1.1 Background of the study

Vaccination remains the single most effective public-health intervention for preventing childhood morbidity and mortality from vaccine-preventable diseases (VPDs). Yet, coverage is uneven within and between countries: gap pockets — especially in dense urban informal settlements — continue to harbour children who are zero-dose or under-immunized, increasing local outbreak risk (Ali et al., 2022). Vaccine hesitancy, defined as a delay in acceptance or refusal of vaccination despite availability of services, is a complex, time-varying phenomenon shaped by confidence (trust in vaccines and systems), complacency (perceived need), and convenience (access and affordability) — factors that interact with social norms and local information environments to determine behaviour. The WHO’s Behavioral and Social Drivers (BeSD) framework organizes these influences into domains (thinking & feeling; social processes; motivation; practical issues) and provides tools to measure them for programmatic use (World Health Organization, 2022).

The COVID-19 era illustrated how volatile vaccine confidence can be: new safety signals, political events, and the rapid spread of misinformation through social and digital networks caused shifts in attitudes that sometimes spilled over to routine childhood vaccines (Larson, Gakidou, & Murray, 2022). Several studies from urban informal settlements — including longitudinal analyses and mixed-method work — show that hesitancy and missed doses are often higher in slums than in better-served city areas, and that the drivers are a mixture of supply problems (stockouts, inconvenient clinic hours), practical barriers (transport costs, lost wages), and behavioural drivers (fear of side effects, distrust of authorities, circulating rumours) (Rajshekhar et al., 2023; Gichuki, Ngoye, & Wafula, 2024). Makoko is one of Lagos’s most well-known informal settlements: a densely populated, spatially constrained community with a large proportion of housing built on stilts and with limited infrastructure, sanitation and reliable health access — characteristics that typify the vulnerabilities of many urban informal settlements to low timely immunization (Gilbert & Shi, 2023). In such contexts, small clusters of distrust or a widely-circulating rumour can rapidly shift social norms and reduce vaccine uptake across neighbourhood networks; therefore, understanding the local constellation of beliefs, information channels, and practical barriers is essential to designing interventions that reach children on time (Gichuki et al., 2024; Ali et al., 2022). Measuring local behavioural drivers — for example using adapted BeSD survey modules and qualitative inquiry — provides action-able data that can tell programme managers whether to prioritise service-delivery fixes (stock management, outreach timing) or demand-side strategies (trusted messengers, myth-targeting, social-norm interventions) (World Health Organization, 2022; Rajshekhar et al., 2023). In short, to close gaps in Makoko it is not enough to measure overall coverage: managers need granular, caregiver-level evidence on why a child is missed or late so interventions can be targeted and resources used efficiently.

1.2 Statement of the problem

Despite national immunization programmes and periodic outreach in Lagos, children living in Makoko and similar informal settlements remain at disproportionate risk of being incompletely or untimely immunized. Macro-level indicators mask large within-city heterogeneity: systematic reviews and meta-analyses show that vaccine coverage inequality persists across LMICs and that urban-average statistics often hide under-served urban pockets (Ali et al., 2022). Qualitative and mixed-methods research in urban poor settlements documents how caregiver decisions reflect an interplay of knowledge gaps, emotional concerns about vaccine safety, social pressures, and concrete barriers such as clinic hours, transport costs, and stockouts (Gichuki et al., 2024; Rajshekhar et al., 2023). Makoko’s built environment and constrained services — rapid, repeated informal expansion, poor sanitation and limited formal public services — create both greater exposure to VPDs and barriers to accessing routine services (Gilbert & Shi, 2023). Nigerian country-level analyses during the COVID-19 vaccine rollout found that lack of confidence (safety concerns and mistrust) often ranked highest among reasons for non-uptake, while convenience and complacency also played variable roles across regions and demographic groups (Agency for All Project, 2023; Centers for Disease Control and Prevention, 2022). If programme responses are based only on supply metrics (e.g., “we need more clinic hours”) without understanding whether hesitancy stems from mistrust, misinformation, or practical constraints, interventions risk being misdirected and ineffective (Larson et al., 2022; World Health Organization, 2022). Therefore, a focused, locality-specific investigation in Makoko is necessary to (a) estimate the prevalence of caregiver vaccine hesitancy for routine childhood vaccines, (b) identify which behavioural, social and service-level determinants are most influential in this setting, and (c) provide data to design locally-tailored interventions that increase timely uptake and reduce the chance of VPD outbreaks.

