Research | Open Access | Volume 9 (4): Article 184 | Published: 10 Nov 2026
Menu, Tables and Figures
Djiba Diakité1,&, Sidikiba Sidibé1,2, Fodé Bangaly Diakité3, Sékou Solano3, Hadja Fanta Camara1, Abdoulaye Barry4, Alexandre Délamou1,2
1Faculty of Sciences and Health Techniques, Gamal Abdel Nasser University of Conakry, Conakry, Guinea, 2CEA-PCMT_Faculty of Sciences and Health Techniques, Gamal Abdel Nasser University of Conakry, Conakry, Guinea, 3World Health Organization, Country office, Guinea, 4Health District, Tougue, Ministry of Health and Public Hygiene, Guinea
&Corresponding author: Djiba Diakité, Faculty of Sciences and Health Techniques, Gamal Abdel Nasser University of Conakry, Conakry, Guinea, Email: djibadiakite943@gmail.com, ORCID : https://orcid.org/0000-0003-4496-8366
Received: 02 Aug 2026, Accepted: 09 Nov 2026, Published: 10 Nov 2026
Domain: Infectious Disease Epidemiology
Keywords: Delayed or non-vaccination, children, associated factors, Health district, Guinea
©Djiba Diakité et al. Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cite this article: Djiba Diakité et al., Factors associated with delayed or non-vaccination among children aged 0–23 months in a rural health district in Guinea: A mixed-methods cross-sectional study. Journal of Interventional Epidemiology and Public Health. 2026; 9(4):184. https://doi.org/10.37432/jieph-d-26-00285
Introduction: Vaccination is a major public health investment and plays an essential role in reducing mortality. This study aimed to explore the factors contributing to delayed or non-vaccination of children aged 0-23 months in the Tougue health district in Guinea.
Methods: This mixed-methods, cross-sectional study collected data on vaccination of children aged 0 to 23 months from mothers/caregivers, community and religious leaders, fathers of children, and vaccinators, and observed child vaccination sessions. A questionnaire, interview guides and an observation grid were used. Logistic regression analysis was performed and adjusted odds ratios (aORs) and their 95% confidence intervals (CIs) were reported. The significance level was set at p < 0.05.
Results: The proportion of children aged 0-23 months who were delayed or unvaccinated was 46.7% (95% CI: 41.8-51.7). Mothers/caregivers who could not read or write (aOR = 1.78; 95% CI: 1.05-3.01), children aged 12-23 months (aOR = 1.93; 95% CI: 1.23-3.03), mothers/caregivers with a low knowledge of vaccination (aOR = 2.13; 95% CI: 1.34-3.40), mothers/caregivers who had not received vaccination advice from health workers (aOR = 1.64; 95% CI: 1.05-2.57) and those who their peers did not influence (aOR = 2.76; 95% CI: 1.64-4.63) were the factors associated with delayed or non-vaccination of children.
Conclusion: This study shows that around half of all children are delayed or unvaccinated. Targeted interventions on these key factors could improve the quality of immunization service provision.
Vaccination helps to immunise individuals by boosting the body’s immune system and reducing the risk of contracting specific infectious diseases [1]. Immunization is one of the major investments in global health and plays a key role in achieving 14 of the 17 Sustainable Development Goals (SDGs). It is one of the broadest health interventions and is fully in line with the SDG philosophy of “leaving no one behind” [2]. Routine immunization plays a key role in significantly reducing childhood morbidity and mortality from vaccine-preventable diseases. It saves 4.4 million lives worldwide every year [3]. If optimal vaccination coverage is achieved, vaccine-preventable deaths among children could be reduced by 1.5 million [4].
According to estimates by the World Health Organization (WHO), 96% of children visiting healthcare facilities for treatment missed their vaccination. Global coverage with the third dose of diphtheria, tetanus and pertussis (DPT3) vaccine has remained at approximately 80% since 2006, indicating that about one-fifth of children worldwide have not received the third dose of DPT vaccine [5]. The number of children receiving no dose of DPT rose from 13.9 million in 2022 to 14.5 million in 2023. In 2023, the first dose of measles vaccine was administered to 83% of children in routine services [6]. According to WHO/UNICEF estimates, in West and Central Africa, the percentage of children who received no DPT vaccine and children who received the first dose but not the third dose of DPT was 22% and 11%, respectively [7]. Several studies have been published in the literature on routine vaccination of children under the age of two. The proportion of unvaccinated or insufficiently vaccinated children varies from one region to another. It was 29.2% in a rural area in southern India [8], 32% in Bangladesh [9] and Brazil [10]. In sub-Saharan countries, the proportion was 14.5% in Tanzania [11], 32.4% in Sierra Leone [12], 40.8% in South Africa [13] and 63.3% in Gambia [14].
The main factors contributing to low immunization coverage among children are lack of access to vaccination services, missed opportunities to be vaccinated during medical check-ups, and reluctance to be vaccinated [15,16]. Several studies in sub-Saharan Africa have explored the factors that influence children’s vaccination in routine services [17–20]. These factors are intra-individual, such as knowledge, attitudes and perceptions [19,20]; interpersonal influences [17–19]; health system factors [19,20]; community factors [18,19]; and political factors, including free vaccination services and vaccine supply [19,20].
