Effectiveness of demand-incentives on uptake and coverage of basic child immunisation in low-income-settings

SCHOOL OF HEALTH

ACADEMIC YEAR 2013-2014

EFFECTIVENESS OF DEMAND INCENTIVES ON UPTAKE AND COVERAGE OF BASIC CHILD IMMUNISATION IN LOW-INCOME-SETTINGS

YAHAYA HASSAN OLORIEGBE

COURSE SUPERVISOR: Karen Beaulieu

Dissertation Supervisor: Kirsty Mason

Masters dissertation in partial fulfilment of the requirements for the degree of Masters of Science in Public health

Copyright

The author and the supervisor give permission to put this Masters Dissertation to disposal for consultation and copy parts of it for personal use. Any other use falls under the limitations of copyright regulations, in particular to explicitly mention the source when citing parts of this Masters dissertation.

University of Northampton, 7th July 2014

------------------------------------------------------------------------------------

Yahaya H. OloriegbeKirsty Mason

-----------------------------------------------Karen Beaulieu

DEDICATION

This project work is dedicated to Almighty God for his infinite mercies on me, my family and in making me one of the successful ones in this life.

I want to specially dedicate this work to the pillars in my life, my father (Dr. Ibrahim Oloriegbe) and my Mother (Hajia Maimunat Ibrahim). I owe everything in my life to both of you.

ACKNOWLEDGEMENT

All praise and glory be to the Almighty GOD for HIS infinite mercies on making this project a success. My Sincere appreciation to my father and Mother, I thank God for choosing you to give birth to me. Your contribution to my life is immensely appreciated; no amount of words could justify how much I appreciate all you support, understanding and care. I pray that GOD in HIS infinite mercies grants you Aljanatulfirdous (ameen).My profound gratitude goes to Kirsty Mason for her support, understanding and endurance. If I come back to this world several times, you will always forever be held up - high in my life. I want to specially thank Sue Everret for all her support, understanding through out the course of my masters education. Please know that you are one in a million.To the board of University of Northampton, I say a big thank you for giving me the opportunity to rediscover myself. I appreciate the supports by all others in ensuring this project was a success.Thank you All!

TABLE OF CONTENTCHAPTER ONE2INTRODUCTION21.0 INTRODUCTION21.1 RESEARCH OVERVIEW:21.2 JUSTIFICATION OF STUDY5CHAPTER TWO6BACKGROUND62.0 INTRODUCTION62.1 NEED FOR DEMAND INCENTIVES STRATEGY: EFFECT ON UNIMMUNISED CHILDREN62.2 FACTORS UNDERLYING SUBOPTIMAL IMMUNISATION COVERAGE82.3 EVIDENCE OF USE OF INCENTIVES GLOBALLY92.4 CURRENT STUDIES THAT HAVE ACCESSED THE EFFECTIVENESS OF DEMAND INCENTIVES ON IMMUNISATION AND OTHER PREVENTIVE HEALTH BEHAVIOURS.102.5 TYPES OF DEMAND-INCENTIVES112.6 SUMMARY AND TAKING IT FORWARD11CHAPTER THREE12RESEARCH AIM, OBJECTIVE AND QUESTIONS123.0 INTRODUCTION123.1 RESEARCH AIM123.2 RESEARCH OBJECTIVE123.3 RESEARCH QUESTIONS12CHAPTER FOUR13METHODOLOGY134.0 INTRODUCTION134.1GENERATING RESEARCH QUESTION13Figure 1.0: Illustration of the use of standard PICOT and mind mapping in focusing the research questions (Fineout-Overhott and Johnston 2005).144.2SELECTING RESEARCH METHODOLOGY154.3RESEARCH PROCESS164.3.1 SELECTION CRITERIA16FIG 2.0: Table highlighting the inclusion and selection criteria for articles to be selected.164.3.2 DATA BASE SEARCHING19Figure 3.0Table highlighting the choice of database used with rationale for selection.204.3.3 KEY TERMS SEARCH21Figure 4.0Table highlighting key terms used in including and excluding journal articles224.3.4 SEARCHING THROUGH THE DATABASE234.4SELECTION OF ARTICLES244.4.1DATA MANAGEMENT244.5 DATA ENTRY AND ANALYSIS254.6 DEVELOPMENT OF THEMES25Figure 5.0Table highlighting the summary findings and study designs of the selected journal articles.26CHAPTER 5295.0 EVIDENCES ON THE EFFECT OF DEMAND INCENTIVES FOR CHILD IMMUNISATION UPTAKE AND COVERAGE IN LOW-INCOME-SETTINGS29CHAPTER SIX366.0 EVIDENCES ON THE FACTORS AFFECTING THE EFFECTIVENESS OF DEMAND INCENTIVES ON CHILD IMMUNIZATION UPTAKE AND COVERAGE IN LOW-INCOME-SETTINGS366.1 INTEGRATING DEMAND-INCENTIVE(s) WITH OTHER INTERVENTIONS366.2 BASELINE IMMUNIZATION COVERAGE RATES376.3 BASELINE CHARACTERISTICS OF SETTLEMENT AREA386.4 OTHER FACTORS40CHAPTER SEVEN427.0 EVIDENCE ON THE MOST EFFECTIVE TYPE OF DEMAND-INCENTIVE(s) FOR BASIC CHILD IMMUNISATION UPTAKE AND COVERGAE IN LOW-INCOME-SETTINGS42CHAPTER EIGTH44DISCUSSION448.0 INTRODUCTION448.1 SYNTHESES AND SUMMARY OF THE REVIEW FINDINGS448.2 OVERALL COMPLETENESS AND GENERALIZABILITY OF EVIDENCE478.3 QUALITY OF EVIDENCE GENERATED FROM THE REVIEW488.4 POTENTIAL BIAS OF THE REVIEW PROCESS498.5 AGREEMENT AND DISAGREEMENTS WITH PREVIOUS STUDIES50CHAPTER NINE51CONCLUSION519.0 INTRODUCTION519.1 KEY FINDINGS519.2 IMPLICATION FOR PRACTICE529.4 RECOMMENDATION FOR FUTURE RESEARCH539.5 DISSEMINATION OF FINDINGS54REFERENCES55APPENDIX61APPENDIX 2: FLOW CHART OF THE SELECTION PROCESS OF JOURNAL ARTICLES61APPENDIX 3: CASP Critiquing Tool62

