Knowledge, perception, and disposition of healthcare workers toward malaria vaccine in Obafemi Awolowo University Teaching Hospital Complex (OAUTHC)

Study design

This study is a cross-sectional study measuring the knowledge, attitude, and disposition of healthcare workers to the malaria vaccine at a point in time.^[20] This design was chosen as it allows for the observation of gaps in vaccine knowledge and the factors that lead to these outcomes, which will form the basis of intervention design. The study employs both descriptive and analytical approaches to achieve its objectives.

Study setting

This study was a single-center study conducted at the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC) in Osun State, Nigeria. The hospital is a 724-bed, tertiary facility with 6 healthcare units. Its primary medical services include anesthesia and intensive care, oral and maxillofacial surgery, radiology, family medicine, and community health.

Ethical consideration

Ethical approval was sought and obtained from the Ethical Committee of Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria (IRB/IEC/Z0004553) and from the University of Sunderland in London Campus Ethics Committee (ref: 029414). Participants were briefed on the study’s purpose and malaria vaccine, and informed consent was obtained online. The study protocol adhered to standard practices. Confidentiality and anonymity of participants were also maintained.

Target population

The population considered in this study is the healthcare workers at the OAUTHC. The hospital employs about 3,034 clinical staff as of November 2023.^[21]

Inclusion criteria

1. Respondent must be a medical doctor, nurse, pharmacist, or physiotherapist

2. For pharmacists, respondents must have a Bachelor of Pharmacy or a Doctor of Pharmacy degree

3. For nurses, respondents must have a Bachelor of Nursing Sciences degree or a higher national diploma in nursing

4. Respondent must be a permanent staff member of OAUTHC.

Exclusion criteria

1. Medical practitioners who are not doctors, nurses, pharmacists, or physiotherapists

2. Age <18 or more than 70.

Sampling technique/sample size

This study followed a convenience sampling approach.^[22] The sample size was determined using the standard formula for a quantitative cross-sectional study. The formula for sample size was given as

Where N = Sample size

P = Prevalence of event

E = Precision of error

D = Design effect

$Z_{\alpha +2}^2$ = 1.96 (for alpha of 0.05).

Although there is a dearth in studies on knowledge of malaria vaccines among health professionals in Nigeria, it is expected to be higher than that of the public and other policymakers.^[23,24] Therefore, a 50% awareness level is expected. Using a 95% confidence interval and a design effect of 1 for simple random sampling, the calculated sample size is given thus.

N = 153⋅664

This value can be approximated to 154, which is the number of respondents to be included in the study.

Data collection and instrumentation

Data collection was carried out between October and November 2023. The data were collected using online structured questionnaires with both open and closed-ended questions developed using Google Forms. The questionnaire is divided into four domains. The first domain covers sociodemographic variables such as age, sex, religion, qualifications, and years of experience. The second to fourth domains covered knowledge of the malaria vaccine, perception, and attitude. It is a semi-structured questionnaire adapted from several peer-reviewed studies.^[25-30] The link to the form was shared on the hospital group and unit social media platforms.

Measurement of variables

Knowledge questions assessed healthcare workers’ awareness, familiarity, and understanding of the malaria vaccine, including their training and self-assessed expertise. Four questions (Q9-Q12) were included under this category:

Responses were scored on a binary scale (e.g., Yes = 1, No = 0) for Q9-Q11. For Q12, a Likert scale was employed, ranging from none = 1 to high = 4. The total possible score for knowledge ranged from 1 to 7, with higher scores indicating greater knowledge. Based on the total scores, respondents were categorized as:

• Low knowledge (1–3)

• Moderate knowledge (4–5)

• High knowledge (6–7).

This approach was informed by previous studies that utilized self-reported knowledge measures to assess healthcare workers’ familiarity with new health interventions.^[6,17]

Attitude questions and scoring

Attitude questions measured healthcare workers’ willingness, readiness, and actions toward recommending or promoting the malaria vaccine. Three questions (Q14, Q15, Q18) were included:

Responses for all three questions were scored on a binary scale (Yes = 1, No = 0). The total attitude score ranged from 0 to 3, with respondents categorized as:

• Negative attitude: 1–2

• Neutral attitude: 3

• Positive attitude: 4–5.

