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Effect of Zero-Dose Child Identification on Routine Immunization Uptake in Rural Nigeria

Abstract

Routine immunization is a critical public health intervention for preventing childhood morbidity and mortality from vaccine-preventable diseases. Despite progress in immunization programmes, some children remain completely unreached by routine vaccination services and receive no basic vaccine doses. These children are commonly referred to as zero-dose children and often represent populations experiencing significant barriers to healthcare access. Zero-dose child identification refers to systematic activities undertaken by healthcare workers, community health workers, and immunization programme personnel to locate, document, verify, and track children who have not received routine vaccination. Routine immunization uptake refers to the utilization of recommended vaccination services by eligible children according to the national immunization schedule. In rural Nigeria, geographical isolation, limited healthcare access, inadequate community-level records, population mobility, low awareness, socioeconomic constraints, and weaknesses in routine immunization tracking may contribute to the persistence of zero-dose children. Identifying these children can provide health workers and immunization programmes with the information required to target vaccination activities, conduct household follow-up, provide appropriate referrals, and connect previously unreached children with routine immunization services. Against this background, this study investigates the effect of zero-dose child identification on routine immunization uptake in rural Nigeria. The study is anchored on the Health Belief Model, Andersen's Behavioral Model of Health Services Use, and the Health Systems Framework. The Health Belief Model explains vaccination behaviour through perceptions of disease susceptibility, severity of vaccine-preventable diseases, benefits of vaccination, perceived barriers, and cues to action. Andersen's Behavioral Model explains healthcare utilization through predisposing, enabling, and need-related factors, providing a basis for understanding how identifying unreached children may facilitate access to immunization services. The Health Systems Framework recognizes health information systems, service delivery, health workforce, and access to essential health services as important components of effective immunization programmes. Collectively, these theoretical perspectives provide a suitable framework for explaining how systematic identification of zero-dose children may influence routine immunization uptake in rural Nigeria. The study will adopt a quantitative quasi-experimental research design. Selected rural communities will participate in a structured zero-dose child identification and follow-up programme and will be assessed before and after the intervention. A multistage sampling technique will be employed to select states, local government areas, rural communities, households, and eligible children. The zero-dose identification intervention will involve household enumeration, review of immunization records, community mapping, use of community health workers, verification of vaccination status, identification of children without documented routine vaccination, household follow-up, caregiver notification, referral to appropriate vaccination points, and tracking of identified children until vaccination services are accessed. Zero-dose child identification will be assessed using indicators such as number of children identified, completeness of identification records, household coverage, accuracy of vaccination-status verification, frequency of follow-up, referral of identified children, and documentation of identified zero-dose children. Routine immunization uptake will be assessed using indicators such as the proportion of identified children who subsequently receive at least one recommended routine vaccine, completion of age-appropriate vaccine schedules, number of vaccination doses received, timeliness of vaccination, and reduction in the proportion of children remaining zero-dose. Immunization cards, facility registers, community records, and vaccination registers will be reviewed where available to validate vaccination status. Descriptive statistics will be used to summarize participants' characteristics, zero-dose identification activities, and immunization uptake. Inferential statistical techniques, including paired-sample tests, chi-square tests, correlation analysis, and regression analysis, will be used to determine the effect of zero-dose child identification on routine immunization uptake. Diagnostic tests will also be conducted to assess the reliability of research instruments and the robustness of the findings. The study is expected to find that systematic identification of zero-dose children has a significant positive effect on routine immunization uptake in rural Nigeria. Communities where zero-dose children are actively identified, verified, referred, and followed up are expected to demonstrate higher rates of routine immunization uptake than communities where such identification activities are limited or absent. Household identification may help immunization programmes locate children who are not captured through routine facility-based records and identify specific barriers preventing them from accessing vaccination. Follow-up and referral activities are expected to increase opportunities for identified children to receive vaccines, while accurate documentation may strengthen immunization planning and resource allocation. The intervention may also improve the ability of health workers to target outreach activities toward settlements with higher concentrations of unreached children. Conversely, failure to identify zero-dose children may allow vulnerable children to remain outside the routine immunization system. However, identification alone may not guarantee vaccination because vaccine availability, distance to health facilities, caregiver acceptance, healthcare-worker availability, transportation, security conditions, and reliability of immunization services may also influence uptake. Therefore, zero-dose identification should be combined with accessible and reliable vaccination services. The study is expected to contribute to the literature on zero-dose children, routine immunization uptake, childhood vaccination, immunization equity, community-based surveillance, rural healthcare, maternal and child health, epidemiology, and public health in Nigeria by providing empirical evidence on the importance of identifying previously unreached children. The findings will provide useful information to the Federal Ministry of Health and Social Welfare, National Primary Health Care Development Agency, state ministries of health, state primary healthcare development agencies, local government health authorities, primary healthcare centres, immunization programme officers, community health workers, traditional and community leaders, development partners, and policymakers regarding strategies for reducing the number of zero-dose children. The study will also provide evidence-based recommendations for strengthening household identification systems, improving community immunization registers, expanding community mapping, training community health workers in zero-dose identification, strengthening referral and follow-up mechanisms, improving data quality, and integrating zero-dose identification into routine immunization and outreach programmes across rural Nigeria.

Keywords: Zero-dose child identification, routine immunization uptake, rural Nigeria, zero-dose children, childhood immunization, vaccination coverage, immunization equity, community health workers, primary healthcare, maternal and child health, epidemiology, public health.