Socioeconomic and health system determinants of zero-dose and under-immunization among children in Zambia: Evidence from the 2024 Demographic and Health Survey
4 affiliations
- 1World Health Organization Country Office for Zambia, Lusaka, Zambia.
- 2Zambia National Public Health Institute, Lusaka, Zambia.
- 3United Nations Children's Fund (UNICEF) Zambia Country Office, Lusaka, Zambia.
- 4Child Health and Nutrition Unit, Ministry of Health, Lusaka, Zambia.
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.
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BibTeX
@article{mwale2026socioeconomic,
title = {{Socioeconomic and health system determinants of zero-dose and under-immunization among children in Zambia: Evidence from the 2024 Demographic and Health Survey}},
author = {Moses Mwale and Peter Jay Chipimo and Andrew Phiri and Patrick Sakubita and Penelope Masumbu and Bryson Musonda and Chipo Mwela and Kelvin Mwangilwa and Musole Chipoya and Priscilla Nkonde Gardner and Francis Dien Mwansa and Azmach Gebregiorgis and Muziya Chika and Kennedy Matanda and Freddie Masaninga and Jacob Sakala and Peter Clement Lugala},
journal = {PLOS Global Public Health},
year = {2026},
month = oct,
doi = {10.1371/journal.pgph.0006618},
url = {https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0006618},
note = {CC BY},
}
RIS
TY - JOUR
TI - Socioeconomic and health system determinants of zero-dose and under-immunization among children in Zambia: Evidence from the 2024 Demographic and Health Survey
AU - Moses Mwale
AU - Peter Jay Chipimo
AU - Andrew Phiri
AU - Patrick Sakubita
AU - Penelope Masumbu
AU - Bryson Musonda
AU - Chipo Mwela
AU - Kelvin Mwangilwa
AU - Musole Chipoya
AU - Priscilla Nkonde Gardner
AU - Francis Dien Mwansa
AU - Azmach Gebregiorgis
AU - Muziya Chika
AU - Kennedy Matanda
AU - Freddie Masaninga
AU - Jacob Sakala
AU - Peter Clement Lugala
PY - 2026
DA - 2026/10/30
JO - PLOS Global Public Health
DO - 10.1371/journal.pgph.0006618
UR - https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0006618
AB - 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.
SN - 2767-3375
ER -