
Caleb
Caryl
Menougong
Youmbi
5
1
Higher Institute of Medical Technology
Yaoundé
Cameroon
2
Challenges Initiative Solutions
Yaoundé
Cameroon
3
Faculty of Medicine and Biomedical Sciences
University of Yaoundé I
Yaoundé
Cameroon
4
University of Yaoundé 1
Yaoundé
Cameroon
5
School of Health Sciences
Catholic University of Central Africa
Yaoundé
Cameroon
Ludrique Dang1,2*, Fabien Fouda Ombogo1,2, Brenda Bime Burinyuy3, Gilles Tounsi Kamdem4, Caleb Caryl Menougong Youmbi5
1. Higher Institute of Medical Technology, Yaoundé, Cameroon
2. Challenges Initiative Solutions, Yaoundé, Cameroon
3. Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
4. University of Yaoundé 1, Yaoundé, Cameroon
5. School of Health Sciences/Catholic University of Central Africa, Yaoundé, Cameroon
*Corresponding Author: Ludrique Dang, 1. Higher Institute of Medical Technology, Yaoundé, Cameroon
Email: dangludrique237@gmail.com
A
Abstract
Background
Malaria remains a major cause of morbidity and mortality in sub-Saharan Africa. In Cameroon, malaria accounts for 48% of all hospital admissions, 30% of morbidity and 67% of childhood mortality per year, despite ongoing control strategies. However, data on community acceptability of this vaccine remain limited. This study aimed to assess the acceptability of the malaria vaccine and identify factors associated among caregivers of children under 25 months in the Soa Health District, Cameroon.
Methods
A community-based cross-sectional descriptive and analytical study was conducted between March and November 2024. Caregivers of children under 25 months residing in the Soa Health District were recruited using a non-probability convenience sampling method. Data were collected using a structured, pre-tested questionnaire and analysed using R software. Associations between independent variables and vaccine acceptability were assessed using Pearson’s chi-square or Fisher’s exact tests. Multivariable logistic regression model was used to estimate adjusted odd ratio (aOR) at a 95% confidence level. A p-value < 0.05 was considered statistically significant.
Results
A total of 541 caregivers participated in the study. Overall, 73.4% of caregivers expressed willingness to vaccinate their children against malaria. Higher odds of vaccine acceptability were observed among caregivers residing in Ngali II (aOR = 12.20; 95% CI: 3.23-46.02; p < 0.001), Koulou (aOR = 5.66; 95% CI: 1.74–18.35; p = 0.004), Soa (aOR = 4.23; 95% CI: 1.59-11.25; p = 0.004), and Ebang (aOR = 2.66; 95% CI: 1.16–6.14; p = 0.021), Female caregivers (aOR = 1.85; 95% CI: 1.06-3.22; p = 0.031), Catholics (aOR = 3.85; 95% CI: 1.18–12.51; p = 0.025), caregivers who had prior awareness of the malaria vaccine (aOR = 2.06; 95% CI: 1.28 − 3.30; p = 0.003), caregivers who sought treatment in hospitals (aOR = 2.02; 95% CI: 1.15-3.55; p = 0.015) or used street medicine (aOR = 2.46; 95% CI: 1.09-5.55; p=0.03).
Conclusion
Acceptability of the malaria vaccine among caregivers in the Soa Health District was relatively high and was significantly influenced by geographic location, sex, religion, health-seeking behaviour, and awareness of the vaccine. Targeted health education and culturally sensitive community engagement strategies are essential to improve vaccine acceptability and support the successful scale-up of malaria vaccination programmes in Cameroon and other endemic settings.
Keywords
Malaria; RTS, S vaccine; Vaccine acceptability; Caregivers; Cameroon; Immunisation; Child health
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Background
Malaria remains a major cause of morbidity and mortality worldwide, particularly in sub-Saharan Africa, where the disease continues to impose a significant public health and socio-economic burden despite substantial progress in control efforts[1–3]. According to the World Health Organization (WHO), there were an estimated 249 million cases of malaria and 608,000 malaria-related deaths globally in 2022, with approximately 95% of cases and 96% of deaths occurring in the African Region [4]. Children under five years of age remain the most vulnerable group, accounting for about 80% of all malaria deaths in the region [5].
Malaria is a mosquito-borne parasitic disease that is largely preventable and treatable through a combination of interventions, including the use of insecticide-treated nets (ITNs), indoor residual spraying (IRS), seasonal chemoprevention, prompt diagnosis, and effective case management [6]. However, the effectiveness of some of these strategies has been threatened by increasing insecticide resistance among malaria vectors, parasite resistance to antimalarial drugs, and inadequate funding in many endemic countries [7, 8]. These challenges, coupled with weak health systems in low-resource settings, have contributed to persistent malaria transmission and recurrent outbreaks[9].
In Cameroon, malaria remains one of the leading causes of outpatient consultations, hospital admissions, and mortality, especially among children under five years of age[10]. It is estimated that malaria accounts for 48% of all hospital admissions, 30% of morbidity and 67% of childhood mortality per year[11]. Children under five years contribute significantly to malaria-related hospitalisations and deaths, making malaria control a national public health priority [10]. The persistent high burden of malaria has serious consequences on household income, productivity, and national economic growth.