In Guinea, only 24% of children aged 12-23 months had received all the basic vaccines at the time of the survey, and 19% had received them at the appropriate age. Around 22% of children aged 12-23 months had not received any Expanded Program on Immunization vaccines [21]. The percentage of children under one year of age who received no dose of DPT and who were insufficiently vaccinated were 38% and 15%, respectively [7]. This situation creates a backlog of unvaccinated children, leading to epidemics of vaccine-preventable diseases such as polio, measles, yellow fever, diphtheria and Pertussis.
Tougue Health District is not exempt from this situation, having suffered two pertussis outbreaks in December 2023 and March 2024. Around 85% of children who contracted pertussis were not vaccinated or were insufficiently vaccinated with the pentavalent vaccine. This shows that under-vaccination of children is an issue that the health district should address to improve the health status of children. To understand the factors influencing routine child immunization, we conducted this study to explore the factors associated with delayed or non-vaccination of children aged 0-23 months in the Tougué Health District.
Study design, setting and participants
This was a mixed-methods cross-sectional study, combining quantitative and explanatory qualitative approaches, conducted in the Tougué health district, located in the Labé region of Guinea, from 15 September to 10 October 2024. It is located 521 km from the capital, Conakry and covers an area of 6,400 km2. In 2024, its population is estimated at 165,537, including 90,588 women [22]. Tougue health district covers 10 health areas, including 09 rural and one urban. Its rugged terrain makes access to many health facilities difficult. The study district is predominantly rural and comprises one urban commune and nine rural communes. The study areas were classified as urban or rural based on their official administrative status.
The study included mothers/caregivers and fathers of children aged 0–23 months, community and religious leaders, and vaccinators, while child immunization sessions were also observed; participants who had resided in the district for at least six months and provided informed consent were eligible for inclusion. As this study was conducted as a routine operational evaluation, ethical approval was not required; however, all participants provided verbal informed consent before participation.
For the quantitative approach, in each health area, three levels of sampling were carried out, covering villages (level 1), households (level 2), and mothers/caregivers and their children aged 0 to 23 months (level 3).
At the first stage, a list of all villages in rural areas and neighbourhoods in urban areas within each health area was established and sequentially numbered. Three villages/neighborhoods were selected by simple random sampling from each health area. The selection of three villages/neighborhoods per health area was primarily determined by the limited financial resources available for the study, which was entirely self-funded by the health district. This approach aimed to ensure minimum geographical coverage of the different health areas while remaining compatible with the available resources. The localities were classified as urban or rural according to their administrative status. At the second stage, 15 households were randomly selected in each selected village. At the third stage, a child aged 0 to 23 months and their mother/caregiver were randomly selected in each selected household. The sample size was determined by the standard formula:
N = sample size;
\(Z\alpha\) = 1.96 for a risk of error \(\alpha\) = 0.05;
p = vaccine coverage at 50% (maximum size);
q = 1 – p = 0.50;
i = precision set for this study = 5%.
The sample size was increased to 400 based on 40 mother/caregivers-child pairs per health area. For household selection, the interviewer positioned themselves at the centre of each selected village/neighborhood, which served as an easily identifiable reference point and allowed the starting point of data collection to be standardised across the different localities. From this point, the interviewer tossed a pen vertically into the air to determine the initial direction of the route. The direction indicated by the tip of the pen when the pen landed was used as the starting direction. The interviewer then proceeded in this direction, and the first household encountered was selected as the starting household for the survey. From this household, interviewers proceeded along the right-hand side of the route. The right-hand side was chosen as a standardised field procedure to ensure that all interviewers followed the same household selection approach and to minimise subjective decisions regarding which side of the route to follow. Every other household was selected until the required number of households was reached. At the end of the route, interviewers turned right and continued the selection procedure using the same approach.
If more than one eligible mother/caregiver–child pair was present in a selected household, one pair was selected by simple random selection. If the selected mother/caregiver had more than one eligible child, the youngest child was selected. If no eligible mother/caregiver–child pair was present in a selected household, the next household was approached. Data were collected by trained interviewers using a pre-tested structured questionnaire administered directly to mothers/caregivers in Pular (predominant local language), Malinké, French, or Soussou. The questionnaire took approximately 25–30 minutes to complete.
For the qualitative approach, in each health area, a selection of mothers/caregivers were invited to participate in focus group discussions (FGDs). In addition, one father of children included in the quantitative component of the study, one community or religious leader and one vaccinator per health area were selected for in-depth interviews (IDIs). For the observation of child vaccination sessions, each surveyor observed a child vaccination session, using an observation grid to assess vaccinators’ attitudes and practices towards the children’s parents. Items included welcoming parents, interpersonal communication (importance of vaccination, target disease against which the child is being vaccinated, possible adverse effects of vaccines, attitude of the caregiver in the event of adverse effects, appointment date for the next vaccination, disease against which the child will be vaccinated, establishment of the vaccination record, importance of complete immunization, asking parents if the message has been understood or if they have any questions about vaccination). Ten interviewers trained for three days collected quantitative data over a period of seven days within the overall study period (15 September to 10 October). The researcher supervised all activities. Data were collected using mobile technology via the KoboToolbox server. All field data collection activities were supervised by the researcher.
The questionnaire, observation grid, individual in-depth interview (IDI) guide, and focus group discussion (FGD) guide have been added as supplementary appendices.
