Acceptance of a malaria vaccine among caregivers of sick children under 5 years of age in Burundi

Abstract

Background

Malaria poses a significant public health burden globally, particularly in Burundi, where it is the leading cause of mortality and morbidity. To eliminate malaria, the malaria vaccine will be introduced in childhood vaccination. However, the information on malaria vaccine acceptance is limited. Therefore, this study investigates malaria vaccine acceptance and associated factors in Burundi.

Methods

This was a descriptive cross-sectional study that involved caregivers of sick children under 5 years old to assess the acceptability of the malaria vaccine. A questionnaire was used to collect data, and SPSS was used to analyse data and identify factors significantly associated with malaria vaccine acceptance.

Results

Overall, 405 (90.6%) participants indicated they would accept a malaria vaccine for their children under 5 years. The predictive factors that are significantly associated with the acceptance of the malaria vaccine include the caregivers’ knowledge regarding the malaria vaccine (OR = 10.326, P-value = 0.035), the caregivers’ employment (OR = 6.088, P-value = 0.02), and previous experience with childhood vaccination (OR = 3.145, P-value = 0.004).

Conclusion

This study shows a high proportion of caregivers’ willingness to accept the malaria vaccine. Factors including caregivers’ employment, prior childhood vaccination experience, and awareness of the malaria vaccine significantly influence acceptance. These findings highlight the need for targeted awareness campaigns to increase awareness, thus, the potential for widespread vaccine adoption. Consequently, building on existing trust in childhood vaccinations, policymakers should prioritize targeted public health interventions that address knowledge gaps and concerns, ultimately contributing to malaria prevention and control efforts.

Background

Malaria is a major public health burden globally, particularly in sub-Saharan Africa. In 2022, the World Health Organization (WHO) recorded 249 million malaria cases, marking an increase of five million over 2021 and 608,000 malaria-related, distributed across 85 countries and territories affected by the disease [1]. The majority of malaria cases (95%) and deaths (96%) occurred in Africa, where 80% of malaria-related deaths also occur in kids under five years [1]. In Burundi, the epidemiological data indicate an increase in cases starting from 2020, with a rise of 54% until 2022. The cases went from 4.5 million in 2020 to 7.2 million in 2022 [2].

Globally, children under five are the most affected by the disease [3], which is not different from Burundi. The incidence rates of malaria were very high, with 470.3 per 1000 inhabitants in 2020, 537.6 per 1000 inhabitants in 2021, and 539.7 per 1000 inhabitants in 2022 [4]. The case fatality rate due to malaria in health centres is 0.001, while the hospital fatality rate is 0.74%, which decreased compared to the rate in 2021 (0.79%) [4].

The Ministry of Public Health has implemented several preventive and curative measures through the Malaria Programme (NMCP) to prevent and control malaria. These interventions include the use of long-lasting insecticidal mosquito nets (LLINs) every three years, the use of indoor residual spraying within households in health districts of Buye, Kiremba, Gashoho and Muyinga, chemoprevention (IPTp) of malaria during pregnancy, ensuring proper management of malaria cases according to WHO guidelines, and community case management of malaria through iCCM and PECADOM strategies [2, 3]. Despite several interventions in place, the disease remains a major health issue and continues to cause high morbidity and mortality rates in Burundi. In response to the limitations of current malaria prevention and control interventions, experts have explored novel approaches to eliminate the disease, including using a malaria vaccine. Twenty-eight countries in the WHO African Region have shown interest in introducing the malaria vaccine following the WHO’s recommendation to use the malaria vaccine in 2021. Several countries have applied to Gavi, and 18 received approval for support in rolling out the malaria vaccine, including Burundi. The malaria vaccine is the tool that will contribute to reducing malaria infection in areas with higher malaria transmission [5, 6].

However, a successful introduction and implementation of new interventions, especially new vaccines, necessitates a critical and thorough understanding of the local socio-cultural context. In Kenya, the study conducted by Hoyt et al. mentioned that lack of awareness, and previous negative experience with childhood vaccination, contributed in caregivers initially delaying uptake of the malaria vaccine [7]. A systematic review revealed an overall malaria vaccine acceptance rate to be generally high, ranging from 84.2 to 99.3% [8]. Studies conducted in Nigeria reported the highest acceptance rate above 97.6% [8, 9], and Ghana around 94.6% [8], but malaria vaccine acceptance (76%) was very low in Guinea [10].

