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Vaccine Preventable Disease: State-Of-The-Art Appraisal of Impact
and Challenges Across Fragile, Conflict-Affected and Vulnerable
(FCV) Communities in Northern Nigeria
Umaru, N
1
, Akyala, A. I
1
, Ngwai, Y. B
1
. and Ajodo, E. U
2
.
1
Global Health and Infectious Diseases Control Institute, Nasarawa State University, Keffi, Nassarawa
State.
2
Center for Disaster Risks Management and Development Studies, Federal University of Technology,
Minna, Niger State.
DOI:
https://doi.org/10.51244/IJRSI.2025.1215000174P
Received: 05 October 2025; Accepted: 10 October 2025; Published: 06 November 2025
ABSTRACT
This paper is a Systematic Literature Review (SLR) that appraised the impact of vaccine-preventable diseases
(VPDs) and associated immunization challenges in fragile, conflict-affected and vulnerable (FCV) communities
of Northern Nigeria. The paper draw on 18 empirical studies published between 2015 and 2025. The papers were
sourced through a rigorous PRISMA-guided search across major databases and grey literature. The review
synthesizes evidence on three focal areas: the effects of ongoing conflict on vaccination coverage, socio-cultural
and logistical barriers to vaccine uptake and strategies employed to improve immunization outcomes challenges
in FCV communities. The findings revealed that armed conflicts, particularly the Boko Haram insurgency,
substantially disrupt vaccination programmes by damaging healthcare infrastructure, displacing populations and
impeding access to routine immunization services. The disruption resulted in marked declines in vaccine
coverage and increased outbreak risks. Socio-cultural factors such as misinformation, religious skepticism and
low health literacy intensify vaccination hesitancy, while inadequate cold chain facilities and transportation
barriers associated with logistic further hinder vaccine delivery. The review showed the promising adaptive
strategies including mobile clinics, community engagement leveraging local leaders, targeted health
communication campaigns and government-led integrated outreach, which collectively mitigate these challenges
and enhance vaccine acceptance. The diverse methodological approaches—quantitative, qualitative and mixed
methods—adopted by the included studies ensured a robust understanding of the context-specific barriers and
facilitators. This review indicated the necessity of multifaceted, culturally sensitive and contextually tailored
interventions combining policy reforms with grassroots participation to improve immunization equity in FCV
communities in Northern Nigeria. The evidences synthesized in this review aims to inform policymakers, health
practitioners and stakeholders in designing effective, sustainable vaccination programmes amidst persistent
insecurity and fragility in fragile, conflict-affected and vulnerable (FCV) communities of Northern Nigeria.
Keywords: Vaccine Preventable Disease, Vaccine impacts, Vaccines challenges, Fragile, Conflict-affected and
Vulnerable (FCV) Communities, Northern Nigeria.
INTRODUCTION
Vaccine-preventable diseases (VPDs) remain a significant public health challenge worldwide particularly in
fragile, conflict-affected and vulnerable (FCV) communities [1,2,3]. Historically, immunization programmes
have contributed to major reductions in morbidity and mortality from VPDs, such as measles, polio and
diphtheria, through widespread vaccination coverage and the establishment of herd immunity [4,5]. However,
the distribution of these gains are uneven with FCV regions disproportionately affected due to disruptions in
health services, insecurity and population displacement [6]. The Northern part of Nigeria, characterized by
ongoing conflict, poverty and weak health infrastructures exemplifies a good case of struggling region where
vaccine uptake remains critically low and VPD outbreaks persist [7,8,9].
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The nexus between conflict and healthcare delivery in Northern Nigeria creates complex barriers to effective
immunization [8]. Bliss and Burke [10] posited that armed conflicts undermine immunization efforts by
destroying health infrastructure, depleting healthcare personnel, limiting humanitarian access and displacing
vulnerable populations thereby obstructing routine vaccination schedules. Additionally, conflict settings often
present heightened risks of disease outbreaks due to overcrowded living conditions and poor sanitation among
internally displaced persons (IDPs) and host communities [11]. Sabahelzain et al. [12] observed that efforts to
deliver vaccines in conflict environments require innovative strategies, including negotiated ceasefires and
community engagement, yet these remain challenging to sustain.
Multiple studies have identified socio-cultural determinants influencing vaccine hesitancy and refusal in
Northern Nigeria’s FCV zones [8,9,13]. Religious beliefs, misinformation, mistrust in government programmes
and low health literacy contribute substantially to low immunization rates in affected communities [14,15]. The
World Health Organization listed vaccine hesitancy as one of the top global health threats [6,16]. This is
particularly entrenched in fragile areas where the health system is weak and rumors about vaccine safety
proliferate unchecked [6]. Therefore, addressing vaccine hesitancy requires culturally sensitive health education
and trust-building interventions tailored to local realities [8,17].
