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Multilevel Analysis of Zero-Dose Children in Sub-Saharan Africa: A Three Delays Model Study

Charles S Wiysonge1, Muhammed M B Uthman2, Duduzile Ndwandwe1

  • 1Cochrane South Africa, South African Medical Research Council, Francie van Zijl Drive, Parrow Valley, Cape Town 7501, South Africa.

Vaccines
|September 27, 2025
PubMed

Insights

Zero-dose children in sub-Saharan Africa are most common among disadvantaged groups, with maternal health-seeking behavior being the key predictor. Policy should integrate antenatal care with vaccination and remove financial barriers.

Area of Science:

  • Public Health
  • Global Health
  • Pediatrics

Background:

  • Zero-dose children pose a significant barrier to universal immunization in sub-Saharan Africa.
  • The Three Delays Model provides a framework for understanding factors contributing to zero-dose status.

Purpose of the Study:

  • To examine multilevel factors associated with zero-dose children in sub-Saharan Africa.
  • To identify individual, community, and country-level determinants of zero-dose status.

Main Methods:

  • Analysis of demographic and health survey data from 30,500 children (12-23 months) across 28 sub-Saharan African countries (2015-2024).
  • Definition of zero-dose status as no diphtheria-tetanus-pertussis vaccine first dose.
  • Application of multilevel logistic regression to identify determinants.

Main Results:

  • Overall zero-dose prevalence was 12.19%, with significant variation across countries.
  • Poor maternal health-seeking behavior (OR 12.00) was the strongest predictor.
  • Paternal education, maternal empowerment (decision-making, financial barriers, media access), community literacy, and national health expenditure were significant factors.

Conclusions:

  • Zero-dose children are concentrated in disadvantaged populations, highlighting the critical role of maternal health-seeking behavior.
  • Policy recommendations include integrating antenatal care with vaccination, targeting high-parity mothers, and increasing national health expenditure.
Abstract

Keywords:
health systemsmultilevel analysissub-Saharan Africazero-dose children

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