Multi-level determinants of timely routine childhood vaccinations in The Gambia: Findings from a nationwide analysis.

INTRODUCTION: Achieving the ambitious goals of the Immunisation Agenda 2030 (IA2030) requires a deeper understanding of factors influencing under-vaccination, including timely vaccination. This study investigates the demand- and supply-side determinants influencing the timely uptake of key childhood vaccines scheduled throughout the first year of life in The Gambia. METHODS: We used two nationally-representative datasets: the 2019-20 Gambian Demographic and Health Survey and the 2019 national immunisation facility mapping. Using Bayesian multi-level binary logistic regression models, we identified key factors significantly associated with timely vaccination for five key vaccines: birth dose of hepatitis-B (HepB0), first, second, and third doses of the pentavalent vaccine (Penta1, Penta2, Penta3), and first-dose of measles-containing vaccine (MCV1) in children aged 12-35 months. We report the adjusted Odds Ratios (aORs) and 95 % Credible Intervals (95 % CIs) in each case. RESULTS: We found that demand-side factors, such as ethnicity, household wealth status, maternal education, maternal parity, and the duration of the household's residency in its current location, were the most common drivers of timely childhood vaccination. However, supply-side factors such as travel time to the nearest immunisation clinic, availability of cold-storage and staffing numbers in the nearest immunisation clinic were also significant determinants. Furthermore, the determinants varied across specific vaccines and the timing of doses. For example, delivery in a health facility (aOR = 1.58, 95 %CI: 1.02-2.53), living less than 30 min (aOR = 2.11, 95 %CI: 1.2-8.84) and living between 30 and 60 min (aOR = 3.68, 95 %CI: 1.1-14.99) from a fixed-immunisation clinic was associated with timely HepB0, a time-sensitive vaccine that must be administered within 24 h of birth. On the other hand, children who received Penta1 and Penta2 on time were three- to five-fold more likely to receive subsequent doses on time (Penta2 and Penta3, respectively). Finally, proximity to an immunisation facility with functional vaccine cold-storage was a significant supply-side determinant of timely MCV1 (aOR = 1.4, 95 %CI: 1.09-1.99). CONCLUSIONS: These findings provide valuable insights for programme managers and policymakers. By prioritising interventions and allocating scarce resources based on these identified determinants, they can maximize their impact and ensure children in The Gambia receive timely vaccinations throughout their first year of life, contributing to IA2030 goals.