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In response to the high burden of malaria and following successful pilot implementation in Ghana, Kenya, and Malawi, Cameroon adopted the WHO recommendation for the introduction of the RTS, S/AS01 malaria vaccine as a complementary tool for malaria prevention. With technical and financial support from partners, including the Global Alliance for Vaccines and Immunization (GAVI), Cameroon received its first shipment of the RTS, S vaccine in November 2023[12]. The vaccine was introduced into the Expanded Programme on Immunization (EPI) targeting children at 6, 7, 9, and 24 months of age in selected high-burden health districts across the country, including Soa Health District[12].Despite the scientific advances represented by the introduction of the malaria vaccine, experiences with previous vaccination programmes in Cameroon, such as the Human Papillomavirus (HPV) and COVID-19 vaccines, have demonstrated that vaccine hesitancy, low awareness, misinformation, and mistrust may significantly affect uptake[13]. Evidence from other malaria-endemic settings suggests that, although general perceptions of the malaria vaccine may be positive, concerns about safety, side effects, effectiveness, and cultural beliefs can influence its acceptability [14–16]. In addition, health system-related barriers, including limited access to services, inadequate communication from health workers, and inconsistent vaccine availability, may further hinder successful implementation [14, 17].
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The success of malaria vaccination programmes therefore depends not only on vaccine availability and efficacy but also on the acceptability and willingness of caregivers to vaccinate their children[18]. In semi-rural settings such as Soa Health District, where malaria transmission remains high and access to health information may be limited, understanding community perceptions is essential to guide effective implementation strategies. A
Therefore, this study aimed to assess the acceptability of the RTS, S malaria vaccine and its associated factors among caregivers of children under 25 months in Soa Health District, Cameroon. The findings are expected to inform policymakers, programme managers, and public health stakeholders in designing targeted interventions to improve vaccine uptake and strengthen malaria control efforts in Cameroon and similar malaria-endemic settings.Methods
Study design and setting
A community-based, descriptive and analytical cross-sectional study was conducted over a five-month period, from 22 March to 22 November 2024, with data collection carried out between August and September 2024 in the Soa Health District (HD). Soa HD is located approximately 17 km from Yaoundé, the political capital of Cameroon, and is composed of six health area (HA) which are: Ebang, Soa, Ngali II, Ntsouessong, Koulou, and Ting melen; of which are 4 rural areas and 2 urban areas.
Study population and eligibility criteria
The study population consisted of parents or caregivers of children under 25 months of age residing in the Soa HD.
Inclusion and Exclusion criteria
Were included in this study participants who were: Aged 18 years and above, parent or caregiver of at least one child under 25 months, resided in Soa Health District for at least six months prior to the study, provided informed consent, able and willing to respond to the questionnaire.
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Were excluded in this study participants who where: Unable to give informed consent; unable to understand or respond to the questionnaire; temporary visitors or individuals residing in the district for less than six months; absence at the time of the survey and participants who had 50% of the questionnaire unfilled.Sampling technique and sample size
A non-probability convenience sampling technique was used to recruit eligible participants during household visits. This method was chosen due to the absence of an updated sampling frame and the community-based nature of the study. The minimum sample size required for the study was calculated using the Cochran formula for single proportions[19]:
Where: P = 52.6% (estimated acceptability of malaria vaccine from a previous study in the Democratic Republic of Congo) [20]; Z = 1.96, (95% confidence level) and m = 0.05 (margin of error)[19]. This yielded a minimum required sample size of approximately 384 participants.
Recruitment and data collection procedures
Households were approached using a door-to-door strategy, modeled on the Supplementary Immunization Activities (SIAs) of the Expanded Programme on Immunization (EPI). This approach has historically been used for the distribution of oral polio vaccines and vitamin A supplementation. Data were collected through face-to-face interviews using a structured questionnaire adapted from similar studies and administered in either English or French, and where necessary, translated into local languages. Prior to data collection, the questionnaire was pre-tested on a small sample of 20 caregivers in a neighboring community to assess clarity and validity. The questionnaire captured information on: Socio-demographic characteristics (sex, age, marital status, religion, education, occupation, region of origin, health area, household size, number of children under 25 months); Child health history, including reported malaria episodes in the past 12 months; Previous vaccination experiences; Awareness, acceptability and perceptions regarding the malaria vaccine. Data collection was fully digitalized. The questionnaire was designed and uploaded to KoboToolBox, and responses were collected using the KoboCollect mobile application installed on Android devices. Interviewers were Master’s students in public health who received a two-day training on malaria, malaria vaccination, research ethics, and data collection techniques before the start of data collection.
Study variables
Dependent variable
The primary outcome variable was acceptability of the malaria vaccine, operationally defined as the caregiver’s willingness to have their child vaccinated against malaria. This was assessed by asking: “Are you willing to vaccinate your child(ren) against malaria or, if your child has already been vaccinated, would you accept to do it again?”. Responses were coded as:1 = Yes (willingness); 0 = No (unwillingness)
Independent variables
The independent variables included: Socio-demographic factors: sex, age, marital status, religion, region of origin, health area, household size, number of children under 25 months, locality, level of education and occupation; Health-related factors: Prior knowledge of malaria, Perceived mode of malaria transmission, History of malaria in the child within the previous 12 months, Preferred treatment method (traditional medicine, street medicine, hospital care); Vaccine awareness: Prior awareness of the malaria vaccine, Source of information about the malaria vaccine
Data management and statistical analysis
Data were exported from KoboToolBox and cleaned using SPSS version 27 and Stata 17. All statistical analyses were conducted using R software. Descriptive statistics were used to summarize the data: Categorical variables were presented as frequencies and percentages; Continuous variables were summarized using means ± standard deviations or medians (interquartile range), where appropriate. Bivariate associations between independent variables and the dependent variable were assessed using Pearson’s chi-square test or Fisher’s exact test when expected cell counts were less than 5. Variables with a p-value < 0.25 in the bivariate analysis were included in the multivariable logistic regression model to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI). A p-value < 0.05 was considered statistically significant.