This binary scoring was based on prior research where attitudes toward vaccines were assessed using direct questions about willingness to recommend and support immunization programs.^[18,31]

Data analysis

The data obtained from the online questionnaires was downloaded as a spreadsheet. Data cleaning was done using MS Excel 2021. Thereafter, the data were analyzed using International business machine’s statistical package for the social sciences (IBM-SPSS) version 24. The respondent characteristics, knowledge, and attitude were analyzed and presented as descriptive statistics (frequencies and percentages). Further inferential analyses using Chi-square tests were carried out to determine the association of selected sociodemographic characteristics with knowledge levels and attitudes toward the malaria vaccine [Table 4]. Spearman’s ranked correlation test was used to test the relationship between knowledge and attitude. The results were visualized in charts and tables using MS Excel software.

Data quality control

Before the data collection, the questionnaires were pretested on 5% of the total sample size on healthcare service providers in a different facility, which is not part of the sample population. Based on the findings of the pretest, modifications were made to the data collection instruments.

Sociocultural demographic information

The study surveyed a total of 154 healthcare workers. Due to the method of distribution of the questionnaires, the study had a 100% response rate. The majority of respondents were between the ages of 29–39 years. The study had more female respondents, but the distribution was even among the married and the unmarried. Christianity was the predominant religion among the respondents.

Although the professional distribution was skewed toward pharmacists (64.94%), the respondents’ years of professional experience were diverse, with the largest group having 5–10 years of experience (40.26%). Nearly half of the respondents (43.51%) had been working in the facility for <2 years [Table 1].

Table 2 shows that the majority of the participants (84.42%) had heard of the existence of a vaccine. However, only 11.04% had received any form of malaria vaccine training. Consequently, about 87% reported their knowledge of the vaccine as less than average. Interestingly, 49.35% were not sure of its preventive effect [Table 2].

From Table 3, the respondents report positive attitudes about the malaria vaccine, attesting to its effectiveness and recommending its use. However, the confidence for counseling and health education was low (35.06%) despite 82.47% of respondents agreeing to the necessity of the vaccine. This dissonance between knowledge and need is seen as 82% agreed to the notion that access to training would positively impact attitude and perception [Table 3].

Figure 1 shows the expected challenges to the adoption and administration of malaria vaccine interventions in Nigeria. Chief among these was the lack of education/training. Hesitancy among health professionals was not considered a major barrier by the respondents. However, they still had concerns regarding efficacy, safety, and costs [Figure 2].

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Figure 1:

Perceived implementation challenges for the malaria vaccine program. This figure visualizes perceived challenges that the respondents perceive will be faced during the implementation of the malaria vaccine program in Nigeria.

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Figure 2:

Concerns of healthcare workers regarding the malaria vaccine. As part of the study, the respondents were asked to report concerns regarding the use of the approved malaria vaccines. This bar visualizes the results, allowing for the ranking of perceived concerns.

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A Chi-square test was used to test the association between respondent characteristics and their level of knowledge on the vaccine. None of the sociodemographic variables was significantly associated with knowledge levels [Table 4].

Similarly, a Chi-square test was used to determine the association between sociodemographic variables and the attitude of healthcare workers toward the vaccine. Only religion was shown to have a significant relationship with respondents’ attitudes [Table 4].

Knowledge of healthcare workers on the malaria vaccine

This study aimed to assess healthcare workers’ knowledge of the malaria vaccine. The findings showed that most respondents had limited knowledge of the malaria vaccine. This aligns with previous research identifying significant gaps in understanding among healthcare workers regarding malaria vaccines, especially in sub-Saharan Africa.^[6,17] Although many healthcare workers knew about the existence of malaria vaccines, there was a lack of understanding about their mechanisms of action, effectiveness, and recommended use.

This is concerning, as these professionals are responsible for educating the public, administering vaccines, and advocating for their use.^[32] Healthcare workers may not feel sufficiently prepared to promote the malaria vaccine, which could impede the success of vaccination programs. Conversely, healthcare workers in OAUTHC demonstrated a high level of knowledge about the COVID-19 vaccine, likely due to targeted efforts to educate healthcare workers about COVID-19 vaccination.^[33,34]

High vaccine knowledge has previously been linked to exposure to the disease and vaccination, a pattern observed with older vaccine-preventable diseases such as polio and yellow fever.^[34,35] The respondents also reported a lack of training or involvement in vaccination efforts. Therefore, this study emphasizes the need for targeted educational interventions among health workers. The strong association between healthcare workers’ access to training and their knowledge, perceptions, and attitudes toward the malaria vaccine underscores the urgent need for targeted and equitable training programs. Training should not only address vaccine efficacy and safety but also focus on improving healthcare workers’ confidence in communicating the vaccine’s benefits to patients, paying attention to significant religious influences. An understanding of the vital role healthcare workers’ knowledge plays in ensuring the success of vaccination programs, especially in resource-limited settings like Nigeria, is crucial, as low knowledge levels are directly associated with acceptance and implementation.^[6,17] These interventions should be designed to address misconceptions and behaviors as well as to improve clinical knowledge.