Variables of study
Dependent variable: The dependent variable in this study was delay or non-vaccination of the child. Children who were unvaccinated or delayed in their vaccination calendar were coded as “1”. Children whose vaccination status was up to date were coded “0”. In this study, delayed vaccination was defined when a child had not received a vaccine dose at the age recommended in the routine vaccination calendar, with a grace period >15 days after the due date.
Vaccination status was assessed at the child level, based on the vaccines and doses received compared with the recommended vaccination schedule. The vaccines assessed included DPT-HepB-Hib doses 1–3, Measles-Rubella vaccine 1, and Measles-Rubella vaccine 2. Children who had received none of the assessed vaccines were classified as non-vaccinated, while those who received the relevant vaccine dose(s) after the recommended age or schedule were classified as having delayed vaccination.
Age-appropriate vaccination benefits from a grace period established based on previous studies [23–25]. We checked the children’s immunization status on the basis of health records or vaccination cards. Non-vaccination was recorded when the child had no document or other proof of vaccination.
Independent variables: For the independent variables, we used the socio-ecological model. The socio-ecological model is one of the theories of behaviour change that examines how population health is influenced by individual, interpersonal, organisational, community and political factors [19,26,27]. In addition to some of the tools used in the literature, the WHO guide “Practical tools and advice for achieving high vaccine uptake” [28] was used to develop the questionnaire and observation grid to understand the factors contributing to delayed or non-immunization of children. Individual-level factors include knowledge, attitudes, beliefs/perceptions, level of education, autonomy, time constraints and socio-demographic characteristics of mothers/caregivers and children (age, literacy, occupation, residence, child’s sex). Interpersonal factors include social support (family, friends, peers). Organizational-level factors include the availability, accessibility and affordability of vaccination services, and incentives. In addition, we checked health worker coverage, attitudes and advice towards parents of children for routine immunization. Community-level factors include the influence of community and religious leaders, community awareness and the availability of community resources. Policy-level factors include free immunization services, the supply of vaccines and other inputs, and the provision of immunization documents (health record or immunization card).
For routine childhood immunization, two antigens are administered at birth (BCG and Oral Polio Vaccine [OPV 0]), two antigens at 6 weeks of age (DPT-HepB-Hib 1 and OPV 1), two antigens at 10 weeks (DPT-HepB-Hib 2] and OPV 2), and three antigens at 14 weeks (DPT-HepB-Hib 3, OPV 3, and Inactive Polio Vaccine). At 9 months, two antigens are administered (Measles-Rubella vaccine 1 and Yellow Fever vaccine), and two additional antigens are scheduled from 15 months of age (Measles-Rubella vaccine 2 and Meningococcal A vaccine). Therefore, children aged 12–23 months may have received all vaccines scheduled up to 9 months, while Measles-Rubella vaccine 2 and Meningococcal A vaccine are due from 15 months of age. The pentavalent vaccine protects against five diseases: diphtheria, pertussis (whooping cough), tetanus, hepatitis B, and Haemophilus influenzae type b (Hib) infections [29]. The data collection tools, observation checklist, interview guides, and requested vaccination schedule are provided in the appendices.
Data analysis
Data management and analysis were performed using Stata 16 software. Data were collected using a questionnaire administered through the KoboToolbox platform, in which questions were configured as mandatory to minimise missing values. After the data were exported to Excel, data completeness was checked before statistical analysis. No missing values were identified in the variables included in the analysis, and therefore no imputation procedure was required. Knowledge scores were generated based on five items: knowledge of the importance of vaccination, vaccine-preventable diseases, vaccine side effects, age of start and end of vaccination calendar. Each correct answer was assigned one point. The knowledge score was calculated by summing the points obtained for all knowledge questions. The mean knowledge score in the study population was used as the cutoff: scores below the mean were classified as poor knowledge, whereas scores equal to or above the mean were classified as good knowledge. In this study, the mean score was 8; therefore, knowledge was classified as poor for scores <8 and good for scores ≥8. Results were presented as frequencies and proportions for qualitative variables, and means (with standard deviation) for quantitative variables. We performed an analysis using Pearson’s Chi 2 test to compare proportions. Multicollinearity between explanatory variables was checked using the variance inflation factor (VIF).
Explanatory variables with a p-value < 0.20 in the bivariate analysis were considered for inclusion in the multivariable logistic regression model. This threshold was chosen instead of the conventional 0.05 threshold to avoid excluding potentially relevant variables at the preliminary selection stage. Associations observed in bivariate analyses may change after adjustment for other variables, and variables that are not statistically significant in bivariate analyses may still contribute to the multivariable model, particularly as potential confounders. This approach is consistent with methodological recommendations for variable selection in logistic regression [30]. To compare models and assess goodness of fit, we used the Akaike Information Criterion (AIC). A smaller AIC value indicates a better-fitting model [31]. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported. Statistical significance was defined as p < 0.05. The data recorded during the interviews were transcribed verbatim in French. All qualitative data were anonymized prior to analysis. A deductive thematic analysis based on the framework of the socio-ecological model was used with NVIVO 12 software. Emerging themes were explored, and analysis revealed trends and key ideas. For the observation grid scoring, points ranged from 0 (if the item was not addressed) to 3 (if the item was fully addressed). The points for the various items were summed up and the results expressed as a percentage (less than 50% = Poor; 50-69% = Fair; 70-89% = Acceptable; 90-100% = Very Good).
