Knowledge and acceptance of malaria vaccine among parents of under‐five children of malaria endemic areas in Bangladesh: A cross‐sectional study

Abstract Background Malaria exists as an endemic in many countries including Bangladesh and the malaria vaccine is not yet available here. The study aimed to assess the level of knowledge and acceptance of the malaria vaccination among the parents of children under the age of five in Bangladesh's malaria‐endemic areas and the sociodemographic, behavioural, and household factors associated with the acceptance and knowledge of the malaria vaccine. Methods From January to March 2022, a cross‐sectional study was conducted in all five malaria‐endemic districts of Bangladesh, involving 405 parents of children under the age of 5 who met the inclusion criteria. Multiple logistic regression was used to analyze the factor affecting parents' acceptance and knowledge of malaria vaccination in children under five and other variables. Results Majority (54%) of the respondents were mothers. Almost half (49%) of the respondents were aged between 26 and 35 years old and around 90% were from rural areas. A small portion (20%) of the participants were housewives and 46% of them completed primary education. Overall, 70% of the study participants reported that they would accept malaria vaccination independently. About one‐fourth (25%) heard about the malaria vaccine and 48% of them mentioned health professionals as the source of information. Knowledge of malaria vaccination was found associated with residence, income, and family size. Acceptance and knowledge were both associated with residence, education, occupation, income, and family size. In a multivariable analysis, housing structure, house wall, house window, knowledge of malaria, testing for malaria, and being diagnosed with malaria were all associated with knowledge of and acceptance of getting vaccinated against malaria. Conclusions The present study highlights the necessity of creating awareness of malaria vaccines in epidemic areas of Bangladesh. This study offers crucial data to develop a policy for a novel malaria vaccine, supporting its adoption in Bangladesh. Public Contribution This study was based on interviews. The interviewees were recruited as public representatives from the malaria‐endemic area to assist us in building an understanding of knowledge and acceptance of the malaria vaccine among parents of under‐five children in Bangladesh.


| INTRODUCTION
Malaria is a parasitic infection that spreads to humans through the bites of infected female Anopheles mosquitoes.It is both avoidable and treatable.][10] Plasmodium falciparum is still the most common cause of malaria in Bangladesh, with a range from 54% to 93%. 5,8,11,12Bangladesh has a history of endemic malaria transmission in 13 districts, and approximately 17.5 million people are at risk, although only 27,737 cases were reported in 2016. 13laria is a significant public health concern in Bangladesh, and while recent progress has been made, the disease burden is very spatially and temporally diverse.An episode of malaria in the Netrakona district in 2005 resulted in 1087 cases and 14 deaths. 14 2004, Chittagong, Netrakona, and Cox's Bazar outbreaks affected 4.1, 2.2, and 1.9 million people, and led to 25, 10, and 168 fatalities, respectively.An outbreak in the Bandarban, Rangmati, and Khagrachari districts in 2002 produced approximately 16,000 clinical cases and 177 deaths. 15The 'Southeast area' (SeA), notably the CHTs and Cox's Bazar, has historically had the most significant malaria incidence. 16Malaria was significantly more common in SeA than Northeast area (NeA) which has previously been demonstrated in different studies. 8,15,17,18ny malaria vaccines are now being tested in clinical trials and are intended to yield a better malaria control approach.The RTS, S malaria vaccine candidates undergo clinical testing in three sub-Saharan African nations. 19,20Malaria vaccine development has advanced dramatically over the last two decades.As of 2015, the RTS, S vaccine is the only one authorized; it requires four injections and has limited efficiency. 21The RTS, S/AS01 malaria vaccine should be given to children starting at 5 months on a four-dose schedule to reduce the disease prevalence and associated expenditure. 21In locations with seasonal solid malaria transmission or periodic malaria transmission with seasonal peaks, countries may contemplate delivering the RTS, S/AS01 vaccine seasonally, with a five-dose plan, based on a growing body of research. 22Malaria resistance has been reported in most new chemotherapeutic measures given out of vaccines. 23These vaccines must be provided to children under five because they are one of the most vulnerable groups suffering from the disease.Their immune systems are still constructed and not as potent, and these vaccines could prevent them from the disease. 24A consistent measure of confidence and a baseline for comparison is needed to understand the changing trends of vaccination acceptance over time, which can act as an early warning system for taking essential efforts to avert reductions in vaccine knowledge and acceptance.However, there is a lack of data on vaccination acceptability in low-and middle-income countries, primarily in Central and South Asia. 25 To fill the gap in developing a comprehensive national vaccination programme, this study intends to investigate the public's intention to take malaria vaccine by sociodemographic, clinical, and regional characteristics among Bangladeshi adults living in malaria-endemic areas.In malaria-endemic regions, vaccination will reduce the burden of the disease's likelihood of incidence.The community will directly and indirectly benefit.In the endemic regions of Bangladesh, there is still no major study focusing on malaria vaccine awareness and acceptability.In light of recent developments in the realm of malaria vaccine innovation, it is crucial to comprehend the degree of awareness and acceptance of this vaccine in nations that are most vulnerable to this perilous and avoidable diseases.The study aimed to assess the knowledge and acceptance of the malaria vaccine with the associated factors among the parents of under-five children residing in malaria-endemic areas in Bangladesh.

