# Prevalence, spatial patterns and determinants of zero-dose vaccination among children aged 12–23 months in Sub-Saharan Africa: A multilevel spatial analysis

## TL;DR

This study finds that 13.3% of children in Sub-Saharan Africa have not received any vaccines, with specific regions showing higher rates, and identifies factors like poverty and lack of education that contribute to this issue.

## Contribution

The study provides a multilevel spatial analysis of zero-dose vaccination in Sub-Saharan Africa, identifying both individual and community-level determinants.

## Key findings

- The prevalence of zero-dose vaccination among children aged 12–23 months in Sub-Saharan Africa is 13.3%.
- Hotspots of zero-dose vaccination are clustered in regions like Nigeria, Angola, and Ethiopia.
- Factors such as poverty, home delivery, and low maternal education are strongly associated with zero-dose vaccination.

## Abstract

Vaccination is one of the most cost-effective strategies for enhancing public health and well-being. Despite widespread immunization efforts, zero-dose vaccination among children remains a pressing public health challenge in sub-Saharan Africa (SSA) and there exists a notable gap in research regarding its current burden, spatial distribution and determinants. Hence, this study was aimed at assessing prevalence, spatial patterns and determinants of zero-dose vaccination among children aged 12–23 months in SSA, 2025.

A secondary data analysis of community-based cross-sectional Demographic and Health Survey data from 2015 to 2024 was conducted using a total weighted sample of 58,443 children aged 12–23 months. Descriptive statistics were summarized using texts, tables, and figures, and a multilevel spatial analysis was applied to identify the determinants of zero-dose vaccination. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were computed to determine the level of significance, with a p-value < 0.05 considered statistically significant.

The prevalence of zero-dose vaccination among children aged 12–23 months in SSA was 13.3% with 95% CI (10.2%, 16.3%). The hot spot clusters were located in most of Nigeria, Angola, Ethiopia, Madagascar, Guinea, Cote d’Ivoire, the southern border of Mauritania, and southeastern of Mali and Mozambique. The poorest household wealth index (AOR = 1.30; 95% CI: 1.10–1.53), home delivery (AOR = 2.60; 95% CI: 2.39–2.83), having no media exposure (AOR = 1.25; 95% CI: 1.14–1.35), no (AOR = 2.41; 95% CI: 2.17–2.68) or low antenatal care visits (AOR = 1.37; 95% CI: 1.26–1.49), having no tetanus toxoid vaccination (AOR = 1.63; 95% CI: 1.49–1.79), having no (AOR = 1.81; 95% CI: 1.62–2.03) or only primary maternal education (AOR = 1.28; 95% CI: 1.16–1.43), perceived problem of distance to health facility (AOR = 1.13; 95% CI: 1.05–1.21) and rural residence (AOR = 1.25; 95% CI: 1.07–1.67) were significantly associated with zero-dose vaccination.

In SSA, zero-dose vaccintion was high compared to the global target of no tolerance for zero-dose. The distribution of zero-dose vaccination was spatially clustered with individual and community level factors significantly associated with it. Therefore, spatially targeted interventions taking these factors into account should be implemented by stakeholders in the SSA region to address zero-dose children.