Results
Socio-demographic characteristics of caregivers
A total of 541 caregivers, with 597 children, participated in the study. The majority of participants (72.6%) resided in rural areas. Most were female (79.1%), giving a female-to-male ratio of approximately 3.8:1; the highest participation was recorded in Ebang HA (32.9%), while Ntsouessong (6.7%) had the lowest participation; the mean age of caregivers was 30.9 ± 9.2 years, with 42.5% of participants aged between 28 and 37 years; Catholicism was the most frequently reported religion (56.0%). More than two-thirds of participants (67.7%) originated from the North-West, South-West, West and Littoral regions of Cameroon. (Table 1) Regarding occupation, 26.6% of participants were unemployed or retired, 24.6% were retailers, 19.2% worked in the private sector, and 17.6% were farmers; almost two-fifth (40.3%) were in cohabitation; the mean household size was 6.3 ± 3.1 persons, and the average number of children under 25 months per household was 1.1±0.3 (Table 1).
|
Variables and modalities
|
Count(n)
|
Percentage (%)1
|
|---|---|---|
|
Health area
|
||
|
Ebang
|
178
|
32.9
|
|
Koulou
|
78
|
14.4
|
|
Ngali2
|
61
|
11.2
|
|
Ntsouessong
|
36
|
6.7
|
|
Soa
|
129
|
23.9
|
|
Ting melen
|
59
|
10.9
|
|
Locality
|
||
|
Rural
|
393
|
72.6
|
|
Urban
|
148
|
27.4
|
|
Sex
|
||
|
Male
|
113
|
20.9
|
|
Female
|
428
|
79.1
|
|
Age (years)
|
30.88 ± 9.17
|
|
|
Age category
|
||
|
18–25
|
152
|
28.1
|
|
26–35
|
263
|
48.6
|
|
36–45
|
88
|
16.3
|
|
46 and over
|
38
|
7
|
|
Religion
|
||
|
Catholic
|
303
|
56
|
|
Protestant
|
92
|
17.1
|
|
Other christians
|
97
|
17.9
|
|
Muslim
|
31
|
5.7
|
|
Animist and none
|
18
|
3.3
|
|
Region of origine
|
||
|
Far north, North and Adamawa
|
36
|
6.6
|
|
Centre, East and South
|
139
|
25.7
|
|
North-west, South-west, West and Littoral
|
366
|
67.7
|
|
Level of education
|
||
|
No formal
|
36
|
6.6
|
|
Primary
|
95
|
17.6
|
|
Secondary
|
338
|
62.5
|
|
University
|
72
|
13.3
|
|
Occupation
|
||
|
Public sector
|
25
|
4.6
|
|
Private sector
|
104
|
19.2
|
|
Retailer
|
133
|
24.6
|
|
Farmer
|
95
|
17.6
|
|
Unemployed and retired
|
144
|
26.6
|
|
Others (Student and housewives)
|
40
|
7.4
|
|
Marital status
|
||
|
Single
|
141
|
26.1
|
|
Cohabitation
|
218
|
40.3
|
|
Maried
|
170
|
31.4
|
|
Widow
|
12
|
2.2
|
|
Household size (people)
|
6.29 ± 3.07
|
|
|
Category of household size
|
||
|
< 6 |
260
|
48.1
|
|
> 5 |
281
|
51.9
|
|
Number of children under 25 months
|
1.10 ± 0.33
|
|
|
Category of children under 25 months
|
||
|
1
|
490
|
90.6
|
|
2 and plus
|
51
|
9.4
|
|
1Mean ± SD
|
|
Variables and modalities
|
Count(n)
|
Percentage (%)
|
|---|---|---|
|
Heard about malaria
|
||
|
No
|
13
|
2.4
|
|
Yes
|
528
|
97.6
|
|
Child had malaria in the past 12 months
|
||
|
No
|
217
|
40.1
|
|
Yes
|
324
|
59.9
|
|
Knowledge about malaria transmission
|
||
|
Disease transmitted by mosquitoes
|
476
|
88
|
|
Disease caused by an unclean environment
|
51
|
9.4
|
|
I don’t know
|
14
|
2.6
|
|
Malaria treatment method
|
||
|
Traditional medicine
|
88
|
16.3
|
|
Street medicine
|
78
|
14.4
|
|
Medicine prescribed by a health professional
|
375
|
69.3
|
Health- and malaria-related information
Almost all participants (97.6%) reported having heard of malaria. More than half (59.9%) indicated that at least one child in their household had suffered from malaria during the previous 12 months (Table 2). Regarding malaria transmission, 88.0% correctly identified mosquito bites as the main mode of transmission, while 9.4% believed that malaria was caused by a dirty environment (Table 2). With respect to treatment-seeking behaviour, the majority of caregivers (69.3%) reported seeking treatment for malaria at a health facility, while 16.3% used traditional remedies and 14.4% practiced self-medication or used street drugs (Table 2).
Previous experience with childhood vaccination
Previous experience with vaccines from the EPI was generally high. The most familiar vaccine was BCG (95.0%), whereas vaccination against chickenpox had the lowest familiarity (40.5%) among caregivers of under 25 months old children (Table 3).
|
Vaccine experience*
|
Count(n)
|
Percentage (%)
|
|---|---|---|
|
BCG
|
514
|
95
|
|
Polio oral (VPO)
|
486
|
89.8
|
|
Vaccine pentavalent (PENTA)
|
476
|
88
|
|
Vitamin A
|
476
|
88
|
|
Measles
|
410
|
75.8
|
|
Hepatitis B
|
316
|
58.4
|
|
Rotavirus
|
316
|
58.4
|
|
Conjugated pneumococcal Vaccine
|
238
|
44
|
|
Yellow fever
|
225
|
41.6
|
|
Meningitis
|
221
|
40.8
|
|
Chicken pox
|
219
|
40.5
|
| *Multiple response | ||
Awareness of the malaria vaccine
Overall, 68.6% of caregivers reported having heard about the malaria vaccine, while 31.4% had not (Table 4). Among those who had heard about the vaccine, the main sources of information were healthcare workers (85.6%), followed by television and radio (25.1%), family or friends (15.8%) and social media (12.8%) (Table 4). Among participants who were aware of the vaccine, 69.8% did not know the specific eligibility criteria for vaccination (Table 4). Among the 170 caregivers who had not heard about the malaria vaccine, 77.6% expressed interest in receiving more information (Table 4). More than half of participants (52%) considered the malaria vaccine to be very important, while 33.4% considered it important. Only 6.2% stated that the vaccine was not important at all (Figure 1).
