Vaccination is widely recognised as one of the most effective and cost-efficient public health interventions for reducing morbidity and mortality due to infectious diseases in children under five years of age. Routine immunization programs have prevented countless illnesses (e.g. diphtheria, measles, pertussis, polio, tetanus, neonatal tetanus, Haemophilus influenzae B, rotavirus) and substantially lowered death rates among infants and young children worldwide. The Expanded Programme on Immunization (EPI), launched by the World Health Organization (WHO), has played a central role in this achievement; over 50 years, vaccination against a set of 14 vaccine-preventable diseases has averted an estimated 154 million deaths, including 146 million among children under five years, of whom 101 million were infants under one year [1]. These gains translate into vast improvements in child survival; in the African Region, immunization has contributed more than 50% of the observed decline in infant mortality over the same period [1][2].

Despite these successes, challenges remain. According to the WHO and UNICEF, in recent years global childhood vaccination coverage has held steady but significant numbers of infants still miss doses. In 2024, about 14 million infants remain unvaccinated with even a single dose of “DTP” vaccine [3]. These gaps expose children to risks of vaccine-preventable diseases and threaten the continued health gains made under EPI.

One of the major barriers to achieving high vaccination coverage is vaccine hesitancy. WHO defines vaccine hesitancy as “delay in acceptance or refusal of vaccines despite availability of vaccination services”, influenced by factors such as confidence, complacency, and convenience [4]. In 2019, WHO ranked vaccine hesitancy among the top ten global health threats, noting that although vaccines currently prevent between two to three million deaths per year, improving global coverage could prevent another 1.5 million deaths annually [5][6].

In Sub-Saharan Africa, vaccine hesitancy has emerged as a significant impediment to reaching immunization coverage targets. Cultural beliefs, rumours or misinformation about vaccine safety, lack of trust in health authorities, and low perceived risk of disease are recurrent in many studies. These barriers, combined with access issues, have contributed to outbreaks of measles, yellow fever, pertussis, and other preventable infections [7]-[10].

In Guinea, the Expanded Program on Immunization (EPI) has expanded access to essential childhood vaccines over the decades, supported by partners such as Gavi, WHO, and UNICEF. Coverage has improved, but remains below the targets set by WHO and by Gavi goals. There are substantial disparities across health districts, socioeconomic strata, and urban versus rural areas. Densely populated urban settings, including Conakry, present challenges: high population density, mobility, diversity of population origin, and sometimes strain on health services. The municipality of Matoto, as Conakry’s largest health district, is densely populated and socio-culturally diverse, but the specific determinants of parental hesitancy in Matoto have not been sufficiently studied.

Previous studies in Guinea have identified various contributing factors to low vaccine acceptability: rumours and misinformation, distrust in vaccine safety, low perceived risk of vaccine-preventable disease, limited knowledge or awareness, lack of prenatal care attendance, lack of health infrastructure, and socioeconomic determinants [11]-[14]. However, many of these are from broader surveys or cover national or regional samples, without focusing on Matoto specifically.

Understanding parental hesitancy toward routine childhood vaccination in Matoto is crucial. First, because hesitancy can directly reduce vaccine uptake, undermining herd immunity and exposing children to outbreaks. Second, because tailored interventions (communication, community engagement, service delivery) require knowledge of which factors (educational, geographic, experiential, health system related) are driving hesitancy locally. Finally, densely populated urban districts such as Matoto may have unique dynamics: greater exposure to rumours via media or social networks; greater heterogeneity; variable health service access; and possibly more negative facility experiences due to overload or staff constraints.

Therefore, this study aims to estimate the prevalence of parental hesitancy toward routine childhood vaccination in the Matoto health district, Conakry, Guinea; and to identify the factors associated with this hesitancy. This will provide evidence to guide targeted interventions, strengthen trust in vaccines, improve communication, enhance access and thus improve vaccination coverage and child health in Matoto and similar urban settings in Guinea.

Vaccine hesitancy poses a significant barrier to the efforts of childhood immunization programs, which have nevertheless led to substantial reductions in morbidity and mortality associated with vaccine-preventable diseases. Overcoming this obstacle is therefore essential to increase the uptake of vaccination services, particularly within the context of routine immunization, where parental hesitancy can influence the decisions of parents of children under five years old regarding the vaccination of their children. The objective of this study was to assess the proportion and frequency of parental hesitancy toward routine vaccination of children under five years of age in the Matoto health district of Conakry.

The present study found that the prevalence of parental hesitancy toward routine childhood vaccination in the Matoto health district was 21.1%. This indicates that roughly one in five parents are hesitant to some degree, even when vaccination services are available. Meanwhile, more than 70% of parents strongly agreed on the importance of vaccines for their children (75.82%), and 76.31% strongly agreed with the statement that “vaccines provided by the government are beneficial for their children.” Yet nearly forty percent (39.35%) of parents were neutral with respect to the claim that new vaccines carry greater risks than older ones. These findings highlight both a high baseline acceptance of vaccination, and the presence of ambivalence or uncertainty about risk, especially regarding newer vaccines.

A hesitancy prevalence of approximately 21% aligns with the range reported in other urban or low- and middle-income country (LMIC) settings, although comparisons can be challenging due to differing definitions of hesitancy, vaccine schedules, and survey methods. In Sub-Saharan Africa, systematic reviews of vaccine hesitancy, often centered on COVID-19 vaccines but relevant to routine immunization, indicate that levels can be higher or lower depending on the specific context, access, and trust in the health system [16][17]. About routine immunization, prior surveys in Guinea have documented low rates of full immunization coverage (for example, among children aged 12 - 59 months), with incomplete coverage often linked to limited prenatal care attendance or missing vaccination cards [11]. The high proportion of parents in our study who strongly agreed on the importance of vaccines and on the benefits of government-provided vaccines demonstrates that many parents in Matoto recognize the positive role of vaccination. However, a significant minority remain hesitant or uncertain, particularly regarding the safety of newer vaccines or the risk of potential adverse events.

