Effect of food coupon incentives on timely completion of DTP immunization series in children from a low-income area in Karachi, Pakistan: A longitudinal intervention study
Introduction
Immunizations are among the most cost-effective interventions in public health to reduce infant and child mortality [1], [2], [3]. Since the inception of the Expanded Program on Immunization (EPI) in 1974, millions of deaths have been prevented each year [4], [5]. However, despite continuous efforts, many national EPI programs have not been able to achieve high immunization coverage levels required for effective control of preventable diseases. The result of suboptimal immunization rates in developing countries is persistent existence of several vaccine-preventable diseases which have been optimally controlled in developed countries [2]. Globally, various strategies and interventions are being tested to increase the immunization coverage including reminders to parents, out-reach services, health education, information dissemination, vaccination requirements for schools, enhancing access to vaccination centers and monetary incentives [6], [7].
Pakistan's EPI was launched in 1978 with the objectives of controlling six childhood diseases: polio, tuberculosis, diphtheria, pertussis, tetanus and measles. Subsequently hepatitis B and Haemophilus influenzae type b vaccines were added in 2001 and 2008, respectively [8], [9], [10], [11]. Initially successful in the early 1980s, the program deteriorated following the withdrawal of international support in the mid-1990s; the national DTP3 coverage decreased from 83% in 1990 to 58% in 1995 [12], [13]. The program is currently working to achieve the Millennium Development Goal (MDG) of reducing mortality and morbidity resulting from the eight EPI target diseases by immunizing children 0–11 months of age and women of child bearing age [7], [8]. However, Pakistan's DTP3 coverage remains modest (<20–80+%) and the country is lagging far behind in meeting the MDG of reducing childhood mortality [13], [14], [15].
Despite evaluations and strategic initiatives, there has been no significant improvement in the overall immunization coverage. Several observational studies to identify the reasons for low immunization coverage have been conducted in Pakistan [9], [14], [16], [17], [18] but very few interventional studies have been carried out.
Children who are members of a racial or ethnic minority, who are poor, or who live in inner-city or rural areas tend to have lower immunization rates than children in the general population [19]. Providing incentives to parents for achieving high immunization coverage has been explored in some developed countries with mixed results [6], [20], [21]. Testing similar strategies to improve childhood immunization has not received much attention in developing countries. One study in Nicaragua demonstrated a significant impact of food incentives on improved immunization coverage in rural areas [22]. This study evaluated the impact on vaccine coverage of coupons, redeemable for food and medicines, as an incentive for mothers of infants visiting EPI centers.
Section snippets
Study setting
The study was conducted in 11 union councils (a sub-district level administrative region in Pakistan) of Lyari and two adjoining union councils (Kharadar and Old Haji Camp) of Saddar. The study area includes the oldest and most densely populated regions of Karachi, Pakistan. The total population of the study area in 2006–2007 was approximately 1.1 million persons living in an area of 8.3 km2 (3.2 miles2). Residents form an ethnically diverse community of middle-income to very-low-income
Results
A total of 2506 infants were enrolled in the intervention cohort and 2039 in the control cohort. Out of the enrolled infants 294 (14%) in intervention cohort, and 1192 (58%) in control cohort were excluded as they were either older than 6 weeks at BCG or 10 weeks at DTP1 immunizations, or they were not followed through the age of 126 days (due to early cessation of study activities as a result of end of project funding). Included in the analysis were 3059 infants—with 847 infants in the
Discussion
The food/medicine coupon incentive was associated with a two-fold increase in the timely completion of DTP immunization series. The DTP3 coverage (22%) by 18 weeks of age in the no-incentive cohort was much lower than the EPI Pakistan estimates of 83% at the national level [25] for children who had received DTP3 and OPV3 by 12 months of age and the provincial coverage of 66.5% in Sindh [8]. The DTP3 coverage in Karachi (city including the study area) was reported to be 78% in 2006 and 72% in
Conclusion
While increasing immunization coverage is a complex structural and behavioral process, financial incentives may improve routine immunization coverage in developing countries. Food/medicine coupon incentives increased immunization coverage in our low-income communities. Governments could use the strategy of economic incentives to target the poorest areas that have constantly shown slow progress despite continuous efforts.