Ethical considerations
This was a routine operational evaluation aimed at improving the quality of child immunization services in the health district, and no ethical approval was required. Before starting the survey, authorization for data collection was obtained from the Tougue administrative and health authorities. All participants were informed of the objectives of the study, the anonymous nature of the survey and gave their prior verbal informed consent. There was no financial compensation for participating in the study.
Quantitative section
Description of the characteristics of mother/caregivers-child pairs
The study involved 394 mothers/caregivers and their children. The average age of the mothers/caregivers was 27.3 (±5.8) years, and the average age of the children was 10.6 (±6.3) months. Those aged 25 years and over represented 69.0% of the participants, and 77.2% of the mothers were not literate. Children aged 0-11 months represented 61.2% of the sample, and 55.6% of the children were female. Around 90.4% of children lived in rural areas (Table 1).
Mothers/caregivers’ knowledge of vaccination
The importance of vaccination was known by 84% of mothers/caregivers. The most frequently cited diseases targeted by vaccination were Poliomyelitis (71.6%), measles and tuberculosis (34.0%), tetanus (31.0%) and meningitis (30.5%). Fever (80%) and crying (50%) were the most frequently cited vaccine side effects. Nearly 90% of mothers knew the age at which vaccination should begin, and only 20% knew the age at which vaccination should end. Around 65.0% of mothers had little knowledge of vaccination (Table 2).
Description of interpersonal, institutional, community and political influences on vaccination
Nearly a third (32.7%) of mothers/caregivers were not autonomous in deciding whether to vaccinate their children, and in 90.9% of cases, the husband made this decision. Two-thirds of mothers/caregivers said their family had positively influenced them, and 96% by their peers. If they missed an appointment, 67.0% of mothers/caregivers were reminded by health workers. More than half (57.9%) of mothers/caregivers said they had received advice on vaccination from health workers. Only 11.7% of mothers said they had been turned away when their child was vaccinated. More than half (58.9%) of mothers were influenced by religious or community leaders, and 43.6% reported a lack of community awareness about vaccination. Almost all (99.5%) reported that child immunization was free of charge, and only 14.7% had not received an immunization document for their child (Table 3).
Prevalence of delayed or non-vaccination among children aged 0-23 months
In our study, 16% were not vaccinated with Pentavalent vaccine 1, 38% were not vaccinated with Pentavalent vaccine 3, 45% were not vaccinated with Measles-Containing Vaccine 1 (MCV), and 59% were not vaccinated with MCV 2. The proportion of children aged 0-23 months who were delayed or unvaccinated was 46.7% (95% CI: 41.8 – 51.7).
The proportion of delayed immunization was higher among mothers/caregivers who could not read or write (51%, p = 0.004) and among children aged 12-23 months (53%, p = 0.048), compared with children aged 0-11 months. This proportion was higher among mothers/caregivers with a low level of knowledge about vaccination (52%, p = 0.002). Mothers/caregivers who reported no influence from family members (53.79%, p = 0.045) or peers (63.37%, p < 0.001) had the highest proportions of children with delayed vaccination. Mothers of children who had not been contacted in the event of a missed appointment (66%, p <0.001) and those who had not received vaccination advice from agents (55%, p = 0.006) had the highest proportions of late or unvaccinated children. For the other variables, there were no statistically significant differences between the different modalities (Table 4).
Reasons for delayed or non-vaccination of children
The reasons given by mothers/caregivers for delaying or not vaccinating their children were forgetting the date of the vaccination appointment (27%), fear of vaccine side effects (26%), mothers travelling with their child (12%), lack of information about vaccination (9%), lack of time (7%), vaccination site far away (6%), child illness (5%), and few children to open a vaccine (4%).
Factors associated with delayed or non-vaccination of children
Mothers/caregivers who could not read or write (aOR = 1.78; 95% CI: 1.05-3.01) were more likely to be delayed or not vaccinated than mothers who could read or write. Children aged 12-23 months (aOR = 1.93; 95% CI: 1.23-3.03) were more likely to be delayed or unvaccinated than children aged 0-11 months. Children of mothers/caregivers with low immunization knowledge (aOR = 2.13; 95% CI: 1.34-3.40) were more likely to be delayed or not immunized than children of mothers with high immunization knowledge. Mothers/caregivers whose peers did not influence (aOR = 2.76; 95% CI: 1.64-4.63) were more likely to delay or not vaccinate their children. Mothers who had not received immunization advice from agents (aOR = 1.64; 95% CI: 1.05-2.57) were more likely to delay or not vaccinate their children than those whose mothers had received immunization advice (Table 5).
Qualitative section
Characteristics of participants
We organized 10 FGDs with mothers/caregivers (n = 72, 6-8 participants per FGD), 30 IDIs (10 IDIs with fathers of children, 10 IDIs with community and religious leaders, 10 IDIs with vaccinators) and observation of 10 vaccination sessions. We grouped the concepts identified in our analysis into five themes in line with the framework of the socio-ecological model, namely: intrapersonal, interpersonal, institutional, community and political.
