1 Background

Malaria is a communicable illness spread by female Anopheles mosquitoes and caused by bacteria of the genus Plasmodium [1]. The condition produces symptoms such as high body temperature, diaphoresis, chills and headaches. Poorly managed cases can result in complications and even death [2]. Global estimates indicate that approximately 240 million and 627,000 cases and deaths, respectively, were recorded in 2020 [3]. Among children under 5 years of age for the same year, the number of cases and deaths were 117.1 million and 329,000, respectively [4]. While all persons, especially individuals in developing countries, are at risk of the disease, it poses an extensive threat to the survival of children who are 5 years and younger. Approximately 76% of all malaria mortalities are among this age group worldwide [5]. In 2019, there were 416,000 malaria deaths in children under the age of five globally [6]. African countries bear a particularly large percentage of this burden, where more than 250,000 malaria deaths occur annually [7]. In Ghana, a survey in 2009 indicated that the average malaria parasite prevalence was 58% among all age groups. A higher prevalence rate was observed among children as the average frequency of malaria in children under the age of five was 64% (95% CI: 61.9, 66.0) [8]. Additionally, some children under the age of five experience up to seven malaria bouts each year [8]. The mortality rate of under 5 malaria cases in Ghana is estimated to be 52 per 1000 live births as at 2018 [9]. Considering the dire consequences of childhood malaria, the development and approval of the malaria vaccine would provide effective supplemental protection against malaria in children as well as contribute tremendously toward the attainment of the Sustainable Development Goal three (SDG 3). That is, the promotion of well-being of children under five through malaria vaccination [10,11,12]. However, heightened awareness of the new vaccine will play a critical role in its mass deployment and acceptance among potential recipients.

Vaccines, a common and crucial public health tool, have proven to be useful in saving children and even adults with regard to disease control when well publicized and accepted by communities [13]. To strengthen malaria control efforts, Mosquirix development was initiated in 1984 by scientists at GlaxoSmithKline (GSK) [14]. The project reached Phase II and Phase III trials between 2009 and 2013. The trials were performed among children at 11 different locations in 7 African nations with various malaria incidence intensities [15]. The potential malaria vaccine proved up to 39% efficient at averting the condition in children, especially upon receipt of a booster after the initial dosage. Mosquirix vaccination further resulted in reductions in anemia, hospitalizations due to malaria, and all-cause hospitalizations [13]. Following a successful pilot program by GSK, PATH, the Ministry of Health—Ghana, Gavi, the Vaccine Alliance (Gavi), the Global Fund and the World Health Organization (WHO), a massive roll out of the malaria vaccines in routine immunizations has stated in Ghana [16]. Awareness of the vaccine by women, especially those in childbearing-age, is one of the key factors for successful vaccine implementation and roll-out. Media, however, have been the backbone of public health awareness creation, particularly for new interventions [17].

The media are a major contributor to the community's increased health responsiveness since they inform and educate people [18]. In malaria prevention efforts in Ghana, community exposure to malaria-related messages through various channels, most likely radio and television, has been shown to promote the use of malaria preventive methods [19]. In sub-Saharan Africa, mass media (radio and television) has been identified as an impactful tool for improving vaccination uptake [20, 21] since it has been the primary source of vaccination information [22].