Different factors are reported in the literature to positively or negatively affect the acceptance of the malaria vaccine [11, 12]. According to the study conducted in the Democratic Republic of Congo, among sociodemographic characteristics, religion seems as a positive influencer of malaria vaccine acceptance. Demographic factors play a significant role with older, medium education level, residence in semi-rural areas showing higher vaccine acceptance and receptiveness [13]. The research conducted in Nigeria concluded that fear of adverse reactions of vaccine was the major refusal factor to accept the malaria vaccine: caregivers would agree that their children could receive the vaccine if it was proven to be safe and without side effects and efficacious [14]. Otherwise, factors such as age group, residence, education level, occupation, and income class influence the awareness and acceptability of the malaria vaccine. Also, factors like insecticide use for malaria prevention, house structures, and history of malaria testing influence vaccine decisions in Bangladesh [15].

This study has provided valuable information regarding acceptance and associated factors required to guide decision-makers, policy-makers, and malaria vaccine supply chain management required to introduce and implement the malaria vaccine. The aim of this study is to assess the willingness of caregivers to accept the malaria vaccine for their children and the factors that influence malaria vaccine acceptance.

Methods

Study area

This study was conducted in Burundi, a landlocked nation in central-eastern sub-Saharan Africa. Over 90% of the population lives in rural areas and is relatively young, with 65% under 25 [16]. This research was undertaken in health facilities of health districts classified into four zones based on the malaria incidence rate zone, which are very high-risk zones characterized by an annual parasite incidence of 450 or more cases of malaria per 1000 inhabitants, the high-risk zone characterized by an annual parasite incidence of 350–450 cases of malaria per 1000 inhabitants, a moderate-risk zone characterized by an annual parasite incidence of between 250 and 350 cases of malaria per 1000 inhabitants, and low-risk zone characterized by an annual parasite incidence of less than 250 cases of malaria per 1000 inhabitants.

Study design and population

A descriptive cross-sectional study design was used, and a quantitative approach was employed to determine the malaria vaccine acceptance rate among caregivers of sick children under five years. The total number of sick children under five years who visited healthcare facilities in the health districts is 735,764 [4]. The health districts that were targeted and the children under five years treated are the health districts of Muyinga (291,014), Gitega (111,510), Kiganda (138,274), Rwibaga (48,375), and Buja Nord (146,591). The study involved parents with children under five years old.

Sample size

The sample size of the study is estimated using Cochran’s formula.

n = Sample size, e = 0.05% is the margin of error, Z = 735,764 here is the total number of children under five years who visited the health facilities for care in 2022, p is the prevalence of willingness to accept malaria vaccine, and it was estimated that p = 50% because no previous study has been conducted on malaria vaccine acceptance in Burundi, and q = (1–P).

Sampling technique

A random sampling technique was employed to select five health districts across risk zones. Two health districts were chosen to account for the higher prevalence of malaria in the very high-risk zone. A minimum sample size of 422 participants was established. Table 1 provides the details.

Table 1.

Sample size determination

Risk-zone	Health District	Targeted population	Sample size	Number of HF	HF per HD visited
Very higher risk-zone	Muyinga	291,014	167	21	8
	Gitega	111,510	64	12	2
Higher risk-zone	Kiganda	138,274	79	9	2
Moderate-risk zone	Rwibaga	48,375	28	12	1
Low risk-zone	Buja Nord	146,591	84	9	2
Total		735,764	422	63	14

In addition, an adjustment of 6% was included to account for non-response, resulting in a total sample size of 447 participants. A modest percentage was taken into consideration due to perceived high response rate.

To determine the sample in each health district, the following formula was used: $n_d=\frac{N_d}{N}\times n$ with N_d: The total number of sick children in the health district and N, the total number of caregivers of sick children in the health districts selected.

In each health district, the number of health centres to be selected was calculated according to the proportion of the sample it represents ( $n_{\mathit{HC}}=\frac{n_d}{n}{N}_{\mathit{HC}}$) with$N_{\mathit{HC}}$: the total number of health centres in the health district. The total number of children whose caregivers would be surveyed in the study was found by dividing the n_d/n_HC.

Data collection tool and measurements

A structured questionnaire was designed for this study, drawing from existing relevant literature on malaria vaccine acceptance [15, 17, 18]. Before data collection, the questionnaire underwent a pilot test to assess its reliability and validity. Based on the pilot test findings, necessary adjustments were made to improve the questionnaire's clarity and comprehensiveness. The questionnaire was then translated into Kirundi, the local language, and then electronically programmed using KoBoToolbox.

