Spatial distribution and multilevel determinants of unvaccinated children in Somaliland: analysis of the 2020 Somaliland Health and Demographic Survey (SLHDS)

Abstract

Children who have never received any vaccination represent one of the clearest markers of health system inequity. In this study, unvaccinated status was defined as caregiver report that a child under five years had never received any routine vaccine, reflecting complete non-vaccination rather than dose-specific (e.g., DTP1-based) definitions. This study examined the prevalence and determinants of unvaccinated children in Somaliland using nationally representative data. We analyzed data from 1,104 children under five years from the 2020 Somaliland Health and Demographic Survey (SLHDS). Multilevel logistic regression models were fitted to assess individual-, household-, and community-level factors associated with being unvaccinated. The prevalence of unvaccinated children was 79.9%. In the fully adjusted model, children of mothers with secondary education had significantly lower odds of being unvaccinated compared with those whose mothers had no education (AOR = 0.32; 95% CI: 0.14–0.74). Antenatal care attendance was strongly associated with reduced odds of non-vaccination (1–3 visits: AOR = 0.37; 95% CI: 0.28–0.52; ≥4 visits: AOR = 0.40; 95% CI: 0.26–0.64). Older children were less likely to be unvaccinated compared to infants aged 0–8 months (9–23 months: AOR = 0.37; 95% CI: 0.19–0.72; 24–59 months: AOR = 0.32; 95% CI: 0.19–0.58). Children not currently breastfeeding had lower odds of being unvaccinated (AOR = 0.68; 95% CI: 0.52–0.90). At the community level, residence in areas with high ANC utilization was associated with substantially lower odds of non-vaccination (AOR = 0.37; 95% CI: 0.25–0.57). Descriptive mapping revealed marked regional variation, with particularly high prevalence observed in Awdal and Sool. Complete non-vaccination in Somaliland is strongly associated with maternal education, engagement with antenatal care, child age, breastfeeding status, and community-level health service utilization. Integrated maternal–child health strategies and targeted regional interventions are urgently needed to reduce the exceptionally high burden of unvaccinated children.