Beyond the pandemic: vaccine hesitancy among youth in rural Malawi as a standing challenge for immunization programming in sub-Saharan Africa - a cross-sectional analytical study

BackgroundVaccine hesitancy among young people in low-resource settings is not a problem that arrived with COVID-19 and departed with it. It is a standing structural challenge that shapes the uptake of every immunization program from routine childhood vaccines to HPV and measles campaigns and that will determine how effectively communities respond to the next epidemic. This study examined COVID-19 vaccine hesitancy among youths aged 18 to 35 years in rural northern Malawi, a population that is systematically under-researched yet critically important for immunization program success. The aim was to generate actionable evidence on the prevalence, demographic predictors, information pathways, and belief-based drivers of hesitancy, applicable to future immunization programming in similar low-resource settings. MethodsA cross-sectional analytical design was employed. Using simple random sampling, 378 participants were recruited from four strategically selected community sites in Nyungwe, Karonga District. Data were collected through structured, pretested, interviewer-administered questionnaires and analysed using IBM SPSS version 26. Descriptive statistics characterised the sample; chi-square tests examined bivariate associations; and binary logistic regression identified independent predictors of hesitancy, adjusting for potential confounders. ResultsVaccine hesitancy was high, affecting 299 of 378 participants (79.1%). Awareness of specific vaccines was moderate: 35% recognised Johnson & Johnson and 34% AstraZeneca, while 31% had never heard of any COVID-19 vaccine. Friends were the dominant information source (40.7%), followed by radio (25.9%), television (24.3%), and WhatsApp (9.0%). Critically, neither vaccine awareness nor information source predicted vaccination status, demonstrating that information exposure alone does not drive uptake. Age was the only statistically significant demographic predictor of hesitancy (OR = 0.60, 95% CI: 0.38-0.94, p = 0.026), with older youths substantially less likely to hesitate. Safety concerns (47%) and perceived personal immunity (30%) were the leading drivers of hesitancy. ConclusionsIn rural Malawi, youth vaccine hesitancy is pervasive, age-differentiated, and driven primarily by trust and risk perception deficits rather than information gaps. These findings have immediate relevance for HPV vaccination programs, measles catch-up campaigns, and future epidemic preparedness in sub-Saharan Africa. Immunization strategies that invest in trust-building, peer-mediated communication, and age-targeted risk messaging are more likely to succeed than those relying on information dissemination alone. This study provides evidence that Malawis health system and its development partners urgently need to design programs that truly reach and persuade the countrys youth.