1.3 Aim and Objectives of the Study

Aim: To assess the prevalence of vaccine hesitancy and identify individual, social and service-level determinants of hesitancy among caregivers of children under five in Makoko community, Lagos Island LGA, Lagos State.

Specific objectives:

1. To determine the proportion of caregivers in Makoko who express hesitancy toward routine childhood vaccines (delay, refusal, or uncertainty).
2. To describe caregivers’ knowledge, attitudes, perceived vaccine benefits/risks, and primary sources of vaccine information.
3. To identify service-level barriers (clinic hours, stockouts, wait times, staff attitudes) that correlate with caregiver hesitancy.
4. To model socio-demographic predictors of hesitancy (caregiver education, household income, household crowding, parity, and length of residence).
5. To produce programmatic recommendations — grounded in local evidence — for targeted demand- and supply-side interventions appropriate for Makoko.

1.4 Research Questions

1. What proportion of caregivers of children aged 0–59 months in Makoko report vaccine hesitancy?
2. Which knowledge items, attitudes, and primary information sources are associated with hesitancy in Makoko caregivers?
3. Which health-service factors (clinic opening times, stockouts, waiting times, staff attitudes) influence caregiver decisions about routine childhood vaccination in Makoko?
4. Which socio-demographic factors predict higher odds of vaccine hesitancy among caregivers in Makoko?

1.5 Scope of the Study

This study will use a cross-sectional household survey of caregivers and a concurrent facility assessment of immunization services serving Makoko community, Lagos Island LGA. Inclusion: caregivers (biological parent or primary guardian) of children aged 0–59 months who have resided in Makoko for at least six months prior to data collection. Data collection tools will include an interviewer-administered questionnaire (adapted BeSD modules for childhood vaccination) and a simple facility checklist assessing cold-chain, vaccine availability (stockouts), staff availability and clinic hours. A complementary qualitative component (focus groups or key informant interviews) is recommended to contextualize survey findings and explore social norms and information channels in depth. Findings will be reported with operational recommendations for local health authorities and implementing partners.

References

Ali, H. A., Hartner, A.-M., Echeverria-Londono, S., Roth, J., Li, X., Abbas, K., Portnoy, A., Vynnycky, E., Woodruff, K., Ferguson, N. M., Toor, J., & Gaythorpe, K. A. M. (2022). Vaccine equity in low and middle income countries: A systematic review and meta-analysis. International Journal for Equity in Health, 21, Article 82. https://doi.org/10.1186/s12939-022-01678-5

Agency for All Project. (2023, June 26). An analysis of COVID-19 vaccine hesitancy in Nigeria (Research snapshot). Agency for All Project / Breakthrough ACTION. https://agencyforall.coregroup.org/wp-content/uploads/2023/08/Agency-for-All-Nigeria-Buy-in-Research-Snapshot-1_Final.pdf

Centers for Disease Control and Prevention. (2022, August 29). CDC investigates COVID-19 vaccine hesitancy and supports vaccine rollout in Nigeria. U.S. Department of Health & Human Services. https://archive.cdc.gov/www_cdc_gov/globalhealth/stories/2022/nigeria-vaccine-rollout.html

Gichuki, J., Ngoye, B., & Wafula, F. (2024). “I’ll take them another day”: A qualitative study exploring the socio-behavioral complexities of childhood vaccination in urban poor settlements. PLOS ONE, 19(5), e0303215. https://doi.org/10.1371/journal.pone.0303215

Gilbert, K. M., & Shi, Y. (2023). Slums evolution and sustainable urban growth: A comparative study of Makoko and Badia-East areas in Lagos city. Sustainability, 15(19), 14353. https://doi.org/10.3390/su151914353

Rajshekhar, N., Pinchoff, J., Boyer, C. B., Barasa, E., Abuya, T., Muluve, E., Mwanga, D., Mbushi, F., & Austrian, K. (2023). Exploring COVID-19 vaccine hesitancy and uptake in Nairobi’s urban informal settlements: An unsupervised machine-learning analysis of a longitudinal prospective cohort study from 2021 to 2022. BMJ Open, 13, e071032. https://doi.org/10.1136/bmjopen-2022-071032

World Health Organization. (2022). Behavioural and social drivers of vaccination: Tools and practical guidance for achieving high uptake. World Health Organization. https://www.who.int/publications/i/item/9789240049680

Larson, H. J., Gakidou, E., & Murray, C. J. L. (2022). The vaccine-hesitant moment. The New England Journal of Medicine, 387(1), 58–65. https://doi.org/10.1056/NEJMra2106441