Besides socio-cultural challenges, logistical and operational constraints significantly hinder immunization
programmes in FCV region of Northern Nigeria [8,18]. These include inadequate vaccine supply chains,
insufficient cold chain infrastructure, poor transportation networks and financial barriers that limit access to
health facilities [18,19]. The combination of long distances to healthcare centers and the cost of transportation
discourages caregivers from seeking vaccination services for their children and it often led to missed
opportunities for immunization [19]. Additionally, inconsistent availability of vaccines and trained healthcare
workers exacerbates the problem, resulting in irregular immunization schedules and incomplete vaccine
coverage [20].
The impact of these challenges is evident in the recurrence of outbreaks of measles and polio diseases in Northern
Nigeria despite global efforts toward eradication [21]. Conflict-affected communities carry a disproportionate
burden of VPDs, which not only results in preventable morbidity and mortality but also strains the already fragile
healthcare system [6,21]. Furthermore, outbreaks in these regions pose risks of cross-border transmission that
might threaten public health security beyond local communities [24]. Thus, understanding the multifaceted
impact of conflict on immunization and the subsequent challenges is essential for designing effective
interventions.
This systematic literature review (SLR) provide a detailed appraisal of the current state of vaccine-preventable
diseases, their impacts and immunization challenges in FCV communities of Northern Nigeria. The SLR
synthesised evidence from diverse sources and highlighted the gaps in policy and practice, inform strategic
responses and identify best practices from similar fragile areas. This work aims to support stakeholders' efforts
to strengthen vaccination programmes and reduce the burden of VPDs in conflict-affected and vulnerable
populations.
Review Objectives and Rationale
The review objectives focus on assessing the impact and challenges of vaccine-preventable diseases in fragile,
conflict-affected and vulnerable (FCV) communities in Northern Nigeria, particularly against the backdrop of
ongoing insecurity and insurgency. The rationale for this review stems from the urgent need to understand how
persistent conflict such as the Boko Haram insurgency, armed banditry and herders-farmers clashes significantly
disrupts vaccination services, healthcare infrastructure, and trust in immunization programs, thereby
exacerbating disease outbreaks in the region [21,23]. Equally important is to identify socio-cultural, economic,
and political barriers, including misinformation, vaccine hesitancy, and low literacy levels, that hinder vaccine
acceptance among displaced and vulnerable populations [23]. Finally, the review aims to appraise adaptive
strategies and delivery innovations such as mobile clinics and community engagement that can improve
immunisation coverage despite the operational complexities posed by conflict [8,24]. This systematic appraisal
is important to informing approaches to tailored public health interventions, policy decisions and resource
allocation to mitigate the burden of vaccine-preventable diseases in these hard-to-reach populations.
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Table 1: Research Questions (RQ) and Rationale
Research Area
Research Question
Rationale
Impact of Conflict on
Vaccination
How does ongoing conflict and
insecurity in Northern Nigeria's fragile
and conflict-affected communities
impact vaccination coverage and uptake?
To understand the extent to which
conflict disrupts immunization services,
reduces healthcare access, and
contributes to vaccine-preventable
disease outbreaks in FCV areas.
Barriers to Vaccination
Uptake
What socio-cultural, economic, and
political barriers affect vaccine
acceptance and uptake in vulnerable
communities affected by Boko Haram
insurgency?
To identify key factors such as mistrust,
misinformation, poverty, and low
literacy that hinder vaccination efforts,
essential for designing context-sensitive
interventions.
Strategies for
Improving
Immunisation
What adaptive strategies and delivery
mechanisms have proven effective in
increasing vaccine coverage in FCV
settings of Northern Nigeria?
To evaluate the effectiveness of mobile
clinics, community engagement, and
targeted campaigns in overcoming
conflict-related barriers and improving
vaccination outcomes.
METHODOLOGY
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method is an evidence-
based set of guidelines designed to improve transparency and completeness in reporting systematic reviews and
meta-analyses. The PRISMA framework guides authors to document the rationale for the review, the methods
employed, and the findings obtained. It comprises a checklist of essential reporting items and a flow diagram
depicting the review process, including search results, articles screening and study selection. The PRISMA
guidelines are adaptable to various types of systematic reviews, with extensions available for specific research
areas. This systematic literature review (SLR) on vaccine-preventable diseases in FCV communities in Northern
Nigeria, the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for
Scoping Reviews) framework was adopted. PRISMA-ScR aims to clarify information and enhance the scoping
review protocol, addressing key sections such as the title, abstract, objectives, research questions, evidence
source selection, result summaries, and expected outcomes. It includes a checklist of 20 essential reporting items
and 2 optional items.