Intrapersonal factors
The participants mentioned several individual factors that influence children’s vaccination. These included knowledge, perceptions, and neglecting or forgetting appointments. Most participants had a good understanding of the importance of vaccination. On the other hand, some said that lack of information, the displacement of mothers and parental illiteracy had a negative influence on child immunization.
Although some diseases such as measles, polio, meningitis and yellow fever are well known, participants had limited knowledge of other vaccine-preventable diseases, vaccine side effects, and the age at which vaccination should be stopped. This limited knowledge is a barrier to the complete vaccination of children.
While most participants were aware of the most common vaccine side effects (fever, crying), some felt that the fear of the child becoming ill after the vaccine was administered was an obstacle to vaccination. Most of the mothers surveyed believe that a child’s vaccination ends before his or her first birthday.
Another individual factor that participants mentioned as important was forgetting the date of vaccination appointments.
“If a child is vaccinated against measles, even if pimples come out on his body, it won’t be serious. And if a child is vaccinated against tetanus, even if he hurts himself, it won’t be serious. These are all advantages of vaccination.” FGD_MOTHERS
“Vaccination is affected by mothers’ movements and lack of information.” FGD_MOTHERS
“I can’t read and the appointment is in the notebook.” IDI_FATHER
“Vaccine-preventable diseases include measles, yellow fever, polio and meningitis.” FGD_MOTHERS
“Measles, yellow fever, tuberculosis, meningitis, malaria and diarrhea.” FGD_MOTHERS
“When a child is vaccinated, the body becomes hot, the area swells and the child cries.” FGD_MOTHERS
“Vaccination ends at 9 months of age.” FGD_MOTHERS
“Mothers often forget the date of their children’s vaccination appointment.” FGD_MOTHERS
“Peers and friends vaccinate their child.” FGD_MOTHERS
“No one contacts me for the child’s appointment.” FGD_MOTHERS
“Some mothers don’t have the cost of the medicine to give their child in the event of illness after vaccination. For this reason, they prefer not to send it.” FGD_MOTHERS
Interpersonal factors
In our study, participants discussed the influence of family, friends and peers on children’s vaccination. All participants were unanimous that the husband decides whether or not to vaccinate his children.
The participants revealed that in their localities, households are in favour of vaccinating children to protect them against diseases.
“Our concern is that if the children take the vaccines, the game swells and the abscess develop.” IDI_FATHER
“My husband authorizes the child’s vaccination.” FGD_MOTHERS
Institutional factors
Participants discussed the impact of institutional factors on child immunization. Some facility-related factors included geographic and financial access, which had an impact on vaccination. Other health worker factors included lack of appointment reminders and insufficient communication when vaccinating children.
“If you travel for miles and are told to come back another day, because you need a certain number of children to open the vaccine, it’s discouraging.” FGD_MOTHERS
“Help us to have the means of transport for advanced strategies and refrigerators for storing vaccines.” IDI_VACCINATOR
“I’ve been unmotivated since I’ve been here, I haven’t received any bonuses.” IDI_VACCINATOR
“Some parents feel that when their children are vaccinated, they will suffer adverse reactions and this creates reluctance.” IDI_VACCINATOR
Community factors
Participants discussed the impact of community awareness and the role played by community and religious leaders. This analysis shows that leaders and awareness positively influence parents’ use of vaccination services. Analysis shows that customs and habits are favourable to vaccination.
“Community leaders influence us, but in a positive way, they accompany us.” FGD_MOTHERS
“Provide community relays with means of transport to reach the most remote families.” IDI_ COMMUNITY_LEADER
“Customs and habits do not influence vaccination, and here everyone sends their children for vaccination.” FGD_MOTHERS
Political factors
Participants described the crucial importance of free vaccination services in health facilities and providing vaccination documents. However, some stressed the need to review the multi-dose vial policy in order to facilitate the use of vaccination services. For this volunteer vaccinator, he stresses the need to motivate them financially to make it easier for them to carry out their activities.
For some participants, health centres need to be equipped with refrigerators, and health workers need to be equipped with motorcycles for advanced strategies.
“The State must make individual vaccines available, one child = one dose.” FGD_MOTHERS
Observation of child vaccination sessions
We observed ten (10) vaccination sessions. During the vaccination sessions observed, none of the health workers asked the children’s parents whether the message communicated about vaccination was understood. The importance of complete vaccination was discussed in 21% of cases, the target diseases for the child’s next vaccination in 29% of cases, and the side effects of the vaccines administered to the child in 38% of cases.
This study aimed to explore the factors associated with delayed or non-vaccination of children aged 0-23 months in the Tougue health district of Guinea. Nearly half of children aged 0-23 months were late or unvaccinated. This result is higher than that of studies carried out in Tanzania (14.5%) [11] and Sierra Leone (32.4%) [12]. On the other hand, it was lower than in Gambia (63.3%) [14] and Ethiopia (65%) [32]. In our study, fear of vaccine side effects, forgetting the date of the vaccination appointment, lack of familiarity with the vaccination calendar and the frequent travel of mothers with their children were the reasons given for delaying or not vaccinating children. These reasons are consistent with those of a study carried out in a district in Ethiopia [33]. In addition, insufficient collaboration with the community when planning immunization activities using advanced strategies has a negative impact on child immunization.
