Knowledge, Attitudes, Behavioural and Social Determinants of Childhood Immunisation Among Caregivers and Healthcare Workers in Sierra Leone: A Convergent Mixed-Methods Study

Vaccines are among the most powerful tools in modern medicine, acting as a shield that trains a child's body to fight off dangerous diseases before they can cause harm. For decades, this simple act of protection has saved millions of lives worldwide, turning once-deadly illnesses into rare memories. Yet, even with these life-saving tools available, many children around the world still miss out on their shots. This gap is not usually because the vaccines do not exist, but because of the complex web of human decisions, daily struggles, and community beliefs that stand between a parent and a clinic. In Sierra Leone, a nation rebuilding its health systems after years of conflict and disease outbreaks, researchers set out to understand exactly what keeps children from being fully protected. They wanted to know not just how many children were vaccinated, but why some parents said yes while others hesitated, and what the people delivering the shots faced every day.

To answer these questions, a team of researchers traveled to six different districts across Sierra Leone, ranging from areas where vaccination rates are high to those where they struggle. They spoke with more than 1,400 caregivers—mostly mothers, but also fathers and grandparents—whose children were between one and three years old. They asked these parents what they knew about vaccines, how they felt about them, and what stopped them from getting their children immunized. At the same time, the team interviewed sixty healthcare workers and held group discussions with community members to hear the stories behind the numbers. The goal was to piece together a complete picture of the situation, looking at both the facts parents knew and the real-world barriers they faced.

The results revealed a surprising and encouraging truth: most parents in Sierra Leone already believe in vaccines. When asked, nearly all of the caregivers said they had heard of childhood immunization, and the vast majority understood that its purpose is to protect children from serious diseases. More than eight out of ten parents held positive attitudes toward vaccination, trusting the information given by doctors and nurses. They recognized that even a healthy-looking child needs shots, that missing an appointment does not mean starting over, and that vaccines are safe for infants. This high level of trust and knowledge suggests that the years of health education and community outreach have successfully planted the seed of confidence in these families.

However, knowing that vaccines are good is not the same as being able to get them. The study found that while parents were willing, the path to the clinic was often blocked by things entirely outside their control. The researchers discovered that the biggest hurdles were not fear or refusal, but practical difficulties. Many caregivers live far from health centers, and the roads can be impassable during the rainy season. Others struggle with the cost of transportation or simply cannot spare the time because they are busy farming, mining, or trading to feed their families. In some cases, the clinics themselves ran out of vaccines or lacked the staff and equipment needed to serve everyone. These logistical gaps meant that even eager parents sometimes left their children unvaccinated, not because they did not want to, but because the system made it too hard to do so.

The study also highlighted how different factors influence a parent's understanding of vaccines. For instance, caregivers with a university education or those who held formal jobs were much more likely to have a deep understanding of how immunization works. Conversely, married caregivers were found to have lower knowledge levels compared to single parents, perhaps because the demands of running a household and caring for a family left less time to seek out health information. Religion also played a role, with Muslim caregivers in this study showing higher levels of knowledge than their Christian counterparts. Yet, despite these differences in knowledge, the desire to protect children remained strong across all groups.

A critical finding was the powerful role of trust in the relationship between the community and the healthcare workers. Parents consistently said they trusted the nurses and community health workers who visited their villages, provided they were treated with respect and kindness. When healthcare workers spoke clearly, listened to concerns, and used local languages, parents felt more confident. But this trust could be fragile; if a clinic ran out of vaccines or if a worker was rude, that confidence could quickly fade. The researchers also heard from healthcare workers who felt stretched thin, lacking the transport, fuel, and training needed to reach remote areas. They described a cycle where a lack of resources led to missed appointments, which in turn made it harder to keep the community engaged.

Ultimately, the study paints a clear picture of a population that is ready and willing to vaccinate their children but is held back by a system that is not yet fully capable of meeting them halfway. The barrier is rarely a lack of belief in the science of vaccines. Instead, it is the collision of good intentions with the harsh realities of poverty, distance, and understaffed clinics. The researchers concluded that to fix the problem, efforts must go beyond simply telling people that vaccines are safe. They must also fix the broken roads, ensure clinics are never empty, and support the health workers who serve as the bridge between the community and the medicine. By addressing these practical and social hurdles, Sierra Leone can move closer to ensuring that every child, no matter where they live or who their parents are, receives the full protection they deserve.