Acknowledgements
The authors would like to thank Ismat Lotia for her assistance in data management and Waseem Akbar for ensuring the smooth running of the study.
References (40)
- et al.
Improvement in coverage of primary health care in a developing country through use of food incentives
Lancet
(1986) - et al.
Health care incentives in immunisation
Aust N Z J Public Health
(1999) Can you pay people to be healthy?
Lancet
(2008)- et al.
Increases in vaccination coverage for children in child care, 1997 to 2000: an evaluation of the impact of government incentives and initiatives
Aust N Z J Public Health
(2002) - et al.
Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: cluster randomised trial
Lancet
(2004) - et al.
Effectiveness of the linkage of child care and maternity payments to childhood immunisation
Vaccine
(2004) Ten great public health achievements, 1900–1999: impact of vaccines universally recommended for children
MMWR Morb Mortal Wkly Rep
(1999)Achievements in Public Health, 1900–1999: impact of vaccines universally recommended for children—United States, 1990–1998
MMWR Morb Mortal Wkly Rep
(1999)Public Health at Glance: Immunization
(2009)- et al.
Expanded programme on immunization
World Health Stat Q
(1988)
Global Immunization Data
Improving immunization coverage rates: an evidence-based review of the literature
Epidemiol Rev
Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults
Am J Prev Med
National Programme for Family Planning & Primary Health Care (LHW Programme)
Is Expanded Programme on Immunization doing enough? Viewpoint of health workers and managers in Sindh, Pakistan
J Pak Med Assoc
National Programmes: Expanded Program on Immunization
The Hib initiative
WHO Vaccine-Preventable Diseases: Monitoring System. 2008 Global Summary
Issues and challenges in expanded programme on immunization in Sindh, Pakistan
J Coll Physicians Surg Pak
Cited by (33)
Small mobile conditional cash transfers (mCCTs) of different amounts, schedules and design to improve routine childhood immunization coverage and timeliness of children aged 0-23 months in Pakistan: An open label multi-arm randomized controlled trial
2022, eClinicalMedicineCitation Excerpt :Yet more affordable CCTs (USD ≤15 per child delivery/HIV test/fully immunized child) have been shown to increase institutional deliveries among pregnant women,12 improve patient HIV test acceptance,13 and raise immunization uptake. Conditional cash transfers of <USD 3 plus reminders increased FIC in Kenya by 8 ppt (4ppt versus SMS only),14 in-kind small transfers (lentils and a set of plates) costing <USD 1 per immunization increased FIC in India by 21 ppt,15 small airtime CCTs of USD 0.5 per immunization increased coverage by 17 ppt over baseline estimates in another RCT from India16 and food/medicine vouchers worth USD 2 doubled up-to-date DTP3 (Diphtheria, Tetanus, Pertussis) coverage at 18 months in Pakistan.17 While these studies serve as proof of concept that small mCCTs can promote immunization, they do not determine the most effective way to structure small mCCTs in terms of amount, schedule, and design, nor do they test a scalable platform for delivering the small mCCT.
Sustainability of mHealth solutions for healthcare system strengthening
2020, Digital Health: Mobile and Wearable Devices for Participatory Health ApplicationsEnsuring childhood vaccination among slums dwellers under the National Immunization Program in India - Challenges and opportunities
2018, Preventive MedicineCitation Excerpt :Several studies have demonstrated positive effect of incentives on immunization coverage. Thus, it can be an important strategy, especially for low income group settings with low immunization coverage (Shei et al., 2014; Chandir et al., 2010; Giles et al., 2014). Some of the other tested strategies include, extended immunization service hours to catch working groups, training of service providers to increase knowledge of vaccines specifically targeting slums, finding opportunities for immunization of children while they are visiting health facilities and a community volunteer group to support immunization sessions for increasing participation (Uddin et al., 2010).
Parents’ preferences for interventions to improve childhood immunization uptake in northern Nigeria
2018, VaccineCitation Excerpt :The literature was primarily sought through PubMed, with supplemental online searches for gray literature. From this review, we identified six intervention attributes that may affect immunization demand, including location, type of incentive, bundled services, leaders’ involvement, vaccine information source, and government role (Table 1) [9–14,33–47]. Each attribute was given three levels.