
==== Front
Nurs Open
Nurs Open
10.1002/(ISSN)2054-1058
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Nursing Open
2054-1058
John Wiley and Sons Inc. Hoboken

10.1002/nop2.70025
NOP270025
NOP-2022-Oct-1783.R3
Empirical Research Quantitative
Empirical Research Quantitative
Community awareness, knowledge and perception about malaria vaccine in the Kassena‐Nankana East Municipality: A descriptive cross‐sectional survey
Mohammed et al.
Mohammed Abdulai 1 2
Bam Victoria https://orcid.org/0000-0003-2780-7579
1 elormbam@yahoo.com
vbbam.chs@knust.edu.gh

Armah Jerry https://orcid.org/0000-0002-8831-4543
1
Kusi‐Amponsah Diji Abigail 1
Lomotey Alberta Yemotsoo https://orcid.org/0000-0001-9028-1739
1
Poku Collins Atta https://orcid.org/0000-0002-5065-3048
1
Budu Hayford Isaac 1
1 Department of Nursing Kwame Nkrumah University of Science and Technology Kumasi Ghana
2 Midwifery Training College Tumu Upper West Region Ghana
* Correspondence
Victoria Bam, Department of Nursing, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
Email: elormbam@yahoo.com and vbbam.chs@knust.edu.gh

02 9 2024
9 2024
11 9 10.1002/nop2.v11.9 e7002513 6 2024
08 11 2022
08 8 2024
© 2024 The Author(s). Nursing Open published by John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Abstract

Aim

To assess community awareness, knowledge and perception of the malaria vaccine.

Design

A descriptive cross‐sectional survey.

Methods

Multistage sampling was adopted in recruiting 400 participants. A structured questionnaire designed based on study objectives guided data collection.

Results

Participants were 18–47 years with a mean age of 30 years. A statistically significant association was observed between socio‐demographic characteristics (age, marital status, religion, education) and the awareness of the malaria vaccine. Majority of the participants (n = 190, 86.4%) said the vaccine was for the protection of children and they perceived that the vaccine would improve children's ability to fight diseases (n = 158, 71.8%), hence should be administered to every child (n = 201, 91.4%). Nurses and other health workers should intensify public education on the malaria vaccine.

Patient or Public Contribution

Caregivers of children in Kassena‐Nankana East Municipality.

caregivers
knowledge
malaria
nurses
perception
vaccine
source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:03.09.2024
Mohammed, A. , Bam, V. , Armah, J. , Kusi‐Amponsah Diji, A. , Lomotey, A. Y. , Poku, C. A. , & Budu, H. I. (2024). Community awareness, knowledge and perception about malaria vaccine in the Kassena‐Nankana East Municipality: A descriptive cross‐sectional survey. Nursing Open, 11 , e70025. 10.1002/nop2.70025
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pmc1 INTRODUCTION

In the last two decades, the upsurge of malaria has sparked a significant amount of scientific and medical research. Millions of people have been affected by malaria, a disease that is of public health importance. Over 247 million people were affected by the illness in 2021 and over 619,000 people died as a result of it, with sub‐Saharan Africa accounting for the majority of cases and fatalities (over 96%), out of which 67% of the mortality cases were children under the age of 5 years (Addai‐Mensah et al., 2019; World Malaria Report, 2022). Interventions including rapid diagnostic tests, microscopic tests and confirmatory diagnosis; the use of long‐lasting insecticide nets and mass campaigns have contributed to the decline of the malaria burden (Aregawi et al., 2017; Jarvis et al., 2019). However, the condition remains a threat, and is of global concern; hence, the introduction of other interventions, such as vaccination could complement existing interventions.

2 BACKGROUND

Malaria has a high mortality rate, especially among children under 5 years in sub‐Saharan Africa. It continues to be one of the most widespread illnesses spread by plasmodium parasites, with a significant morbidity and fatality rate. Plasmodium falciparum and Plasmodium vivax are the primary two species responsible for the majority of the symptoms in humans (Schiess et al., 2020). These plasmodium species are responsible for a wide range of human illnesses, including cerebral malaria and multiorgan failure. In areas where malaria is endemic, like sub‐Saharan Africa, repeated exposure to plasmodium sporozoite inoculations and subsequent blood infections only produce a temporary partial immunity. This immunity progressively builds up over many years of parasite exposure and numerous clinical episodes (Matuschewski, 2017; Zhou et al., 2017).