Search Strategy
A structured, Systematic and replicable literature search was conducted across multiple electronic databases
including PubMed, Scopus, Web of Science and African Journals Online (AJOL). Grey literature were explored
through sources such as WHO reports, government health policies and relevant NGO publications. The search
covered articles published from January 2015 to the present to capture recent and relevant data reflecting
contemporary challenges and interventions. Search terms included keywords such as "vaccine hesitancy,"
"immunization barriers," "conflict-affected populations" and Medical Subject Headings (MeSH) related to
vaccine-preventable diseases, immunization, conflict zones, FCV settings, Northern Nigeria and associated
impacts or challenges. Boolean operators (AND, OR) and truncations were used to refine the search.
Inclusion and Exclusion Criteria
Studies were included based on the following criteria. Conducted in or relevant to Northern Nigeria FCV
communities or comparable conflict-affected settings. Focus on vaccine-preventable diseases (for example,
measles, polio, diphtheria) and immunization uptake, impact, or challenges. Empirical research including
quantitative, qualitative, and mixed-methods studies published in English. The exclusion criteria included studies
not focused on vaccine-preventable diseases or immunization. Research outside the geographical or contextual
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scope unless providing relevant comparative insights. Non-empirical articles such as editorials, opinion pieces
and commentaries without original data.
Data Extraction
A standardized data extraction form was developed and pilot-tested. Extracted data included in the study
characteristics were author, year of publication, study design and location where the study was carryout. The
population details, intervention or exposure, outcomes related to vaccination coverage and VPD impact, reported
barriers and facilitators, and key findings relevant to FCV regions. Dual independent reviewers performed data
extraction to ensure accuracy, with discrepancies resolved through discussion and third party reviewer.
Quality Assessment
The methodological quality and risk of bias in studies inclusion were assessed using validated tools appropriate
for study design, such as the Joanna Briggs Institute (JBI) Critical Appraisal Checklists for qualitative and
quantitative studies. This evaluated aspects such as sample representativeness, data collection methods,
confounding factors and analysis rigor.
Data Synthesis
A narrative synthesis approach was employed to integrate findings across heterogeneous study designs and
outcomes. Themes were organized around vaccination impact, immunization coverage rates, contextual
challenges (for example, security, logistics, socio-cultural factors), and programmatic responses. Where
quantitative data allow, meta-analysis was conducted for vaccination coverage statistics. Evidence gaps and
research priorities were identified to inform policy and practice.
Reporting
The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines to ensure transparency and completeness in reporting. A PRISMA flow diagram (Figure 1) was
documented to show the study selection process. Since the systematic review focuses on understanding the
impact of conflict on immunisation coverage and the challenges faced in Northern Nigeria's FCV settings, where
health infrastructure is often compromised, and vaccine hesitancy and misinformation are prevalent. The
PRISMA flow diagram was used to display the process of study identification, screening, eligibility assessment
and inclusion to ensure transparency in literature selection and synthesis.
Figure 1: PRISMA Flowchart Developed for SLR Methodology
Identification
Databases
n = ?
Scopus
N = ?
PubMed
n = ?
ScienceDirect
n = ?
Web of Science and
African Journals
Online (AJOL)
n = ?
Screening
Records screened
n = ?
Years
n = ?
Language
n = ?
Records excluded
n = ?
Eligibility
Full-text articles
assessed for
eligibility
n = ?
Full-text articles
excluded
n = ?
Included
Articles
n - ?
Conference
Proceedings
n = ?
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PRESENTATION OF FINDINGS
Figure 2 shows result of a standard searches using PRISMA framework with 1,842 records identified from four
databases: Scopus (1,049), PubMed (315), ScienceDirect (364), and Web of Science and African Journals Online
(114). The records were screened through region and year filters and 1,711 records were excluded, leaving 131
records for closer examination. Out of the 131 articles, only 27 were full-length articles and assessed for
eligibility, while 104 excluded for various reasons. Ultimately, the 18 studies included in the review were 12
articles and 6 conference proceedings, while 9 opinion pieces articles were excluded.
