Community-level determinants of RTS,S/AS01 vaccine acceptance in a hyperendemic Ghanaian Region: A Bayesian multilevel analysis from Kpando Municipality, Ghana

The successful scale-up of Ghana's RTS,S/AS01 malaria vaccine depends on understanding community-level variation in caregiver acceptance. This study investigates vaccine acceptance and its predictors in a hyperendemic municipality bordering Volta Lake, where geographic and contextual disparities may hinder equitable implementation. A weighted, community-based cross-sectional survey was conducted from November 2023 to January 2024 among 452 caregivers of children aged 6-59 months in Kpando Municipality. Data were collected via structured digital interviews and analyzed using Bayesian multilevel logistic regression to identify individual and contextual determinants, with spatial mapping to visualize geographic disparities. Overall vaccine acceptance was 89.9% (95% CI: 89.2-90.7), with sub-district variation from 41.1% in Agbenorhoe to 100% in several island and rural communities. Among children initiating vaccination, 6.0% received one dose, 17.6% two doses, 10.4% three doses, and 66.0% completed four doses. Booster completion (66.0%) significantly exceeded primary series completion (34.0%, p < 2 × 10 ⁻ ¹⁶). For initial acceptance, bush-surrounded households had higher odds (aOR = 2.69) while vaccine risk concern reduced acceptance (aOR = 0.32). For booster completion, higher household income (1500-1900 GHC: aOR = 3.19; 2000-2400 GHC: aOR = 2.75), older child age (1 year: aOR = 2.27; 2 years: aOR = 2.14), family/peer influence (aOR = 2.09), and perceived convenience (aOR = 1.58) were positive predictors, while bush-surrounded residence reduced odds (aOR = 0.26). Sub-district-level factors explained 85% of variance (ICC = 0.85). Despite high acceptance, sharp spatial disparities and uneven dose completion persist. To ensure equitable coverage as Ghana scales up RTS,S/AS01, interventions must both address initial hesitancy in low-acceptance areas and improve primary series retention by reducing economic barriers and enhancing service convenience in rural communities.