According to estimates, 20% of children in Ghana have malaria parasites in their blood, and the illness claims the lives of about 2000 people annually, with children under five accounting for around 48% of the fatalities (Aheto et al., 2020). Malaria is a major contributor to absenteeism from school and frequently interferes with children's physical and mental growth (de Jager et al., 2019; King et al., 2015). Adults are also susceptible to the disease's incapacitating effects, which frequently cause them to miss days or weeks of work at a time (Bingham et al., 2012). Due to the illness' huge negative impact on a country's socioeconomic growth and development, it is ideal that the necessary actions be taken to control, or possibly eliminate it. The use of insecticide‐treated bed nets and artemisinin‐based combination therapy, among other recent technological advancements, have significantly reduced the burden of malaria, particularly in terms of morbidity and mortality (Aregawi et al., 2017; Jarvis et al., 2019).

Over the past 70 years, malaria vaccine development has been focused on creating an immunization method that provides protection that is superior to naturally acquired immunity (Matuschewski, 2017). For control and eventual elimination, a malaria vaccine is urgently required. Different strategies are used to either replicate naturally acquired immunity by reducing blood‐stage parasite densities and disease severity, or to produce sterile immunity targeted against pre‐erythrocytic parasites (Nahrendorf et al., 2015). However, the biology of malaria parasites, which go through numerous stages of growth in the human host, and each stage expressing hundreds of distinct antigens, is much more complex than that of the viruses and bacteria for which there are vaccines. Since different antigens are the targets of protective immunity at different stages, it is harder to produce a vaccine for parasites than for viruses and bacteria because of this complexity. This is because an immune response targeting one stage may not protect a subsequent stage (Hoffman et al., 2015). The RTS, S vaccine (also called Mosquirix), is the first and only one that has been shown to considerably lower malaria infection with a favourable safety profile as of now. Preliminary findings from ongoing Phase 3 testing indicate that the most popular pre‐erythrocytic vaccine candidate, RTS,S has a 46% overall efficacy against clinical malaria (Ouattara & Laurens, 2015; Ward et al., 2018) but some side effects have been reported from the clinical trials (Doshi, 2020; WHO, 2019).

To continue to evaluate safety issues identified in the clinical trials, Ghana, Kenya and Malawi have adopted the vaccine and pilot implementation of the RTS, S vaccine is ongoing as a public health intervention, in addition to other interventions to control the disease in these countries. There are, however, other concerns about breach of ethical standards in obtaining informed consent from those participating in the pilot programme (Doshi, 2020; WHO, 2019). Ghana has made great strides in the fight against malaria by significantly lowering morbidity and death from malaria‐related causes. Central, Volta, Ahafo, Bono, Bono East and Upper East are the six regions in Ghana where the vaccine program is being implemented (Adepoju, 2019; Asante et al., 2019). The government aims at eliminating malaria in the country. However, according to studies, the success of a vaccination program depends on community acceptance, which is mostly influenced by the level of awareness and perceptions of the vaccine. There is a higher rate of acceptance when community knowledge and awareness is high (Habersaat & Jackson, 2020; Wilson, 2021). Febir et al. (2013) found from a study in Kintampo, Ghana that the widespread knowledge about the malaria vaccine was responsible for community acceptance as opposed to the Hepatitis B and Haemophilus influenza type B vaccines where the knowledge and acceptance levels were low. This brings to light the importance of conducting a community assessment to determine the success of a vaccination program. Data from the Kassena‐Nankana Municipal Health Directorate (KNMHD) indicates that about 28,047 of a total population of 133,610 were infected with malaria in 2019, with over 90% being children below 5 years (Babayara & Addo, 2018). This study, therefore, aims to assess community awareness, knowledge and perception of the malaria vaccine in the Kassena‐Nankana East Municipality of Ghana.

3 METHODS

3.1 Design

A descriptive, cross‐sectional survey was adopted for the study.