| Study site
Bangladesh is divided into eight divisions, 64 districts, 485 upazilas, and 4498 unions. 26Eight of the thirteen malaria-endemic districts are in the northeast and border India, while the remaining five are in the southeast and have a border with both India and Myanmar (Figure 1).This study defines two geographical areas in Bangladesh.The eight malaria-endemic districts 26 in the northeast are referred to as 'the NeA'.We randomly selected one district 'Netrokona', as it is one of the malaria hotspot zones of Bangladesh, to make (the NeA) a country representative sample.In contrast, the four malaria-endemic districts in the southeast are referred to as 'the SeA'.We collected data from four districts; Bandarban, Chittagong, Khagrachari, and Rangamati.These districts are geographically located in the southeast malaria hotspot zones of Bangladesh. 18Due to the higher malaria prevalence in the southeast compared to the northeast, we mainly collected data from four southeast locations.Additionally, due to funding restrictions and limited access, we could not cover more northeastern locations.In terms of population, topography, and malaria risk these places differ (Figure 1).We collected data from the participants, who were selected conveniently as the malaria endemic area was hard to reach.

| Study design
We conducted a cross-sectional study in the malaria-endemic areas of Bangladesh to determine the knowledge and acceptance of malaria vaccination by parents of under-five children.We used quantitative methods to collect data.

| Sampling and selection
The required sample size was calculated by using a single population proportion formula with an assumption of 95%, 22 a 5% margin of F I G U R E 1 Knowledge and acceptance of the malaria vaccine among parents of under-five children: northeast and southeast parts of malaria-endemic areas in Bangladesh.
error, and a 50% proportion of willingness towards the malaria vaccine among caregivers of children under the age of five.The sample size was found to be 384.After adding a 5% nonresponse rate, the final sample size was 405.From January to March 2022, the study was conducted in all five malaria-endemic districts of Bangladesh, involving 405 parents of children under the age of five who met the inclusion criteria.The inclusion criteria of the participants were; parents older than 18 have at least one underfive child living in Bandarban, Chittagong, Khagrachari, Rangamat, and Netrokona and have been residents of the area for at least a year.Parents who did not give consent were excluded from the study.Stable malaria hotspots in Bangladesh were divided into two zones: northeast-Netrokona and southeast-Bandarban, Chittagong, Khagrachari, and Rangamati.
A multistage sampling process selected the households in the districts.In the first round of ballots, one community per district was chosen at random.Then, 80 houses were chosen at random using the same procedure to match the study participants.
Households were randomly selected in groups of five, with sampling beginning at each community's central place.When a household did not qualify, the next eligible one was chosen.The following step involved selecting homes to take part in the study based on their eligibility.Only residents of the area for at least a year, those over the age of 18, and those with children less than 5 years old were considered for participation.Members of the targeted groups convened at each community centre for a sensitization exercise before the data collection began, during which they were informed about the upcoming household surveys and why their participation was crucial.Community leaders were asked for their input before the visit date was set, and they helped get the group ready.

| Ethical considerations
Our study received ethical clearance from the Institutional Review Board/Ethical Review Committee of NSU (2022/0R-NSU/IRB/0207) and adhered to the 1975 Declaration of Helsinki's ethical criteria (6th version, 2008), as shown in a priori approval by the institutional review committee.All individuals agreed to participate in the study and completed a consent form before the interview.