|
Variables and modalities
|
Count(n)
|
Percentage (%)
|
|---|---|---|
|
Heard about malaria vaccine
|
||
|
Yes
|
371
|
68.6
|
|
No
|
170
|
31.4
|
|
If yes, know eligibility age
|
||
|
Yes
|
112
|
69.8
|
|
No
|
259
|
30.2
|
|
If no, will to know more
|
||
|
Yes
|
132
|
77.6
|
|
No
|
38
|
22.4
|
|
Means*
|
||
|
Health personnel
|
314
|
84.6
|
|
Media (radio, tv)
|
92
|
24.8
|
|
Relatives
|
58
|
15.6
|
|
Social medias
|
47
|
12.7
|
|
Government agencies
|
5
|
1.3
|
Fig. 1
Perceived importance of malaria vaccine among caregivers aware of the vaccine in Soa District
Willingness to accept the malaria vaccine
Among the 541 participants, 397 (73.4%) expressed willingness to vaccinate their children against malaria (Figure 2). The most commonly cited reasons for acceptance were protection of the child (77.6%), routine acceptance of childhood vaccines (13.6%), general acceptability (5.8%), and trust in vaccines (3%) (Table 5). Among the 144 caregivers (26.6%) who were unwilling to accept the malaria vaccine, the main reasons were fear of side effects (45.9%), lack of interest (24.3%), and insufficient information on the vaccine (11.1%) (Table 5). When asked what might change their decision, 33.3% reported that nothing would change their mind, 24.3% mentioned improved sensitization, 13.2% requested proof of vaccine efficacy, and 11.1% indicated the need for approval from their spouse (Table 5).
|
Variables
|
Count (n)
|
Percentage (%)
|
|---|---|---|
|
If yes, reason
|
||
|
To protect the child
|
308
|
77.6
|
|
Out of habit of vaccinating children
|
54
|
13.6
|
|
General acceptability
|
23
|
5.8
|
|
Trust in vaccines
|
12
|
3
|
|
If no, reason
|
||
|
Fear of side effects
|
66
|
45.9
|
|
Lack of interest
|
35
|
24.3
|
|
Lack of information
|
16
|
11.1
|
|
Partner’s refusal
|
12
|
8.3
|
|
Cultural beliefs
|
12
|
8.3
|
|
Religious beliefs
|
3
|
2.1
|
|
If no, what can change your mind?
|
||
|
Nothing at all
|
48
|
33.3
|
|
More sensitization
|
35
|
24.3
|
|
Evidence supporting vaccine effectiveness
|
19
|
13.2
|
|
Spouse’s approval / Partner’s consent
|
16
|
11.1
|
|
Local vaccine production in Africa
|
11
|
7.6
|
|
I don’t know
|
9
|
6.3
|
|
If the child gets sick
|
6
|
4.2
|
Factors associated with acceptability of the malaria vaccine
Univariate analysis
Univariate analysis demonstrated a significant association between willingness to accept the malaria vaccine and the following variables: HA (p < 0.001), locality (p < 0.001), sex (p = 0.020), age group (p = 0.043), religion (p < 0.001), region of origin (p < 0.001), occupation (p = 0.022), history of malaria (p = 0.035), malaria treatment method (p < 0.001), and awareness of the malaria vaccine (p < 0.001) (Table 6). On the other hand, no statistically significant associations were found with level of education (p = 0.637), household size (p = 0.351), number of children under 25 months (p = 0.848), child’s history of malaria in the past 12 months (p = 0.806), perceived mode of malaria transmission (p = 0.344), or marital status (p = 0.052) (Table 6).
|
Variables and modalities
|
Overall
N = 5411
|
Acceptability
|
OR(95% CI)
|
p-value2
|
|
|---|---|---|---|---|---|
|
No
N = 1441
|
Yes
N = 3971
|
||||
|
Health area
|
< 0.001
|
||||
|
Ebang
|
178 (100)
|
53 (29.8)
|
125 (70.2)
|
2.11(1.01–4.39)
|
|
|
Koulou
|
78 (100)
|
6 (7.7)
|
72 (92.3)
|
3.90(3.90–33.3)
|
|
|
Ngali2
|
61 (100)
|
4 (6.6)
|
57 (93.4)
|
4.14(4.14–48.7)
|
|
|
Ntsouessong
|
36 (100)
|
17 (47.2)
|
19 (52.8)
|
1
|
|
|
Soa
|
129 (100)
|
34 (26.4)
|
95 (73.6)
|
2.5(1.16–5.38)
|
|
|
Ting melen
|
59 (100)
|
30 (50.8)
|
29 (49.2)
|
0.86(0.37–1.98)
|
|
|
Locality
|
< 0.001
|
||||
|
Rural
|
393 (100)
|
87 (22.1)
|
306 (77.9)
|
2.2(1.46–3.31)
|
|
|
Urban
|
148 (100)
|
57 (38.5)
|
91 (61.5)
|
1
|
|
|
Sex
|
0.02
|
||||
|
Male
|
113 (100)
|
40 (35.4)
|
73 (64.6)
|
1
|
|
|
Female
|
428 (100)
|
104 (24.3)
|
324 (75.7)
|
1.71(1.09–2.65)
|
|
|
Age category
|
0.043
|
||||
|
18–25
|
152 (100)
|
31 (20.4)
|
121 (79.6)
|
2.84(1.32, 6.04)
|
|
|
26–35
|
263 (100)
|
70 (26.6)
|
193 (73.4)
|
2.01(0.98–4.02)
|
|
|
36–45
|
88 (100)
|
27 (30.7)
|
61 (69.3)
|
1.64(0.74–3.61)
|
|
|
46 and over
|
38 (100)
|
16 (42.1)
|
22 (57.9)
|
1
|
|
|
Religion
|
< 0.001
|
||||
|
Catholic
