High Second Year Immunisation Coverage Alongside Persistent Newer Vaccine Hesitancy: A Mixed-Methods Study in Three Districts of Malawi

Background/Objectives: The Immunisation Agenda 2030 places sustained coverage and vaccine confidence at the centre of immunisation strategy. Less is known about the determinants of sec-ond-year-of-life vaccine uptake in sub-Saharan Africa. This study assessed the completion of vac-cines due after 12 months of age, caregiver confidence in newly introduced vaccines, and the factors associated with completion in three districts of Malawi. Methods: A mixed-methods cross-sectional survey of 1,177 caregivers in Chikwawa, Kasungu, and Mangochi assessed household wealth, food insecurity, and vaccination status. The primary outcome was caregiver-reported completion of all vaccines due after 12 months, assessed among children aged 18 months or older. Associations were examined using logistic regression. Focus group discussions with caregivers and key-informant in-terviews with community volunteers and leaders were then analysed thematically to explain the survey findings. Results: Among 1287 age-eligible children,1212 (94.2%) had completed second-year vaccines. Coverage ranged from about 94% for the measles-rubella vaccine to 61% for the Human papillomavirus (HPV) vaccine. Completion did not differ by household wealth, food insecurity, distance, or caregiver literacy. Health worker reminders were associated with vaccine completion (adjusted odds ratio 0.33, 95% confidence interval 0.17 to 0.62) Infertility concerns about the HPV vaccine were the most commonly reported concern (20.3 %). After excluding age-ineligibility, lack of vaccine awareness was the main reason for children missing newer vaccines. Conclusions: Sec-ond-year coverage was high and equitable. The main modifiable correlate of completion was health worker reminders and follow-up, a function that appears to be under-resourced.