Title : Unmasking urban immunization inequities: A cross-sectional LQAS analysis of zero-dose drivers in slum and non-slum settings of Uttar Pradesh, India
Abstract:
Background: Despite steady gains in routine immunization, substantial intra-urban inequities persist in Uttar Pradesh, particularly within informal settlements. Urban slums represent complex ecosystems where social vulnerability, mobility, and service delivery constraints converge, resulting in persistent Zero-Dose (ZD) pockets. This study applies the WHO Behavioral and Social Drivers (BeSD) framework to systematically examine determinants of Full Immunization Coverage (FIC) and Zero-Dose prevalence across slum (High-Risk Areas; HRAs) and non-slum urban settings in 14 districts of Uttar Pradesh.
Methods: A cross-sectional house-to-house survey was conducted between July–September 2025 using Lot Quality Assurance Sampling (LQAS). A total of 7,013 caregivers were interviewed, including 2,462 (35%) from 291 identified slums and nomadic settlements. Immunization status was analyzed across the four BeSD domains—Thinking & Feeling, Social Processes, Motivation, and Practical Issues—to identify differential drivers of partial and zero-dose immunization in urban contexts.
Results: A pronounced urban equity gradient was observed. FIC in slums (HRA) was 76%, compared to 81% in non-HRAs, while the ZD burden was three times higher in slums (6% vs. 2%), indicating spatial clustering of exclusion.
Social & Structural Determinants: Although Muslim families constituted 59% of the slum sample, they accounted for 74% of the ZD burden, highlighting the role of intersecting social marginalization. Poverty amplified exclusion, with 41% of ZD children residing in Kuccha housing with poor sanitation.
Thinking & Feeling (Confidence): Maternal education emerged as the strongest predictor of immunization confidence; caregivers with no formal education contributed 48% of the ZD burden. Fear of adverse events following immunization (9%) and vaccine hesitancy (13%) were present but secondary contributors.
Systemic & Practical Barriers: Operational gaps were the most actionable drivers. Among partially immunized and ZD children, 39% reported no contact by health workers, 15% were missed due to migration, and economic constraints—wage loss and working-hour conflicts—restricted access for 6% of caregivers, underscoring the rigidity of conventional service delivery models in informal urban settings.
Conclusion: This study empirically demonstrates that urban Zero-Dose status is not primarily a function of vaccine refusal, but of structural exclusion reinforced by social vulnerability and system-level access failures. While practical barriers drive incomplete immunization, Zero-Dose clustering in slums is predominantly shaped by social processes and low caregiver confidence linked to education and religious marginalization. Achieving the final equity mile in urban routine immunization requires a paradigm shift—from uniform mobilization to hyper-local, socially attuned strategies, including engagement of community and religious leaders, proactive outreach to mobile populations, and flexible service delivery (evening and workplace-adapted sessions). These findings provide actionable evidence to operationalize Gavi 5.0’s urban equity agenda and accelerate Zero-Dose reduction in rapidly urbanizing settings.
