Abstract
<title>Abstract</title> <p>Background Zero-dose children who receive no routine vaccinations represent a critical gap in immunization coverage and a persistent public health challenge in sub-Saharan Africa. Despite Ghana's relatively strong immunization program, subnational disparities in zero-dose prevalence remain poorly characterized. This study examined the spatial distribution and determinants of zero-dose and under-vaccinated status among children aged 12–23 months in Ghana. Methods We conducted a secondary analysis of data from 487 children aged 12–23 months from the 2022 Ghana Demographic and Health Survey (GDHS). Descriptive statistics, chi-square tests, and multivariate logistic regression were employed to identify individual and community-level determinants. Spatial analysis examined regional and sub-regional variations. Results The prevalence of zero-dose and under-vaccinated children was 48.3% (95% CI: 43.9–52.7%). Significant spatial variation was observed across regions (χ² = 17.17, p = 0.046), with the highest rates in Upper West (64.7%), Eastern (59.6%), and Northern (55.7%) regions, and the lowest in Volta (32.0%) and Central (34.3%). Sub-regional analysis revealed Northern Ghana had significantly higher rates (56.7%) compared to the Southern zone (40.3%; χ² = 10.06, p = 0.007). In multivariate analysis, significant determinants included: no antenatal care visits (AOR = 3.63; 95% CI: 1.64–8.04), Northern sub-region residence (AOR = 2.06; 95% CI: 1.27–3.34), rural residence (AOR = 1.86; 95% CI: 1.25–2.76), home delivery (AOR = 1.83; 95% CI: 1.09–3.07), no tetanus toxoid vaccination (AOR = 1.83; 95% CI: 1.03–3.25), and perceived distance to health facility as a big problem (AOR = 1.60; 95% CI: 1.03–2.48). Protective factors included secondary education (AOR = 0.41; 95% CI: 0.23–0.71) and higher wealth quintiles. The concentration index (0.065) indicated modest pro-rich inequality. Conclusions Zero-dose and under-vaccinated children in Ghana are concentrated in Northern regions and among populations with limited maternal healthcare engagement, lower education, and rural residence. Interventions should prioritize geographic targeting of Northern regions, integration of immunization counseling into antenatal care, and community-based outreach to home-delivered and rural populations.</p>