Figure 2: Result of the SLR Using PRISMA Flowchart
Figure 3 illustrates the distribution of research studies on immunization in Nigeria across three main areas. The
result revealed that impact of conflict on vaccination (33 %, 6 studies), barriers to vaccination uptake (39 %, 7
studies), and strategies for improving immunisation (28 %, 5 studies). The largest focus on barriers highlights
the significant attention given to understanding challenges of vaccine uptake. Studies on the impact of conflict
emphasize the detrimental effects of armed conflicts like Boko Haram on vaccine availability and healthcare
utilization, while a relatively smaller proportion of studies concentrate on strategic interventions to improve
immunization uptake. The findings indicate the importance of balanced research to inform effective policies and
programmes aimed at increasing vaccine coverage and equity in Nigeria.
Identification
Databases
n = 1842
Scopus
N = 1049
PubMed
n = 315
ScienceDirect
n = 364
Web of Science and
African Journals
Online (AJOL)n = 114
Screening
Records screened
n = 131
Records excluded
n = 1711
Eligibility
Full-text articles
assessed for eligibility
n = 27
Full-text articles
excluded
n = 104
Included
n = 18
Articles
n - 12
Opinion piece
n = 9
Conference
Proceedings
n = 6
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Figure 3: Classification of the Selected Papers Base on the Review Objectives
Table 2 outlines the selected studies on vaccination and immunization across fragile, conflict-affected and
vulnerable (FCV) communities in Northern Nigeria. The studies explore vaccine hesitancy in specific
populations, such as mothers in Minna [9], urban healthcare workers in Benue State [25] and communities
affected by cultural and religious beliefs [26], which reflected the challenges in vaccine acceptance. Others assess
childhood immunization barriers, low coverage in nomadic and farming communities and factors influencing
vaccine uptake across regions [27,28], which highlighted the sociocultural and logistical determinants of vaccine
acceptance. A distinct group of studies addresses the effects of armed conflict, particularly in northeastern
Nigeria and the Sahel region, on vaccination coverage, healthcare utilization and vaccine access
[21,29,30,31,32,33]. These studies illustrated the compounded challenges across FCV communities in Northern
Nigeria. Additionally, government campaign evaluation and community engagement strategies [17,34], which
showcased the efforts to improve immunization through public health initiatives and trust-building. The studies
revealed that Northern Nigeria faces the challenges of vaccine hesitancy as a result of sociocultural and logistical
barriers, and the impact of armed conflict on immunization coverage.
Table 2: Selected Studies and their Focus Areas and Sources
S/N
Year
Title
Focus
Source / Notes
1
2021
Measles Information
Vaccine Hesitancy-
Case Study of Mothers
in Minna, Niger State
Vaccine
Hesitancy,
Measles
http://irepo.futminna.edu.ng:8080
/jspui/handle/123456789/14337,
Doctoral dissertation
2
2025
Factors affecting
childhood
immunization across
communities in Sokoto
State, Nigeria, and
recommendations to
improve vaccine uptake
Childhood
Immunization
Barriers
https://indigo.uic.edu, Doctoral
dissertation
3
2023
Appraisal of
government
immunization
Government
Campaign
Evaluation
ResearchGate, Online report,
https://www.researchgate.net/
publication/332499870_
6, 33%
7, 39%
5, 28%
Impact of Conflict on
Vaccination
Barriers to Vaccination
Uptake
Strategies for Improving
Immunisation
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campaigns in Niger
State, Nigeria
4
2019
Achieving maternal and
child access to vaccines
in Nigeria
Vaccine Access
Doctoral dissertation, general
Nigeria
5
2024
COVID-19 Vaccine
Hesitancy among
Urban Healthcare
Workers in Benue
State, Nigeria
COVID-19
Vaccine
Hesitancy
Researchgate
6
2024
Evaluating health
communication effects
on COVID-19
vaccination uptake in
Plateau State, Nigeria
Health
Communication,
Vaccine uptake
JMIR Preprints
7
2023
Low immunization
completion in nomadic
& farming communities
in North Central
Nigeria
Immunization
Coverage
Nigerian Journal of Clinical
Practice
8
2023
Effect of immunization
information on vaccine
acceptance in Niger
State, Nigeria
Immunization
Information
Impact
https://www.cabidigitallibrary.org/
doi/full/10.5555/20230289344
9
2019
The CORE Group
Partners Project in
North East Nigeria:
community
engagement strategies
to combat skepticism
and build trust for
vaccine acceptance
Community
Engagement for
Vaccination
The American journal of tropical
medicine and hygiene, PubMed.
10
2019
Effect of armed conflict
on vaccination:
evidence from the Boko
Haram insurgency in
northeastern Nigeria
Impact of armed
conflict on
vaccination
coverage
Conflict and health, Springer.