Studies from the areas where malaria vaccine trials were piloted in Ghana indicated that the life-saving intervention was met with mixed reactions. While some people welcomed the vaccines, other people were skeptical about them. In the Sunyani municipality, the uptake of the malaria vaccine was affected by the rising concerns of some mothers that children are receiving too many immunizations [23]. In the Kassena Nankana Municipality in Ghana's Upper East Region, there was a gradual decline in dosage uptake, with the fourth dose uptake being the poorest. The implication was that mothers/caregivers were not aware of the vaccination schedule for malaria [24]. The initial phase of the pilot program was also marked by poor vaccination uptake and caregiver reluctance due to the propagation of depopulation rumors leading to vaccine refusals [25, 26]. Therefore, heightened health education to create awareness and address the challenge of refusals, low knowledge of dose schedules and high numbers of childhood vaccines and rumors are needed. The National Malaria Control Program and nongovernmental organizations channel tremendous resources for malaria prevention, including the creation of awareness of malaria vaccines [27, 28]. While it may be assumed that awareness level may be low at this time, it is not clear how it relates to sociodemographic factors and varies by region. In addition, the role of mass media in malaria vaccine awareness creation efforts has not yet been determined. To promote evidence-based health education strategies by the Ghana Health Service and partners toward the routine roll-out of the Mosquirix vaccine with regards to targeting appropriate populations, selecting effective communication channels and ensuring necessary modification to achieve optimum results, this study determined variations in awareness level and applied statistical methods to specify the main drivers of malaria vaccine awareness.

2 Methods

2.1 Study design and measures

A cross-sectional study on the influence of mass media and sociodemographic characteristics on malaria vaccine awareness. Awareness was measured as respondents who had heard about the malaria vaccine. The measurement of traditional media exposure considered the availability of media channels such as radio and television sets in a household. It is assumed that respondents with household radio and television will be exposed to variety of information, including health messages, malaria prevention-related advertisements and health talks on routine immunization. The day-to-day operation of these devices relies significantly on access to electrical power sources. Hence, access to electricity was included in the study. Sociodemographic characteristic measurements focused on the personal features of respondents, such as age, educational attainment, literacy, wealth status and ethnicity.

2.2 Data source and acquisition

The 2019 Malaria Indicator Survey (MIS) data were used for the study. The dataset was sourced from the Demographic and Health Survey (DHS) platform (https://dhsprogram.com/methodology/survey/survey-display-557.cfm), a private database upon a justifiable request was made for this research. The MIS data were collected from September to December 2019 during the pilot implementation of the malaria vaccine. The final report from DHS was released in July 2020 [29].

2.3 Data collection and sample size

This study used secondary data from the DHS. In general, four (4) separate survey tools were administered in the malaria indicator survey. The tools were household, individual women, biomarker and fieldworker questionnaires. The data in this work were limited to individual women’s questionnaires. The specific sections of the women’s questionnaire that were relevant to the study included the respondent’s background and the section on social behavior change and communication [29]. The MIS data were obtained through in-person questionnaire administration. The individual women included in the survey were approximately 5246 women between the ages of 15 and 49. Overall, 5181 entries were retained as valid. This served as the sample size for the study. However, 98 “Not a dujure resident” were excluded from this study. They represent respondents eligible for the individual women’s questionnaire who were not usual residents of the household where they were interviewed.

2.4 Sampling

The MIS was created to offer countrywide estimates of important malaria indicators. In that regard, study participants were drawn from all regions in two stages: household listing and questionnaire administration. Across the regions, 200 out of 37,675 enumeration areas/clusters were selected through probability proportional to size sampling based on the 2010 population and housing census enumeration area demarcations. In the household listing, information was collected in the clusters pertaining to the names of household heads, structures and their global positioning system (GPS) coordinates. The information was directly recorded on electronic devices (tablets) through a computer-assisted personal interviewing (CAPI) system. The household list generated from this activity served as a sample frame for the second phase. In the second stage, households and eligible women aged 15 to 49 were selected through systematic sampling and interviewed in person.