| Data collection instrument
We used a structured questionnaire to collect data for the study.
The questionnaire was divided into three domains.The first domain covered socioeconomic factors, the second and third domains covered knowledge and acceptance of malaria infections and vaccinations.A pilot study was carried out with 20 participants to pretest the questionnaire and necessary changes were made.The Bangla translation of the study's English interview questionnaire was vetted by five outside experts (who were not part of the study team and had expertize in the relevant field inside the country, and their feedback and suggestions were considered to improve the quality and validity of the Bangla translation) with fluency in both languages.Once we had the participants' permission and comfort to use their native language Bangla, we went over the interview questions in Bangla.The questionnaires consisted of three sections.Section 1 contained sociodemographic variables such as age, gender (female, male), residence (rural, urban), educational status (no formal education, primary completed, secondary completed, higher), occupation (service holder, business, farmer, day labourer, rickshaw/van puller, boat driver, housewife, unemployed, other), income class (10,000, 10,000-20,000, 20,001-50,000), family size (≤4, ≥5), smoking history and housing structure, malaria-associated awareness, and associated questions.
Sections 2 and 3 contained knowledge and attitudes regarding malaria infection and vaccination.Moreover, the response was recorded as 'Yes/No'.We calculated each participant's response under the 'yes' and 'no' categories based on their knowledge and attitude.

| Data collection procedure
The study involved training data collectors in data collection methodology, obtaining permission from local leaders in malariaendemic areas.Participants were briefed on the study's purpose and malaria vaccine topics, and written informed consent was obtained.Regular reviews were conducted to ensure data quality, and a 20% sample was double-checked for accuracy.The research was conducted in a malaria-endemic region, where the local population is exposed to malaria-related information through government initiatives and stakeholder engagement.

| Variables of interest
[29][30][31][32][33][34] The variables relevant to knowledge and acceptance of the malaria vaccine included age, gender, residence, educational status, occupation, income class, family size smoking status, comorbidity, bed net, insecticide-treated bed net, used insecticide to control mosquitoes, housing structure, house wall, house floor, house window, awareness of malaria, having ever been tested for malaria, ever been diagnosed for malaria.Our dichotomization and cutoff values were theoretical, and a verified approach might have strengthened our findings.In the questionnaire and for the analysis, we added and incorporated those relevant variables.The distribution of responses of the questioners and the goal of distinguishing 'good' and 'poor' levels led to a cutoff value of 4. The median value above 4 separated the groupings.This method is used in comparable investigations to evaluate and interpret data.

| Data analysis
We entered the data into the STATA version 16.0 software.We then calculated each participant's response under the category of 'yes' and 'no' based on their knowledge and acceptance with the scoring of 0-1.Moreover, the score ranges for both knowledge and attitude were 0-7.Participants with a score of 4 or above were considered to have adequate knowledge and a positive attitude.We developed and modified the questionnaire based on a study in Nigeria. 24 used descriptive analysis to describe the independent and dependent variables in terms of frequency and percentage.We described the knowledge and acceptance of the malaria vaccine among the study respondents in proportion.
We categorized acceptance and knowledge scores as good (≥4) and poor (≤3).The choice of a cutoff value of 4 was determined by considering the distribution of responses and aiming to capture a meaningful distinction between 'good' and 'poor' levels.The median value above 4 was chosen to delineate the two categories.We conducted a bivariate analysis for the associated factors of knowledge and acceptance and measured the association by χ 2 test.
Covariates with a p < .20 obtained from the χ 2 test in the bivariate analysis were included in the multiple regression model.Multiple logistic regression models were fitted to examine the potential adjusted associations between binary outcome data (knowledge and acceptance) and categorical or nominal data (demographic and malaria-related variables).Exponential coefficients of the binomial logistic regression models were used and presented as odds ratios with a corresponding 95% confidence interval (CI).
All tests were two-tailed, with a p < .05has considered statistically significant.To measure the internal consistency or reliability of the survey items or questions, Cronbach's α with Bootstrap 95% CI based on 1000 samples was used.we found Cronbach's α .893with a 95% CI: 0.879-0.905for 24 variables which were considered identical questions for malaria risk of infection and vaccination.Again, Cronbach's α with 95% CI for the respective seven variables of knowledge and acceptance categories are 0.825 (0.794, 0.85) and 0.949 (0.936, 0.959), respectively.This indicates the items were sufficiently consistent to indicate the measure was reliable.

