Understanding household-level risk factors for zero dose immunization in 82 low- and middle-income countries

• Published in: PloS one 2023-12, Vol.18 (12), p.e0287459
• Main Authors: Farrenkopf, Brooke Amara, Zhou, Xiaobin, Shet, Anita, Olayinka, Folake, Carr, Kelly, Patenaude, Bryan, Chido-Amajuoyi, Onyema Greg, Wonodi, Chizoba
• Format: Article
• Language: English
• Subjects: BCG; BCG vaccines; Births; Children; Children & youth; Childrens health; Complications and side effects; Diphtheria; Evaluation; GNI; Gross National Income; Health care; Health care access; Health care reform; Households; Immunization; Income; Low income groups; Management; Maternal health services; Medical research; Medicine, Experimental; Multivariate analysis; Population; Population studies; Public health; Public health administration; Risk factors; Rural areas; Tetanus; Tetanus antitoxin; Vaccination; Vaccines
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0287459

In 2021, an estimated 18 million children did not receive a single dose of routine vaccinations and constitute the population known as zero dose children. There is growing momentum and investment in reaching zero dose children and addressing the gross inequity in the reach of immunization services. To effectively do so, there is an urgent need to characterize more deeply the population of zero dose children and the barriers they face in accessing routine immunization services. We utilized the most recent DHS and MICS data spanning 2011 to 2020 from low, lower-middle, and upper-middle income countries. Zero dose status was defined as children aged 12-23 months who had not received any doses of BCG, DTP-containing, polio, and measles-containing vaccines. We estimated the prevalence of zero-dose children in the entire study sample, by country income level, and by region, and characterized the zero dose population by household-level factors. Multivariate logistic regressions were used to determine the household-level sociodemographic and health care access factors associated with zero dose immunization status. To pool multicountry data, we adjusted the original survey weights according to the country's population of children 12-23 months of age. To contextualize our findings, we utilized United Nations Population Division birth cohort data to estimate the study population as a proportion of the global and country income group populations. We included a total of 82 countries in our univariate analyses and 68 countries in our multivariate model. Overall, 7.5% of the study population were zero dose children. More than half (51.9%) of this population was concentrated in African countries. Zero dose children were predominantly situated in rural areas (75.8%) and in households in the lowest two wealth quintiles (62.7%) and were born to mothers who completed fewer than four antenatal care (ANC) visits (66.5%) and had home births (58.5%). Yet, surprisingly, a considerable proportion of zero dose children's mothers did receive appropriate care during pregnancy (33.5% of zero dose children have mothers who received at least 4 ANC visits). When controlled for other factors, children had three times the odds (OR = 3.00, 95% CI: 2.72, 3.30) of being zero dose if their mother had not received any tetanus injections, 2.46 times the odds (95% CI: 2.21, 2.74) of being zero dose if their mother had not received any ANC visits, and had nearly twice the odds (OR = 1.87, 95% CI: 1