|
303 (100)
|
58 (19.1)
|
245 (80.9)
|
3.38(1.24–8.94)
|
|
|
Protestant
|
92 (100)
|
35 (38)
|
57 (62)
|
1.3(0.46–3.62)
|
|
|
Other christians
|
97 (100)
|
28 (28.9)
|
69 (71.1)
|
1.97(0.69–5.52)
|
|
|
Muslim
|
31 (100)
|
15 (48.4)
|
16 (51.6)
|
0.85(0.26–2.74)
|
|
|
Animist et none
|
18 (100)
|
8 (44.4)
|
10 (55.6)
|
1
|
|
|
Region of origin
|
< 0.001
|
||||
|
Far north, North, and Adamawa
|
36 (100)
|
13 (36.1)
|
23 (63.9)
|
1.19(0.56–2.61)
|
|
|
Centre, East, and South
|
139 (100)
|
56 (40.3)
|
83 (59.7)
|
1
|
|
|
North-west, South-west, West, and Littoral
|
366 (100)
|
75 (20.5)
|
291 (79.5)
|
2.62(1.71-4.00)
|
|
|
Level of education
|
0.637
|
||||
|
No formal
|
36 (100)
|
13 (36.1)
|
23 (63.9)
|
1
|
|
|
Primary
|
95 (100)
|
25 (26.3)
|
70 (73.7)
|
1.58(0.69–3.57)
|
|
|
Secondary
|
338 (100)
|
87 (25.7)
|
251 (74.3)
|
1.63(0.77–3.32)
|
|
|
University
|
72 (100)
|
19 (26.4)
|
53 (73.6)
|
1.58(0.66–3.72)
|
|
|
Occupation
|
0.022
|
||||
|
Public sector
|
25 (100)
|
10 (40)
|
15 (60)
|
1
|
|
|
Private sector
|
104 (100)
|
32 (30.8)
|
72 (69.2)
|
1.5(0.59–3.67)
|
|
|
Retailer
|
133 (100)
|
44 (33.1)
|
89 (66.9)
|
1.35(0.55–3.22)
|
|
|
Farmer
|
95 (100)
|
15 (15.8)
|
80 (84.2)
|
3.56(1.33–9.44)
|
|
|
Unemployed and retired
|
144 (100)
|
33 (22.9)
|
111 (77.1)
|
2.24(0.90–5.42)
|
|
|
Others (Student and housewives)
|
40 (100)
|
10 (25)
|
30 (75)
|
2(0.68–5.94)
|
|
|
Marital status
|
0.052
|
||||
|
Single
|
141 (100)
|
35 (24.8)
|
106 (75.2)
|
4.24(1.27–15.1)
|
|
|
Cohabitation
|
218 (100)
|
51 (23.4)
|
167 (76.6)
|
4.58(1.40–16.1)
|
|
|
Maried
|
170 (100)
|
51 (30)
|
119 (70)
|
3.27(1-11.5)
|
|
|
Widow
|
12 (100)
|
7 (58.3)
|
5 (41.7)
|
1
|
|
|
Household size
|
0.351
|
||||
|
< 6 |
260 (100)
|
74 (28.5)
|
186 (71.5)
|
1
|
|
|
> 5 |
281 (100)
|
70 (24.9)
|
211 (75.1)
|
1.2(0.82–1.76)
|
|
|
No of children under 25 months
|
0.848
|
||||
|
1
|
490 (100)
|
131 (26.7)
|
359 (73.3)
|
1
|
|
|
2 and over
|
51 (100)
|
13 (25.5)
|
38 (74.5)
|
1.07(0.56–2.14)
|
|
|
Heard about malaria
|
0.035
|
||||
|
No
|
13 (100)
|
7 (53.8)
|
6 (46.2)
|
1
|
|
|
Yes
|
528 (100)
|
137 (25.9)
|
391 (74.1)
|
3.33(1.09–10.5)
|
|
|
Child had malaria in the past 12 months
|
0.806
|
||||
|
No
|
217 (100)
|
59 (27.2)
|
158 (72.8)
|
1
|
|
|
Yes
|
324 (100)
|
85 (26.2)
|
239 (73.8)
|
1.05(0.71–1.55)
|
|
|
Knowledge about malaria transmission
|
0.344
|
||||
|
Disease transmitted by mosquitoes
|
476 (100)
|
131 (27.5)
|
345 (72.5)
|
1
|
|
|
Disease caused by an unclean environment
|
51 (100)
|
11 (21.6)
|
40 (78.4)
|
1.38(0.71–2.90)
|
|
|
I don’t know
|
14 (100)
|
2 (14.3)
|
12 (85.7)
|
2.28(0.61–14.8)
|
|
|
Malaria treatment method
|
< 0.001
|
||||
|
Traditional medicine
|
88 (100)
|
40 (45.5)
|
48 (54.5)
|
1
|
|
|
Street medicine
|
78 (100)
|
18(23.1)
|
60(76.9)
|
2.78(1.43–5.54)
|
|
|
Medicine prescribed by a health professional
|
375 (100)
|
86(22.9)
|
289(77.1)
|
2.8(1.72–4.54)
|
|
|
Awareness of malaria vaccine
|
< 0.001
|
||||
|
No
|
170 (100)
|
68 (40)
|
102 (60)
|
1
|
|
|
Yes
|
371 (100)
|
76 (20.5)
|
295 (79.5)
|
2.59(1.74–3.85)
|
|
|
1n (%)
2Pearson's Chi-squared test; Fisher's exact test
Abbreviations: CI = Confidence Interval, OR = Odds Ratio
|
|||||
|
Variables and modalities
|
Overall
N = 5411
|
Acceptability
|
aOR (IC 95%)
|
p-value
|
|
|---|---|---|---|---|---|
|
No
N = 1441
|
Yes
N = 3971
|
||||
|
Health area
|
|||||
|
Ebang
|
178 (100)
|
53 (29.8)
|
125 (70.2)
|
2.66(1.15–6.14)
|
0.021
|
|
Koulou
|
78 (100)
|
6 (7.7)
|
72 (92.3)
|
5.66(1.78–19.8)
|
0.004
|
|
Ngali2
|
61 (100)
|
4 (6.6)
|
57 (93.4)
|
12.2(3.48, 51.7)
|
< 0.001
|
|
Ntsouessong
|
36 (100)
|
17 (47.2)
|
19 (52.8)
|
1
|
|
|
Soa
|
129 (100)
|
34 (26.4)
|
95 (73.6)
|
4.23(1.59–11.5)
|
0.004
|
|
Ting melen
|
59 (100)
|
30 (50.8)
|
29 (49.2)
|
1.18(0.37–3.75)
|
0.778
|
|
Locality
|
|||||
|
Rural
|
393 (100)
|
87 (22.1)
|
306 (77.9)
|
1.53(0.74–3.25)
|
0.257
|
|
Urban
|
148 (100)
|
57 (38.5)
|
91 (61.5)
|
1
|
|
|
Sex
|
|||||
|
Male
|
113 (100)
|
40 (35.4)
|
73 (64.6)
|
1
|
|
|
Female
|
428 (100)
|
104 (24.3)
|
324 (75.7)
|
1.85(1.05–3.25)
|
0.031
|
|
Age category
|
|||||
|
18–25
|
152 (100)
|
31 (20.4)
|
121 (79.6)
|
2.06(0.63–6.42)
|
0.218
|
|
26–35
|
263 (100)
|
70 (26.6)
|
193 (73.4)
|
1.6(0.54–4.48)
|
0.384
|
|