Mother/caregiver literacy, child age, peer influences, mother/caregiver knowledge, and receiving immunization advice from health workers were factors associated with delayed or non-vaccination of children. Children aged 12-23 months were more likely to be delayed or not vaccinated than those aged 0-11 months. This result is similar to that of the study carried out in Burkina Faso [34]. This association could be explained by the fact that in our study, 80% of mothers/caregivers did not know the age at which vaccination had ended, and for most of them, the child’s vaccination ended before their first birthday.
Mothers/caregivers who were not literate were at risk of delayed or non-vaccination of their children. This result is similar to that of a similar study carried out in the Jigjiga district of Ethiopia, where maternal literacy was associated with full child immunization [33]. Few parents who cannot read or write could initiate communication with health care providers, understand messages or remember what they were told. In our study, 77% of mothers/caregivers were not literate. Yet literacy makes it easier to understand the messages conveyed to increase the use of health services and improve health-promoting behaviors. As a result, non-literate women may be unaware of the consequences of not vaccinating their children.
Low levels of immunization knowledge among mothers/caregivers were positively associated with delayed or non-vaccination of children. Several studies have shown that children’s parents’ level of knowledge about vaccination impacts demand for child immunization services [19,20,35–38]. In our study, 65% of mothers/caregivers had low knowledge of child immunization. Increased awareness and health education are needed to improve immunization knowledge.
Mothers/caregivers who did not receive vaccination advice from health workers were more likely to delay or not vaccinate their children in our study. Other studies have shown that inadequate communication between health workers and caregivers during the provision of care was an obstacle to the complete vaccination of children [39,40]. Communication is essential for caregivers to adhere to different health care services [39,41,42], including child vaccination. Observation of the various vaccination sessions revealed that no healthcare providers had asked the children’s mothers or caregivers if they had any concerns or questions about their child’s vaccination. In addition, vaccination service providers did not communicate sufficiently with the children’s parents about the diseases targeted by vaccination, the possible side effects of vaccines and the importance of full immunization. Yet effective communication is needed to reduce vaccine hesitancy in a population where the majority can neither read nor write.
Peers positively influenced mothers to vaccinate their children. Several studies have shown the impact of relatives, friends and neighbours on child vaccination [18,19,43,44]. Parents’ attitudes to vaccinating their children are influenced by the environment in which they live. In our study, the majority of participants mentioned that their friends or relatives were in favour of vaccinating their children.
In addition to these factors, there is poor planning of advanced strategy activities, which are often carried out without community participation. According to the WHO, the “Reach Every District” strategy is key to achieving sustainable and equitable increases in immunization coverage rates [45]. Its strategies are good planning and management of resources, access to all eligible populations, collaboration with communities, positive supervision, monitoring and use of data for action. These strategies should be the cornerstone of all immunization activities.
Our study has certain limitations. Most responses are self-reported and could be influenced by social desirability factors or recall bias. Another limitation of the study is that respondents were selected from a single district of Guinea and cannot fully represent the situation in the country. Although the study district is predominantly rural, it includes one urban commune and several rural communes; the inclusion of participants from the urban commune may affect the representativeness of the findings when interpreted as reflecting exclusively rural populations. The household selection procedure may have introduced selection bias, as the route-based approach may have underrepresented households outside the selected trajectory. This study does not allow us to establish a causal link between the associated factors and the delay or non-vaccination of children. Despite these limitations, this research offers insightful results for understanding the factors that contribute to delayed or unvaccinated children aged 0-23 months.
This study, the first conducted in the Tougué health district, identified several factors associated with delayed or non-vaccination among children aged 0–23 months. Nearly half of the children were delayed in receiving their vaccinations or were unvaccinated. Low maternal/caregiver literacy, limited knowledge about immunization, older child age, lack of peer influence, and inadequate communication between health workers and parents were statistically associated with delayed or non-vaccination. However, these associations should be interpreted with caution and do not establish causal relationships.
These findings have important implications for immunization programs and policies. Within available resources, vaccination services should strengthen communication with parents through simple, culturally appropriate messages, particularly regarding the vaccination schedule and the importance of keeping vaccination appointments. Health workers could also benefit from strengthened skills in interpersonal communication and immunization counseling. Community-based follow-up of children who miss vaccination appointments should be strengthened, including simple reminder and tracing mechanisms for children who are delayed or unvaccinated. In the longer term, interventions aimed at improving education and health literacy among girls and women could help strengthen their ability to understand and adhere to their children’s vaccination schedules. These context-appropriate and feasible measures could contribute to improving timely vaccination and reducing delayed and non-vaccination in the Tougué health district.
What is already known about the topic
What this study adds
The authors would like to thank the management team of the Tougue health district for taking the initiative and facilitating the implementation of the study.
