Securitized Health and Zero Dose Children: Structural and Service Contact Determinants of Non-Vaccination in Nigeria

This study of Nigeria's 2023 Demographic and Health Survey data reveals that zero-dose children status is primarily driven by deep structural exclusion and fragmented early health system contact—specifically the lack of antenatal care visits, maternal education, and facility-based delivery—rather than isolated individual preferences, with regional disparities largely mediated through these systemic pathways.

The Gist

The Big Picture: The "Zero-Dose" Problem

Imagine a massive library (the health system) filled with life-saving books (vaccines) that can protect children from deadly diseases. A "zero-dose child" is a kid who has never even stepped through the library doors to get their first book.

This paper looks at Nigeria, a country where millions of children are missing out on these vaccines. The authors wanted to know: Why are these children missing the library? Is it because they don't want the books? Or is the library locked, broken, or too far away?

The Investigation: A National Snapshot

The researchers didn't interview people one by one; instead, they used a giant, high-tech map called the 2023 Nigeria Demographic and Health Survey. Think of this as a massive, nationwide "census" that took a snapshot of almost 5,000 children aged 12 to 23 months.

They asked: Who is missing the vaccines, and what do their families have in common?

The Findings: It's Not Just About "Where" You Live

For a long time, people thought the main problem was geography. They assumed, "Oh, the North-East is dangerous and poor, so that's why kids there aren't vaccinated."

The paper's big surprise: When they adjusted for other factors, the "North-East" label itself wasn't the magic bullet. Instead, the real reasons were structural barriers (things that block the path) and missed connections (moments where the family and the health system lost touch).

Here are the five main "roadblocks" the study found, explained with analogies:

1. The "First Door" That Was Never Opened (No Antenatal Care)

• The Finding: The single biggest predictor of a child getting zero vaccines is if the mother never visited a doctor during pregnancy.
• The Analogy: Imagine the health system is a train station. Antenatal care (ANC) is the ticket counter. If a mother never goes to the ticket counter to buy a ticket (get prenatal care), she never gets the schedule, never meets the staff, and never learns how to board the train. By the time the baby is born, the family is completely disconnected from the system.
• The Stat: Kids whose moms had zero prenatal visits were nearly 7 times more likely to be zero-dose.

2. The "Home Detour" (Home Births)

• The Finding: Children born at home are much less likely to get vaccinated than those born in a clinic.
• The Analogy: If a baby is born in a hospital, the doctor hands the parents a "Welcome Kit" that includes a vaccination card and a map to the next stop. If the baby is born at home, that hand-off never happens. The family is left without a map, and the journey to the clinic never starts.
• The Stat: Home births increased the risk of being zero-dose by 40%.

3. The "Education Ladder"

• The Finding: Mothers with no education are much more likely to have zero-dose children.
• The Analogy: Think of education as a flashlight. In a dark forest (a complex health system), a flashlight helps you see the path, read the signs, and understand the rules. Without a flashlight (education), the path looks scary and confusing, so families might stay home.
• The Stat: Children of mothers with no education were nearly 5 times more likely to be zero-dose.

4. The "Wallet Barrier" (Poverty)

• The Finding: The poorest families are the most likely to miss out.
• The Analogy: Even if the library is free, you still need to pay for the bus fare to get there, or buy a snack while you wait. For the poorest families, the "cost" of getting to the clinic (time, transport, lost wages) is too high. They are priced out of the system before they even arrive.
• The Stat: The poorest families were almost 3 times more likely to have zero-dose children compared to the richest.

5. The "Rural Fog" (Living in the Countryside)

• The Finding: Living in rural areas makes it harder.
• The Analogy: Imagine the health clinics are lighthouses. In the city, the lighthouse is right next to your house. In the rural countryside, the lighthouse is miles away across a foggy sea. The distance and the fog (lack of roads, transport) make it very hard to reach the light.

The "North-East" Mystery Solved

The study looked specifically at the North-East, a region known for conflict and insecurity.

• Old View: "The North-East is bad, so kids there don't get vaccines."
• New View: The North-East has more poor people, more uneducated mothers, and more home births.
• The Takeaway: It's not the region itself that is the problem; it's that the region is packed with these other roadblocks. If you fixed the poverty and the access to prenatal care in the North-East, the vaccination gap would shrink significantly.

What Does This Mean for the Future?

The authors argue that we can't just build more clinics or send more trucks with vaccines (the "technical" fix). We need to fix the relationship between the community and the health system.

• The "Trust Bridge": The study suggests that the first time a mother meets a doctor (during pregnancy) is the most critical moment. If that meeting is warm, respectful, and helpful, she builds a "trust bridge" to the system. If that meeting is scary, rude, or non-existent, the bridge is burned.
• The Solution: We need to make sure every mother gets a warm welcome at the "ticket counter" (prenatal care) and a clear map when her baby is born. Once they are on the train, getting the vaccines becomes much easier.

Summary in One Sentence

Zero-dose children in Nigeria aren't missing vaccines because they don't want them; they are missing them because the path to the health system is blocked by poverty, lack of education, and a failure to connect with doctors early in pregnancy.

Technical Summary

1. Problem Statement

The study addresses the critical public health challenge of "zero-dose" children in Nigeria—defined as children who have not received even a single dose of a diphtheria–pertussis–tetanus (DPT)-containing vaccine. Nigeria is a major contributor to the global burden of zero-dose children, particularly in the North-East region, which faces intersecting crises of conflict, displacement, and governance fragility.

