{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,19]],"date-time":"2026-10-19T16:31:27Z","timestamp":1792427487495,"version":"4.5.0"},"reference-count":36,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T00:00:00Z","timestamp":1783382400000},"content-version":"unspecified","delay-in-days":6,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["bmjph"],"accepted":{"date-parts":[[2026,6,24]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Malaria remains a leading cause of under-5 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a mixed-methods study from June to August 2025 among 618 caregivers of under-5 children engaged with the routine immunisation 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 was applied to integrate the findings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Awareness overall was low (38.2%; 95%\u2009CI 34.5% to 42.0%)\u2009but 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 (adjusted OR (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: \u2018fragmented information\u2019 explained rural gaps and \u2018maternal instinct\u2019 amplified willingness to accept.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Based on our findings, caregivers demonstrated strong acceptance of malaria vaccines despite critically low awareness, a disparity fuelled by information gaps and socio-demographic inequities such as low education and rural residence that threaten vaccine rollout and malaria elimination goals. Consequently, this pioneering mixed-methods study recommends that specific channels that leverage primary healthcare centre providers and community leaders for information dissemination should be used, given the high levels of trust, to ensure malaria vaccine uptake and accelerate progress in reducing under-5 deaths.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjph-2025-004538","type":"journal-article","created":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T16:10:22Z","timestamp":1783440622000},"page":"e004538","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Awareness and acceptance of malaria vaccines by caregivers of under-5 children in Abia State, Nigeria: a mixed methods study"],"prefix":"10.1136","volume":"4","author":[{"given":"Eziyi Iche","family":"Kalu","sequence":"first","affiliation":[{"name":"Department of Medical Microbiology, Gregory University, Uturu, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5950-3719","authenticated-orcid":false,"given":"Ugo Uwadiako","family":"Enebeli","sequence":"additional","affiliation":[{"name":"Department of Community Medicine, Federal University of Technology Owerri, Owerri, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benjamin S Chudi","family":"Uzochukwu","sequence":"additional","affiliation":[{"name":"Department of Community Medicine, University of Nigeria - Enugu Campus, Enugu, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ebelechukwu Lawence","family":"Enebeli","sequence":"additional","affiliation":[{"name":"Department of Science and Technology, Lancaster University - Ghana Campus, Accra, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Faith Adamma","family":"Kalu","sequence":"additional","affiliation":[{"name":"Department of Biochemistry, Michael Okpara University of Agriculture, Umudike, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Perfection Chinyere","family":"Igwe","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Federal Medical Centre Umuahia, Umuahia, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justin Junior","family":"Kalu","sequence":"additional","affiliation":[{"name":"Department of Community Medicine, University of Calabar, Calabar, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beauty Olamma","family":"Kalu","sequence":"additional","affiliation":[{"name":"Department of Pharmacy, Igbinedion University Okada, Benin City, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Agwu Nkwa","family":"Amadi","sequence":"additional","affiliation":[{"name":"Department of Public Health, Federal University of Technology Owerri, Owerri, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-3724-9886","authenticated-orcid":false,"given":"Yakubu Joel","family":"Cherima","sequence":"additional","affiliation":[{"name":"Center for Artificial Intelligence Accountability in Health, Abuja, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Uchenna Stephen","family":"Nwokenna","sequence":"additional","affiliation":[{"name":"Center for Artificial Intelligence Accountability in Health, Abuja, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rejoice Kaka","family":"Hassan","sequence":"additional","affiliation":[{"name":"Center for Artificial Intelligence Accountability in Health, Abuja, Nigeria"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,7,7]]},"reference":[{"key":"2026070709101251000_4.3.e004538.1","unstructured":"WHO . World malaria report 2024: addressing inequity in the global malaria response. WHO Licence: CC BY-NC-SA 3.0 IGO. 2024."},{"key":"2026070709101251000_4.3.e004538.2","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1186\/s12982-025-00668-6","article-title":"Critical analysis of infectious disease surveillance and response system in Nigeria","volume":"22","author":"Adewumi","year":"2025","journal-title":"Discov Public Health"},{"key":"2026070709101251000_4.3.e004538.3","first-page":"1","article-title":"Assessment of water, sanitation and hygiene practices and the occurrence of childhood malaria in Abia State, Nigeria","volume":"5","author":"Enebeli","year":"2019","journal-title":"Res J Public Health"},{"key":"2026070709101251000_4.3.e004538.4","doi-asserted-by":"crossref","DOI":"10.1186\/s12936-024-04939-6","article-title":"Factors associated with the risk of malaria among children: analysis of 2021 Nigeria Malaria Indicator Survey","volume":"23","author":"Isiko","year":"2024","journal-title":"Malar J"},{"key":"2026070709101251000_4.3.e004538.5","unstructured":"WHO . Full evidence report on the RTS,S\/AS01 malaria vaccine. 2021. Available: https:\/\/cdn.who.int\/media\/docs\/default-source\/immunization\/mvip\/full-evidence-report-on-the-rtss-as01-malaria-vaccine-for-sage-mpag-(sept2021).pdf [Accessed 05 Nov 2025]."},{"key":"2026070709101251000_4.3.e004538.6","unstructured":"WHO . WHO recommends R21\/matrix-M vaccine for malaria prevention in updated advice on immunization. WHO News Release; 2023. Available: https:\/\/www.who.int\/news\/item\/02-10-2023-who-recommends-r21-matrix-m-vaccine-for-malaria-prevention-in-updated-advice-on-immunization [Accessed 02 Oct 2023]."},{"key":"2026070709101251000_4.3.e004538.7","unstructured":"WHO Nigeria . Nigeria introduces the R21 vaccine in a pivotal move for malaria control. WHO Africa; 2024. 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Strategies for addressing vaccine hesitancy - a systematic review. WHO SAGE working group dealing with vaccine hesitancy. 2014. Available: https:\/\/cdn.who.int\/media\/docs\/default-source\/immunization\/sage\/2014\/october\/3-sage-wg-strategies-addressing-vaccine-hesitancy-2014.pdf?sfvrsn=b632b81e_4 [Accessed 05 Nov 2025]."},{"key":"2026070709101251000_4.3.e004538.18","doi-asserted-by":"publisher","DOI":"10.1186\/s13012-017-0605-9"},{"key":"2026070709101251000_4.3.e004538.19","unstructured":"Nigeria Data Protection Commission (NDPC) . Nigeria data protection act 2023. 2023."},{"key":"2026070709101251000_4.3.e004538.20","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1080\/14780887.2020.1769238","article-title":"One size fits all? 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