11
2025
Implications of conflict
on vaccination in the
Sahel region.
Implications of
conflict on
vaccination
efforts
BMJ global health
12
2021
Differential effect of
conflicts on
vaccination: Boko
Haram insurgency vs.
other conflicts in
Nigeria
Differential
impact of
conflicts on
vaccination
Medicine, Conflict and Survival,
Taylor and Francis
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13
2022
The impact of armed
conflicts on health-care
utilization in Northern
Nigeria: A difference-
in-differences analysis
Effects of armed
conflicts on
healthcare
utilization
World Medical & Health Policy,
Wiley Online Library.
14
2022
Will people in conflict-
affected zones in Africa
have access to COVID-
19 vaccine? A case of
Nigeria
Vaccine access
in conflict zones
The International Journal of
Health Planning and Management,
Wiley Online Library.
15
2025
Health outcomes and
health service use
during armed conflicts:
a comparison of
conflict and non-
conflict areas in
Northern Nigeria
Health outcomes
and service use
in conflict
settings
https://cris.maastrichtuniversity.nl/
files/271119192/c8843.pdf
16
2019
Cultural and religious
beliefs influencing
vaccine hesitancy in
Nigeria
Cultural barrier
to childhood
Immunization
Researchgate
17
2017
Approaches to
vaccination among
populations in areas of
conflict.
Strategy on
improving
vaccine uptakes
The Journal of infectious diseases,
Academia.oup.com
Table 3 presents the impact of conflict on vaccination and health service utilization in conflict-affected areas of
Northern Nigeria. The findings revealed that the selected studies adopted diverse but complementary
methodological approaches with converging findings. Methodologically, the studies predominantly employed
quantitative techniques to evaluate vaccination coverage data pre- and during conflict periods, statistically
[29,30] and econometric difference-in-differences analyses comparing healthcare utilization in conflict versus
non-conflict zones [31]. These rigorous quantitative methods enable causal inference regarding the adverse
effects of armed conflict on health service delivery. In contract, Sabahelzain et al. [21] adopted mixed-methods
approaches that provided a richer contextual understanding by combining policy reviews with field data from
conflict-affected areas. Similarly, Oladunni et al. [33] employed surveys and qualitative interviews that add a
valuable dimension by capturing real-world barriers faced by populations in accessing COVID-19 vaccines amid
insecurity.
Findings across these studies consistently revealed detrimental effects of armed conflict on vaccination coverage
and healthcare access. Sato [29] found a pronounced 47.2 % reduction in vaccination odds for children living
near conflict events, with greater impacts among uneducated populations. Sabahelzain et al. [21] documented
severe impairment of immunization programmes because of population displacement and destruction of health
infrastructure in conflict-affected regions. The result of comparative analyses showed that Boko Haram
insurgency exerted a more severe negative impact than other conflicts [30]. Further, the econometric analyses
by Ojeleke et al. [31] revealed significant declines in healthcare utilization especially for maternal and child
health services in conflict zones. The study of Oladunni et al. [33] highlighted that insecurity and logistical
challenges caused substantial barriers to COVID-19 vaccine access in the affected areas. Finally, Ojeleke [32]
noted worse health outcomes and lower service usage in conflict-affected areas compared to non-conflict
regions. The methodologies robustly elucidated the multifaceted impacts of conflicts on vaccination and the
findings showed severe consequences of conflict on vaccination and health service delivery in Northern Nigeria.
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Table 3: Summary of studies on the impact of conflict on vaccination and health service utilization in
Conflict Affected Areas of Northern Nigeria
Article Title
Methodology
Findings
Impact of Conflict on Vaccination
Effect of armed conflict on
vaccination: evidence from the
Boko Haram insurgency in
northeastern Nigeria [29]
Quantitative analysis using
vaccination coverage data
before and during
insurgency; statistical
evaluation
Armed conflict significantly
reduced vaccination coverage due
to access issues and disrupted
health services.
Implications of conflict on
vaccination in the Sahel region [21]
Mixed-methods including
policy review and field
data from conflict-affected
areas
Conflict severely impairs
vaccination programs through
displacement of populations and
destruction of health infrastructure.
Differential effect of conflicts on
vaccination: Boko Haram
insurgency vs. other conflicts in
Nigeria [30]
Comparative quantitative
study analyzing
vaccination rates across
different conflict zones
Boko Haram insurgency had a
more pronounced negative effect
on vaccination than other regional
conflicts.
