Compliance-linked incentives increase infant immunizations rates in rural India
1. Infantile immunization rates were higher among children whose caregivers received compliance-linked incentives when compared to those who received only mobile phone reminders and those who received no intervention.
2. Incentives were also linked to improved immunization timeliness compared to reminders alone or no intervention.
Evidence level: 1 (Excellent)
Study Rundown: Efforts to increase childhood immunization in the last decade, particularly in low- and middle-income countries, have improved vaccination coverage among pediatric populations worldwide. However, immunization programs face significant barriers, including lack of reliable vaccine records and patient inaccessibility to follow-up care, such that millions of infants remain partially or fully unimmunized. Researchers in this study compared the impact of telephone message reminders with and without small denomination incentives (mobile phone talk time) to no intervention on immunizations rates among infants in rural India. Results showed significantly higher vaccination rates among the group that received compliance-linked incentives. Reminders alone were not associated with increased immunization rates compared to no intervention. As participants in intervention and control groups were from the same geographical community, it is possible that this study was biased by the Hawthorne effect, whereby individuals modify their behavior when they are aware they are being observed. However, this effect would have artificially lowered the observed effect of the intervention. Results suggest small incentives can be used to improve immunization compliance among children in resource-limited regions.
In-depth [randomized control trial]: Researchers analyzed immunization completion and timeliness data from 549 infants aged ≤24 months old (median age 5 months, 51.4% female, 83.6% of their mothers had no schooling) who lived in a rural community in Haryana, India. Participants were randomized to 1 of 3 study groups: a control group utilizing the mobile phone software for record keeping only, an intervention group receiving automated mobile phone reminders only, and an intervention group receiving automated reminders and small denominations of mobile phone talk time as compliance incentives. Immunization coverage was calculated as the number of immunizations received divided by the number required at the time of enrollment, and at the study's end. Timeliness was calculated as the proportion of immunizations given within 14 days of the scheduled visit. Results showed that the median baseline coverage rates across all groups was 33.3%. At study end, coverage rates were 41.7%, 40.1% and 50.0% for the control, reminders alone, and incentives groups respectively. After adjusting for participant age, maternal education, birth place and other baseline characteristics, compliance-linked incentives were found to be independently associated with increased coverage rates compared to the control group (adjusted risk ratio (aRR) 1.09, 95%CI 1.002-1.18, p = .04). Reminders alone were not associated with increased coverage (aRR 1.02, 95%CI 0.94-1.11, p = .64). Compliance-linked incentives were also found to significantly improve timeliness of immunizations (40.8%, 26.7% and 31.3% timely immunizations for the incentives, reminders and control groups respectively, p < .03 for the incentives group compared to control).
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