Attitudes of healthcare workers toward recommendation and implementation

Assessing attitudes toward the vaccines, the results show a positive attitude among healthcare workers, particularly regarding their inclusion in the national immunization program. However, they perceive inadequate funding and logistical challenges as major obstacles to the vaccine’s rollout.^[36,37] Cultural barriers and hesitancy among healthcare workers were not regarded as significant [Figure 1]. Previous studies have found generally positive views toward vaccination among healthcare workers, especially in regions with high malaria burdens, suggesting that culture and religion are lesser determinants within this demographic.^[31,38]

Conversely, Bakare reported high levels of hesitancy and low confidence for new vaccines among healthcare workers in Nigeria.^[35] Hesitancy was recognized with newer vaccines such as COVID-19, hepatitis B, and human papillomavirus. This hesitancy was attributed mainly to safety concerns and low understanding of long-term effects, an outcome that was also observed in the present study. Despite expressing strong support for the malaria vaccine, their confidence in discussing the benefits of the vaccine with patients was widely varied. Further analysis showed this attitude to be correlated with knowledge of the vaccine. As in similar studies, the respondents were likely to recommend the vaccine if they believed it to be effective.^[19] In addition, access to training was strongly associated with more favorable perceptions of the vaccine, as trained healthcare workers were better able to understand and advocate for its benefits.

Addressing vaccine hesitancy and safety concerns remains a priority. Evidence-based communication strategies should be implemented to counter misinformation and build trust. Collaboration with religious and community leaders is essential to tailor these campaigns to local cultural and social contexts, particularly in rural areas. In addition, research could focus on assessing the effectiveness of tailored training programs and community engagement initiatives in improving vaccine knowledge and uptake.

Concerns regarding malaria vaccine use and program implementation

The majority of the respondents expressed concerns about the safety of the malaria vaccine, with common concerns including short-term and long-term side effects, efficacy, and insufficient clinical trials. Research on vaccine hesitancy identifies safety concerns as a major factor contributing to reluctance toward vaccine acceptance.^[18,19] Unlike the COVID-19 vaccine, the malaria vaccines have undergone lengthy and thorough clinical trials with proven efficacy and minimal side effects.^[13,39] The existing doubts are further confirmation of poor knowledge of the malaria vaccines [Table 5]. However, as a novel intervention, there is relatively limited data on long-term effectiveness and safety. Efforts to improve vaccine logistics, particularly storage and transportation, are critical. Investments in cold chain systems and outreach infrastructure are necessary to ensure that the malaria vaccine reaches remote regions without compromising its therapeutic potency. Investigating the role of systemic barriers, such as policy inconsistencies and resource constraints, could also provide actionable insights to strengthen vaccine rollout strategies in Nigeria.

Association between sociodemographic variables and knowledge or attitude

The analysis revealed no significant association between age, gender, religion, cadre of professional training, or years of experience with knowledge of malaria vaccine. This could be due to the research criteria that included only medical doctors, pharmacists, nurses, and physiotherapists, professions that have equal access to vaccine information.^[38] Although a higher percentage of respondents with more years of experience had higher levels of knowledge, this difference was not statistically significant (NO_PRINTED_ FORM) (NO_PRINTED_FORM). It can be inferred that since all respondents were educated and within similar earning statuses, wealth and education do not influence knowledge and, by extension, attitude, contrary to evident reports.^[40]

Limitations

Self-selection is a common bias associated with online questionnaires.^[41] It was possible that individuals who did not meet the inclusion criteria filled out the questionnaire. Therefore, the data were cleaned to optimize validity. Another limitation was the cadre imbalance and small subgroup sizes, skewing the data and affecting the ability to run the necessary inferential analysis. Furthermore, this may lead to overrepresentation of respondents with similar views on vaccines.

The single-center focus and the exclusion of primary health care and some allied health professionals limit generalizability.^[42] Although a convenience sample was used, small sample sizes may be acceptable when the effect size under investigation is presumably large or when the researcher aims to determine the presence of an effect only and not the effect size.^[43] In this study, the aim was to identify associations only, making this method suitable for the study.