The impact of armed conflicts on
health-care utilization in Northern
Nigeria: A difference-in-differences
analysis [32]
Econometric analysis
comparing pre/post-
conflict health service use
in affected versus non-
affected areas
Significant decline in healthcare
utilization in conflict zones,
especially for maternal and child
health services.
Will people in conflict-affected
zones in Africa have access to
COVID-19 vaccine? A case of
Nigeria [33]
Survey and qualitative
interviews assessing
COVID-19 vaccine access
in conflict zones
Conflict zones face substantial
barriers to COVID-19 vaccine
access due to insecurity and
logistical challenges.
Health outcomes and health service
use during armed conflicts: a
comparison of conflict and non-
conflict areas in Northern Nigeria
[32]
Cross-sectional
comparison using health
surveys and conflict data
Conflict areas show worse health
outcomes and lower health service
usage compared to non-conflict
areas.
Table 4 summarized studies on barriers to vaccination uptake in Northern Nigeria employing different but
complementary methodologies. The studies of Abdulkadir [9] and Adedin et al. [35] utilize in-depth exploration
of mothers' and communities' perceptions and the findings revealed that socio-cultural factors, misinformation,
fear of side effects and religious skepticism as core drivers of vaccine hesitancy. These qualitative designs
approach provided rich-contextual insights into attitudinal barriers. Conversely, Asekun [27] and Nwachukwu
et al. [28] adopt cross-sectional quantitative survey approaches that analysed immunization records to identify
structural barriers such as low education, poverty, limited healthcare access, nomadic lifestyles, and insufficient
outreach affecting immunization completion. Mixed-method designs combining surveys approach with
ethnographic data was adopted by Bamidele et al. [26], which added to distinction understanding of the complex
role of cultural and religious beliefs in fostering vaccine hesitancy and refusal behaviors. Systematic reviews by
Itodo et al. [25] highlighted institutional and professional barriers including safety concerns, misinformation and
distrust in authorities, while the experimental approaches by Otojareri et al. [36] further showed the positive
impact of targeted information campaigns in improving vaccine acceptance and reducing hesitancy.
Consistently, findings across these studies pinpoint misinformation about vaccine safety, cultural and religious
misconceptions, and systemic access challenges as key barriers to vaccination uptake in across conflict-affected
areas of Northern Nigeria. The synthesis of qualitative and quantitative methodologies enriches understanding
by combining personal-level beliefs with population-level determinants. More importantly, intervention studies
revealed the critical role of accurate information dissemination in addressing hesitancy. These methodologically
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diversity employed in these studies provided a robust and evidence-base findings that advocated for culturally
sensitive messaging system, multifaceted strategies to enhance immunization coverage in the region.
Table 4: Summary of the studies related to barriers to vaccination uptake in Northern, Nigeria
Article Title
Methodology
Findings
Barriers to Vaccination Uptake
Measles Information Vaccine
Hesitancy-Case Study of
Mothers in Minna, Niger State
[9].
Qualitative interviews
exploring mothers’
perceptions and attitudes
Vaccine hesitancy primarily driven by
misinformation, fear of side effects, and
cultural beliefs among mothers.
Qualitative research on vaccine
hesitancy in Kano State [36]
In-depth qualitative study
using focus groups and
interviews
Revealed societal mistrust, religious and
cultural skepticism, and concerns about
vaccine safety as key barriers.
Factors affecting childhood
immunization in Sokoto State
[27]
Cross-sectional survey
and analysis of
immunization records
Identified low education, poverty, and
limited access to healthcare facilities as
significant barriers to immunization
completion.
Cultural and religious beliefs
influencing vaccine hesitancy
in Nigeria [26]
Mixed-method study
combining surveys and
ethnographic methods
Religious beliefs and cultural
misconceptions were major factors that
foster vaccine hesitancy and refusal.
COVID-19 Vaccine Hesitancy
among Urban Healthcare
Workers in Benue State [25]
Systematic review and
survey research among
healthcare workers
High hesitancy linked to safety
concerns, misinformation, fear of side
effects, and distrust in government and
health authorities.
Low Immunization Completion
in Nomadic and Farming
Communities in North Central
Nigeria [28]
Community-based cross-
sectional survey with
structured questionnaires
Nomadic lifestyle, poor health
infrastructure, and inadequate
immunization outreach programs
majorly reduce vaccine completion
rates.
Effect of immunization
information on vaccine
acceptance in Niger State [36]
Experimental study
assessing impact of
information campaigns
Providing accurate vaccine information
significantly improved vaccine
acceptance and reduced hesitancy.
