Community Perceptions and Attitudes Toward Vaccination in Madagascar

Background/Objectives: Low vaccination coverage and the persistence of zero-dose children remain the principal challenges for immunization efforts in Madagascar. To address these barriers, a socio-anthropological study was conducted to identify the determinants of both vaccination and non-vaccination in eight districts of the country. Methods: District selection was based primarily on immunization performance-specifically the proportion of zero-dose children-along with criteria of geographic and cultural diversity. A qualitative approach was employed, comprising 162 semi-structured individual interviews and 41 focus group discussions with key informants, including political-administrative, religious, and traditional authorities, healthcare workers, community health workers, and parents. Results: Overall, the benefits of vaccination were widely acknowledged by the population. Anti-vaccine rumors were found to be sporadic and, due to their provisional nature, potentially reversible even among those who relay them. Beyond conventional barriers such as scheduling constraints and limited accessibility, fluctuating motivation among community health workers and structural challenges affecting their work emerged as notable findings. Conversely, factors promoting vaccine acceptance were associated with trust in the vaccinators themselves and with a good understanding of vaccination-related issues, fostered through increased and context-specific sensitization efforts. Conclusions: In conclusion, no evidence was found to associate contexts such as rural settings or low-performing vaccination areas with lower vaccine acceptance. Similarly, anti-vaccine rumors were not confined to any particular category or group. Ultimately, the main obstacles are the prioritization of economic risk and concerns about potential side effects. The primary recommendation concerns strengthening awareness-raising efforts, while strengthening trust and improving the working conditions of community health workers.