In Malawi, many children miss the measles, polio and typhoid vaccines due at 9 months, but not because their families oppose vaccination. During the first months of life, immunization is reinforced through a steady rhythm of monthly visits to health facilities. But after the early vaccination series ends around 3 months, that rhythm often fades. As fathers shift their focus back to other priorities, the responsibility for managing vaccinations increasingly falls to mothers, alongside household chores, income-generating work and caregiving.
By the time the child reaches 9 months, mothers often have less support to remember upcoming vaccines and fewer interactions with the health system. The late infancy visit can slip past, forgotten. Dropouts at 9 months rarely come down to a single barrier. It was more often a combination of challenges, including previous negative experiences at the health facility, information gaps, competing pressures, and access barriers, stacking up until a family fell off schedule.
Why fathers’ influence is amplified in Malawi
A gender analysis was conducted to understand disparities that could shape immunization uptake. The analysis found that caregivers, particularly in Chikwawa, and heads of household may have limited access to vaccine information. Malawi is a patriarchal society with pronounced disparities between genders; for example, men are more likely than women to be literate and to access media sources. This means that women’s decision-making agency can be limited.
The evidence points to a practical challenge: if household decision-making and information access are unequal, then a strategy focused only on mothers, especially through clinic-based channels, may miss a key determinant of 9-month adherence.
What VillageReach did differently: participatory research that includes heads of household
To understand what was happening at 9 months, VillageReach and the Malawi Ministry of Health conducted a participatory study in Zomba and Chikwawa. Trained peer researchers collected interviews, observations and workshop inputs, engaging caregivers and heads of household of children who were vaccinated on time as well as those who were delayed or missed at the 9-month point, alongside health workers, community influencers and government officials.
Solutions were co-created through ideation workshops and then prototyped and refined through role-plays, storyboarding and feedback sessions.
Engaging male champions in education and mobilization
Among the solutions communities prioritized, one directly addresses the “shared responsibility” gap in late infancy: engage male champions to educate and follow up with fellow heads of household, particularly during male-dominated gatherings, on their critical role in ensuring children receive 9-month vaccinations on time.
This approach is intentionally targeted to the drivers it can plausibly influence: loss of routine cues and reminders, reduced perceived importance of later vaccines and knowledge gaps specific to the 9-month touchpoint, including rumors.
1) Male champion identification
In prototyping sessions, participants emphasized that selection of male champions must be transparent and community-endorsed, because perceived favoritism could undermine trust. One study participant warned: “Issues of favoritism may arise… community members… might not be pleased with the choice by community influencers.”
Participants also noted that relying solely on voting could leave others discouraged, while self-volunteering requires deliberate mobilization because men may not attend gatherings. As another study participant explained: “The volunteering process can be effective, but it requires strong mobilization efforts… because… men are known to rarely participate in such gatherings.”
The refined approach combined what people felt would work: self-nomination, selection by community influencers and community voting.
2) Scripts and messages built for male spaces
Participants tested message delivery through role-play in settings like churches, markets and funerals, and emphasized that male champions must be able to answer questions and address misconceptions.
They also pushed for messages that resonate with fathers’ identity and duty, including protecting children, being recognized as a good father and linking vaccines to household responsibility. One study participant suggested incorporating familiar metaphors such as “Prevention is better than cure” and “No man is an island.”
3) Incentives
Participants were direct that incentives matter for sustaining effort and avoiding burnout or disengagement. As one study participant described the risk: “If they’re busy with other things or don’t see any benefit in being male champions, they won’t want to be in the spotlight or be spoken to disrespectfully.”
Suggested incentives were practical and tied to doing the job well: bicycles for transport, refresher trainings, protective gear during rainy seasons and branded visibility materials like bags.
Designing for reality and setting up for success
This study generated actionable insights grounded in community perspectives and lived realities. The findings point to a clear opportunity: addressing 9-month vaccination gaps in Malawi requires engaging not only caregivers, but also heads of household who influence decisions, information flow and follow-through.
These insights are intended to inform implementers and decision-makers. For the Malawi Ministry of Health, district health teams and partner organizations, this includes considering how approaches like male champion engagement could be adapted, tested and integrated into existing immunization strategies and platforms. For donors and global partners, the research highlights where targeted investments could strengthen late-infancy immunization adherence.
By clarifying who influences decisions at 9 months and how communities themselves propose to address barriers, this work provides a practical evidence base for action. This solution is not about shifting blame onto men but reducing the burden that gender roles can place on mothers, especially in late infancy, when children look stronger, reminders are fewer, and social pressures can take over, through shared responsibility for immunization.
Protecting children from measles, polio and typhoid in Malawi requires engaging both mothers and fathers as active partners in vaccination. This research offers a transferable lesson for regional and global partners. When a schedule includes a long gap with fewer touchpoints, adherence becomes less about what caregivers believe and more about what households remember, prioritize and support. Malawi’s participatory research shows what it looks like to design for reality—with communities, not around them.