List of abbreviations
AIC: Akaike Information Criterion
aOR: Adjusted Odds Ratio
BCG: Bacillus Calmette–Guérin
CI: Confidence Interval
DPT: Diphtheria, Pertussis and Tetanus
FGD: Focus Group Discussions
IDI: In-Depth Interview
MCV: Measles-Containing Vaccine
Ref: Reference Category
SDG: Sustainable Development Goal
UNICEF: United Nations Children’s Fund
VIF: Variance inflation factor
WHO: World Health Organization
Conceptualization: Djiba Diakité, Sidikiba Sidibé, Fodé Bangaly Diakité
Methodology: Djiba Diakité, Sidikiba Sidibé, Fodé Bangaly Diakité
Data Curation: Djiba Diakité and Sidikiba Sidibé
Formal Analysis: Djiba Diakité, Sidikiba Sidibé, Fodé Bangaly Diakité
Investigation: Djiba Diakité and Sidikiba Sidibé
Funding Acquisition: Djiba Diakité and Sidikiba Sidibé
Project Administration: Djiba Diakité, Sidikiba Sidibé
Resources: Djiba Diakité, Sidikiba Sidibé
Software: Djiba Diakité and Sidikiba Sidibé
Validation:Djiba Diakité and Sidikiba Sidibé, Sékou Solano, Hadja Fanta Camara, Abdoulaye Barry, Alexandre Délamou
Visualization: Djiba Diakité and Sidikiba Sidibé, Hadja Fanta Camara, Abdoulaye Barry
Supervision: Alexandre Délamou
Writing – Original Draft: Djiba Diakité, Sidikiba Sidibé, Fodé Bangaly Diakité, Sékou Solano
Writing – Review & Editing: Djiba Diakité, Hadja Fanta Camara, Abdoulaye Barry, Alexandre Délamou
Table 1: Characteristics of mothers/caregivers and children, Tougue health district, 2024 (n = 394)
| Variables | Frequency | % |
|---|---|---|
| Age of mother/caregivers (years) | ||
| 15–24 | 122 | 31.0 |
| 25 or more | 272 | 69.0 |
| Mother’s/caregiver’s occupation | ||
| Housewives | 335 | 85.0 |
| Other activities | 59 | 15.0 |
| Mother/caregiver can read and/or write | ||
| No | 304 | 77.2 |
| Yes | 90 | 22.8 |
| Age of child (months) | ||
| 0–11 | 241 | 61.2 |
| 12–23 | 153 | 38.8 |
| Sex of child | ||
| Female | 219 | 55.6 |
| Male | 175 | 44.4 |
| Residence | ||
| Urban | 38 | 9.6 |
| Rural | 356 | 90.4 |
Table 2: Knowledge of mothers/caregivers about child immunization, Tougue health district, 2024 (n = 394)
| Variables | Frequency | % |
|---|---|---|
| Knowledge of the importance of vaccination | ||
| No | 63 | 16.0 |
| Yes | 331 | 84.0 |
| Knowledge of diseases targeted by vaccination | ||
| Tuberculosis | 134 | 34.0 |
| Poliomyelitis | 282 | 71.6 |
| Diphtheria | 26 | 6.6 |
| Pertussis | 103 | 26.1 |
| Haemophilus influenzae | 5 | 1.3 |
| Hepatitis B | 27 | 6.8 |
| Tetanus | 122 | 31.0 |
| Measles | 135 | 34.3 |
| Meningitis | 120 | 30.5 |
| Knowledge of the adverse effects of vaccines | ||
| Crying | 198 | 50.3 |
| Fever | 317 | 80.5 |
| Refusal to suck | 31 | 7.9 |
| Redness at injection site | 25 | 6.3 |
| Swelling at injection site | 81 | 20.6 |
| Abscess | 32 | 8.1 |
| Vomiting | 35 | 8.9 |
| Diarrhea | 29 | 7.4 |
| Knowledge of age at start of vaccination | ||
| No | 40 | 10.2 |
| Yes | 354 | 89.8 |
| Knowledge of age at which vaccination ends | ||
| No | 314 | 79.7 |
| Yes | 80 | 20.3 |
| Knowledge of mothers/caregivers about vaccination | ||
| Low | 256 | 65.0 |
| Good | 138 | 35.0 |
Table 3: Interpersonal, institutional, community and political influences on vaccination, Tougue health district, 2024 (n = 394)
| Variables | Frequency | % |
|---|---|---|
| Request authorization to vaccinate the child | ||
| No | 129 | 32.7 |
| Yes | 265 | 67.3 |
| Who gives authorization to vaccinate the child | ||
| Husband | 241 | 90.9 |
| Mother- or sister-in-law | 15 | 5.7 |
| Other family members | 9 | 3.4 |
| Influence of family | ||
| No | 132 | 33.5 |
| Yes | 262 | 66.5 |
| Influence of peers | ||
| No | 17 | 4.3 |
| Yes | 377 | 95.7 |
| Reminder for missed appointments | ||
| No | 130 | 33.0 |
| Yes | 264 | 67.0 |
| Receives vaccination advice from health workers | ||
| No | 166 | 42.1 |
| Yes | 228 | 57.9 |
| Distant vaccination site (>5 km) | ||
| No | 97 | 24.6 |
| Yes | 297 | 75.4 |
| Being turned away at the vaccination site | ||
| No | 348 | 88.3 |
| Yes | 46 | 11.7 |
