{
  "abstract": "Despite progress in childhood immunization, Zambia retains pockets of zero-dose children (those who have not received the first dose of diphtheria-tetanus-pertussis-containing vaccine, DTP1) and under-immunised children (those missing one or more vaccines in the recommended schedule), sustaining vulnerability to vaccine-preventable diseases. Understanding the factors associated with missed vaccination is essential for achieving Immunization Agenda 2030 targets. We analysed cross-sectional data from 1,738 children aged 12–23 months identified through the 2024 Zambia Demographic and Health Survey, a nationally representative survey using a stratified two-stage cluster sampling design. Three outcomes were assessed: zero-dose status (no DTP1), under-immunization by the basic schedule (BCG, DTP1–3, OPV1–3, measles-1), and under-immunization by the national expanded schedule (basic plus PCV1–3 and rotavirus1–2). Survey-weighted multivariable regression identified associated factors. Nationally, 3.2% (95% CI: 2.1–4.3%) of children were zero-dose, 36.1% (95% CI: 33.0–39.2%) were under-immunised by the basic schedule, and 69.9% (95% CI: 67.0–72.8%) by the national schedule. Zero-dose prevalence ranged tenfold across provinces, from 0.6% in Lusaka to 6.9% in North Western. In adjusted models, children in the richest households had 93% lower odds of zero-dose than the poorest (aOR 0.07, 95% CI: 0.02–0.29). Facility delivery reduced zero-dose by 68% (aOR 0.32, 95% CI: 0.15–0.69). For basic-schedule under-immunization, secondary education (aOR 0.50, 95% CI: 0.30–0.82; prevalence ratio 0.68) and vaccination card possession (aOR 0.24, 95% CI: 0.14–0.40; prevalence ratio 0.53) were associated with lower odds. Wealth effects differed significantly by residence for all outcomes (p < 0.001). Zero-dose and under-immunization in Zambia are profoundly socioeconomically and geographically patterned. Reaching zero-dose children requires targeting the poorest households and those with home deliveries, particularly in North Western and Northern provinces. Improving vaccination card coverage may reduce broader under-immunization. Gaps in national schedule coverage are consistent with supply-side constraints requiring structural health system responses, though direct supply-side measurement was beyond the scope of this analysis.",
  "abstract_shown": true,
  "affiliations": [
    "World Health Organization Country Office for Zambia, Lusaka, Zambia.",
    "Zambia National Public Health Institute, Lusaka, Zambia.",
    "United Nations Children's Fund (UNICEF) Zambia Country Office, Lusaka, Zambia.",
    "Child Health and Nutrition Unit, Ministry of Health, Lusaka, Zambia."
  ],
  "article_type": "Research Article",
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  "author_total": 17,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Moses Mwale",
      "orcid": "0000-0002-3414-3523"
    },
    {
      "affs": [
        0
      ],
      "name": "Peter Jay Chipimo"
    },
    {
      "affs": [
        0
      ],
      "name": "Andrew Phiri"
    },
    {
      "affs": [
        0
      ],
      "name": "Patrick Sakubita"
    },
    {
      "affs": [
        0
      ],
      "name": "Penelope Masumbu"
    },
    {
      "affs": [
        0
      ],
      "name": "Bryson Musonda",
      "orcid": "0009-0006-4379-6071"
    },
    {
      "affs": [
        0
      ],
      "name": "Chipo Mwela"
    },
    {
      "affs": [
        1
      ],
      "name": "Kelvin Mwangilwa"
    },
    {
      "affs": [
        1
      ],
      "name": "Musole Chipoya"
    },
    {
      "affs": [
        1
      ],
      "name": "Priscilla Nkonde Gardner",
      "orcid": "0000-0001-8937-3142"
    },
    {
      "affs": [
        2
      ],
      "name": "Francis Dien Mwansa"
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    {
      "affs": [
        0
      ],
      "name": "Azmach Gebregiorgis"
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    {
      "affs": [
        0
      ],
      "name": "Muziya Chika"
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    {
      "affs": [
        3
      ],
      "name": "Kennedy Matanda"
    },
    {
      "affs": [
        0
      ],
      "name": "Freddie Masaninga"
    },
    {
      "affs": [
        3
      ],
      "name": "Jacob Sakala"
    },
    {
      "affs": [
        0
      ],
      "name": "Peter Clement Lugala"
    }
  ],
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  "doi": "10.1371/journal.pgph.0006618",
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  "licence_label": "CC BY",
  "licence_source": "article",
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  "native_subjects": [
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      "heading",
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  "published": "2026-10-30",
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  "subjects": [
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  "title": "Socioeconomic and health system determinants of zero-dose and under-immunization among children in Zambia: Evidence from the 2024 Demographic and Health Survey",
  "title_text": "Socioeconomic and health system determinants of zero-dose and under-immunization among children in Zambia: Evidence from the 2024 Demographic and Health Survey",
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