Background/Objectives: Vaccines delivered after infancy remain vulnerable to missed uptake. Less is known about the determinants of second-year-of-life vaccine uptake in Malawi. This study assessed the completion of vaccines due after 12 months of age, caregiver confidence in newer vaccines, and associated factors in three districts of Malawi. Methods: A mixed-methods cross-sectional study surveyed 1177 caregivers. Logistic regression examined factors associated with caregiver-reported completion of vaccines due after 12 months among age-eligible children. Focus group discussions with caregivers and key-informant interviews with community volunteers and leaders were then analysed thematically to explain the survey findings. Results: Among 1287 age-eligible children, 94.2% completed second-year vaccines, although coverage of the Human papillomavirus (HPV) vaccine was lower. Distance over 5 kilometres from a facility was associated with lower odds of completion, while health worker reminders were associated with higher odds of vaccine completion (adjusted odds ratio 3.03, 95% confidence interval 1.61 to 5.88). Qualitative accounts highlighted defaulter tracing and infertility concerns about HPV (22.2%). Conclusions: Second-year coverage was high among caregivers reached by immunisation services, but distance and lower uptake of newer vaccines remained important gaps. Strengthening geographical access, communication about newer vaccines, and adequately resourced health-worker follow-up may improve completion.

Introduction: Existing evidence on why children miss vaccines after infancy has focused on the demand side, that is, on the attitudes and circumstances of caregivers. The supply side, meaning the system’s capacity to make vaccines available, accessible, and deliverable, has received less attention, even though it determines whether a willing caregiver can be served. This study examined the supply-side determinants of second-year and newer vaccine uptake in Malawi through a coverage-cascade and bottleneck analysis. Methods: A mixed-methods study drew on one cross-sectional survey with a caregiver component (n = 1177) and a frontline health worker component (n = 453), a data quality assessment of stock records at 37 sites, and key-informant interviews and focus group discussions at community, facility, district and national level. Findings were organised through the Tanahashi coverage framework, which follows the steps from the availability of commodities and staff, through geographic access, to service contact and coverage. Supply-side constraints on uptake were profiled at each step and set against the coverage achieved for each antigen. Results: Coverage fell across the antigen sequence, from 93.4% for the second dose of measles–rubella vaccine and 91.2% for the second dose of inactivated polio vaccine, to 74.6% for the typhoid conjugate vaccine and 61.4% for the HPV vaccine. Stock management was largely in place. Stock records were maintained and reconciled at 35 of 37 assessed sites, and only 4.5% of caregivers who gave a reason for a missed dose named a stockout. Yet 24.8% (95% CI 21.2–28.8) of caregivers (district range 20–35%) reported having ever been turned away because a vaccine was unavailable. Human-resource readiness was weaker, with over half of frontline workers never receiving refresher training. Between 9% and 37% of caregivers, by district, lived more than five kilometres from a facility. Transport was the constraint on mobilisation most often named by health workers (72%). Interviews described outreach as dependent on fuel and external funding. Stock systems worked on paper, but vaccination was less reliably available when caregivers attended. Constraints appeared at this point of contact, in the continuity of outreach and in the maintenance of frontline capacity. National respondents placed these constraints within a financing system that is partly donor-dependent and fragmented across separate partner plans. Conclusions: The supply system delivered the established second-year antigens well. It was less consistent for the newer ones and at the point of contact. Sustaining uptake will require protecting stock at the point of need, resourcing outreach, maintaining frontline capacity, and adapting supply for the newer vaccines.

Background/Objectives: Efforts to improve routine health data often focus on tools and forms, yet data quality depends as much on the organization around the data and the behavior of the people who produce it. The Performance of Routine Information System Management framework separates these technical, organizational, and behavioral determinants. This study applied that framing to routine immunization data in five districts of Malawi, in order to ask not only how good the data were but why. Materials and Methods: A mixed-methods facility assessment measured data accuracy by recounting the third dose of pentavalent vaccine against monthly reports in 50 facilities, of which 44 being the subset that had both reported and verified values. Technical, organisational, and behavioural determinants were assessed through a structured checklist, a survey of data staff, and key-informant interviews, and were interpreted through the framework. The relationship between the determinants and accuracy was examined using a composite readiness score and descriptive comparison. Results: The technical determinants were largely in place, because registers, reporting forms, and the electronic system were available in about 98% of facilities. The organizational and behavioral determinants were weaker. Governance structures were widely present, yet none of ten governance or data-use functions was associated with accuracy. A composite score of the organizational and behavioral determinants showed no association with accuracy (Spearman ρ = 0.22, p = 0.153), so facilities that met almost every condition were no more accurate than those that met few. Staff described audits, supervision, and training as dependent on external funding, and as lapsing under the 2025 withdrawal of that funding. Confidence in the data was high at 91 to 100%, and review before submission was near universal, although accuracy was uneven. The median accuracy ratio was 100%, but only 34 of 44 facilities (77%) fell within the acceptable range, while over-reporting and under-reporting nearly cancelled, leaving the aggregate accurate to within 1%. Conclusions: The technical foundations of the routine data systems were largely in place, but organizational and behavioral mechanisms did not consistently translate these foundations into accurate facility level data. Strengthening routine immunization data quality will require greater attention to how data verification, feedback and corrective actions are routinely implemented and sustained.

Introduction: Existing evidence on why children miss vaccines after infancy has focused on the demand side, focusing on the attitudes and circumstances of caregivers. The supply side, meaning the system’s capacity to make vaccines available, accessible, and deliverable, has received less attention, even though it determines whether a willing caregiver can be served. This study examined the supply-side determinants of second-year and newer vaccine uptake in Malawi through a coverage-cascade and bottleneck analysis. Methods: A mixed-methods study drew on a caregiver survey, a survey of frontline health workers, a facility checklist and data quality assessment, and key-informant interviews at facility, district, and national level. Findings were organised through the Tanahashi coverage framework, which follows the steps from the availability of commodities and staff, through geographic access, to service contact and effective coverage. Supply-side constraints in uptake were profiled at each step and set against the coverage achieved for each antigen. Results: Effective coverage fell across the antigen sequence, from 95.9 percent for the second dose of measles-rubella vaccine and 93.1 percent for the second dose of polio vaccine, to 74.6 percent for typhoid, to 63 percent for HPV. Commodity availability was high, with cold chain and vaccines present in every checklist facility, and stock records in 47 of 50, yet a quarter of caregivers had been turned away due to stockouts. Human-resource readiness was weaker, with over half of frontline workers never receiving refresher training. Geographic access constrained a fifth of caregivers, and outreach, though present everywhere, was limited by fuel and, in staff accounts, reduced by the 2025 withdrawal of external funding. The bottleneck was not commodity availability but the contact step and the maintenance of frontline capacity. National respondents placed these constraints within a financing system that is partly donor-dependent and fragmented across separate partner plans. Conclusions: The supply system delivered the established second-year antigens well and faltered for the newer ones and at the point of contact. Sustaining uptake will require protecting stock at the point of need, resourcing outreach, maintaining frontline capacity, and adapting supply for the newer vaccines.

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.