| Sociodemographic characteristics
Of the 430 people interviewed, 405 responded to the questionnaires (a response rate of 94%).Most respondents (48.89%) were aged between 26 and 35 years, 24.44% were below or equal to 25 years, and 24.69% were between 36 and 50 years old.Among the respondents, 53.33% were female, and 46.67% were male.The majority (89.63%) were from rural areas, and a greater proportion [BDT]), 37.28% had income 10,000-20,000 (BDT), and 14.2% had income between above 20,001-50,000 (BDT).A total of 49.14% of participants had a family size below, or equal to four persons, and 50.86% had ≥5 persons in their family (Table 1).

| Sources of knowledge about malaria vaccine
Among the 105 participants who heard about the malaria vaccine, 31.21%learned about it from health professionals.Among all sources, 29.20%, 28.19%, 8.6%, 8.5%, and 2.1% of participants learned about the malaria vaccine from television, government agencies, newspapers, social media, and friends, respectively.
The remaining 42.28% of participants learned about the malaria vaccine from other sources (Figure 3).

| Knowledge regarding malaria infection and vaccination
The survey revealed that 74.07% of participants were unaware of the malaria vaccine, while 25.93% had just heard about it.Around | 2635 stated that they do not think such problems will occur as a result of the vaccination (Table 2).

| Acceptance of malaria vaccination
Around 70.86% of respondents stated they would vaccinate their children against malaria, and 69.63% said they wanted to be vaccinated.Approximately 62% of participants desired to spend money on the vaccine, whereas 75.06% wanted it if the government provided it.Around 72.84% thought everyone should get vaccinated.
Family size and neighbours would be encouraged to vaccinate their children, according to 74.57% of respondents (Table 3).
Northern Bangladesh has 84.3% and 92.2% better knowledge and acceptance of malaria infection and vaccine compared to southern Bangladesh, with a significant difference observed, where the p-value indicates a significant difference in the knowledge and acceptance category between the northern and southern parts of Bangladesh (Table 4).
We discovered that those who responded with good knowledge had around 95% good acceptance of the malaria vaccine, but those who responded with bad knowledge only had 70% poor acceptance (Table 5).
According to our study's findings, the p-value was found to be significant in knowledge of the malaria vaccine factors with sociodemographic; in the cases of residence (where urban had 91% good knowledge), educational status (where higher education had 82% good knowledge), occupation (where businessman had 82% good knowledge), Income (where income 20,001-50,000 had 88% good knowledge).Again, p-value was found to be significant in acceptance of the malaria vaccine with sociodemographic; in the cases of residence (where urban had 92% good knowledge), educational status (where higher education had 85% good knowledge), occupation (where service holder had 81% good knowledge), Income (where income 20,001-50,000 had 97% good knowledge) (Table 6).
The multiple logistic regression model illustrates that, the participants from urban areas were found to have four times more  6).
In a multiple logistic regression models analysis to identify variables linked to the category of knowledge and acceptance of malaria infection and vaccination concerning knowledge about malaria infection and vaccination, the following factors were found to be significantly related: user of the insecticide-treated, housing structure, wall, floor, and window, knowledge of malaria, and having ever had a malaria test.People using the bed net (70%), lived in stilted house (85%), tin house wall (85%), brick house floor (87%), awareness of malaria (71%), tested for malaria (74%), diagnosed case of malaria (82%) had significantly (p < .05)good knowledge about the malaria vaccine.Again, the people using lived in stilted House (86%), tin house wall (88%), brick house floor (100%), tested for malaria (83%), diagnosed case of malaria (92%) had significantly (p < .05)good acceptance about the malaria vaccine ( (AOR = 3.50, 95% CI = 1.28, 9.60) (Table 7).
We separately analyze the essential questions to determine acceptability (would you vaccinate your child with the malaria vaccine) and knowledge (have you heard of the malaria vaccine).
Residence, occupation, smoking status, comorbidity, insecticide treated bed net, house wall, house floor and window, diagnosed and tested for the malaria significantly associated with the knowledge about the malaria vaccine and also residence, educational status, occupation, income class.family member, bed net, housing structure, house floor and window, awareness of malaria and diagnosis for malaria significantly associated with the acceptance of the malaria vaccine (Supporting Information: Tables S1 and S2).