3.2 Setting

The study was carried out in the Kassena‐Nankana East Municipality, with its capital at Navrongo. Kologo, Pungu, Manyoro, Vunania, Navrongo Central, Navrongo East and Wuru are the seven sub‐municipalities that make up the municipality. There are about 29 health facilities in the municipality such as War Memorial Hospital located in the Municipal capital Navrongo which served as the referral centre. Two Health Centers, 17 Community‐based Health Planning and Services (CHPS) compounds, the Navrongo Health Research Centre, a Private Clinic and a Health post are also within the municipality.

3.3 Sampling and sample size

A multistage sampling technique was used for selecting the communities and the participants. Navrongo Central was purposively selected because it was the municipal capital. A simple random sampling technique without balloting replacement was used to select Kologo, Pungu and Vunania sub‐municipals from the remaining six sub‐municipals. A proportionate sampling technique was then used to allocate quota to each sub‐municipal based on the population of children under 5 years as shown in Table 1. At the time of the study, the Navrongo Health Research Center had enrolled 4800 children in the Malaria vaccine programme. This was therefore used as the population in calculating the sample size using Yamane's formula n=N1+Ne2 where n = sample size, N = population of children and e = margin of error. Approximately 10% was added to bring the sample size to 400. This was then distributed based on the relative proportions of the sub‐municipalities in Table 1.

TABLE 1 Selected sub‐municipalities and communities.

Sub‐municipal	Population of children <5 years	Number of communities	Percentage (%)	Sample size	
Navrongo Central	5028	8	40	158	
Kologo	3238	5	25	102	
Pungu	2667	4	21	84	
Vunania	1786	3	14	56	
Total	12,719	20	100	400	

A total of 400 caregivers who satisfied the inclusion criteria were selected for the study. The inclusion criteria were (1) Caregivers of children below the age of 5 years, (2) Caregivers who were 18 years and above. (3) Caregivers who resided in the selected sub‐municipals.

3.4 Data collection and analysis

A structured questionnaire designed based on study objectives guided data collection. The questionnaire which was originally designed in English was translated into Kassim and Nankan languages, and back to English by a translator. The intent was to prevent language as a barrier to some eligible participants from taking part in the study. Six experts in quantitative research reviewed the instrument to ensure that it met its intended use and to ascertain its validity. A pretesting of the instrument was conducted using 20 participants from Wuru. Results from the pretest and expert comments guided the modification of the questionnaire to accurately meet the study objectives. The questionnaires were administered directly by the researchers to participants who were or were not participating in the vaccine program in the selected communities in the study area. All parts of the questionnaires were thoroughly explained to participants to gain their willingness and cooperation to participate in the study. The questionnaires were administered, and translation was done for participants who could not read English. Data collection was between May and July 2021.

The analysis was based on responses from 385 participants. The data were cleaned and entered into the Open Data Kit (ODK) and were double‐checked for errors and corrections. The data was then imported to STATA version 16.0 and analyzed using descriptive and inferential statistics. Descriptive statistics were employed to summarize and present the data in frequencies, mean, mode, standard deviation and percentages. Linear regression analysis aided in making inferences about the population of the study.

3.5 Ethical consideration

Ethical approval was obtained (REDACTED). Administrative approval was also sought from the Upper East Regional Health Directorate before data collection began. To ensure voluntary participation, informed consent was obtained from all participants before proceeding with the data collection. All essential parts of the study including the purpose, risks and benefits were explained to each participant. Their right to withdraw from the study at any point during the study was also explained to them. Participants who agreed to be part of the study were given a consent form to sign or thumbprint. All other ethical principles such as fairness, beneficence and nonmaleficence were ensured.

4 RESULTS

4.1 Sociodemographic characteristics of participants

Table 2 details the socio‐demographic characteristics of participants. The majority of the participants were between the ages of 28–37 years (n = 225, 58.4%) with more than three‐fifth married (n = 232, 60.3%) and Christians (n = 256, 66.5%). With regards to educational status, about two‐fifth had completed tertiary (n = 151, 39.2%). Almost 35% were engaged in private business (n = 134, 34.8%). The majority of the participants had males as their family heads (n = 314, 81.6%).

TABLE 2 Socio‐demographic characteristics of participants.