2.5 Statistical analysis

The data were thoroughly examined for logical coherence, completeness and discrepancies. No major errors were identified. The outcome of interest (Have you heard about the malaria vaccine?) was initially presented on a three-level nominal categorical scale. They were “No”, “Yes” and “Don’t know”. However, the “Don’t know” responses (27/5083) were recoded as “No” for the purpose of this study on awareness. The variable “region” also had 10 response options for the regional demarcations at the time of data collection. For the purposes of this analysis, they were reclassified according to the 3 ecological zones as described in the 2020 malaria five-year plan of work [9]. The broad geographic divisions include the northern belt (upper east, upper west, northern regions), middle belt (brong/ahafo, ashanti, and eastern regions) and southern belt (greater Accra, central, western and volta regions). The variable “religion” was also reclassified from its initial presentation in the data. Religions were regrouped by combining Catholic, Anglican, Methodist and Presbyterians into Orthodox churches. The response “other Christians” was added to the Pentecostal/Charismatic churches. Traditionalists and individuals with no religion were added to “others”.

Tabulation was performed for frequencies and percentages to generate univariate statistics for background characteristics (age, highest education, wealth index, residence, religion and region) of the respondents. A chi-square test was employed to examine the association between malaria vaccine awareness and demographic/media characteristics. Sociodemographic and media exposure variables with significant associations with malaria vaccine awareness at the 95% confidence interval were modeled in a complex survey bivariate/multivariate logistic regression analysis. Statistical tests in this study were performed using STATA 18.0 statistical software. Design base-corrected chi-square and P-values were reported for the chi-square test, and odds ratios and corresponding 95% confidence intervals were reported for the complex survey logistic regression models.

2.6 Ethical considerations

The 2019 MIS fulfilled all ethical requirements. The Demographic and Health Survey (DHS) program obtained approval for the survey protocol from the Ghana Health Service Ethical Review Committee. The Demographic and Health Surveys (DHS) program data archivists granted permission for this study. Informed consent was obtained from all subjects and/or their legal guardian(s) after providing them with relevant information. The obtained data were exclusively utilized for this authorized research. The data were handled with strict confidentiality and no effort was made to identify any specific home or individual responder.

3 Results

3.1 Background characteristics of participants and malaria vaccine awareness

The study involved 5083 women aged 15 to 49 years. The participants were usual (dujure) residents of the households selected for the survey. From the weighted frequency distribution shown in Table 1, the majority of women in the study were aged between 25 and 29. This age group accounted for 17.90% of the study population. Another predominant age group in the study was teenagers, with 17.59% of individuals aged 15 to 19. While 16.70% of the participants have not had any formal education, 18.81% and 56.58% had primary and secondary education, respectively, and only 7.93% had tertiary education. The participants resided mostly in urban areas (51.31%). The majority of the participants were from the southern region (45.88%). The middle belt constituted 37.69% of the study population, and the northern belt constituted only 16.41%. The malaria vaccine awareness level was 35.65%, with a 95% confidence interval (CI) of 33.83%–37.51%.

Table 1 Background characteristics of the study participants, Malaria Indicator Survey 2019
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3.2 Factors associated malaria vaccine awareness

From Table 2, the sociodemographic factors associated with malaria vaccination include age (χ2 = 11.79, p < 0.01), educational level (χ2 = 7.04, p < 0.01), residence (χ2 = 6.62, p = 0.01), and region (χ2 = 8.29, p = 0.01). Other factors associated with awareness were ethnicity and literacy. Awareness was associated with listening to/or seeing malaria messages in the past 6 months (χ2 = 42.42, p < 0.01) and radio set ownership (χ2 = 24.71, p < 0.01). Television set ownership did not exhibit a significant association with awareness. However, the variable was retained in the bivariate and multivariate logistic regression models since it was a key variable of interest as part of mass media exposure. Additionally, scientific literature recognizes television’s association with health awareness [30]. Access to electricity also showed no significant association with malaria vaccine awareness but was retained as a covariate of the media exposure variable.

