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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Public Health . 2026 Mar 5;26:1192. doi: 10.1186/s12889-026-26904-5 Search in PMC Search in PubMed View in NLM Catalog Add to search Assessment of parental knowledge, attitude, and acceptance toward malaria vaccine for children under five years in Sudan, 2025 Abdelfatah Abdelelah ElZain Hassan Abdelfatah Abdelelah ElZain Hassan 1 Faculty of Medicine, Alzaiem Alazhari University, Ahmed Gasim Street, Khartoum North, Khartoum, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Abdelfatah Abdelelah ElZain Hassan 1, 6 , Nafeesa Abdelgyum Hassan Ali Nafeesa Abdelgyum Hassan Ali 2 Faculty of Medicine, Gezira University, Wad Medani, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Nafeesa Abdelgyum Hassan Ali 2, 6 , Mohamed Abubakr Abdalsalam Elshareef Mohamed Abubakr Abdalsalam Elshareef 2 Faculty of Medicine, Gezira University, Wad Medani, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Mohamed Abubakr Abdalsalam Elshareef 2, 6 , Thoraya Salah Murtada Sidahmed Thoraya Salah Murtada Sidahmed 1 Faculty of Medicine, Alzaiem Alazhari University, Ahmed Gasim Street, Khartoum North, Khartoum, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Thoraya Salah Murtada Sidahmed 1, 6 , Hind Elmukashfi ShamsEldin Elobied Hind Elmukashfi ShamsEldin Elobied 1 Faculty of Medicine, Alzaiem Alazhari University, Ahmed Gasim Street, Khartoum North, Khartoum, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Hind Elmukashfi ShamsEldin Elobied 1, 6, ✉ , Abdelrahman Edris Osman Ali Abdelrahman Edris Osman Ali 3 Faculty of Medicine, Omdurman Islamic University, Omdurman, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Abdelrahman Edris Osman Ali 3, 6 , Dafaalla Abdelmoneim Dafaalla Salih Dafaalla Abdelmoneim Dafaalla Salih 1 Faculty of Medicine, Alzaiem Alazhari University, Ahmed Gasim Street, Khartoum North, Khartoum, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Dafaalla Abdelmoneim Dafaalla Salih 1, 6 , Amal Mahdi Mohammed AL Rahma Amal Mahdi Mohammed AL Rahma 1 Faculty of Medicine, Alzaiem Alazhari University, Ahmed Gasim Street, Khartoum North, Khartoum, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Amal Mahdi Mohammed AL Rahma 1, 6 , Amani Wadalbahar Ahmed Abdallha Amani Wadalbahar Ahmed Abdallha 1 Faculty of Medicine, Alzaiem Alazhari University, Ahmed Gasim Street, Khartoum North, Khartoum, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Amani Wadalbahar Ahmed Abdallha 1, 6 , Areej Mustafa Suliman Hussain Areej Mustafa Suliman Hussain 4 Faculty of Medicine, Sudan International University, Khartoum, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Areej Mustafa Suliman Hussain 4, 6 , Aseel Mustafa Suliman Hussain Aseel Mustafa Suliman Hussain 4 Faculty of Medicine, Sudan International University, Khartoum, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Aseel Mustafa Suliman Hussain 4, 6 , Esraa Yasir Mostafa Mohammed Esraa Yasir Mostafa Mohammed 1 Faculty of Medicine, Alzaiem Alazhari University, Ahmed Gasim Street, Khartoum North, Khartoum, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Esraa Yasir Mostafa Mohammed 1, 6 , Khadija Alamin Hassan Ahmed Khadija Alamin Hassan Ahmed 2 Faculty of Medicine, Gezira University, Wad Medani, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Khadija Alamin Hassan Ahmed 2, 6 , Samar Yousif Mohammed Awadallah Samar Yousif Mohammed Awadallah 5 Faculty of Medicine, University of Sinnar, Sinnar, Sudan 6 Medical Research Group, Khartoum, Sudan Find articles by Samar Yousif Mohammed Awadallah 5, 6 Author information Article notes Copyright and License information 1 Faculty of Medicine, Alzaiem Alazhari University, Ahmed Gasim Street, Khartoum North, Khartoum, Sudan 2 Faculty of Medicine, Gezira University, Wad Medani, Sudan 3 Faculty of Medicine, Omdurman Islamic University, Omdurman, Sudan 4 Faculty of Medicine, Sudan International University, Khartoum, Sudan 5 Faculty of Medicine, University of Sinnar, Sinnar, Sudan 6 Medical Research Group, Khartoum, Sudan ✉ Corresponding author. Received 2025 Jul 21; Accepted 2026 Feb 27; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13072525 PMID: 41787369 Abstract Introduction Prevention methods for malaria include indoor residual spray, insecticide-treated bed nets, and, most recently, vaccines. Given widespread insecticide resistance impacting existing prevention methods, Sudan initiated malaria vaccination in November 2024.This studyaimed to assess parents’ knowledge, attitudes, and acceptance of the malaria vaccine for children under five years in Sudan. Method A descriptive cross-sectional study was conducted in high malaria-burden regions of Sudan from April to June 2025. Using a convenience sampling method,706 eligible parents participated. A structured questionnaire, piloted for reliability (Cronbach’s alpha = 0.741), was administered to gather data on demographics, malaria and vaccine knowledge, attitudes and acceptance. Results Nearly all participants (98.2%) were aware of malaria. However, only 268 (38.0%) participants had heard of the malaria vaccine. Fathers were more likely to be aware of the vaccine than mothers (19.0% vs. 10.7%, p = 0.002). Participants from Kassala (30.6%), those with postgraduate education (11.9%), public sector employees (13.1%), and those with higher monthly incomes (26.9% for > 500 K SDG; p = 0.010) exhibited higher levels of awareness. Conclusion Parents in Sudan had strong general knowledge of malaria but limited awareness of the vaccine. Acceptance was high and influenced by sex, education, income, profession, and residence. These findings suggest a need for targeted awareness campaigns, integration of vaccine information into routine health services, and community-based education strategies to support Sudan’s national malaria program and elimination goals. