Individual-and Community-Level Determinants of Zero-Dose Children in Nigeria: A Multilevel Analysis using the 2024 Nigerian Demographic and Health Survey

Abstract

Abstract Background Zero-dose children, defined as those who have not received the first dose of a diphtheria-tetanus-pertussis-containing vaccine (DPT1), are a key indicator of inequitable access to immunization services. Nigeria remains one of the largest contributors to the global burden of zero-dose children. This study estimated the prevalence of zero-dose children aged 12-23 months and identified individual-and community-level determinants using the 2024 Nigeria Demographic Health Survey (NDHS). Methods A secondary analysis of cross-sectional analysis was conducted using data from 4,711 children aged 12-23 months in the 2024 NDHS kids recode dataset. A multilevel mixed-effects logistic regression model was fitted to account for the hierarchical structure of the data. Four models were compared: null, individual-level, community-level, and combined models. Adjusted odds ratios (AORs) with 95% confidence interval (CI) were used to identify significant determinants at p<0.05. Results The weighted prevalence of zero-dose children was 37.3% (95% CI: 35.1-39.6%). Significant factors included birth order, maternal age, maternal occupation, parental education, household wealth, antenatal attendance, postnatal care utilization, place of delivery, religion, distance to health facilities, and geographical region. Children whose mothers had higher educational attainment, attending antenatal care, deliver in the health facilities, and received postnatal care were significantly less likely to be zero-dose status. Conversely, children from poorer households, those facing distance barriers to health facilities, those belongings to Muslim and traditional religion group and those residing in certain geographical regions had higher odds of zero-dose children, with significant regional variations observed. Conclusion zero-dose vaccination remains highly prevalent in Nigeria and is strongly influenced by socioeconomic disadvantage, maternal healthcare utilization, religion, and regional inequities. Strengthening integrated maternal and child health services and improving access in underserved regions are essential to achieving equitable vaccination coverage.