Table 5 presents studies on strategies for improving immunization in conflict-affected zone of Nigeria. The
methodologies span policy and program document reviews with rapid local assessments [17], program
evaluations [37], mixed-method surveys and qualitative interviews [38], qualitative case studies involving
interviews and focus groups [34] and field-based evaluations and case studies in conflict zones [8]. These
approaches reflected integrated evidence synthesis, field data collection and stakeholder perspectives to assess
both broad systemic initiatives and localized community-level efforts in improving vaccine uptake.
Findings across these studies collectively highlighted the importance of multi-dimensional strategies to improve
immunization coverage and acceptance. Government-led campaigns benefit from intensified outreach,
integrated service delivery and accountability frameworks, yet require continuous improvement to address
persistent gaps [17]. Also, enhancing maternal and child vaccine access depends significantly on community-
based interventions and strengthening primary healthcare systems. Duburu [37], who posited that active
stakeholder engagement, is important to community-based interventions.
Furthermore, targeted health communication effectively counteracts misinformation and builds trust necessary
for increasing COVID-19 vaccine uptake [38]. Community engagement initiatives demonstrated success when
leveraging local leaders and culturally appropriate messaging to enhance vaccine acceptance [34]. This finding
revealed the necessity of contextualized strategies in improving vaccine uptake in conflict-affected areas. In
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addition, adaptive strategies including mobile clinics, collaboration with security personnel and negotiation with
local communities facilitate continued vaccine delivery despite insecurity [8]. The varied but complementary
evidences revealed that effective immunization strategies in context-sensitive must blend top-down
programmatic reforms with bottom-up community engagement, communication and adaptive service models
that are specific to conflict settings. This holistic approach is essential for overcoming multifaceted barriers
preventing improved vaccine coverage and equity.
Table 5: Summary of Selected studies on Strategies for Improving Immunisation in Nigeria
Article Title
Methodology
Findings
Strategies for Improving Immunisation
Appraisal of government
immunization campaigns in
Niger State [17]
Policy and program
document review combined
with rapid local assessments
Identified successes and gaps; key
strategies include intensified outreach,
integrated service delivery and
accountability frameworks.
Achieving maternal and child
access to vaccines in Nigeria
[37]
Program evaluation and
review of maternal and child
vaccination initiatives
Improved access through community-
based interventions, strengthening
PHC and stakeholder engagement.
Evaluating health
communication effects on
COVID-19 vaccination uptake
in Plateau State [38]
Mixed-methods: surveys
and qualitative interviews
assessing campaign impact
Health communication significantly
boosted vaccine uptake by countering
misinformation and building trust.
Community engagement
strategies for vaccine
acceptance in NE Nigeria [34]
Qualitative case study using
interviews and focus groups
with community
stakeholders
Community engagement leveraging
local leaders and culturally tailored
messaging enhanced vaccine
acceptance.
Approaches to vaccination
among populations in areas of
conflict [8]
Case study and field
evaluation of vaccination
programs in conflict zones
Use of mobile clinics, security
collaboration, and community
negotiation improved vaccine delivery
amid insecurity.
DISCUSSION
The systematic review on vaccination and immunization uptake across fragile, conflict-affected and vulnerable
(FCV) communities in Northern Nigeria using PRISMA framework, focusing on barriers to vaccination uptake,
the impact of conflict on vaccination and strategies to improve immunization showed significant strength.
Bohannon [39] and Grgic et al. [40] demonstrated that systematic review methodology is a strong approach to
comprehensive and structured literature searches that minimizes bias through explicit, reproducible inclusion
and exclusion criteria. The rigorous methodological approach of SLR ensures a thorough aggregation and critical
appraisal of all relevant empirical available evidence and provide high level of reliability and robustness in
summarizing existing research findings. Additionally, SLR exemplify the use of systematic methods for quality
assessment of included studies, which enhanced the validity of synthesized conclusions and strengthens the
evidence base practical recommendations.
This SLR review found that 39 % of the selected studies focus on barriers, 33 % on conflict impacts and 28 %
on strategies; showed the complexity of challenges and responses necessary to enhance vaccination coverage.
This data suggests the importance of meta-analysis. Grgic et al. [40] posited that the inclusion of meta-analytic
techniques allows for quantitative synthesis, which provide precise effect that increase the statistical power
beyond individual studies, while Bohannon [39] illustrated how systematic reviews can identify clinically
meaningful thresholds in physical therapy research. The tripartite division in this SLR highlighted that a
successful immunization programme must simultaneously address demand-side issues related to vaccine
hesitancy and sociocultural factors, supply-side challenges presented by conflict and insecurity, and
implementation of tailored improvement strategies.