| DISCUSSION
Malaria has become one of the most severe public health issues facing worldwide.Malaria claims the lives of hundreds of thousands of people each year, most of whom are children. 22The WHO's goal is for the world to be 'malaria-free'.However, factors like antimalarial resistance are delaying eradication in Southeast Asia, and malaria vaccine knowledge and acceptance can be an issue.Bangladesh had some of the highest childhood immunization rates in the WHO T A B L E 5 Analysis of overlap between knowledge and acceptance among the participants.South-East Asia Region for multiple antigens, and coverage rose significantly over the 10 years 2004-2014. 35,36This is the first research in Bangladesh to assess the knowledge and acceptance rate of a malaria vaccination among parents of children under five living in malaria-endemic areas.
Periodic, hypoendemic malaria transmission primarily occurred in geographic regions in Bangladesh, persisting over time.High-risk groups contribute significantly to the overall malaria burden, despite representing a minor percentage of the population.
Vaccination is the most effective method for controlling infectious diseases, but its success is disputed by withholding or denying vaccinations.This raises the likelihood of outbreaks and epidemics due to vaccine reluctance.The development of a malaria vaccine will significantly impact malaria eradication plans.
A study in Nigeria found that information about the RTS, S malaria vaccine was initially obtained from healthcare professionals, similar to our research.In Ethiopia, marital status, knowledge, and childhood vaccination experience were significantly associated with willingness to accept the vaccine but in our study knowledge of malaria vaccination was found associated with residence, income, and family size.In India, males showed higher vaccine awareness than females, with education and child care being associated with vaccine knowledge.
When the malaria vaccine became available, 287 parents (70.8%) said they would be willing to give their children a dose.The results of this study were lower than those of studies conducted in Nigeria's capital city of Abuja (98%) and the cities of Ibadan (87%) and Tanzania (94.5%),8][39][40][41][42] This variation may be brought about by variations in the sociodemographic characteristics of survey respondents, study timeframe, sample size, and study methodology.In this study, respondents answered for the vaccination to be distributed for free, indicating that they might be unable to afford the price or unwilling to pay for the dose.Our study found that 61.9% of parents of children under five were willing to pay for the children's malaria vaccine, which is virtually the same as research done in Ethiopia (60.6%). 43A study in Kenya 40 88% of participants and 56% of those who had never attended school indicated they would welcome malaria immunization for a baby in their culture and their child.
Compared to this study, our participants' acceptance of a malaria vaccine for their child was around 70%, while our answer to not having any education was only 10%.In Ghana, 44 malaria vaccination preference was 70%, the same as in our study.
Regarding the housing variables, their direct impact on knowledge and acceptance might not be immediately apparent.However, it is possible that housing conditions serve as proxies for broader socioeconomic factors, such as access to education, healthcare services, or information sources.Bangladesh remains one of the world's fastest-growing countries, with over 162 million people. 46In 2020, there were 29.1 fatalities per 1000 live births among children under five. 47While Bangladesh has made substantial progress in increasing childhood immunization coverage, more attention to the series completion of all recommended EPI vaccinations is required to achieve even more significant reductions in childhood morbidity and mortality. 48Malaria could become a future calamity in malaria-endemic areas of Bangladesh if we do not consider malaria vaccines for children under the age of five.Childhood immunization coverage was highest among children in Bangladesh, so approximately 25% of respondents heard about the malaria vaccine in this study.However, their acceptance of the malaria vaccine for their children was around 70%, which is quite surprising for only being possible for the highest acceptance vaccination in Bangladesh.
Hence, it is possible for individuals who have no awareness of malaria to still have some knowledge of the vaccine, although limited or general knowledge.Based on our findings, we observed that a considerable proportion of participants expressed acceptance of the malaria vaccine, even in cases where they reported not hearing about it.This suggests that acceptance may not solely depend on awareness or knowledge of the vaccine.Other factors such as trust in healthcare providers, perceived benefits of vaccination, and cultural beliefs could influence individuals' acceptance of the vaccine.
Bangladesh has made significant progress in immunization coverage through the Expanded Programme on Immunization (EPI) programme, focusing on essential vaccines for infants and children.
The country has achieved high coverage rates for measles, diphtheria-tetanus-pertussis, and polio, and has reduced child mortality rates.The study aimed to explore factors associated with malaria vaccine acceptance, but acknowledges that high acceptance rates may be a cause of the EPI programme's success.However, we acknowledge that the high acceptance rates of different vaccines in the EPI programme in Bangladesh might be one of the causes of the EPI programme and could provide valuable insights into the acceptance of malaria vaccine patterns among the population.
There are several implications for this study.First, the study was the first in Bangladesh to assess hotspot areas' knowledge of and acceptance of malaria vaccination and its determinants.Second, the study's high response rate (94%) was likely due to participants' interest (especially in malaria-endemic areas) in the subject matter and the survey's objectives being communicated succinctly and clearly.Criterion-based sampling approaches were used to achieve the study's objectives.Seven more locations (endemic malaria sites in Bangladesh) were left unexplored due to a lack of funding, investigation, and/or accessibility.Furthermore, while key findings are consistent with those reported in other studies, some findings may be subject to social desirability bias, which means that in some situations, such as when asked about a vaccine that does not yet exist, participants may have been more inclined to give socially desirable responses rather than describe actual beliefs and practices.
The results would be more informative if this study used a mixedmethods approach.

