Determinants of Caregiver Awareness and Uptake of the R21 Malaria Vaccine Among Under Five Children in Aweil South and West Counties, Northern Bahr el-Ghazal, South Sudan

Introduction: Malaria is one of the leading causes of morbidity and mortality among children under five in South Sudan. In 2024, the South Sudan Ministry of Health introduced the R21/Matrix-M malaria vaccine as part of an integrated malaria control strategy. This study examines caregivers' awareness of the malaria vaccine, vaccine uptake among eligible children, and their associated determinants. Methods : This is a secondary analysis of data collected during a routine monitoring survey to assess seasonal malaria chemoprevention (SMC) coverage in Aweil West and Aweil South counties, South Sudan. The survey was conducted in November 2024, five months after the vaccine rollout. Multi-stage random sampling was utilized to select 1,500 child-caregiver pairs across 75 survey clusters: 40 in Aweil West and 35 in Aweil South. All 1,500 participants were considered in the analysis for assessing level of awareness and associated factors, but only 533 children who met the malaria vaccine age eligibility criteria at rollout – aged between 5 and 23 months at the time of the survey – were included in the analysis for malaria vaccine coverage and factors affecting its uptake. The data were collected using a structured questionnaire using SurveyCTO. Logistic regression was used to determine factors associated with vaccine awareness and uptake, with a level of significance of α=0.05. Findings : Only 15.9% (95% CI: 14.1-17.9) of caregivers had heard of the malaria vaccine, with awareness considerably higher in Aweil South (18.4%, 95% CI: 19.7-26.2) than in Aweil West (7.6%, 95% CI: 7.9-12.1) (p<0.001). Awareness was higher among caregivers with higher education compared to those with no education (aOR = 2.01 (p < 0.05), 3.44 (p < 0.0 5 ), and (p < 0.05) for primary, secondary, and tertiary education levels, respectively). Coverage of the first dose of malaria vaccine among eligible children was 9.0%, with higher rates in Aweil South (13.9%) than Aweil West (4.9%) (p < 0.001). Coverage was significantly associated with caregiver education, agricultural employment, nomadic lifestyle, and the child's age group. Conclusion : The study revealed low levels of malaria vaccine awareness and uptake in both counties. However, there were notable disparities in both outcomes influenced by location, caregiver demographics, and the child’s age. Strengthening vaccination messaging and social and behaviour change efforts, particularly targeting key sociodemographic drivers, may improve knowledge of malaria vaccines and vaccine uptake.