Dependent variable: Caregivers’ willingness to accept the malaria vaccine for their child was the outcome of this study. This was assessed by asking the following question: “Are you willing to accept vaccinating your child with the malaria vaccine?”.

Independent variables: These included the sociodemographic characteristics of caregivers (age, gender, marital status, religion, education status, employment, and relationship to the child), sociodemographic characteristics of children (gender and education status), previous vaccination experience, as well as knowledge about malaria vaccine.

Data collection procedures

Prior to initiating data collection, permission to engage research participants was obtained from the Ministry of Health. Research assistants were then recruited and thoroughly trained on data collection methodologies, ethical considerations, and confidentiality protocols to ensure that data was collected responsibly and ethically.

After training, preliminary steps involved meetings between research assistants and health facility managers to provide information about the study's objectives and data collection procedures. Data collection was conducted at health facilities, targeting caregivers of sick children under five years who had received treatment and care. The questionnaire was presented to those who consented to participate. Research assistants ensured that participants clearly understood the study's objectives and their rights as participants. Informed consent was a crucial step in the data collection process. Apart from collecting data, research assistants were also responsible for obtaining informed consent from participants before collecting any data.

The data collection process lasted a month, from March to April 2024. Throughout the period, research assistants received regular check-ins and support to address any issues or concerns that may have arisen.

Data analysis

After cleaning and organizing the collected data, it was transferred into SPSS for analysis. Descriptive analysis was used to present the demographic characteristics of caregivers of sick children under five and the characteristics of sick children.

Logistic regression analysis was used to assess the relationship between the independent variables with other outcome variables. The significant variables are considered for multivariate analysis using multiple logistic regression to assess the most significant factors associated with the acceptance of the malaria vaccine among caregivers of sick children under five years. The association is considered statistically significant if the P-value < 0.05.

Results

Socio-demographic results characteristics of caregivers

Table 2 indicates that 399(89.3%) of the respondents were female, and more than half 228(51%) were in the age range of 18 to 29 years. Almost half, 223 (49.9%) of the participants had no education, and the majority were farmers 349 (77.9%). Table two provides more details.

Table 2.

Socio-demographic characteristics of caregivers

Variables	Frequency	Percent
Sex (n = 447)
Female	399	89.3
Male	48	10.7
Age in years (n = 447)
18 to 29	228	51
30 to 39	180	40.3
40 and above	39	8.7
Relationship to child (n = 447)
No relationship	2	0.4
Parent	433	96.9
Brother/sister	8	1.8
Housewife	4	0.9
Marital status (n = 447)
Single	29	6.5
Married	410	91.7
Separated and Widowed	8	1.8
Religion (n = 447)
No Catholic	134	30
Catholic	313	70
Education status (n = 447)
No formal education	223	49.9
Primary completed	143	32
Secondary and above	81	18.1
Occupation (n = 447)
Unemployed	42	9.4
Employed	57	12.8
Farmer	348	77.8
Family size (n = 447)
< 5	250	55.9
5 to 10	193	43.2
> 10	4	0.9
The caregiver ever had malaria in the past year (n = 447)
No	245	54.8
Yes	202	45.2

Characteristics of sick children

Table 3 reveals that malaria test was done on 298(66.7%) of the children, and among these, 129 (43.3%) were positive. Table three provides more details.

Table 3.

Demographic characteristics of sick children

Variables	Frequency	Percentage
Sex (n = 447)
Female	191	42.7
Male	256	57.3
Malaria test (n = 447)
No	149	33.3
Yes	298	66.7
Malaria test (blood smear or rapid test) (n = 298)
Positive	129	43.3
Negative	169	56.7
The child ever had malaria in the past year (n = 447)
No	246	55
Yes	201	45

Awareness and willingness to accept malaria vaccine

Table 4 shows that only half 234 (52.3%) of the study participants had previous experience with childhood vaccination (meaning that the child has had all recommended vaccines), and only a few 55 (12.3%) had ever heard about the malaria vaccine. However, 405 (90.6%) respondents were willing to accept a malaria vaccine for their child. Besides, a high number of 398 (89.3%) could use a malaria vaccine to protect their children. More details are found in Table 4.

Table 4.