36–45
|
88 (100)
|
27 (30.7)
|
61 (69.3)
|
1.51(0.49–4.45)
|
0.464
|
|
46 and over
|
38 (100)
|
16 (42.1)
|
22 (57.9)
|
1
|
|
|
Religion
|
|||||
|
Catholic
|
303 (100)
|
58 (19.1)
|
245 (80.9)
|
3.85(1.16–12.5)
|
0.025
|
|
Protestant
|
92 (100)
|
35 (38)
|
57 (62)
|
2.44(0.69–8.49)
|
0.159
|
|
Other christians
|
97 (100)
|
28 (28.9)
|
69 (71.1)
|
3.07(0.87–10.8)
|
0.078
|
|
Muslim
|
31 (100)
|
15 (48.4)
|
16 (51.6)
|
0.68(0.15–2.95)
|
0.607
|
|
Animist and none
|
18 (100)
|
8 (44.4)
|
10 (55.6)
|
1
|
|
|
Region of origine
|
|||||
|
Far north, North, and Adamawa
|
36 (100)
|
13 (36.1)
|
23 (63.9)
|
2.87(1.09–7.99)
|
0.037
|
|
Centre, East, and South
|
139 (100)
|
56 (40.3)
|
83 (59.7)
|
1
|
|
|
North-west, South-west, West and Littoral
|
366 (100)
|
75 (20.5)
|
291 (79.5)
|
2.29(1.36–3.89)
|
0.002
|
|
Occupation
|
|||||
|
Public sector
|
25 (100)
|
10 (40)
|
15 (60)
|
1
|
|
|
Private sector
|
104 (100)
|
32 (30.8)
|
72 (69.2)
|
1.58(0.56–4.35)
|
0.376
|
|
Retailer
|
133 (100)
|
44 (33.1)
|
89 (66.9)
|
1.46(0.53–3.94)
|
0.459
|
|
Farmer
|
95 (100)
|
15 (15.8)
|
80 (84.2)
|
1.38(0.43–4.40)
|
0.580
|
|
Unemployed and retired
|
144 (100)
|
33 (22.9)
|
111 (77.1)
|
1.79(0.62–5.08)
|
0.272
|
|
Others (Student and housewives)
|
40 (100)
|
10 (25)
|
30 (75)
|
1.32(0.37–4.78)
|
0.671
|
|
Marital status
|
|||||
|
Single
|
141 (100)
|
35 (24.8)
|
106 (75.2)
|
1.96(0.30–13.8)
|
0.490
|
|
Cohabitation
|
218 (100)
|
51 (23.4)
|
167 (76.6)
|
1.96(0.31–13.2)
|
0.480
|
|
Maried
|
170 (100)
|
51 (30)
|
119 (70)
|
2.30(0.38–14.7)
|
0.366
|
|
Widow
|
12 (100)
|
7 (58.3)
|
5 (41.7)
|
1
|
|
|
Heard about malaria
|
|||||
|
No
|
13 (100)
|
7 (53.8)
|
6 (46.2)
|
1
|
|
|
Yes
|
528 (100)
|
137 (25.9)
|
391 (74.1)
|
3.28(0.84–12.6)
|
0.082
|
|
Malaria treatment method
|
|||||
|
Traditional medicine
|
88 (100)
|
40 (45.5)
|
48 (54.5)
|
1
|
|
|
Street medicine
|
78 (100)
|
18(23.1)
|
60(76.9)
|
2.46(1.10–5.64)
|
0.03
|
|
Medicine prescribed by a health professional
|
375 (100)
|
86(22.9)
|
289(77.1)
|
2.02(1.14–3.56)
|
0.015
|
|
Awareness of malaria vaccine
|
|||||
|
No
|
170 (100)
|
68 (40)
|
102 (60)
|
1
|
|
|
Yes
|
371 (100)
|
76 (20.5)
|
295 (79.5)
|
2.06(1.28–3.33)
|
0.003
|
|
1n (%)
Abbreviations: CI = Confidence Interval, aOR = Adjusted Odds Ratio
|
|||||
Multivariate analysis
After adjustment for potential confounders, several factors remained significantly associated with willingness to accept the malaria vaccine (Table 7). Compared with caregivers living in Ntsouessong health area, those living in Ngali II (aOR = 12.20; 95% CI: 3.48-51.70; p < 0.001), Koulou (aOR = 5.66; 95% CI: 1.78–19.80; p = 0.004), Soa (aOR = 4.23; 95% CI: 1.59–11.50; p = 0.004) and Ebang (aOR = 2.66; 95% CI: 1.15-6.14; p = 0.021) had significantly higher odds of vaccine acceptability. Female caregivers were more likely to accept the malaria vaccine compared with males (aOR = 1.85; 95% CI: 1.05-3.25; p = 0.031). Catholics had higher odds of vaccine acceptance compared with animists or those with no religious affiliation (aOR = 3.85; 95% CI: 1.16-12.50; p = 0.025). Participants originating from the North-West, South-West, West and Littoral regions (aOR = 2.29; 95% CI: 1.36-3.89; p = 0.002) and those from the Far North, North and Adamawa regions (aOR = 2.87; 95% CI: 1.09–7.99; p = 0.037) showed significantly higher odds of acceptance compared with those from the Centre, East and South regions. With regard to malaria treatment practices, caregivers who treated malaria using street medicine (aOR = 2.46; 95% CI: 1.10-5.64; p = 0.030) or who sought care in a hospital (aOR = 2.02; 95% CI: 1.14–3.56; p = 0.015) were more likely to accept vaccination compared with those relying on traditional medicine. Finally, prior awareness of the malaria vaccine was significantly associated with acceptability, as caregivers who had previously heard about the vaccine were more likely to accept it for their children (aOR = 2.06; 95% CI: 1.28-3.33; p = 0.003).
Discussion
A