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-026-26904-5. Keywords: Sudan, Malaria vaccine, children under five, Parental knowledge Introduction Malaria is a life-threatening disease spread through the bites of infected female Anopheles mosquitoes [ 1 ]. It is mostly found in tropical regions like Africa and parts of Asia, which accounted for 94% and 1.5% of the world’s cases, respectively, in 2024 [ 2 , 3 ]. With Approximately 76% of the deaths in Africa occurring among children under five years of age [ 3 ]. It is preventable and curable. The infection is caused by a parasite and does not spread from person to person. Symptoms can be mild or life-threatening. Mild symptoms are fever, chills, and headache. Severe symptoms include fatigue, confusion, seizures, and difficulty breathing [ 4 ]. Malaria remains a substantial global health challenge, with 282 million malaria cases and 610 000 deaths worldwide in 2024, representing 3% and 2% increases, respectively, compared with 2023 [ 3 ]. Major Plasmodium species in Sudan are Plasmodium falciparum (~ 87.6%) and Plasmodium vivax (~ 8.1%) [ 5 ]. Plasmodium falciparum burden is higher in the central region (Khartoum area), the western and southwestern regions (Darfur and South Kordofan), and the eastern regions (Sennar, White Nile, and Al-Gezira), while Plasmodium vivax , which accounts for 10% of the cases in the country, has a higher percentage in the eastern and central states. Plasmodium falciparum incidence peaks follow the rainy season, and Plasmodium vivax peaks afterwards and even extends to the dry season [ 6 ]. Malaria transmission occurs when female Anopheles mosquitoes seek a blood meal to support egg development and, in the process, inject sporozoites into the human host during biting [ 7 ]. Clinical symptoms are brought on by the rupture of infected red blood cells [ 8 ]. Prevention methods for malaria have been developed throughout the years to reduce the disease burden. They include indoor residual spray, insecticide-treated bed nets, and most recently in November 2024; vaccines [ 9 ]. The WHO recommended two malaria vaccines lately: RTS, S and R21 in endemic countries. But with the widespread resistance to pyrethroids in some countries, including Sudan, the efficiency of the current insecticides and bed nets used locally is decreased [ 3 ]. The displacement of people due to the conflict in Sudan contributed even more to the vulnerability of the communities, hence much adverse malaria suffering, especially after more than 70% of health centers went out of service [ 10 ]. Also, national vaccination coverage in Sudan has plummeted from 85% before the war to approximately 50%. In active conflict zones, the rates average around 30% ,encompassing all routine immunizations across the general population, including children under five years of age [ 10 ]. Sudan initiated malaria vaccination in November 2024 to be the first country in the Eastern Mediterranean Region [ 11 ]. The vaccinations started in health facilities in 15 localities in the Gedaref and Blue Nile states, targeting more than 148,000 children. 129 locations around Sudan received the vaccine between 2025 and 2026 [ 12 ]. The efficacy of the R21/Matrix-M vaccine is higher in seasonal sites, with an efficacy of 75%, than in standard sites (i.e.areas where malaria occurs continuously throughout the year, and vaccines are administered according to the child’s age rather than season) at 68% [ 13 – 15 ]. However, this efficacy decreases over time in both seasonal and standard sites [ 15 ]. The child should take 4 doses of the vaccine to have the best protection against malaria. However, the vaccinated children should continue using insecticide-treated nets at night and take other prevention methods [ 16 ]. The two methods of administration are age-based and seasonal. Children aged five to 36 months receive the first dose of the vaccine, which is administered in a three-dose primary series. The fourth dose is administered twelve months after the third dose [ 17 ]. The R21/Matrix-M works by targeting and stimulating high levels of T cell responses against pre-erythrocytic liver-stage malaria antigens. The vaccine also stimulates a high level of antibodies against the sporozoite stage of the parasite life cycle [ 14 ]. Research indicates that knowledge about vaccines plays a critical role in increasing acceptance rates. For example, Amin (2023) and Bongomin(2025) found that individuals with a greater understanding of vaccines are significantly more likely to accept them [ 18 , 19 ]. Factors like monthly income, the source of knowledge about the malaria vaccine, the number of family members, and religious groups have been identified to influence the decision to take the vaccine. One of the major causes of vaccine hesitancy is the availability of other preventive methods of malaria prevention [ 20 ]. In a study, Emmanuel (2024) indicated that the majority of the participants who hesitated to take the vaccine believe that the vaccine has side effects [ 21 ]. Similarly, a study in Bo, Sierra Leone, found that the spread of rumors about the vaccine and fears of hand swelling, fever, nervous system reactions, and general sickness after injection are identified as reasons for avoiding the vaccine [ 22 ]. Conversely, positive factors like prior experience with childhood vaccines, marriage, and strong knowledge about vaccine safety are linked to higher acceptance rates [ 23 ]. In order