While existing literature has largely focused on structural determinants (e.g., poverty, maternal education, rural residence), there is a significant gap in understanding the relational mechanisms and governance dynamics that shape caregiver decisions in "securitised" environments (where health services may be perceived as extensions of state power or surveillance). The study posits that zero-dose status is not merely a result of logistical gaps or individual preferences but a manifestation of deep structural exclusion and fractured trust in health systems.

2. Methodology

• Study Design: Cross-sectional secondary analysis.
• Data Source: The 2023 Nigeria Demographic and Health Survey (NDHS) Children's Recode (KR) dataset.
• Study Population: Children aged 12–23 months (ensuring sufficient time for DPT1 receipt). The final analytic sample included 4,937 children with non-missing vaccination data.
• Primary Outcome: Zero-dose status (binary: 1 = no recorded DPT1–3; 0 = at least one dose).
• Independent Variables:
  • Structural Determinants: Wealth quintile, maternal education, residence (urban/rural), maternal age.
  • Health System Contact Pathways: Antenatal care (ANC) utilisation (0, 1–3, ≥4 visits) and place of delivery (facility vs. home).
  • Contextual Determinant: Geographic region (six geopolitical zones).
• Statistical Analysis:
  • Weighted descriptive statistics to estimate prevalence.
  • Bivariate analyses (Chi-square tests) to assess crude associations.
  • Survey-weighted multivariable logistic regression to calculate Adjusted Odds Ratios (aOR) with 95% Confidence Intervals (CIs), accounting for the complex sampling design (clustering and stratification).
  • Reference categories included the South-East region, richest wealth quintile, higher maternal education, ≥4 ANC visits, facility delivery, and urban residence.
• Software: R (version 4.x) using packages haven, dplyr, tidyr, survey, and ggplot2.

3. Key Results

Prevalence:
The weighted national zero-dose prevalence was 37.1% (95% CI: 35.2–39.0), indicating that more than one in three eligible children in Nigeria has never received a DPT-containing vaccine.

Bivariate Findings (Crude Associations):

• Region: The North Central (53.9%) and North West (39.6%) showed the highest crude prevalence, while the South East was lowest (6.9%).
• Wealth: A steep gradient existed, with 56.8% zero-dose prevalence in the poorest quintile vs. 6.6% in the richest.
• Maternal Education: 59.1% of children of mothers with no education were zero-dose, compared to 5.3% for mothers with higher education.
• ANC & Delivery: Children of mothers with 0 ANC visits had a 77.1% zero-dose rate. Home delivery was associated with a 53.9% zero-dose rate compared to 16.3% for facility delivery.

Multivariable Regression (Adjusted Findings):
After adjusting for structural and service-contact variables, the strongest independent predictors of zero-dose status were:

1. No ANC Visits: aOR = 6.68 (95% CI: 5.52–8.09). This was the single strongest predictor.
2. No Maternal Education: aOR = 4.70 (95% CI: 2.89–7.67).
3. Poorest Wealth Quintile: aOR = 2.79 (95% CI: 1.82–4.27).
4. Rural Residence: aOR = 1.45 (95% CI: 1.18–1.75).
5. Home Delivery: aOR = 1.41 (95% CI: 1.18–1.69).

Regional Analysis:
Crucially, while the North-East showed high crude prevalence, its effect disappeared (aOR = 0.81, p=0.24) after adjusting for structural and service-contact factors. This suggests that the high zero-dose rates in the North-East are driven by underlying structural deprivation and lack of health system contact rather than the region itself acting as an independent causal factor.

4. Key Contributions

• Quantifying Service-Contact Pathways: The study identifies ANC utilisation and place of delivery as pivotal "touchpoints." It demonstrates that the absence of early health system contact (no ANC, home birth) cascades into immunisation exclusion.
• Reframing Geographic Disparities: By showing that regional disparities (specifically in the North-East) are mediated by structural factors, the paper shifts the focus from "geography" to "mechanisms." It argues that the North-East's vulnerability is a result of clustered deprivation and relational fractures, not just location.
• Conceptual Framework: The paper integrates the concept of "securitised health," theorizing that in conflict zones, health services may be viewed with suspicion. While this study quantifies the structural correlates, it lays the groundwork for future qualitative research to explore the relational and trust-based reasons behind these structural patterns.
• Policy Evidence: It provides a quantitative foundation for moving beyond technical vaccine supply solutions toward adaptive strategies that rebuild trust and continuity of care between maternal health and immunisation platforms.

5. Significance and Implications

• Paradigm Shift: The findings suggest that zero-dose exclusion in Nigeria is less about vaccine hesitancy or logistical gaps and more about systemic fractures in social, economic, and relational domains.
• Intervention Strategy: Interventions must strengthen the continuity of care between maternal health (ANC and delivery) and immunisation. Reaching children who are born at home or whose mothers do not attend ANC is critical.
• Future Research: The study explicitly calls for a mixed-methods approach. While quantitative data identifies where exclusion is concentrated, qualitative inquiry is needed to understand why caregivers in fragile settings (like the North-East) disengage, specifically regarding trust, legitimacy, and perceptions of state actors.
• Limitations: The study acknowledges limitations including reliance on proxy indicators (e.g., education as a proxy for empowerment), potential recall bias in vaccination data, and the inability of cross-sectional data to capture conflict exposure or causal directionality.

In conclusion, the paper establishes that addressing Nigeria's zero-dose burden requires tackling deep structural inequities and rebuilding the relational contract between communities and the health system, particularly by ensuring early engagement through antenatal and delivery services.