Regarding the factors associated with parental hesitancy toward routine vaccination of children under five years old, our analysis identified several factors significantly associated with increased hesitancy, and conversely several protective factors.

Parents with no schooling had more than twice the odds of being vaccine hesitant (AOR = 2.21). This aligns with many prior findings showing that lower educational attainment often correlates with reduced knowledge about vaccines, greater susceptibility to misinformation, and lower health literacy. In Guinea, as elsewhere, education has been associated with improved immunization uptake. For example, studies have shown that mothers’ education is a strong determinant of whether children are fully immunized [11]. In populations with low formal schooling, tailored communication strategies (using community health workers, peer educators, local languages, radio or other media) to explain vaccine safety, address rumours, and clarify risk may be especially important.

Having a child who previously experienced an adverse event following immunization markedly increased parental doubts and mistrust (AOR = 2.67). This underscores how personal experience can strongly affect perceptions of vaccine safety, often more than general messaging. Fear of side effects is a common theme in vaccine hesitancy literature globally [16][18]. Therefore, immunization systems need robust surveillance, timely reporting, transparent communication about adverse events following immunization, and concerted efforts to reassure parents about the rarity of serious outcomes and the fact that the benefits far outweigh the risks. Addressing rumors and misinformation is especially critical in this regard.

Residing more than 5 kilometers from a vaccination center was another important factor (AOR = 1.87). This reflects issues of convenience and physical barriers: distance, transportation costs or difficulties, time cost. Even when people believe in vaccines, logistical constraints can reduce uptake or amplify hesitancy if service provision is seen as burdensome [19][20]. Distance > 5 km to vaccination centers being a factor suggests that convenience and physical accessibility remain major constraints. Strategies such as outreach services, mobile vaccination teams, or establishing additional vaccination points in underserved areas may help.

Perceived lack of respect, or other negative interactions with health personnel, were associated with higher hesitancy (AOR = 1.54). Trust in health workers and health services is key, and disrespectful or unwelcoming patient treatment undermines confidence. These findings echo research elsewhere showing that quality of service, patient-provider communication, and perceived dignity strongly influence attitudes towards vaccination [16][21][22]. Negative experiences at health facilities are modifiable. Training health workers in respectful care, communication, listening to parental concerns, minimizing wait times, ensuring availability of vaccines and addressing perceived neglect or disrespect may help rebuild trust, reduce hesitancy [23].

On the protective side, this study found that parents who attended at least four ANC visits had much lower odds of hesitancy (AOR = 0.29). ANC visits are opportunities for health education, building trust, encountering health workers, and gaining knowledge about preventive child health interventions including immunization. Studies in Guinea and elsewhere have consistently shown that prenatal care attendance is positively associated with knowledge, acceptance, and uptake of vaccination [11][22].

Follow-up by qualified health personnel during pregnancy: Being followed by qualified personnel (e.g. trained midwives, nurses, doctors) served as another protective factor (AOR = 0.32). It suggests that the quality and perceived legitimacy of antenatal care matters; skilled providers tend to be more trusted, better able to give accurate information, and more responsive to concerns. The strong protective effect of antenatal care and skilled personnel during pregnancy suggests that maternal health services are key entry points for strengthening vaccine confidence. Interventions that reinforce ANC attendance, improve the quality of provider-client communication during ANC, and use ANC visits to deliver vaccine education could reduce hesitancy.

Giving birth in a health facility was associated with greater adherence to routine childhood vaccination (AOR = 0.49; 95% CI: 0.34 - 0.67). This is consistent with literature indicating that facility births often facilitate early immunization (e.g. at birth for BCG, polio, sometimes hepatitis B), and provide contacts with health staff who can counsel parents [11][24]. Therefore, improving facility delivery rates could have dual benefit: better maternal and neonatal outcomes and improved vaccination uptake. Ensuring that when mothers deliver in facilities, effective counselling is provided on childhood immunization, and that follow-up services (e.g. postnatal visits) are well organized, likely improves vaccine acceptance [25][26].

This study was conducted as part of the master’s thesis in Public Health at Gamal Abdel Nasser University of Conakry. Prior to the commencement of field data collection, the study protocol was reviewed and approved by the Scientific Committee of the master’s Program in Public Health at the university and subsequently registered under number (N˚128/2025). Participation in the study was entirely voluntary, and informed consent was obtained after a clear explanation of the study objectives. The confidentiality of the collected information was strictly maintained: only the research team had access to the data, and participants’ anonymity was preserved throughout the process.

All co-authors contributed to the study design, manuscript drafting, and critical revision. Data collection and analysis were conducted by BI III and TGK under the supervision of NNL.

This research did not receive any external funding. It was carried out as part of a master’s thesis in Public Health at Gamal Abdel Nasser University of Conakry.

The authors express their deep gratitude to the Chair of Public Health and the master’s Program in Public Health at Gamal Abdel Nasser University of Conakry for their valuable technical support. They also wish to thank the health and administrative authorities of the Matoto health district for their assistance, which greatly facilitated data collection in the field. Finally, the authors extend their sincere appreciation to all participants for their availability and invaluable collaboration.