to support the governmental efforts, it is important to investigate the public perception about the vaccines and develop the upcoming plans in light of the evidence provided by our research. Our study aims to assess parents’ knowledge, attitudes, and acceptance of the malaria vaccine for children under five, identify barriers to vaccination, examine the influence of socio-demographic factors and preventive methods, and compare acceptance rates across different states in Sudan. Since there is a lack of studies that investigate the relationship between knowledge, attitude, and acceptance of parents towards malaria vaccine in Sudan, addressing this gap could identify strategies to improve vaccine acceptance in the region. Methodology Research design This was a cross-sectional study that aimed to investigate the relationship between knowledge, attitude, and acceptance of parents of children under five years regarding the malaria vaccine in Sudan. The study obtained ethical approval from the Ministry of Health Research Ethics Committee, Kassala State, and was conducted in accordance with the Declaration of Helsinki, with written informed consent obtained from all participants at the beginning of the questionnaire. Study area Sudan covers five ecological zones: deserts, coastal areas, savannahs, semi-deserts, and mountains. This leads to extensive differences in malaria transmission. The dry northern part exhibits a low incidence of malaria because of the lack of rainfall coupled with a distance to water sources that would support mosquito reproduction. However, regions adjacent to rivers and irrigated farming areas like Khartoum, Sennar, White Nile, Al-Gezira, Kassala, and Gedaref suffer from high malaria prevalence. Figure 1 [ 6 ]. These states were selected due to their high documented malaria burden, accessibility, and relative security stability, which allowed safe deployment of data collectors. Fig. 1. Open in a new tab Estimated annual incidence of clinical Plasmodium falciparum malaria per 1000 in Sudan for years 2017–2019, Reproduced from Elagali et al., 2022 (Scientific Reports 12:14114), licensed under CC BY 4.0 Sampling technique and sample size A convenience sampling technique was employed due to feasibility, time limitations, and accessibility to the target population. Although convenience sampling carries the risk of selection bias, the following measures were taken to minimize it: Data were collected from diverse locations within each state (urban, peri-urban, and rural communities). Both mothers and fathers were invited to participate. The minimum sample size was calculated using Cochran’s formula [ 24 ], with a 95% confidence level, 5% margin of error, and an expected prevalence of 40% (The choice of p = 0.40 was based on reported awareness/acceptance estimates from comparable Sub-Saharan settings [ 25 , 26 ], also as a conservative estimate in the absence of prior Sudan data. n = z²*P(1-P)/e². n = 380 samples. The final population included 706 participants. Data collection methods and tools Data were collected from April, 2025 to June, 2025, in a community-based setting. A team of interviewers administrated a structured questionnaire in person using mobile devices (tablets and smart phones) connected to Google Forms. This ensured standardized data entry and minimized missing responses. All interviewers were trained and fully briefed on the study purpose, questionnaire content, and all ethical aspects of research involving human participants, ensuring consistent, accurate, and ethically sound data collection. Supervisors also conducted periodic checks to maintain data quality. The Questionnaire consisted of: 1) Consent and eligibility, 2)A custom demographic questionnaire, which consisted of six question items: place of residence, age, educational level, occupation, monthly income, number of family members, 3)Knowledge and experience with malaria; which comprised five question items, 4) Awareness of malaria and the vaccine, 5)Attitude towards malaria vaccine, 6) Factors influencing the parental response to the vaccine, including questions on previous child vaccination history, the use of other preventive methods, family encouragement, etc. The questionnaire was developed for the study by the research team and, some of the questions on knowledge of malaria and willingness to vaccine were adopted form a study in Bangladesh [ 18 ] with modification, and further questions were added for contextual consistency. The questionnaire was prepared in Arabic, the primary language spoken in the study areas. It was translated and back-translated byindependent bilingual experts to ensure linguistic and conceptual equivalence. Apiloting test was conducted on a sample of 50 participants to assess the internal consistency of the questionnaire. Cronbach’s alpha was calculated and yielded a value of 0.741, indicating an acceptable level of reliability.Content validity was assessed by a panel of three public health experts who reviewed the questionnaire for clarity, relevance, and cultural appropriateness.