Factors Associated with Childhood Vaccination in Sub-Saharan African Countries Experiencing Armed Conflicts: A Scoping Review.

Abstract

Background: Armed conflicts substantially disrupt health systems and undermine routine childhood immunization, increasing the risk of vaccine-preventable disease outbreaks. While declines in vaccination coverage in conflict settings are well documented, less is known about the multi-level determinants associated with childhood vaccination outcomes in African countries affected by armed conflict. This scoping review maps and synthesizes existing empirical evidence on factors associated with childhood vaccination in these settings.

Methods: A scoping review was conducted in accordance with PRISMA-ScR guidelines. Systematic searches were performed in PubMed, Embase, and Scopus, with supplementary searches in Google Scholar. Peer-reviewed observational studies and systematic reviews published from January 2015 onwards were included if they examined determinants associated with childhood vaccination outcomes in African countries affected by armed conflict. Findings were synthesized narratively and grouped into thematic determinant domains encompassing caregiver characteristics, socioeconomic factors, geographic barriers, conflict-related determinants, and health-system constraints.

Results: Twenty-eight studies met the inclusion criteria. Evidence was geographically concentrated in a limited number of countries, particularly Ethiopia, Somalia/Somaliland, the Democratic Republic of Congo, and Nigeria. Maternal/caregiver education and empowerment, geographic access barriers/remoteness, and household/community poverty and wealth were the most frequently reported determinant categories. Across settings, maternal education, antenatal care attendance, and facility-based delivery were consistently associated with higher vaccination uptake. Conversely, poverty, rural residence, insecurity, displacement, and disruption of routine services were recurrent barriers to complete and timely immunization. Health-system constraints such as stock-outs, limited outreach services, and shortages of trained personnel further compounded inequities in vaccination access.

Conclusions: Childhood vaccination in conflict-affected African countries is shaped by a complex interplay of socioeconomic vulnerability, caregiver characteristics, conflict dynamics, and health-system disruption. Armed conflict appears to amplify pre-existing inequities in access to routine immunization services. The current evidence base remains geographically uneven, highlighting important gaps in several conflict-affected settings. Strengthening context-specific research is essential to inform resilient, effective, and equitable immunization strategies in conflict-affected settings.