Characteristic (n = 385)	Frequency	Percentage (%)	
Age (years)	
18–27	52	13.5	
28–37	225	58.4	
38–47	108	28.1	
Marital status	
Married	232	60.3	
Single	109	28.3	
Co‐habiting	24	6.2	
Divorced/separated	20	5.2	
Religion	
Christianity	256	66.5	
Islam	82	21.3	
African traditional religion	44	11.4	
Others (no religion)	3	0.8	
Educational status	
Tertiary	151	39.2	
Secondary education	95	24.7	
Basic education	76	19.7	
No formal education	63	16.4	
Occupation	
Private business (e.g. trading)	134	34.8	
Farming	105	27.3	
Public/Civil Servant	104	27.0	
Others (e.g. housewife)	42	10.9	
Sex of Family Head	
Male	314	81.6	
Female	71	18.4	

4.2 Awareness about the malaria vaccine

Most of the participants had heard of the malaria vaccine (n = 220, 57.1%) and about a quarter had been aware of the vaccine for about two to 3 years (n = 91, 23.6%) as shown in Table 3.

TABLE 3 Awareness of Malaria vaccine.

Characteristic	Frequency	Percentage (%)	
Heard of Malaria vaccine (n = 385)	
Yes	220	57.1	
No	165	42.9	
Duration of awareness of the malaria vaccine (n = 385)	
Up to 3 months	35	9.1	
4 months to 1 year	44	11.4	
2–3 years	91	23.6	
4–5 years	25	6.5	
6 years and above	25	6.5	
Not Applicable	165	42.9	

4.2.1 Association between sociodemographic information and malaria vaccine awareness

As shown in Table 4, respondents' awareness of the malaria vaccine had statistically significant association with age (χ 2 (Df = 3, N = …) =57.47, p < 0.0001), marital status (χ 2 (Df = 3, N = …) =33.08, p < 0.0001), religion (χ 2 (Df = 3, N = …) =31.49, p < 0.0001) and education (χ 2 (Df = 3, N = …) =10.835, p < 0.05).

TABLE 4 Association between socio‐demographic information and Malaria Vaccine Awareness.

Items	Awareness of malaria vaccine n, %	No awareness of malaria vaccine n, %	Chi‐Square (χ 2)	p‐Value	
Age (years)	
18–27	12 (5%)	40 (15%)	57.471	0.001	
28–37	193 (88%)	32 (41%)	
38–47	15 (7%)	92 (44%)	
Marital status	
Married	193 (88%)	39 (24%)	33.083	0.001	
Single	12 (5%)	96 (58%)	
Co‐habiting	8 (4%)	16 (10%)	
Divorced/Separated	7 (3%)	13 (8%)	
Religion	
Christianity	152 (69%)	104 (63%)	31.492	0.001	
Muslim	33 (15%)	49 (30%)	
African Traditional	32 (15%)	11 (7%)	
Others	3 (1%)	0 (0%)	
Educational status	
Tertiary	120 (54%)	31 (19%)	10.835	0.013	
Secondary	57 (26%)	38 (23%)	
Basic	35 (16%)	41 (25%)	
No formal education	8 (4%)	54 (33%)	

4.3 Knowledge of malaria vaccine

Participants' knowledge of the malaria vaccine was assessed (Table 5). More than half of the participants indicated that the vaccine is taken four times (n = 126, 57.3%). The majority of the participants responded that the vaccine is taken within the first six (6) to twenty‐four (24) months (n = 178, 80.9%), and knew that the malaria vaccine was intended to protect children against malaria (n = 166, 75.5%).

TABLE 5 Knowledge of Malaria vaccine.

Characteristic	Frequency	Percentage (%)	
Number of times children receive the malaria vaccine (n = 220)	
Once	39	17.7	
Two times	25	11.4	
Three times	19	8.6	
Four times	126	57.3	
Five times	4	1.8	
More than five times	7	3.2	
Age at which children receive the malaria vaccines (n = 220)	
6 months, 7 months, 9 months and 24 months	178	80.9	
6 weeks, 7 weeks, 9 weeks and 24 weeks	42	19.1	
Purpose of malaria vaccine (n = 220)	
To protect from malaria	166	75.5	
To kill the malaria parasite	31	14.1	
To treat malaria	23	10.4	

