Background: Mozambique introduced Rotarix vaccine in September 20125. By 2030, it is projected to save around 9,000 lives and over 7.8 million USD in healthcare costs. However, dropout between the first and second doses remains a barrier to achieving the 90% target coverage. Understanding individual and community-level factors driving this dropout is essential for targeted interventions.

Objective: Examine multilevel determinants of rotavirus vaccine dropout among children aged 12–35 months in Mozambique.

Methods: This is a cross-sectional analysis based on data from the nationally representative Demographic and Health Survey (DHS) conducted in Mozambique between July 2022 and February 2023. The study included 2,572 children aged 12 to 35 months who had received the first dose of the Rotarix vaccine. Factors associated with the outcome variable were considered statistically significant at a p-value ≤ 0.05 in the multilevel logistic regression models. The intraclass correlation coefficient (ICC) was estimated to quantify the degree of community-level clustering. All analyses accounted for the complex survey design and were performed using STATA version 17. Spatial analysis using Getis-Ord Gi* statistics was conducted to identify geographic hotspots and coldspots of vaccine dropout rates across provinces.

Results: Overall rotavirus vaccine dropout rate was 14.7% (95% CI: 12.8%–16.8%). The Intraclass correlation coefficient revealed substantial community-level clustering (ICC=0.679). Multilevel analysis identified significant protective factors: antenatal care attendance with 1 to 3 visits (OR=0.19, 95% CI: 0.06–0.59, p=0.004) and more than 4 visits (OR=0.15, 95% CI: 0.05–0.45, p=0.001), possession of health card (OR=0.43, 95% CI: 0.22–0.85, p=0.014), and absence of geographic barriers to healthcare access (OR=0.46, 95% CI: 0.25–0.82, p=0.009). Rural residence emerged as the strongest risk factor (OR=4.00, 95% CI: 1.78–9.02, p=0.001). Provincial variations were significant, with Inhambane (OR=0.07, p=0.015) and Maputo Province (OR=0.09, p=0.047) showing lower dropout odds compared with the Capital city. Spatial analysis revealed dropout hotspots concentrated in central regions of Mozambique.

Conclusion: Rotavirus vaccine dropout remains high, with community-level clustering underscoring the need for community-tailored interventions. Strengthening antenatal care services, improving health card utilization, addressing rural healthcare accessibility, and implementing geographically targeted strategies in identified hot-spot regions are essential for reducing dropout rates and achieving equitable immunization coverage.

Keywords: Rotavirus, Child Health, Immunization, Multilevel Models, Complex Surveys