Parental EV-A71 vaccine hesitancy amid shifting HFMD pathogens: a cross-sectional study in Guangzhou

Background Following enterovirus A71 (EV‑A71) vaccine introduction, the hand foot mouth disease (HFMD) pathogen spectrum has shifted away from EV‑A71, prompting parental doubts about the vaccine’s continued relevance. This study aimed to investigate the prevalence and determinants of EV‑A71 vaccine hesitancy among parents in Guangzhou. Methods We surveyed parents of children ≤ 5 years at 10 community health centers in Guangzhou using stratified multi-stage sampling. Exploratory factor analysis identified latent variables, followed by structural equation modeling (SEM) to examine their direct and indirect effects on vaccine hesitancy. Logistic regression with cluster-robust standard errors was used to assess the effects of parental knowledge, attitude, and practice (KAP) and physician recommendation practices, specifically examining the cross-level interaction between physician recommendation enthusiasm and parental vaccine confidence. Results The prevalence of EV-A71 vaccine hesitancy among parents was 28.95%. Mothers (OR: 0.46[0.28, 0.76]) and parents with a college degree or associate degree (OR: 0.53[0.32, 0.86]) were less hesitant, whereas being a non‑healthcare worker (OR: 2.38[1.03, 5.55]) and having a child without a history of HFMD (OR: 3.45[1.31, 9.12]) were more hesitant. SEM indicated that vaccine confidence ( β = -0.39), service trust ( β = -0.17), and risk perception ( β = -0.17) exerted negative direct effects on vaccine hesitancy. Knowledge had no direct effect, its total indirect effect via the three mediators was significant( β = -0.45). Furthermore, the interaction between parental confidence and physician recommendation was marginally significant( β = 2.10, P = 0.08). Conclusion Knowledge reduces hesitancy mainly through confidence, trust, and risk perception, not directly. Communication and counseling addressing these attitudes may support informed parental decisions about voluntary, self-paid EV-A71 vaccination.