Table 2 Sociodemographic and mass media exposure-related factors associated with malaria vaccine awareness among women of childbearing age in Ghana, Malaria Indicator Survey 2019
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The final adjusted model revealed factors that increased and decreased the odds of malaria vaccine awareness (Table 3). Generally, all ages above the reference category (15–19) positively predicted awareness. Participants with higher education had 93% greater odds of being aware of the malaria vaccine than individuals with no formal education. Among the three regional belts with the “southern belt” as a reference, only the northern part of the country had a significantly increased awareness level (AOR 1.54, 95% CI: 1.14–2.07). Other positive predictors of awareness were rural residency (AOR = 1.28, 95% CI: 1.05–1.56), malaria health education (AOR = 1.73, 95% CI: 1.45–2.07) and radio set ownership (AOR = 1.39, 95% CI: 1.19–1.62). As shown in Table 3, while the people of the Gurma ethnic group were 33% less likely to be aware of the malaria vaccine, the people in the Guan ethnic group were 75% more likely to be aware of the vaccine. The estimates for Gurma and Guan ethnicity awareness were AOR = 0.67, 95% CI: 0.46–0.98 and AOR = 1.75, 95% CI: 1.09–2.81, respectively. When we controlled for sociodemographics and electricity, television ownership (AOR = 0.84, 95% CI: 0.69–1.01) did not have a statistically significant relationship with vaccine awareness.

Table 3 Logistic regression of sociodemographic and mass media exposure-related factors associated with malaria vaccine awareness among women of childbearing age in Ghana, Malaria Indicator Survey 2019
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4 Discussion

To mitigate the disease and death burden from malaria, researchers have continuously searched for more effective methods to prevent the disease. One such new finding is the 4-dose schedule malaria vaccine targeting children under 5 years of age, which was piloted in 2019 and fully adopted in 2023 by Ghana [31]. Considering the substantial level of hesitancy that encircles new vaccines [32], it is crucial to provide accurate information regarding safety, effectiveness, and availability through health education and awareness creation [33]. This study examined awareness of malaria vaccines in Ghana. The results of the study indicate that there is low general awareness of the malaria vaccine, which is characteristic of the situation in sub-Saharan Africa [31]. The malaria vaccine awareness among women of childbearing age was 35.65%. This level of awareness was lower than that of malaria vaccine awareness in the neighboring country Nigeria (48.90%) [34] and far lower than that in India (71.95%) [35]. It is not unusual that awareness is low at this time since it is in the early days of implementation. However, continuous efforts must be made to raise awareness higher while addressing awareness-related challenges that were encountered during the pilot stage of the implementation, such as concerns about increasing the number of childhood vaccinations [23] and inadequate sensitization on the dose schedule [26].

Studies have shown that an increase in maternal knowledge and education favors vaccine awareness and usage [36, 37]. According to the educational level categories, only tertiary education positively influenced vaccine awareness. A similar finding was reported from a malaria vaccine awareness and knowledge study in India [35]. Less educated individuals have lower awareness levels. It is possible that the malaria vaccine messages were not delivered in methods understandable to the less educated. Higher education attainment can be perceived to be associated with greater comprehension and reading abilities. Hence, it could be that highly educated persons sourced information about the malaria vaccine from news items/articles but not through deliberate attempts by health workers. To lessen the educational barrier to malaria vaccine awareness, stakeholders must go beyond the news about the vaccine to actively propagate the new product in forms and languages that can be comprehended by uneducated or partially educated persons. Similar to two other studies by Immurana et al. in Ghana [38] and Musa-Booth et al. in Nigeria [39], younger women had a lower level of awareness than older women, although they dominated the child-bearing age population, as indicated in Table 1. The reasons for lower awareness among younger age groups are not readily identifiable, but from a modern society perspective, younger women are more likely to spend time on social media than on mass media [40]. If that is the case, then there is a link between reliance on social media for information and apprehensive attitudes toward vaccination awareness and vaccine use [41]. On the other hand, social media could be utilized as an instrument to increase vaccination awareness [41]. Rural‒urban variation is a key demographic factor that influences routine immunization performance [42]. In this study, women of childbearing age in rural areas were more aware of the malaria vaccine than were those in urban areas. It is therefore not surprising that the Northern Belt is the only region with a significant awareness level of the vaccine. Northern Ghana is considered the least developed territory, with several rural communities [43]. A similar finding was reported in a study in Burkina Faso. In the Burkina Faso study, most mothers in rural communities were more aware of the illnesses that the Expanded Program of Immunization (EPI) is intended to prevent and the value of immunizing their children [44]. The phenomenon of rural communities having greater awareness of vaccines is associated with strong and relatively easier social mobilization in rural communities for health activities [44].