Awareness and acceptance of malaria vaccine

Variables	Frequency	Percentage
Caregivers ever heard about malaria vaccine (n = 447)
No	392	87.7
Yes	55	12.3
Previous experience with childhood vaccination
No	213	47.7
Yes	234	52.3
Caregiver could use malaria vaccine to prevent against malaria (n = 447)
No	47	10.7
Yes	398	89.3
Caregiver could buy malaria vaccine if available in the country
No	93	21
Yes	352	79
Caregiver willing to accept to vaccinate their child with malaria vaccine (n = 447)
No	42	9.4
Yes	405	90.6
Caregiver accepts to mobilize malaria vaccine to other people
No	18	5
Yes	420	95

Reasons for not willing to accept the malaria vaccine among caregivers of sick children

Table 5 indicates the reasons for not being willing to accept the malaria vaccine. Fear of adverse reactions to the malaria vaccine 23 (54.76%) and lack of awareness about the malaria vaccine 16 (38.10%) were the main reasons for this refusal.

Table 5.

Caregivers’ reason for unwilling to accept the malaria vaccine

Variables	Frequency	Per cent
Fear of adverse reaction to vaccine	23	54.76
Not aware the vaccine	16	38.10
Spousal refusal	2	4.76
Misconception	1	2.38
Total	42	100.00

Factors influencing willingness to accept the malaria vaccine

Multivariate logistic regression shows that caregivers’ employment, previous experience with childhood vaccination, and the awareness of malaria vaccine are significantly associated with the acceptance of malaria vaccine. More details are in Table 6.

Table 6.

Multivariate logistic regression of factors influencing willingness to accept the malaria vaccine

Variables	Modality	Frequency	OR	C.I. 95%	P-value
Age grouped	18 to 29 years	228	Reference
	30 to 39 years	180	0.62	[0.299–1.2872]	0.2
	40 above	39	78,141,857.08	–	0.998
Gender of caregiver	Female	399	Reference
	Male	48	1.57	[0.416–5.919]	0.505
Marital Status of caregiver	Single	29	Reference
	Married	410	2.432	[0.729–8.111]	0.148
	Separated and Widowed	8	2.264	[0.177–28.887]	0.529
Religion of Caregiver	Not Catholic	134	Reference
	Catholic	313	0.836	[0.369–1.89]	0.666
Education Status of caregiver	No formal education	223	Reference
	Primary education	143	0.728	[0.178–2.973]	0.659
	Secondary education and above	81	1.682	[0.420–6.743]	0.463
Caregiver employment	Unemployed	42	Reference
	Employed	57	2.121	[0.5387–8.357]	0.282
	Fermer	348	6.088	[1.334–27.78]	0.02*
Previous experience with childhood vaccination	No	213	Reference
	Yes	234	3.145	[1.444–6.851]	0.004*
The child had malaria in the past year	No	246	Reference
	Yes	201	1.203	[0.522–2.776]	0.664
The caregiver had malaria in the past year	No	245	Reference
	Yes	202	1.203	[0.522–2.776]	0.664
The caregiver knowledge regarding malaria vaccine	No	392	Reference
	Yes	55	10.326	[1.177–90.61]	0.035*

^*p < .05; OR= Odds Ratio; CI= Confidence Interval

Discussion

This study assessed the caregivers' willingness to accept the malaria vaccine for their children and identified factors associated with vaccine acceptance.

Awareness and acceptance of the malaria vaccine

The findings of this study indicate a high rate of caregiver willingness to accept the malaria vaccine for their children, with over 90% expressing positive intentions. This is consistent with the findings of other studies carried out regarding malaria vaccine awareness by other researchers in Ghana (95.8%) [19], Nigeria (91.9%) [14], and Tanzania (84.2%) [20]. The reported findings are slightly higher than those reported in Bangladesh (70.86%) [15], Guinea (76%) [10], and Sierra Leone (81%) [10]. The current results are higher than those conducted in the Democratic Republic of Congo (46.53%) [13], Ethiopia (32.3%) [18], and Uganda (91.4%) [21].

The high rate of caregiver willingness to accept the malaria vaccine in the current study may be attributed to several factors, including witnessing firsthand the severe consequences of malaria in their children, leading to a strong desire to prevent future infections and the experience of seeking treatment for malaria which might have heightened caregivers' awareness of the disease's burden and the importance of preventive measures. This high acceptance rate can lead to increased vaccine coverage, decreased malaria burden, and, ultimately, progress towards malaria elimination.

Due to widespread unawareness of the malaria vaccine being the leading reason behind the reluctance to accept this vaccine, targeted awareness campaigns are essential to improve knowledge and alleviate caregivers' concerns about the vaccine. These campaigns must be integrated into existing healthcare programmes, particularly routine childhood immunization schedules, as the country plans to introduce the malaria vaccine. Implementing this strategy early is vital to leverage the trust caregivers already have in vaccination services.

