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

BackgroundZero-dose children, defined as those who have not received a first dose of a diphtheria-pertussis-tetanus (DPT)-containing vaccine, represent one of the sharpest manifestations of inequity in immunisation systems. Nigeria remains one of the largest contributors to the global zero-dose burden, with North-East Nigeria facing intersecting crises of conflict, population displacement, governance fragility, and weakened primary health care. Existing research has largely focused on structural determinants such as poverty, maternal education, and rural residence, with far less attention to relational mechanisms and governance dynamics that shape caregiver decisions. MethodsWe conducted a cross-sectional secondary analysis of the 2023 Nigeria Demographic and Health Survey (NDHS) Childrens Recode dataset. Weighted descriptive statistics and survey-adjusted logistic regression models were used to estimate zero-dose prevalence and identify structural and health system-contact determinants among children aged 12-23 months ResultsThe weighted national zero-dose prevalence was 37.1% (95% CI: 35.2-39.0), meaning more than one in three eligible children had never received a DPT-containing vaccine. The strongest independent predictors of zero-dose status were no ANC visits (aOR = 6.68, 95% CI: 5.52-8.09), no maternal education (aOR = 4.70, 95% CI: 2.89- 7.67), poorest wealth quintile (aOR = 2.79, 95% CI: 1.82-4.27), home delivery (aOR = 1.41, 95% CI: 1.18-1.69), and rural residence (aOR = 1.45, 95% CI: 1.18-1.75). Crude regional disparities were marked but attenuated after adjustment, suggesting that the apparent North-East effect is largely mediated through structural and service-contact pathways. ConclusionZero-dose status in Nigeria reflects deep structural exclusion and fragmented early contact with the health system, rather than isolated individual preferences. ANC utilisation and place of delivery emerge as pivotal touchpoints where health systems can either build or erode trust and continuity of care. These findings provide a quantitative foundation for future research exploring relational and contextual mechanisms shaping immunisation exclusion.