According to the Health Belief Model, individuals’ perceptions of disease severity, susceptibility, and the benefits of preventive actions strongly influence their health-related behaviours, including decisions surrounding vaccination[21]. Community engagement and trust are therefore essential determinants of the success of vaccination programmes[22]. Historically, the failure of several vaccination programmes has been linked to poor community involvement, misinformation, and low perceived risk of disease[23–25]. As a result, recent public health strategies increasingly emphasize the importance of community participation in the implementation of preventive interventions. In this context, this study assessed the acceptability of the RTS,S malaria vaccine and the factors associated with willingness to receive the vaccine among caregivers of under 25 months children in the Soa HD of Cameroon.The present study found that 73.4% of caregivers expressed willingness to vaccinate their children against malaria. Although this level of acceptability is lower than that reported in some studies, it remains relatively high in the context of a newly introduced vaccine. A recent systematic review by Ansar et al. reported an overall malaria vaccine acceptability rate of 87.5%, with wide variability ranging from 32.3% in Ethiopia to 99.3% in Peru[26]. Several country-specific studies have reported findings comparable to ours, including Guinea and Sierra Leone (77.9%)[27], Bangladesh (70.9%)[28], and Ghana (77.5%)[29]. By contrast, higher levels of acceptability have been observed in Ghana (94.6%)[30] and Nigeria (98%)[31]. In Cameroon, during the pre-introduction assessment conducted by the Ministry of Public Health reported an acceptability rate of 99.1%[12].
Variations in acceptability across settings may be explained by differences in socio-demographic characteristics, study design, timing of data collection relative to vaccine introduction, and target population[18]. For example, many previous studies were conducted before vaccine implementation and included caregivers of children under five years, whereas the present study focused on caregivers of children under 25 months and was conducted after the vaccine had already been introduced in selected districts. The relatively high acceptability observed in this study is nevertheless encouraging and suggests a favourable environment for strengthening malaria vaccination efforts as part of an integrated malaria control strategy. Malaria vaccination, when combined with existing interventions such as insecticide-treated nets, indoor residual spraying, intermittent preventive treatment, and prompt case management has the potential to substantially reduce malaria incidence and severity, especially among vulnerable populations such as young children and pregnant women[6, 32]. High levels of acceptability are therefore critical to achieving meaningful public health impact and to advancing national and global malaria elimination goals.
Several factors were found to be significantly associated with acceptability of the malaria vaccine in this study. These included HA of residence, region of origin, female sex, Catholic religion, method of malaria treatment, and prior awareness of the vaccine. Caregivers residing in Ngali II, Koulou, Soa, and Ebang had significantly higher odds of accepting the vaccine compared with those in Ntsouessong. This finding highlights the role of local contextual factors, including access to health services, community mobilisation, and prior exposure to health interventions, in shaping attitudes toward vaccination. Similar geographical differences in malaria vaccine acceptability have been reported in Kenya, Tanzania, Ghana, and Ethiopia, where regional variations were linked to disparities in healthcare access, quality of services, and community engagement[33-35].
Female caregivers were more likely to accept the malaria vaccine than their male counterparts. This finding is consistent with several studies indicating that women generally had higher acceptance of childhood vaccines, likely due to their role as primary caregivers and decision-makers regarding child health[36]. However, contrasting evidence has been reported in certain high-income settings, such as Canada, where women demonstrated greater vaccine hesitancy[37]. These differences underscore the importance of considering sociocultural context when interpreting vaccine-related behaviours.