Radio and television are thought to be effective media for spreading health-related information [45]. In this study, radio set ownership by a household increased the chances of vaccine awareness, but television ownership did not. Regular radio listening boosts vaccination awareness and uptake [36]. A quasiexperimental study in Ethiopia presented evidence that a radio enhances newborn immunization rates and promptness [21]. Just as women in households with radio sets were 40.00% more likely to be aware of the malaria vaccine in this study, 39.00% of women with access to community radio were more likely to receive the PENTA 3 immunization in Ethiopia [21]. The presence of TV sets in households did not significantly influence awareness. This may be a result of inadequate health education on TVs. For television to have a stronger influence on public exposure to health-related media messages, it is recommended that long-duration and sufficiently funded initiatives developed and implemented [17]. The malaria control program can invest more in television advertisements toward malaria control and vaccine awareness creation, although this will come at a relatively higher cost.

Although exposure to malaria health messages or education in the past six months is one of the most significant predictors of malaria vaccine awareness, approximately 60% of the participants who had recently heard of malaria messages were not aware of the vaccine. This could imply that the sources of the messages were not aware of the vaccine, that they had not been empowered to talk about it or that the malaria vaccine had not been prioritized for publicity in health education activities. Considering the critical role of the vaccine in preserving children’s health, it is appropriate that health workers are given the needed training and key messages to promote it. To achieve desirable levels of malaria vaccine awareness, all healthcare providers must be well informed to deliver information on the vaccine through their routine, outreach and media health education on malaria [32]. Subsequently, health authorities should initiate a directive to prioritize the creation of awareness of vaccines through health education at health facilities, communities, and radio talk shows.

4.1 Strengths and limitations

This work provides an estimate of malaria vaccine awareness and its relationship with demographic factors and mass media exposure, providing valuable information for health education and the promotion of strategic planning. Furthermore, this study contributes to the growing literature on malaria vaccine mass deployment to end users. However, there are some limitations to this study. As a cross-sectional study, the timing and intensity of the malaria vaccine awareness campaign were not under the control of the researchers. The study assumed that radio and TV ownership could influence malaria vaccine awareness. However, having radio and TV in households does not translate directly into usage and access to health communications. For example, a study on television/radio ownership and reproductive intervention in sub-Saharan Africa revealed that television/radio ownership did not strongly correlate with reproductive initiative compared to the active communication mode through mobile phones [46]. Additionally, there is the possibility of social desirability bias since the outcome response was self-reported. The question (Have you heard about the malaria vaccine?) was so simple that one could just pick yes, no or don’t know. The study has its strengths as well. The study pulled nationwide samples by the proportional to size probability method and weighting by region to ensure representativeness. This allows the study findings to be generalizable to Ghana and similar developing nations implementing malaria vaccine roll out.

5 Conclusion

Many more women of childbearing age are yet to hear about the malaria vaccine. There is the need to improve awareness creation through all possible approaches but with emphasis on radio and community information centers. Television ownership had no impart malaria vaccine awareness. It will there necessary intensify malaria vaccine message delivery on television with extension to mediums to reach younger women, perhaps on social media. Although the general nationwide awareness level has not reached desirable levels, this study suggest that the awareness drive must target less educated young adults, urban neighborhoods and the Gurma ethnic group to ensure awareness parity across social groups. It is also recommended that health workers are trained and provided job aids and posters for health education on the malaria vaccine and other previously ongoing malaria preventive strategies.