Determinants of childhood immunization coverage in Somalia: evidence from the Somalia Demographic and Health Survey 2020

BACKGROUND: Somalia has one of the lowest childhood immunization coverage rates globally, with only 34.8% of children aged 0-59 months having received at least one vaccine and a high burden of zero-dose children. Immunization uptake is influenced by socioeconomic, maternal, healthcare access, and geographic factors. This study examined determinants of childhood immunization coverage in Somalia to inform equity-focused strategies. METHODS: A cross-sectional analysis was conducted using nationally representative data from the 2020 Somalia Demographic and Health Survey (SDHS), including 7,373 mother-child pairs. bivariate and multivariable logistic regression models assessed associations between sociodemographic, economic, maternal, healthcare access, and geographic characteristics and child vaccination status, accounting for survey design and confounders. RESULTS: Overall vaccination coverage was 34.8%. Health facility delivery was the strongest independent predictor (AOR = 1.93; 95% CI:1.68-2.22; p < 0.001). Children from the highest household wealth quintile had higher odds than the poorest (AOR = 2.45; 95% CI:2.00-3.00; p < 0.001). Maternal primary and secondary education were positively associated with vaccination (AOR = 1.58; 95% CI:1.34-1.87 and AOR = 1.94; 95% CI:1.40-2.67; respectively; p < 0.001). Nomadic residence was associated with higher odds compared with rural residence (AOR = 1.69; 95% CI:1.46-1.96; p < 0.001). Compared with infants aged 0-11 months, children aged 12-23 months (AOR = 1.36; 95% CI:1.10-1.69; p = 0.005) and 24-59 months (AOR = 1.33; 95% CI:1.12-1.59; p = 0.001) were more likely to be vaccinated. Lack of radio exposure was associated with lower vaccination odds (AOR = 0.64; 95% CI:0.50-0.82; p < 0.001). Children living in Gedo region had markedly lower odds of vaccination than those in Awdal region (AOR = 0.26; 95% CI:0.17-0.39; p < 0.001). CONCLUSIONS: Childhood immunization coverage in Somalia remains critically low, reflecting socioeconomic, maternal, healthcare access, and geographic inequalities that require strategies targeting disadvantaged populations and regions.