(see the survey questionnaire of the Additional file 1). Data management and analysis Data cleaning: 706 responses remained post applying the response selection criteria (Participants were biological parents (either father or mother) aged 18 years or older who had at least one child under the age of five years. Guardians or other caregivers were excluded to ensure that responses reflected the knowledge, attitudes, and decisions of the child’s legal parent, who is typically responsible for vaccination decisions. All analyses were performed using Jamovi (version 2.6.44; The Jamovi Project, Sydney, Australia). Descriptive statistics were calculated as frequencies and percentages, and the Chi-square test was used to assess relationships between study variables. Results Participants’ sociodemographic All participants (100.0%) reported having a child aged 5 years or younger. The vast majority were mothers (608; 86.1%), while only 98 (13.9%) were fathers. Most resided in Al Jazeera (185; 26.2%), Kassala (170; 24.1%), or Khartoum (165; 23.4%). The average participant age was 30.5 years (SD = 7.2), with ages ranging from 19 to 65 years. Regarding education, 215 (30.5%) had completed high school, and 209 (29.6%) had university degrees, while 76 (10.8%) had no formal education. The majority were housewives (511; 72.4%), and only 119 (16.8%) were employed in either the private or public sectors. Nearly half (340; 48.2%) had a low monthly income (less than 300 K SDG). The average family size was 5.2 members (SD = 2.3), ranging from 1 to 33.(Table 1 ). Table 1. Sociodemographic characteristics of participants Characteristics Overall ( N = 706) Do you have a child aged 5 or younger? Yes 706 (100.0%) What is your relationship to the child? father 98 (13.9%) the mother 608 (86.1%) Place of residence Al Jazeera 185 (26.2%) Gadarif 21 (3.0%) Kassala 170 (24.1%) Khartoum 165 (23.4%) Sennar 92 (13.0%) White Nile 73 (10.3%) How old are you? Mean (SD) 30.5 (7.2) Range 19.0–65.0 Latest academic qualification No formal education 76 (10.8%) Elementary school 154 (21.8%) High school 215 (30.5%) University 209 (29.6%) Postgraduate 52 (7.4%) Profession Private sector employee 46 (6.5%) Public sector employee 73 (10.3%) Daily laborer 34 (4.8%) Housewife 511 (72.4%) No work 17 (2.4%) Other 25 (3.5%) Average monthly income Less than 300 K SDG (Low) 340 (48.2%) 300 K to 500 K SDG (Middle) 216 (30.6%) More than 500 K SDG (High) 150 (21.2%) Number of family members Mean (SD) 5.2 (2.3) Range 1.0–33.0 Open in a new tab Knowledge and experience of malaria among parents In the past 12 months, 502 participants (71.1%) reported having malaria themselves, and 474 (67.1%) reported that their child under five also had malaria. Nearly all participants (693; 98.2%) were aware of malaria. The majority (656; 92.9%) correctly identified mosquito bites as the mode of transmission, while misconceptions were rare—only 8 (1.1%) attributed it to contaminated water and 3 (0.4%) to touching surfaces. Most respondents (543; 76.9%) believed malaria can be fatal (Table 2 ). Table 2. Malaria experience and knowledge among parents of young children Characteristics Overall ( N = 706) Have you had malaria within the past 12 months?/yes 502 (71.1%) Has your child aged five years or younger had malaria in the past 12 months?/yes 474 (67.1%) Do you know what malaria is?/yes 693 (98.2%) How is malaria transmitted? By drinking contaminated water 8 (1.1%) By touching contaminated surfaces 3 (0.4%) Through the bite of an infected mosquito 656 (92.9%) I don’t know 39 (5.5%) Do you think malaria can be fatal?/yes 543 (76.9%) Open in a new tab Awareness, perception, and practice of malaria preventive methods and vaccine among Parents Only 268 participants (38.0%) had heard of the malaria vaccine, mainly through medical staff (133; 18.8%) and family or friends (53; 7.5%). Most (443; 62.7%) were unaware of the vaccine. Knowledge about vaccine dosage was limited, with 565 (80.0%) unsure how many doses are required. Only 27 (3.8%) correctly identified November 2024 as the date of introduction in Sudan. Despite low awareness, 647 (91.6%) believed the vaccine would be effective, and 650 (92.1%) supported its use alongside other preventive methods. However, 220 (31.2%) expressed concern about potential health risks. A large majority (648; 91.8%) reported practicing malaria prevention, primarily using mosquito nets (600; 85.0%) (Table 3 ). Table 3. Awareness, perceptions, and practices regarding the malaria vaccine and prevention methods Characteristics Overall( N = 706) Have you heard of the malaria vaccine?/Yes 268 (38.0%) If yes, through which of the following sources? Television 28 (4.0%) Radio 7 (1.0%) Government publications 5 (0.7%) Medical staff 133 (18.8%) Friend, family member 53 (7.5%) Other 33 (4.7%) I haven’t heard of it 443 (62.7%) How many doses of the vaccine required? Four doses 48 (6.8%) Three doses 42 (5.9%) Two doses 51 (7.2%) I don’t know 565 (80.0%) When was the malaria vaccine introduced and implemented in Sudan? Correct answer: November 2024 27 (3.8%) I don’t know 673 (95.3%) Other wrong answers 6 (0.8%) Do you think the vaccine will be effective against malaria?/yes 647 (91.6%) Do you think we still need a vaccine when other methods of protection exist? (such as pesticides, mosquito nets, etc.)/yes 650 (92.1%) Do you think the vaccine can negatively affect health?/yes 220 (31.2%) Do you apply malaria prevention methods (insecticides, impregnated and unimpregnated mosquito nets, filling shallow water pools, etc.)/yes 648 (91.8%) If yes, what do you use? Pesticides 33 (4.7%) Impregnated and unimpregnated mosquito nets 600 (85.0%) Backfilling shallow water ponds 19 (2.7%) Use mosquito repellent sprays or moisturizers. 36 (5.1%) I don’t use any method. 12 (1.7%) Open in a new tab Parents’ attitude towards malaria vaccine Despite the low awareness level, only 35 participants (5.0%) stated they would not vaccinate their child when the vaccine becomes available, hence a large proportion expressed conditional acceptance. Willingness increased to 94.8% (669) if the vaccine were provided free by the government and to 92.5% (653) if others they knew vaccinated their children. Additionally, 677 (95.9%) said they would encourage family and friends to vaccinate. Nevertheless, 592 (83.9%) were willing to pay for the vaccine, and 632 (89.5%) had previously vaccinated their children. Hesitancy was mainly driven by concerns about side effects (20; 2.8%), perceived sufficiency of other methods like mosquito nets (10; 1.4%), and doubts about effectiveness (5; 0.7%) (Table 4 ). Table 4. Attitudes toward malaria vaccination for children Characteristics Overall ( N = 706) Will you vaccinate your child when the vaccine becomes available?