4.4 Perception of the malaria vaccine

With regards to the perception of the malaria vaccine (Table 6), almost half of the participants agreed that the same vaccine should be given to older children and adults (n = 106, 48.2%), a little above half agreed that vaccines not given to older children and adults will make the malaria prevalence high (n = 117, 53.2%) and about half disagreed that the vaccines are given monthly (n = 113, 51%). The majority of the participants perceived that the vaccine will improve children's ability to fight diseases (n = 158, 71.8%), the vaccine is for children's protection (n = 190, 86.4%) and should be administered to every child (n = 201, 91.4%). Almost half of the participants agreed that the vaccine had side effects (n = 106, 48.1%), however, the majority of them disagreed that the perceptions of side effects prevented people from taking the vaccine (n = 151, 69.0%). The majority of them perceived that cultural beliefs influenced people's decision to take the vaccine (n = 151, 68.6%) and that taking the malaria vaccine saves money and time spent on treating malaria (n = 196, 89.1%).

TABLE 6 Perception of Malaria Vaccine.

Characteristic (n = 220)	Frequency	Percentage (%)	
The same vaccine is to be given to older children and adults	
Agree	106	48.2	
Disagree	74	33.6	
Neutral	40	18.2	
Vaccines not given to older children and adults will make malaria prevalence high	
Agree	117	53.2	
Disagree	50	22.7	
Neutral	53	24.1	
The vaccines are given monthly	
Agree	46	21.0	
Disagree	113	51.0	
Neutral	61	28.0	
Vaccines will improve children's ability to fight diseases	
Agree	158	71.8	
Disagree	31	14.1	
Neutral	31	14.1	
Children to receive malaria vaccine for protection	
Agree	190	86.4	
Disagree	14	6.4	
Neutral	16	7.2	
Should the malaria vaccine be administered to every child?	
Yes	201	91.4	
No	19	8.6	
Perception of Vaccine's side effects	
Agree	106	48.1	
Disagree	43	19.5	
Neutral	69	32.4	
Perception of Vaccine's side effects is preventing people from taking vaccine	
Yes	69	31.0	
No	151	69.0	
Cultural beliefs influence participants' decision to take the malaria vaccine	
Agree	151	68.6	
Disagree	38	17.3	
Neutral	31	14.1	
The malaria vaccine saves money spent on treatment and hours lost to malaria	
Agree	196	89.1	
Disagree	5	2.3	
Neutral	19	8.6	

4.5 Reasons for vaccinating children against malaria and encouraging other caregivers

Regarding the views of participants encouraging other caregivers to vaccinate their children against malaria as shown in Figure 1, the majority of them responded that they would encourage other caregivers to do so (n = 195, 88.6%). About 80% of the participants responded that their motivation to encourage other caregivers was that the vaccine protects children against malaria (n = 178, 80.9%), and about three‐quarters responded that their motivation was the vaccine's ability to prevent malaria‐related death (n = 162, 73.6%).

FIGURE 1 Reasons participants will vaccinate children and encourage others to vaccinate.

5 DISCUSSION

The current study sought to assess the awareness, knowledge and perception of the malaria vaccine within the municipality. The release of the first malaria vaccine (World Health Organization, 2014) offers an innovative path towards the eradication of the disease in Ghana (Healer et al., 2017), and is expected to have a major impact on child survival (malERA, 2017; World Health Organization, 2022a). The licenced malaria vaccine RTS, S is an important step towards this, and its acceptance and utilization are important to making the dream of eradicating malaria a reality, hence the need for this study.

The results revealed a statistically significant relationship between socio‐demographic information and the level of awareness of the malaria vaccine. This relationship is consistent with findings by Onyekachi et al. (2021), Voo et al. (2021) and Aremu et al. (2022), who also found a similar relationship. This relationship exists because, since socio‐demographic characteristics define a definite group of individuals in a population, the social class of some individuals will more likely expose them to some information about malaria than individuals of other social classes. Also, participants who were married were more aware of the malaria vaccine compared to those not married. This finding is consistent with studies done in Nigeria (Oleribe et al., 2017) and Japan (Kuroda et al., 2022) suggesting that a married participant is more likely to receive and share information with the partner about their children's health. Also, a highly educated participant is more likely to be aware of the malaria vaccine than a participant with a lower‐level education. The awareness level goes a long way to influence the level of acceptance because there is a higher probability of individuals accepting the vaccine if they are aware of the vaccine and its efficacy. This may explain similar findings from Chukwuocha et al. (2018), Tabiri et al. (2021) and Acharya et al. (2018) that revealed that higher education is closely associated with vaccine acceptance.

