Zero-Dose Childhood Immunization in Conflict-Affected PSNP Districts of Ethiopia: A Comparative Cross-Sectional Study

Background: Childhood immunisation is one of the most cost-effective public health interventions, preventing 4-5 million deaths annually. This study assessed the prevalence and determinants of zero-dose immunisation among children aged 12-35 months in conflict-affected districts implementing Ethiopia's Productive Safety Net Programme (PSNP) to determine whether intervention and comparison areas are comparable before rollout of the enhanced service-integration model. Methods: A comparative cross-sectional survey was conducted among 4,099 mothers and caregivers of children aged 12-35 months in intervention and comparison PSNP districts. Data were collected using a structured questionnaire administered by trained enumerators. Multivariable logistic regression was used to identify factors associated with zero-dose status. Results: Zero-dose prevalence was 30% in intervention districts and 27% in comparison districts, with notable regional disparities: 22.5% in Amhara, 23% in Afar, and 39% in Tigray. Vaccination dropout showed a different pattern, with the highest rate in Afar (57.6%) and the lowest in Tigray (13.6%). DTP3 coverage was lowest in Afar (42.9%) and highest in Amhara (69.4%), while MCV1 coverage was highest in Tigray (83.8%), followed by Amhara (79.6%) and Afar (49.1%). In intervention districts, zero-dose status was significantly associated with region (AOR = 1.5; 95% CI: 1.1-2.2), lack of maternal education (AOR = 1.7; 95% CI: 1.1-2.7), unmarried status (AOR = 1.8; 95% CI: 1.0-3.2), older child age (24-35 months) (AOR = 3.7; 95% CI: 2.6-5.3), and longer distance to health facilities (AOR = 1.4; 95% CI: 1.0-2.2). In comparison districts, region, maternal education, and older child age remained significant predictors. Conclusions: The study highlights persistent inequities in immunisation coverage in conflict-affected settings. It also demonstrates comparability between intervention and comparison PSNP districts in zero-dose prevalence and its determinants. These baseline findings provide a foundation for attributing future post-intervention improvements to enhanced integration of health services within the PSNP framework.