/No If no, what are your reasons? 35 (5.0%) My partner refuses to vaccinate our children 4 (0.6%) I don’t think the vaccine is effective in fighting malaria. 5 (0.7%) We can’t afford it. 2 (0.3%) Concern about side effects associated with the vaccine 20 (2.8%) Other methods such as mosquito nets are sufficient. 10 (1.4%) Other reasons 17 (2.4%) Would you pay money for the vaccine?/yes 592 (83.9%) Have you ever vaccinated your child?/yes 632 (89.5%) Would you vaccinate your child if the vaccine was provided free of charge by the government?/yes 669 (94.8%) Would you vaccinate your child if someone you know vaccinated their child?/yes 653 (92.5%) Would you encourage family members and friends to vaccinate their children against malaria?/yes 677 (95.9%) Open in a new tab Factors associated with malaria vaccine awareness level Hearing about the malaria vaccine was significantly associated with several sociodemographic factors. Fathers were more likely to be aware of the vaccine than mothers (19.0% vs. 10.7%, p = 0.002). Participants from Kassala (30.6%) had higher awareness compared to other regions, while those from Sennar (7.8%) and White Nile (6.0%) had lower awareness ( p < 0.001). Education level was significantly associated with awareness: 11.9% of those with postgraduate education had heard of the vaccine, compared to only 4.6% among the unaware group ( p = 0.004). Profession also mattered—public sector employees (13.1%) and housewives (65.7%) were more likely to be aware compared to others ( p = 0.001). Lastly, a higher income was associated with better awareness; 26.9% of those earning a high monthly income ( more than 500 K SDG) had heard of the vaccine versus 17.8% among those who had not ( p = 0.01). Age showed no significant difference ( p = 0.9172) (Table 5 ). Table 5. Sociodemographic differences between participants who had heard of the malaria vaccine and those who had not What is your relationship to the child? Yes ( N = 268) no ( N = 438) Total ( N = 706) p value 0.002 1 father 51.0 (19.0%) 47.0 (10.7%) 98.0 (13.9%) the mother 217.0 (81.0%) 391.0 (89.3%) 608.0 (86.1%) Place of residence < 0.001 1 Al Jazeera 71.0 (26.5%) 114.0 (26.0%) 185.0 (26.2%) Gadarif 18.0 (6.7%) 3.0 (0.7%) 21.0 (3.0%) Kassala 82.0 (30.6%) 88.0 (20.1%) 170.0 (24.1%) Khartoum 60.0 (22.4%) 105.0 (24.0%) 165.0 (23.4%) Sennar 21.0 (7.8%) 71.0 (16.2%) 92.0 (13.0%) White Nile 16.0 (6.0%) 57.0 (13.0%) 73.0 (10.3%) How old are you? 0.917 2 Mean (SD) 30.6 (7.3) 30.5 (7.2) 30.5 (7.2) Range 17.0–60.0 5.0–65.0 5.0–65.0 Latest academic qualification 0.004 1 No formal education 24.0 (9.0%) 52.0 (11.9%) 76.0 (10.8%) Elementary school 51.0 (19.0%) 103.0 (23.5%) 154.0 (21.8%) High school 80.0 (29.9%) 135.0 (30.8%) 215.0 (30.5%) University 81.0 (30.2%) 128.0 (29.2%) 209.0 (29.6%) Postgraduate 32.0 (11.9%) 20.0 (4.6%) 52.0 (7.4%) Profession 0.001 1 Private sector employee 20.0 (7.5%) 26.0 (5.9%) 46.0 (6.5%) Public sector employee 35.0 (13.1%) 38.0 (8.7%) 73.0 (10.3%) Daily worker 11.0 (4.1%) 23.0 (5.3%) 34.0 (4.8%) Housewife 176.0 (65.7%) 335.0 (76.5%) 511.0 (72.4%) No work 8.0 (3.0%) 9.0 (2.1%) 17.0 (2.4%) Other 18.0 (6.7%) 7.0 (1.6%) 25.0 (3.5%) Average monthly income 0.010 1 Less than 300 K SDG (Low) 114.0 (42.5%) 226.0 (51.6%) 340.0 (48.2%) 300 K to 500 K SDG (Middle) 82.0 (30.6%) 134.0 (30.6%) 216.0 (30.6%) More than 500 K SDG (High) 72.0 (26.9%) 78.0 (17.8%) 150.0 (21.2%) Open in a new tab 1. Pearson’s Chi-squared test 2. Linear Model ANOVA Sociodemographic and health differences based on previous child vaccination status Participants who had vaccinated their child (632; 89.5%) were significantly more likely to reside in Kassala (25.5%) and Al Jazeera (27.2%) compared to non-vaccinators, who were more concentrated in White Nile (23.0%) and Sennar (18.9%) ( p < 0.001). Those who vaccinated their children were older on average (mean age 30.8 vs. 28.5 years; p < 0.013), and had slightly larger families (mean size 5.2 vs. 4.6 members; p = 0.0382). Profession was also significantly associated with vaccination, with non-working individuals more common among non-vaccinators (8.1% vs. 1.7%; p = 0.004). No significant differences were found in education level ( p = 0.5661), income ( p = 0.1251), or malaria history in the past year ( p = 0.5181) (Table 6 ). Table 6. Sociodemographic and health differences based on previous child vaccination status What is your relationship to the child? Yes ( N = 632) no ( N = 74) Total ( N = 706) p value 0.093 1 father 83.0 (13.1%) 15.0 (20.3%) 98.0 (13.9%) the mother 549.0 (86.9%) 59.0 (79.7%) 608.0 (86.1%) Place of residence < 0.001 1 Al Jazeera 172.0 (27.2%) 13.0 (17.6%) 185.0 (26.2%) Gadarif 21.0 (3.3%) 0.0 (0.0%) 21.0 (3.0%) Kassala 161.0 (25.5%) 9.0 (12.2%) 170.0 (24.1%) Khartoum 144.0 (22.8%) 21.0 (28.4%) 165.0 (23.4%) Sennar 78.0 (12.3%) 14.0 (18.9%) 92.0 (13.0%) White Nile 56.0 (8.9%) 17.0 (23.0%) 73.0 (10.3%) How old are you? < 0.013 2 Mean (SD) 30.8 (7.2) 28.5 (7.0) 30.5 (7.2) Range 16.0–65.0 5.0–60.0 5.0–65.0 Latest academic qualification 0.566 1 No formal education 65.0 (10.3%) 11.0 (14.9%) 76.0 (10.8%) Elementary school 139.0 (22.0%) 15.0 (20.3%) 154.0 (21.8%) High school 197.0 (31.2%) 18.0 (24.3%) 215.0 (30.5%) University 186.0 (29.4%) 23.0 (31.1%) 209.0 (29.6%) Postgraduate 45.0 (7.1%) 7.0 (9.5%) 52.0 (7.4%) Profession 0.004 1 Private sector employee 41.0 (6.5%) 5.0 (6.8%) 46.0 (6.5%) Public sector employee 66.0 (10.4%) 7.0 (9.5%) 73.0 (10.3%) Daily worker 32.0 (5.1%) 2.0 (2.7%) 34.0 (4.8%) Housewife 463.0 (73.3%) 48.0 (64.9%) 511.0 (72.4%) No work 11.0 (1.7%) 6.0 (8.1%) 17.0 (2.4%) Other 19.0 (3.0%) 6.0 (8.1%) 25.0 (3.5%) Average monthly income 0.125 1 Less than 300 K SDG (Low) 297.0 (47.0%) 43.0 (58.1%) 340.0 (48.2%) 300 K to 500 K SDG (Middle) 195.0 (30.9%) 21.0 (28.4%) 216.0 (30.6%) More than 500 K SDG (High) 140.0 (22.2%) 10.0 (13.5%) 150.0 (21.2%) Number of family members 0.038 2 Mean (SD) 5.2 (2.4) 4.6 (1.9) 5.2 (2.3) Range 1.0–33.0 1.0–11.0 1.0–33.0 Have you had malaria within the past 12 months? 