Despite progress in fighting malaria worldwide, the parasitic disease kills close to 800,000 people annually . In Kenya, an estimated 27 million people (about 70 percent of the population) are at risk of infection, and roughly 34,000 young children die of malaria-related causes annually . Current interventions in Kenya include the use of long-lasting insecticide-treated nets, indoor residual spraying with insecticides, intermittent preventive therapy with sulphadoxine-pyrimethamine for expectant mothers, and artemisinin-based combination therapies for malaria case management .
Recent advances in malaria vaccine development have heightened the possibility that, if proven effective, a new anti-malaria tool could be deployed for use alongside existing interventions . A vaccine candidate targeting the most life-threatening malaria parasite, Plasmodium falciparum, is moving through a Phase 3 efficacy trial in Kenya and six other African countries--Burkina Faso, Gabon, Ghana, Malawi, Mozambique, and Tanzania . Data from previous studies indicate that this vaccine candidate--GlaxoSmithKline Biologicals' RTS, S--may cut episodes of clinical malaria in young children by about half . If the efficacy trial confirms earlier findings, the World Health Organization (WHO) has indicated that a policy recommendation for RTS, S is possible as early as 2015, paving the way for implementation in countries through their expanded programs on immunization. Final results from the trial are expected in late 2014.
But experience has shown that licensing a new health intervention hardly guarantees its timely use. In developing countries, it has taken up to two decades for new vaccines to become available to communities after they are licensed . Similarly, while the malaria vaccine community's 2015 mark for a first-generation product  may be within reach, the actual introduction and use of a new vaccine could be held up for years because of a variety of factors. For example, the absence of critical data could slow down the process that policymakers must undertake to determine whether or not to introduce a particular intervention into their health systems . In addition, misinformation within communities or poorly handled information by decision-makers could result in an outright lack of support for an intervention by local communities even after it has been introduced .
The formative study described in this paper is meant to address these communications needs. Information gathered is meant to add to the range of well-timed data required by policymakers to reach a decision on whether or not to add a malaria vaccine to their existing methods . The information is also meant to inform the design of a communications strategy, including ways to engage communities well before a malaria vaccine becomes available. This paper presents the results of the study in Kenya within the context of informed decision-making related to future malaria vaccines and with an eye to the elements that should form the basis of a communications strategy, including those factors that potentially motivate or represent constraints to vaccination.
The impetus for this study came from several sources. The wider malaria vaccine community called for this information to help African decision-makers better understand how and whether they should introduce a malaria vaccine for use with other malaria interventions . Responding to this call, in 2006, the PATH Malaria Vaccine Initiative (MVI), WHO, and national immunization and malaria control programs in several African countries outlined the data required to assess the need for such a vaccine . In addition, WHO's framework for new vaccine introduction calls this type of research a key step toward vaccine introduction, as it provides a solid evidence base for, among other things, designing an informed communications strategy . Other experts have also concluded that it is essential to understand the relevant sociocultural context for a new health intervention, such as a vaccine, to be successful .
The relevant literature on immunization programs and services in sub-Saharan Africa highlights the important role of communications. Some research shows that while communities are generally knowledgeable about vaccine-preventable diseases, mothers may lack key vaccination schedule information, such as how many vaccinations their children should receive or by what age they should have completed the course of vaccines . A communications strategy could also take into account any beliefs about disease severity that may influence whether a child is vaccinated.
Other research has pointed to the importance of communications on issues around access to services, such as the distance that some families must travel for vaccination at primary health care facilities  and interactions between vaccination providers and users. A distrustful climate between communities and immunization programs can contribute to growing pools of non-immunized and partially immunized children [13–15]. Recent research also points to the key role that trusted sources or opinion leaders can play in fostering acceptance for vaccination . In this regard, health care providers are themselves seen as important influencers of parents and other caregivers .
With all this in mind, the African Medical and Research Foundation (AMREF) in Kenya worked with MVI to explore sociocultural and health communications issues among individuals at the community level--both those responsible for decisions about vaccine use and those likely to influence such decisions. The study's objectives were also closely tied to the need to identify and describe target audiences and to highlight the relevant beliefs, values, attitudes, knowledge, and behaviors of these audiences prior to the introduction of an intervention . The study therefore had the following specific objectives:
To determine the perceptions, beliefs, practices, and information gaps related to malaria and vaccines among caregivers, service providers, and others at the community level.
To determine household decision-making and treatment-seeking patterns related to malaria and vaccination.
To identify key audiences and communications and information channels at the community level.
Given these objectives, it is nevertheless important to emphasize that this study should be seen as formative in nature. It is meant to inform other studies on perceptions of vaccination in relation to possible malaria vaccine introduction.