Table 4.

Caregiver themes across the 5A taxonomy and how they changed over time

5A domains	Key themes from caregivers	Changes over time
Awareness	• Low awareness of the malaria vaccine • Incorrect information about eligibility or delivery point of the vaccine	➔ low awareness led to initial delays to get dose-1 but awareness of the vaccine grew over time ➔ incorrect information about eligibility and the delivery point persisted over time and led to delays that pushed children beyond eligibility
Acceptance	• Hindered by fears related to side effects from previous immunisations - infants get ‘too many’ injections • Hindered by concerns that the malaria vaccine is new and being tested • Facilitated by attitudes that vaccines in general are good and effective • Facilitated by perception that the new malaria vaccine is effective	➔ experiences with previous side effects initially delayed dose-1 uptake but this fear subsided over time due to perceived lived benefits of the vaccine & positive messages from peers about the vaccine ➔ malaria vaccine specific concerns caused initial delay, but fears were overcome due to repeated messages at the health facility ➔ attitude that vaccines are generally good persisted across all interviews ➔the perception that the malaria vaccine is effective and protects children grew over time
Access
Individual level (I)	• Burden of getting to the health facility was an access barrier • Competing life events delayed uptake of the vaccine	➔ inconvenience of getting to the facility (with multiple infants or while pregnant) delayed uptake of dose-1 ➔ work, travel away or illness contributed to initial delays in getting dose-1
Health system (HS)	• Negative provider attitudes discouraged attendance at immunisation services • Immunisation services not available (provider strikes, service schedule) • Barriers related to vaccine stockout at the facility-level	➔ delays persisted for some caregivers because of fears that their providers would scold them for being late, missing doses or not having their MCHa booklet ➔ unavailable services or vaccines persistently frustrated caregiver attempts to take up the vaccine
Affordability	• Transportation costs to get to the facility was an uptake barrier	➔ having to find or not having transportation money increased the burden of getting to the health facility
Activation	• Promoted messages about the new malaria vaccine at health facility • Screening by provider that captures missed immunisations provided new opportunities to initiate dose-1	➔ messages about the malaria vaccine encouraged uptake of dose-1 ➔ some eligible children received dose-1 because of provider screening for missing immunisations during a facility visit for other reasons

^aMCH booklet Mother and child health booklet