0.518 1 Yes 447.0 (70.7%) 55.0 (74.3%) 502.0 (71.1%) No 185.0 (29.3%) 19.0 (25.7%) 204.0 (28.9%) Open in a new tab 1. Pearson’s Chi-squared test 2. Linear Model ANOVA Discussion Awareness, perception and practice regarding malaria vaccine among parents of children under five years of age The majority of our respondents were unfamiliar with the malaria vaccine and demonstrated limited understanding of it, including specific details such as the number of required doses and the date of its national launch and implementation. Nonetheless, they exhibited significant perception and acceptability. In line with our awareness versus acceptance pattern, numerous African, malaria-endemic countries showed poor knowledge among caregivers. For instance, caregivers in Tanzania exhibited low awareness. Only 14.7% of caregivers knew about the vaccination; yet willing to vaccinate their children [ 27 ], reflecting the state in our current study. In Cameroon; 60% knewabout the vaccine, although only 26% demonstrated substantial knowledge [ 28 ], raising attention to simply hearing about the vaccine is insufficient. Other Asian countries likewise showed low knowledge level regarding the vaccine among parents and caregivers. In Bangladesh for example, 74% have never heard malaria vaccination [ 18 ]. All three countries in addition to Sudan share a commonality in that vaccination has recently been implemented, accompanied by health and infrastructural difficulties that impede healthcare understanding and accessibility. In contrast, studies from Nigeria have shown mixed levels of awareness and knowledge about the malaria vaccine among mothers of children under five. A 2024 study conducted in Ondo State, a region in southwestern Nigeria, found that 67% of mothers had heard about the malaria vaccine, and notably, half of them were aware of the appropriate age for its administration—indicating not just awareness, but depth of knowledge as well [ 29 ]. However, a 2025 cross-sectional study conducted in North-Central Nigeria reported that 76% of respondents had not heard of the vaccine, despite being in an urban setting [ 30 ]. This contrast may be attributed to regional disparities in health promotion strategies, healthcare infrastructure, and outreach effectiveness. While Ondo State may have benefited from targeted public health campaigns or better access to PHC services and immunization education, the urban area in the North-Central region might lack similar efforts or face challenges related to health communication, trust, or access. These regional differences could play as an important lesson of the Sudanese scene. Additionally, despite the lack of awareness in our population, they showed high perception of the vaccine in terms of its probable high efficacy and low adverse effects, in addition to its necessity with the presence of other preventive measures. This is similar to what has been reported in Ondo, where the majority believed in the vaccination safety, its necessity for children’s well-being, and its role in decreasing malaria incidence among children overall [ 29 ]. The same attitude was reported by Moosa-Buth et al., in Abuja, Nigeria as 91% agreed on the importance of the vaccine in treating malaria [ 31 ]. In contrast, caregivers in Cameroon exhibited a lower attitude. As reported by Abiache et al., only 25% of the population had a positive attitude, despite the fact that 70% agreed on its cruciality for children’s health [ 28 ]. This discrepancy could be explained by the fact that the Cameroon population expressed concerns about the vaccination safety, adverse effects, and showed mistrust in received information, prompting their hesitancy towards the vaccination, which is not the case in our population. Moreover, the majority of our participants also showed acceptance and willingness to vaccinate their children, whether the vaccine was provided free of charge, or paid. We have also noticed that a majority reported willingness to encourage malaria vaccination among family members and friends. Similar results were also found in North-Central Nigeria [ 30 ]. A slightly lower acceptance rate was found in Bangladesh. Amin et al., reported that 70% of the participants would vaccinate their children, and only 61% willing to pay money for the vaccine - compared to the 83.9% in our population -, yet 75% will take it if it was provided freely by the government. And in the same vein, the probability to push others to take the vaccine was lower in Bangladesh [ 18 ]. It is crucial to also address the underlying factors influencing vaccine hesitancy, especially in light of our finding that a small yet noteworthy portion of the population (5%) expressed unwillingness to vaccinate their children once the malaria vaccine becomes available. The primary reason cited was concern over potential adverse effects of the vaccine. This concern