Religion was also significantly associated with malaria vaccine acceptability, with Catholic caregivers showing higher odds of acceptability compared to those of other or no religious affiliations. Religious beliefs can profoundly shape health behaviours[20], and evidence suggests that Christian communities in some settings demonstrate relatively higher acceptance of vaccines[35, 36]. However, other studies report the opposite trend, reinforcing the complexity of the relationship between religion and vaccine acceptance[38]. These findings highlight the critical importance of engaging religious leaders as partners in health promotion. Approaches such as the 3E model (Engage, Equip, and Empower) can support faith leaders to act as trusted messengers, helping to address misinformation, reduce fears, and promote positive attitudes toward vaccination[39].
Treatment-seeking behaviour was also associated with malaria vaccine acceptability.
A
Caregivers who reported treating malaria through hospital care or self-medication using modern pharmaceuticals were more likely to accept vaccination than those relying on traditional remedies. This may reflect a greater level of trust in biomedical interventions among these individuals. Similarly, prior awareness of the malaria vaccine was significantly associated with higher acceptability, reinforcing the importance of targeted information, education, and communication strategies. Evidence from other settings confirms that increased knowledge and exposure to accurate information about vaccines improves acceptance and uptake[40].Overall, the findings of this study emphasize the critical role of sociocultural, geographical, behavioural, and informational factors in determining malaria vaccine acceptability. Tailored community sensitization activities, strengthened health communication, and involvement of trusted community actors’ including healthcare workers and religious leaders may substantially enhance vaccine confidence and acceptability in Soa HD and similar settings.
Strengths and limitations of the study
This study presents several important strengths. First, the relatively large sample size enhances the statistical power of the study and increases the generalisability of the findings to caregivers of children under 25 months in the Soa HD. Second, this study provides valuable baseline data that can inform and strengthen the implementation and scale-up of the malaria vaccine programme in Soa HD and potentially in other similar settings across Cameroon. Third, data completeness was high, with minimal missing information, which strengthens the reliability of the results. Last, this study was conducted in a predominantly rural and hard-to-reach district, making the findings particularly relevant for settings where access to healthcare services and vaccination programmes may be limited.
Despite these strengths, several limitations should be considered when interpreting the findings. Firstly, the study relied on self-reported willingness to accept the malaria vaccine, which may be subject to social desirability bias’s and may not necessarily reflect actual vaccination behaviour. Secondly, attitudes towards vaccination were measured using a structured quantitative approach, which may have oversimplified complex perceptions, beliefs, and motivations related to vaccine acceptance. Thirdly, the possibility of selection bias cannot be entirely ruled out, particularly among caregivers who were unavailable or declined participation. Fourthly, this study did not explore certain potentially relevant factors such as household income, educational influence of partners, parity, or exposure to misinformation regarding vaccines. Finally, as this study was purely quantitative, it did not capture the in-depth personal experiences, cultural beliefs, and contextual influences that may shape vaccine acceptability. Future qualitative or mixed-methods studies are therefore recommended to explore these aspects in greater detail.
Conclusion
This study assessed the acceptability of the malaria vaccine and its associated factors among caregivers of children under 25 months in the Soa HD. The findings demonstrate a generally high level of willingness to vaccinate, which is encouraging for ongoing and future malaria control efforts. Malaria vaccine acceptability was influenced by a combination of geographic (HA and region of origin), sociocultural (female gender and Catholic religion), behavioural (choice of malaria treatment), and informational (prior awareness of the malaria vaccine) factors. Although willingness to vaccinate was relatively high, important concerns remain, particularly regarding fear of side effects and insufficient information about the vaccine. These concerns represent key barriers that must be addressed through targeted, culturally sensitive communication strategies. Strengthening health education campaigns, improving community engagement, and reinforcing the role of healthcare providers and local leaders in disseminating accurate information about the vaccines safety and effectiveness are essential. To maximize the impact of malariaa vaccination programmes, public health authorities should prioritize community-based sensitization activities, integrate malaria vaccine education into routine child health services, and tailor interventions to local sociocultural contexts. Addressing misinformation and building trust in the health system will be critical for achieving optimal vaccine acceptability. Ultimately, improving the acceptability and uptake of the malaria vaccine has the potential to significantly reduce malaria-related morbidity and mortality among vulnerable populations, contributing to national and global malaria elimination goals.
List of abbreviations
aOR: Adjusted Odd Ratio
CI: Confidence Interval
EPI: Expanded Program on Immunization
GAVI: Global Alliance Vaccine
HA: Health Area
HD: Health District
IRS: Indoor Residual Spray
ITNs: Insecticide Treated Nets
OR: Odd Ratio
SIAs: Supplementary Immunization Activities
SPSS v27: Statistical Package for Social Science version 27
WHO: World Health Organization
Declarations
Ethics approval
The study obtained an ethical approval number 4711/IEC-UD/11/2024/M from the ethical committee of the University of Douala/Higher Institute of Medical Technology. Before data collection, participants were thoroughly informed about the purpose, the procedure of the study, and the role they were expected to play. Assurance was equally provided concerning the anonymous nature and confidentiality of their responses. This was done using an information notice. Verbal or written consent was obtained before administering the questionnaires.
Availability of data and materials
The data generated from this study are available on reasonable request
Competing interest
The authors declare no conflict of interest in this study.
A
Funding
The study did not rreceive any funding of any kind from external sources.
A
A
Author Contribution
Study conception: LD, FFO, BBB. Data collection: LD, FFO, BBB. Data analysis and interpretation: All authors. Manuscript writing: All authors. Revision of the manuscript: All authors. Approval for submission: All authors.
A
Data Availability
The data generated from this study are available on reasonable request
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TABLES
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Fig. 2
Willingness of caregivers to accept malaria vaccine for children under 25 months in Soa District
