Negotiating trust and risk: a conceptual model of caregiver decision-making for seasonal malaria chemoprevention in Abuja, Nigeria

Background Seasonal malaria chemoprevention (SMC) is an effective strategy for preventing malaria in children under five. However, uptake depends on caregiver decisions, which are shaped by trust in the medication, perceived risks, social dynamics, and health system factors. Understanding these decision-making processes is critical to improving program coverage. Methods We conducted a qualitative study among caregivers of children aged 3–59 months in the Federal Capital Territory, Abuja, Nigeria. Data was collected through six focus group discussions (FGDs) with purposively selected participants from Abaji (n = 5), Abuja Municipal Area Council (AMAC, n = 5), Bwari (n = 4), Gwagwalada (n = 3), Kuje (n = 5), and Kwali (n = 5). FGDs were audio-recorded, transcribed verbatim, and analyzed thematically. Results We propose the trust–risk negotiation model to explain how caregivers negotiate trust and risk when deciding to use SMC. The model identifies four interacting factors: trust formation through personal experience, risk perception shaped by side effects, social context including family and community influences, and health system factors such as access to drug and credible delivery. We found that these factors influence caregiver decisions, leading to four possible outcomes: accept, continue, discontinue, or reject SMC. Our model shows that uptake of SMC is a negotiated process influenced by experience, social support, and system-level factors. Conclusion Effective SMC implementation requires strategies that strengthen caregiver trust, minimize perceived risks, leverage positive social influence, and ensure reliable health system support. Our model provides a framework for designing interventions to improve uptake and sustain malaria prevention among children under five. Clinical trial number: Not applicable