is not unique to our study. In Tanzania, Mwingira et al. similarly found that 7.2% of caregivers were hesitant due to a lack of reliable information about the vaccine, including fears regarding side effects and doubts about its efficacy [ 27 ]. A comparable pattern was observed in North-Central Nigeria, where 44% of mothers who were unwilling to vaccinate their children attributed their decision to fear of side effects [ 30 ]. The second most mentioned reason was the perceived sufficiency of existing preventive measures, such as insecticide-treated nets. Same as in Guinea, the number of already used preventive measures made parents less willing to accept the malaria vaccine [ 32 ]. Beyond safety concerns and preventive measures, social and cultural dynamics also played a significant role; for instance, in Ondo State, Nigeria, 39% of mothers stated that their husbands’ refusal wasa key barrier to vaccination [ 29 ]. While this factor was also reported in our study, it affected only a small fraction (0.6%) of respondents. The discussion highlights a striking and consistent pattern in Sudan: a significant gap between low public knowledge of the malaria vaccine and remarkably high levels of acceptance and positive perception. While the majority of the population is unfamiliar with specific details like the number of doses or the official launch date, they nonetheless demonstrate a strong belief in the vaccine’s efficacy, safety, and necessity as a crucial complement to existing preventive measures. Considering the broader Sudanese health system context, the ongoing conflict, which has led to the closure of numerous health centers and disruption of primary healthcare services [ 10 ], likely contributed to the very low awareness levels observed in our population. In the absence of consistent health promotion and structured immunization campaigns, parents may have had limited access to reliable information about new interventions including the malaria vaccine. At the same time, the high acceptance and positive perception we observed could reflect the community’s urgent need for additional preventive solutions in a setting where malaria remains a major burden and health services are often inaccessible. This contrast between low awareness and high acceptability underscores the importance of rebuilding and strengthening communication and delivery platforms within Sudan’s fragile health system to ensure effective vaccine roll-out and sustainability. Sociodemographic differences in awareness and acceptance of malaria vaccine among parents Place of residence, educational background, occupation, and monthly income were all substantially associated with knowledge of the malaria vaccine. The largest percentage of citizens in Kassala State knew about the vaccine; which may reflect higher prior exposure to vaccination campaigns. Knowledge of vaccines was strongly positively correlated with education; those with more education showed greater awareness. It’s also interesting to note that housewives were among the most informed groups suggesting that primary caregivers, who are more directly involved in child health, may actively seek information about vaccines. The Bangladesh study revealed similar findings, showing a significant correlation between vaccine knowledge and educational status and residency in urban areas [ 18 ]. In line with that, our urban participants also demonstrated greater knowledge than their rural counterparts ( p = 0.002). These two factors also positively correlated with level of vaccine acceptance in both Guinea and Sierra Leone [ 32 ]. Another factor that had a positive correlation with vaccine awareness was monthly income.In Guinea and Sierra Leone, income showed inverse relation with acceptance, and no significant correlation with vaccine knowledge in Bangladesh [ 18 , 32 ], which is contrary to our findings; which may indicate that families with higher socioeconomic status have better access to information and healthcare facilities. In Northern Nigeria, caregivers’ level of education, and employment status precipitated better acceptance [ 25 ]. In a deeper manner, we also analyzed the association between having a previously vaccinated child, and socio, health variations, that could also give insights on the facilitating and impeding factors for parents’ attitude and willingness. Geographically, participants who vaccinated their child mostly resided in Gezira and Kassala state, suggestive of previous vaccination is prompting to accept malaria vaccine as evidenced by previously demonstrated higher knowledge in the same states. Moreover, Parents who have successfully vaccinated their children with routine childhood vaccines often develop trust in vaccines and health services, making them more receptive to new vaccines, such as those for malaria [ 33 ]. The findings underscore the variation in factors influencing vaccine knowledge and acceptance among various nations and demographics, and the importance of regarding social determinants of health in advocating for malaria vaccination. Another study conducted in Tiko, Cameroon, which primarily focused on the factors influencing malaria vaccine uptake; identified several key determinants. The likelihood of vaccine uptake was more than twice as high among individuals who reported having access to healthcare services (OR = 2.3; 95% CI: 1.18–4.48; p = 0.020), compared to those who experienced difficulties accessing such services. Even more strikingly, trust in healthcare workers was associated with a sixfold increase in the likelihood of vaccine uptake (OR = 6.12; 95% CI: 2.97–12.61) [ 34 ]. These findings show the critical role of health system