| Influence of religious and community leaders | ||
| No | 162 | 41.1 |
| Yes | 232 | 58.9 |
| Community outreach on vaccination | ||
| No | 172 | 43.6 |
| Yes | 222 | 56.4 |
| Vaccination free of charge | ||
| No | 2 | 0.5 |
| Yes | 392 | 99.5 |
| Vaccine availability during vaccination | ||
| No | 31 | 7.9 |
| Yes | 363 | 92.1 |
| Receive vaccination documents | ||
| No | 58 | 14.7 |
| Yes | 336 | 85.3 |
| Variables | No delay in vaccination (n = 210) | Delayed vaccination (n = 184) | p-value | ||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Intra-individual factors | |||||
| Age of mother/caregivers (years) | |||||
| 15–24 | 60 | 49.2 | 62 | 50.8 | |
| 25 or more | 150 | 55.2 | 122 | 44.9 | 0.272 |
| Mother’s/caregiver’s occupation | |||||
| Housewives | 172 | 51.3 | 163 | 48.7 | |
| Other activities | 38 | 64.4 | 21 | 35.6 | 0.064 |
| Mother/caregiver can read and/or write | |||||
| No | 150 | 49.3 | 154 | 50.7 | |
| Yes | 60 | 66.7 | 30 | 33.3 | 0.004 |
| Age of child (months) | |||||
| 0–11 | 138 | 57.3 | 103 | 42.7 | |
| 12–23 | 72 | 47.1 | 81 | 52.9 | 0.048 |
| Sex of child | |||||
| Female | 117 | 53.4 | 102 | 46.6 | |
| Male | 93 | 53.1 | 82 | 46.9 | 0.956 |
| Residence | |||||
| Urban | 22 | 57.9 | 16 | 42.1 | |
| Rural | 188 | 52.8 | 168 | 47.2 | 0.550 |
| Knowledge of mothers/caregivers about vaccination | |||||
| Low | 122 | 47.7 | 134 | 52.3 | |
| Good | 88 | 63.8 | 50 | 36.2 | 0.002 |
| Interpersonal factors | |||||
| Request authorization to vaccinate the child | |||||
| No | 69 | 53.5 | 60 | 46.5 | |
| Yes | 141 | 53.2 | 124 | 46.8 | 0.958 |
| Influence of family | |||||
| No | 61 | 46.2 | 71 | 53.8 | |
| Yes | 149 | 56.9 | 113 | 43.1 | 0.045 |
| Influence of peers | |||||
| No | 37 | 36.6 | 64 | 63.4 | |
| Yes | 173 | 59.0 | 120 | 41.0 | <0.001 |
| Institutional factors | |||||
| Reminder for missed appointments | |||||
| No | 44 | 33.9 | 86 | 66.2 | |
| Yes | 166 | 62.9 | 98 | 37.1 | <0.001 |
| Receives vaccination advice from health workers | |||||
| No | 75 | 45.2 | 91 | 54.8 | |
| Yes | 135 | 59.2 | 93 | 40.8 | 0.006 |
| Distant vaccination site (>5 km) | |||||
| No | 47 | 48.5 | 50 | 51.6 | |
| Yes | 163 | 54.9 | 134 | 45.1 | 0.271 |
| Being turned away at the vaccination site | |||||
| No | 191 | 54.9 | 157 | 45.1 | |
| Yes | 19 | 41.3 | 27 | 58.7 | 0.083 |
| Community factors | |||||
| Community outreach on vaccination | |||||
| No | 92 | 53.5 | 80 | 46.5 | |
| Yes | 118 | 53.2 | 104 | 46.9 | 0.947 |
| Influence of religious and community leaders | |||||
| No | 80 | 49.4 | 82 | 50.6 | |
| Yes | 130 | 56.0 | 102 | 44.0 | 0.193 |
| Political factors | |||||
| Vaccine availability during vaccination | |||||
| No | 12 | 38.7 | 19 | 61.3 | |
| Yes | 198 | 54.6 | 165 | 45.5 | 0.090 |
| Vaccination free of charge | |||||
| No | 1 | 50.0 | 1 | 50.0 | |
| Yes | 209 | 53.3 | 183 | 46.7 | 0.717 |
| Receive vaccination documents | |||||
| No | 31 | 53.5 | 27 | 46.6 | |
| Yes | 179 | 53.3 | 157 | 46.7 | 0.980 |
Table 5: Factors contributing to delayed or non-vaccination of children aged 0–23 months, Tougue health district, 2024 (multivariate analysis)
| Variables | aOR (95% CI) | p-value |
|---|---|---|
| Mother/caregiver can read and/or write | ||
| No | 1.78 (1.05–3.01) | 0.031 |
| Yes | Ref. | |
| Age of child (months) | ||
| 0–11 | Ref. | |
| 12–23 | 1.93 (1.23–3.03) | 0.004 |
| Knowledge of mothers/caregivers about vaccination | ||
| Low | 2.13 (1.34–3.40) | 0.001 |
| Good | Ref. | |
| Influence of peers | ||
| No | 2.76 (1.64–4.63) | <0.001 |
| Yes | Ref. | |
| Reminder for missed appointments | ||
| No | Ref. | |
| Yes | 0.67 (0.44–1.04) | 0.072 |
| Receives vaccination advice from health workers | ||
| No | 1.64 (1.05–2.57) | 0.031 |
| Yes | Ref. | |
| Being turned away at the vaccination site | ||
| No | Ref. | |
| Yes | 1.75 (0.89–3.45) | 0.103 |
| Residence | ||
| Urban | Ref. | |
| Rural | 0.56 (0.26–1.21) | 0.139 |
aOR: Adjusted Odds Ratio; CI: Confidence Interval; Ref: Reference Category.