Prevalence and determinants of full immunization among children under five in sub-Saharan Africa: A systematic review
Tafadzwa Dzinamarira1, Oscar Mano2, Godfrey Musuka3
1School of Health Systems and Pubic Health, University of Pretoria, Pretoria 0002, South Africa; ICAP in Zimbabwe, Harare, P.O. Box 263, Zimbabwe; Africa Centre for Inclusive Health Management, Stellenbosch University, Stellenbosch 7600, South Africa.
Insights
Full childhood immunization in Sub-Saharan Africa (SSA) is only 51%, far below global targets. Key factors influencing immunization include maternal education, healthcare access, and socioeconomic status, highlighting critical areas for intervention to reduce child mortality.
Area of Science:
- Global Health
- Pediatrics
- Public Health
Background:
- Sub-Saharan Africa (SSA) faces challenges with suboptimal childhood immunization coverage.
- High under-five mortality rates persist in SSA despite global immunization progress.
Purpose of the Study:
- To assess the prevalence of full immunization among children under five in SSA.
- To identify key determinants of full immunization in the region between 2013 and 2025.
Main Methods:
- Systematic review and meta-analysis of 31 studies (299,898 children) from electronic databases (2013-2025).
- Random-effects meta-analysis used to determine pooled prevalence and odds ratios (ORs) for determinants.
- Subgroup and sensitivity analyses explored heterogeneity in coverage and determinants.
Main Results:
- Pooled prevalence of full immunization in SSA was 51% (95% CI: 45%-58%), with significant heterogeneity (I²=100%).
- Positive determinants included maternal/paternal education (ORs 2.70, 2.48), institutional delivery (OR 2.99), and household wealth (OR 2.45).
- Lower coverage was observed in rural areas (OR 0.55) and for children of higher parity mothers (OR 0.67).
Conclusions:
- Full immunization coverage in SSA remains critically low, below global targets.
- Significant disparities exist based on country, socioeconomic status, and maternal healthcare access.
- Improving maternal health services, education, and health systems is essential to increase coverage and reduce child mortality.
Background:
Despite global progress in childhood immunization, Sub-Saharan Africa (SSA) continues to report suboptimal coverage and high under-five mortality. This systematic review and meta-analysis assessed the prevalence and determinants of full immunization among children under five in SSA between 2013 and 2025.
Methods:
We systematically searched six electronic databases for studies published between January 2013 and May 2025 that reported the prevalence and/or determinants of full immunization in SSA. Eligible studies were original, peer-reviewed quantitative research. Data were analysed using random-effects meta-analysis, with subgroup and sensitivity analyses conducted to explore heterogeneity. Determinants were synthesised using pooled odds ratios (ORs) where applicable.
Results:
Thirty-one studies comprising 299,898 children were included. The pooled prevalence of full immunization was 51% (95% CI: 45%-58%), with substantial heterogeneity (I2 = 100%). Prevalence varied widely across studies from 6% to 96%. Subgroup analyses revealed lower coverage in recent years and in studies with larger sample sizes. Key positive determinants of full immunization included maternal education (OR = 2.70), paternal education (OR = 2.48), antenatal care attendance (OR = 0.23 for non-attendance), institutional delivery (OR = 2.99), and household wealth (OR = 2.45). Children in rural areas (OR = 0.55) and those with mothers of higher parity (OR = 0.67) were less likely to be fully immunised.
Conclusion:
Full immunization coverage in SSA remains well below global targets, with wide disparities by country, socioeconomic status, and maternal healthcare utilization. Strengthening maternal health services, improving education, and addressing health system barriers are critical to improving coverage and reducing preventable child deaths in the region.
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