Healthcare professionals ought to receive training aimed at delivering consistent and clear communications regarding the safety, efficacy, and advantages of the malaria vaccine. This approach should focus on countering misinformation and fostering confidence in its acceptance.

Policymakers ought to integrate malaria vaccination with current control programmes, such as distributing insecticide-treated bed nets and carrying out indoor spraying, to form a cohesive prevention strategy. By encouraging collaboration among health, education, and community stakeholders, these initiatives can establish a solid groundwork for vaccine acceptance, thereby improving malaria prevention and control initiatives.

Factors influencing willingness to accept the malaria vaccine

The study identified several factors associated with caregiver willingness to accept the malaria vaccine: childhood vaccination experience, employment status, and knowledge of the malaria vaccine. These findings align with previous research conducted in Nigeria [14], which demonstrated that individuals with prior childhood vaccination experience were six times more likely to accept the malaria vaccine.

However, the results contrast with a study conducted in Bangladesh [15]. While the Bangladeshi study did not find a significant association between childhood vaccination experience and malaria vaccine acceptance, it identified other influential factors such as socio-demographic characteristics, education, occupation, and income.

The observed association between childhood vaccination experience and malaria vaccine acceptance may be due to the fact that positive experiences with childhood vaccination may foster trust in healthcare providers and public health initiatives, leading to greater confidence in the malaria vaccine. Additionally, childhood vaccination may highlight the importance of preventive measures, making caregivers more receptive to the malaria vaccine. By targeting populations with positive childhood vaccination experiences, public health interventions can more effectively promote malaria vaccine uptake. This could lead to increased vaccine coverage, decreased malaria burden, and improved child health outcomes.

Strengths, limitations, and future research

While this study provides very useful information on the emerging subject of malaria vaccine and multiple factors associated with malaria vaccine acceptance, it also presents some limitations. The study focused on caregivers of sick children, who are likely to be more concerned about malaria prevention and control due to their firsthand experience with the disease, potentially limiting its generalizability to the entire population of caregivers. Conducting studies with caregivers of healthy children in community settings can provide a broader perspective on malaria vaccine acceptance. Besides, additional qualitative research that help to understand the underlying reasons for caregiver decisions regarding malaria vaccination and also explore other factors including socio-cultural and political that are associated with vaccine uptake are equally important.

Conclusion

This study shows a high rate of caregivers’ willingness to accept the malaria vaccine. Factors such as caregiver employment, prior childhood vaccination experience, and awareness of the malaria vaccine significantly influence acceptance. To maximize the impact of the malaria vaccine, the National Malaria Control Programme and the Expanded Programme on Immunization must collaborate to implement effective awareness campaigns. These campaigns should prioritize individuals who have previously declined vaccination, addressing their concerns and misconceptions. By building on trust in childhood vaccinations and targeting specific populations, policymakers can foster a supportive environment for vaccine uptake, ultimately contributing to malaria prevention and control efforts.

Abbreviations

NMCP

National Malaria Control Programme

WHO

World Health Organization

LLINs

Long-Lasting Insecticidal Nets

EPI

Expanded Programme on Immunization

MOH

Ministry of Health

IPTp

Intermittent Preventive Treatment of malaria in pregnancy

iCCM

Integrated Community Case Management

PECADOM

Community Case Management of Malaria for all age

Author contributions

EN conceived the study, coordinated study implementation, analyzed the data, and drafted the manuscript. DA and MN participated significantly in the data analysis and manuscript writing. TB, SB, DK, and PS contributed substantially to the revision of the paper. All authors have read and approved the final manuscript.

Funding

This research did not receive funding either for data collection or manuscript publication. However, it is prepared from a master’s dissertation that was conducted to fulfill the requirement of a master’s degree in Health Supply Chain Management in EAC RCE – VIHSCM, for the first Author. This master’s degree was funded by the German Federal Ministry for Economic Cooperation and Development (BMZ) through KfW Development Bank.

Availability of data and materials

Data are available upon reasonable request from the first Author.

Declarations

Ethics approval and consent to participate

The ethical approval was delivered by the National Institute of Public Health (DECISION CIE/03/2024). The Administration’s permission to meet the caregivers at the health facilities was received from the Ministry of Health (Ref number 633/223DGSSLS/2024). The purpose, risks, and benefits of the study were explained to the caregivers. Caregivers who agreed to participate in this study and provide information about malaria vaccine acceptance were surveyed. The caregivers who refused to be questioned were excluded from the research.

Competing interests

The authors declare no competing interests.