Correlates of Zero-Dose Vaccination Status among Children Aged 12–59 Months in Sub-Saharan Africa: A Multilevel Analysis of Individual and Contextual Factors

Abstract

Despite ongoing efforts to improve childhood vaccination coverage, including in hard-to-reach and hard-to-vaccinate communities, many children in sub-Saharan Africa (SSA) remain unvaccinated. Considering recent goals set by the Immunization Agenda 2030 (IA2030), including reducing the number of zero-dose children by half, research that goes beyond coverage to identify populations and groups at greater risk of being unvaccinated is urgently needed. This is a pooled cross-sectional study of individual- and country-level data obtained from Demographic and Health Surveys Program and two open data repositories. The sample includes 43,131 children aged 12–59 months sampled between 2010 and 2020 in 33 SSA countries. Associations of zero-dose status with individual and contextual factors were assessed using multilevel logistic regression. 16.5% of children had not received any vaccines. Individual level factors associated lower odds of zero-dose status included mother’s primary school or high school education, employment, use of antenatal care services and household wealth. Compared to children in countries with lower GDP, children in countries with relatively high GDP had nearly four times greater odds of being unvaccinated. Both individual and contextual factors are correlated with zero-dose status in SSA. Our results can inform efforts to identify and reach children who have not received any vaccines.

Uncovering the Drivers of Childhood Immunization Inequality with Caregivers, Community Members and Health System Stakeholders: Results from a Human-Centered Design Study in DRC, Mozambique and Nigeria

“…The Mozambique study identified similar patterns of barriers to vaccination, including the role of gender barriers and power imbalances with health workers. Cross-national quantitative analyses of household survey data show that immunization inequalities are associated with household wealth and maternal education [ 6 ], and that the prevalence of zero-dose children is associated with gender inequality [ 8 ], birth order, birth weight, maternal education, maternal occupation, household wealth, and the number of antenatal care visits [ 9 ].…”

“…Research exists on the drivers of immunization inequality [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 ], yet most of the existing research focuses either on individual attributes or health system drivers, without analysis of the social and structural processes that produce inequalities [ 11 ]. Recent attention to the role of gender in immunization (in)equity is overdue [ 8 , 12 ] but too often, gender is explored alone, without consideration of how it intersects and interacts with other social, institutional, and structural dimensions of inequality, including social determinants of health.…”

Vaccination Coverage and associated factors among under-five children in Ethiopia: Mini Demographic and Health Survey 2019

“…The nding was supported by a study in national studies, and Afghanistan [20,21,22]. This could explain by in wealth index, study shows that countries with high wealth index within each country; As a result, even when few people earn substantial salaries, countries with high natural resource revenues may appear to nd better services in vaccination and health care than others [23].…”

Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children

“…The ongoing COVID-19 pandemic has contributed to at least some of today’s gaps in childhood vaccination [ 3 ], with estimates of under-one children without any doses of the diphtheria–tetanus–pertussis vaccine (no-DTP) rising from 10% prevalence in 2019 to 14% in 2021 [ 3 ]. Communities with high levels of unvaccinated or “zero-dose children” often face myriad vulnerabilities [ 4 , 5 , 6 , 7 ], such as residing in highly remote areas or informal settlements in cities [ 7 , 8 , 9 ]; being affected by displacement and/or prolonged conflict or unrest [ 7 , 8 ]; longstanding poverty and/or societal neglect [ 4 ]; or some constellation of these factors. Subsequently, optimally identifying where and how to better reach zero-dose children will likely require a combination of context-specific strategies and broader investments to address persisting structural challenges.…”

“…Over the last few years, a growing body of research has sought to assess characteristics of zero-dose children and their families or households, as well as potential drivers of high zero-dose prevalence at different geographic levels [ 4 , 5 , 6 , 7 , 8 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. Past work has found that zero-dose children experience a higher odds of missing or lacking access to other types of primary care services [ 6 , 11 , 12 ], while their mothers were more likely to have no antenatal care visits and not deliver at a health facility [ 11 , 12 ]. Lower levels of household wealth, educational attainment, and measures of women’s empowerment also have been associated with higher levels of zero-dose children [ 4 , 10 , 16 , 17 ].…”