accessibility and provider trust in shaping public acceptance and utilization of vaccines. Collectively, they highlight that vaccination knowledge, acceptance, and uptake are influenced by a complex interplay of structural, informational, and social factors. Recognizing and addressing these multifactorial determinants is essential for designing effective, context-sensitive public health interventions aimed at increasing vaccine coverage. To maximize the uptake of the malaria vaccine in Sudan based on our findings, we recommend policymakers must prioritize the population’s high level of trust and positive perception, bridging the gap between the old trusted preventive measure and the newly introduced malaria vaccine, focusing on targeted communicationand last-mile delivery rather than broad awareness campaigns. This involves simplifying public health messaging to provide essential, actionable information about vaccine availability and access points. Furthermore, strategies should proactively address the minor but present concerns about side effects and the perceived redundancy of the vaccine by transparently communicating its safety and its role as a complementary tool to existing preventive measures. Finally, policymakers should leverage the public’s willingness to pay to explore sustainable funding models and invest in strengthening the healthcare infrastructure in underserved regions to ensure equitable and consistent vaccine access for all. Moreover, expanding educational materials and platforms with the current conflict situation is warranted. For example, the use of flyers and posters in PHC centers may not be enough, they should also be distributed in public facilities, and markets will cover larger communities. Lastly, engaging both mothers and fathers in immunization education is essential to address social determinants of vaccine hesitancy due to misconception or side effects, in order to foster long-term acceptance. Limitations The study faced several limitations related to multiple aspects. Firstly, restricted accessibility to some states due to the war circumstances, we had to conduct the data collection in the safe states only. Secondly, convenient sampling technique may promote selection biasas participants who were more available or willing to participate may differ systematically from those who were not included.Also, the data source employed interviewer-administered questionnaires. Participants may have socially desirable biases in responses as a result of providing responses they felt were expected of them instead of their true opinions, especially when responding to more sensitive questions such as their child’s previous vaccination history. Finally, the study did not include multivariate analysis to control for potential confounding variables; therefore, observed associations should be interpreted cautiously, as unmeasured or residual confounding may remain. Conclusion Parents had good general knowledge about malaria, but awareness regarding the vaccine was low. Only 38% knew about the vaccine. However, details like the number of shots were missing. Awareness About the vaccine was influenced by educational level, the parent’s sex (number of knowledgeable fathers were larger), monthly income (higher income was associated with better awareness), region of living and profession (housewives and public sector employees were more aware). People who were aware gained the information primarily from medical staff. Regarding acceptance and readiness, 5% said they would decline the vaccine. Most of them refuse because they believed it will cause some side effects. Al-Jazeera and Kassala states had higher awareness compared to other states in the research. Supplementary Information Supplementary Material 1. (16KB, docx) Acknowledgements The authors would like to express their sincere gratitude to Dr. Hiba Salah Abdelgadir (Family Medicine, Community Medicine Department, Alzaiem Alazhari University, Khartoum, Sudan), and Dr Arig Elias Shabo (MBBS, MPH) for their valuable support in validating the study questionnaire. Abbreviations WHO World Health Organization PHC Primary health care P. falciparum Plasmodium falciparum P. vivax Plasmodium vivax P. malariae Plasmodium malariae P. ovale Plasmodium ovale P. knowlesi Plasmodium knowlesi A. arabiensis Anopheles arabiensis (a mosquito vector) An. Stephensi Anopheles stephensi Authors' contributions AAEH, NAHA, MAAEconceived the idea of this research. AEOA, DADS, AMMA, AWAA, AMSH, AMSH, EYMM, KAHA, andSYMAwere responsible for data collection. Analysis of the data for this study was done by TSMS and AAEH. MAAE wrote manuscript introduction and abstract, HESE wrote the discussion. All authors read and approved the final draft of the manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate The study received ethical approval from the Ministry of Health Research Ethics Committee, Kassala State. It was conducted in accordance with the ethical principles of the Declaration of Helsinki, ensuring respect for participants’ rights and dignity. Written informed consent was obtained from all participants after a detailed explanation of the study’s purpose, with participants given the freedom to withdraw from the study at any time. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Disclosure Statement The interpretation of results was supported by the use of artificial intelligence assistance provided by OpenAI's language model, which aided in drafting and refining the results text. The final interpretations and conclusions presented in this study are the result of the authors' independent analysis. 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