| CONCLUSION
The study found that most parents in Bangladesh's malaria epidemic area are willing to use the malaria vaccine for their children when it is 69.63% believed malaria was preventable, and 72.10% believed it would minimize man-hour loss; 63.21% would not hear the World Health Organization (WHO) recommend the vaccine for children in 2021, while 36.79%positively responded.A total of 70% agreed that a malaria vaccine would reduce treatment costs.The participants were questioned once more on their perceptions of the potential bad effects of malaria immunization on their health, and 72.35% of them F I G U R E 2 Number of participants in five districts of malariaendemic areas of Bangladesh with comparison of urban and rural areas.F I G U R E 3 Sources of knowledge about malaria vaccine.AMIN ET AL.
knowledge (adjusted odds ratio [AOR] = 4.07, 95% CI = 1.35, 12.31)   and five times more likely to accept the vaccine (AOR = 1.49, 18.93) compare to the participants from rural areas.In the case of respondents, whose level of education was increasing, the level of education was found to have good knowledge about the malaria vaccine.People earning 20,001-50,000tk had three times more likely to have good knowledge about the malaria vaccine (AOR = 3.38, 95% CI = 1.23, 9.26) and 14 times more likely to have good acceptance of the malaria vaccine (AOR = 14.26, 95% CI = 2.96, 69.00) in compare less than 10,000 taka earners.Participants aged 36-65 had a two times (AOR = 2.07, 95% CI = 1.06, 4.05) good knowledge in compare to ≤25 years.Regarding occupation, there was a significant association between farmers and their acceptance of the malaria vaccine (AOR = 3.20, 95% CI = 1.08, 9.49).Participants with more than or equal to five family size were significantly more likely to accept and also had good knowledge about the malaria vaccine than those with fewer than five family size (AOR = 0.43, 95% CI = 0.25, 0.72) and (AOR = 0.59, 95% CI = 0.37, 0.94) (Table
had a business, service holders, and day labourers, respectively.Most of their family income (48.40%) was below 10,000 (Bangladesh taka T A B L E 2 Knowledge regarding malaria infection and vaccination (N = 405).Acceptance of malaria vaccination (N = 405).Contingency table for the knowledge and acceptance category regarding malaria infection and vaccination between northern and southern part of Bangladesh.
T A B L E 4*Means significant.

Table 7
acceptance of the malaria vaccine than those who said no.The likelihood that a person would accept the malaria vaccine was 10.72 and 11.30 times higher in people who lived in homes without windows and open walls (AOR = 10.72,95% CI = 3.66, 31.41) and (AOR = 11.30,95% CI = 3.9, 32.72) than in people who lived in homes with closed windows.Participants who checked the boxes for malaria Association of sociodemographic variables with knowledge and acceptance category regarding malaria infection and vaccination.
a Pearson's χ 2 test.T A B L E 6 Association of malaria-related behavioural and household variables with knowledge and acceptance categories regarding malaria infection and vaccination.
(%) Poor (≤3) n (%) p-Value Adj.OR (95% CI) Good (≥4) n (%) available.Factors such as age group, residence, education level, occupation, and income class influence the knowledge and acceptability of the vaccine.Factors like insecticide usage, house structure, and history of malaria testing also influence vaccination decisions.To ensure the availability of the malaria vaccine, the government should T A B L E 7 (Continued)