Knowledge is an important factor in decision‐making as it gives a person much room to examine the pros and cons of a given option, hence, placing the individual in a better position to make an informed choice. The study's results showed that the majority of participants were knowledgeable about the purpose of the malaria vaccine and the intervals at which the children should be given the vaccine. This could be a good sign of people's willingness to accept the vaccine when rolled out. However, evidence from the pilot countries indicate that some children are not brought to the clinic on schedule for the vaccine, and some are also not brought for the last dose (WHO, 2022b), suggesting challenges associated with four‐dose deployment (Greenwood & Doumbo, 2016). Community education on the vaccine will have to be a continuous activity.

Participants had positive perceptions about the malaria vaccine and thought when given to both children and adults, it will reduce the burden of malaria greatly since the disease is a threat to well‐being. This relates with the health belief model that individuals are likely to engage in preventive behaviour to curtail a health problem when such a problem is perceived as a threat (Champion & Skinner, 2008). The positive perception that the vaccine offers protection from the disease, can serve as a major motivator for accepting the vaccine (Achieng et al., 2020; Dimala et al., 2018; Febir et al., 2013) when full‐implementation is rolled out. Health workers must therefore capitalize on the positive perceptions to intensify health education on the vaccines, whiles addressing any concerns on the perceived side effects of the vaccine.

Finally, cultural and religious beliefs were found to be contributing factors that influence caregivers' decision to accept or reject the malaria vaccine. Several studies have also, been conducted over the years concerning the role and impact of cultural and religious beliefs during vaccination programs (Ettarh et al., 2012; Febir et al., 2013; Venturas & Umeh, 2017). This makes it important to assess a community's cultural and religious beliefs to deduce appropriate strategies in rolling out a successful vaccination program. Melillo et al. (2022) also observed from a systematic review that engagement with religious leaders has a valuable impact in influencing mothers' beliefs, and practices, to mobilize them for immunization programs.

6 STRENGTHS AND LIMITATIONS

The study included those whose children were taking the malaria vaccine and other community members; hence, the findings are a fair representation of the community members' awareness, knowledge and perception of the malaria vaccine. The study was however conducted in one municipality which is taking part in the vaccine EPI pilot program hence their views might be different from that of communities that are not participating in the vaccine pilot programme.

7 CONCLUSION AND IMPLICATION

Though the study has established a positive perception about the malaria vaccine, as countries that are in the pilot implementation await the full roll‐out of the implementation of the malaria vaccination program in child welfare clinics as part of the Expanded Programme on Immunization (EPI), caregivers' awareness and readiness to accept the vaccine are crucial for a successful programme. These findings are particularly relevant for nurses and other healthcare professionals who work in communities and deliver vaccines at Child welfare clinics to intensify public education on the malaria vaccine before the full roll‐out of the programme. This is important as most of the caregivers were concerned about the side effects of the vaccine. The major stakeholders should, therefore, design a well‐informed communications plan on allaying the fears associated with the side effects of the vaccine for a successful implementation of the malaria vaccine programme.

AUTHOR CONTRIBUTIONS

AM contributed to the concept and design of the study, collected and analyzed the data; and drafted the manuscript. VB contributed to the concept and design of the study; and drafted the manuscript. JA, AKA contributed to data analysis, critically reviewed and edited the manuscript. AYL, CAP and HIB critically reviewed and edited the manuscript. All authors read and approved the manuscript.

FUNDING INFORMATION

The study was self‐funded by the researchers.

CONFLICT OF INTEREST STATEMENT

All authors have no conflict of interest.

ETHICS STATEMENT

Ethical approval was obtained from the Committee on Human Research, Publications and Ethics (CHRPE/AP/157/21).

ACKNOWLEDGEMENTS

We are grateful to the Kassena‐Nankana East Municipal Health Directorate for the approval to undertake the study and the participants for their voluntary participation in the study.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.
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