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The SLR showed that vaccine hesitancy remains a major barrier in fragile, conflict-affected communities in
Northern Nigeria. This hesitancy is predominantly shaped by a combination of accessibility, sociocultural and
logistical barriers including impact of widespread misinformation, entrenched religious and cultural beliefs and
inadequate access to healthcare infrastructure [9,25,26]. These factors not only reduce vaccine acceptance but
also exacerbate inequities in immunization coverage. Studies by Harrington [41]; Tiwana and Smith [14] and
Vatwani [42] have shown that fear of side effects, mistrust of Western medicine, and skepticism fueled by
religious and cultural narratives collectively undermine vaccine uptake, particularly among vulnerable
populations with limited access to credible health information.
Additionally, this SLR revealed the deleterious impact of armed conflict, especially the Boko Haram insurgency,
Herders-Farmer clashes and banditry on childhood vaccination and healthcare utilization in northern Nigeria is
well-documented. Empirical evidence indicates that regions affected by Boko Haram face severe disruptions in
routine vaccination services, which led to reduced vaccination coverage and adverse health outcomes in conflict
zones relative to non-conflict areas [29,31]. The destruction of health infrastructure, displacement of populations
and insecurity create formidable obstacles for healthcare delivery. It exacerbated the already fragile healthcare
systems in these regions and heightened the risk of resurgence of vaccine-preventable disease outbreaks.
Also, methodological diversity of the studies, which mostly employed quantitative, qualitative and mixed-
methods approaches validates the SLR findings. The convergence of the findings by Sato [29] and Sabahelzain
et al. [21] showed that proximity to Boko Haram conflict events results in a roughly 47.2 % decrease in
vaccination odds among children. Moreover, this reduction is disproportionately greater among less educated
populations, which highlighted how conflict and social determinants of health interact to magnify vaccination
inequalities. The extensive displacement of communities and damage to healthcare facilities further compound
these challenges by interrupting cold chain logistics and immunization outreach. These agreed with the broader
view shared by Comes et al. [43] and Adeyemo et al. [44] on the role of cold chain logistics in vaccine
distribution.
The successful approaches to improving immunization in fragile, conflict-affected and vulnerable (FCV)
communities necessitate multifaceted intervention strategies. Study by Data Project NG [17] revealed that
government-led campaigns have efficacy when outreach efforts are intensified with integrate service delivery
and implementation of accountability mechanisms. Complementary community engagement strategies that
mobilize local leaders and utilize culturally sensitive messaging are pivotal in building public trust and
countering misinformation that fuels vaccine hesitancy [34,38]. These community-centered efforts not only
improve vaccine acceptance but also foster resilience against the socio-political challenges characterizing
conflict-affected regions.
Collectively, these findings emphasize that addressing immunization challenges in conflict-affected areas
requires integrated and context-specific interventions that tackles both structural barriers posed by insecurity and
infrastructural deficits and cultural barriers involving vaccine skepticism, simultaneously. Only through a
holistic approach that blends top-down policy and programme reforms with bottom-up community participation
can sustainable progress be made towards equitable vaccine coverage and herd immunity in fragile settings
[34,45]. Obregón and Waisbord [45] and Shedeed [46] posited that such approaches are essential to protecting
vulnerable populations from vaccine-preventable diseases and advancing public health goals amid persistent
conflict and instability.
CONCLUSION
The systematic literature review (SLR) using the PRISMA framework demonstrated superior records extraction
with 1,842 records identified from databases and filtered to 18 relevant studies through rigorous screening and
eligibility assessment. Barriers to vaccine uptake (39%) accounted for more publications among the three
selected areas base on review objectives. The impact of armed conflict on vaccination and health service
utilization (33%) and strategies to improve immunization coverage (28%) were all equally significant.
Sociocultural and logistical barriers posed significant challenges to vaccine uptake, which are compounded by
the detrimental effects of armed conflicts such as the Boko Haram insurgency. Armed conflicts and banditry
severely disrupted vaccination programmes and access the healthcare in Northern Nigeria. However, government
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campaigns and community engagement initiatives are in place, and they provide promising approaches to
improve immunization uptake through trust-building, integrated service delivery, and culturally tailored
communication strategies. Improving vaccine uptake across FCV communities in Northern Nigeria requires a
holistic, context-sensitive approach combining policy reforms, community involvement and adaptive service
models to overcome vaccination challenges in fragile and conflict-affected areas of Nigeria.
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