Abstract

Incentives have been widely used to promote the use of preventive health care services including basic child immunization. However, few studies have been done to ascertain the significant impact of demand incentives on the uptake and coverage of child immunization in low-income settings. More so, understanding the factors that may affect the effectiveness of the use of the intervention will help health managers improve immunisation coverage in low-income settings. Immunisation plays a pivotal role in the prevention of morbidity and mortality from preventable diseases that accounts for more than 50% of under-five mortality globally. Therefore, exploring what type of incentives would be most effective will aid policy makers and implementers to develop and implement effective programmes that will facilitate the prevention of vulnerable children from preventable deaths. This study was a systemic review of the effectiveness of demand-incentives on uptake and coverage of child immunisation in low-income settings. The study accessed three main aspects; the efficacy of demand incentives on immunisation uptake and coverage in low-income settings, the factors that may affect the effectiveness of demand-incentives on immunisation uptake and coverage in low-income-settings and the type of incentives with the most significant impact. In undertaking this work, predefined selection criteria and relative key terms were used to search the University online subject-base database (NILE) for primary published journal articles on the effect of demand incentives on immunisation uptake and coverage. Journal articles were selected based on preselected criteria by abstract and full reading. A total of 7 journal articles were identified as relevant for the study. Critical appraisal tools were used in analyzing the methodological quality of the articles while findings was extracted using a coding system. RESULTS: Three major themes addressing the predefined question were developed from the extraction. Of the 7 journal articles selected, 6 studies showed that demand incentives had a positive significant impact on immunisation uptake in low-income-settings. However, only one study reported outcome coverage above 95% required for disease eradication. Three major factors were observed as affecting the effectiveness of demand incentives on the uptake and coverage of immunisation in low-income settings. These are; a) integration with other supply and demand sides interventions such as adequate vaccine stock, regular staff presence, proper cold-chain and effective social mobilization. b) Low baseline immunisation coverage and c) Baseline socio-economic characteristics of the population such as level of poverty, urban-rural composition, literacy composition and infrastructure composition. Other factors observed include perceived value of incentives, funding sustainability and ethical consideration. There was no substantial evidence from the study that supports the type of incentive that is most effective. In conclusion, demand-incentives improve immunisation coverage in low-income settings, however the impact is not large enough to eradicate disease. Nonetheless, when demand-incentives is con-currently implemented with a reliable health supply side ensuring uninterrupted cold chain and avoiding vaccine stock out, the effect of demand-incentives are much larger. More so, demand-incentives provides better outcome when implemented in environment with low-baseline immunisation coverage. In addition, long distance to health facilities may limit the effect of the incentives regardless of the presence of incentives; rather value of incentives should be of equivalent to household cost ranging from transport cost to household living cost. Finally, it is inconclusive as to what type of incentives is most effective. However, both monetary and non-monetary are effective when implemented with the right conditions. Therefore, future research may conduct a met-analysis to ascertain which type of demand incentives has more effect in low-income settings.

Key Words: Demand Incentives, Immunisation coverage, Immunisation uptake, low-income-settings, Non-monetary incentives and monetary incentives.

LIST OF TABLES AND FIGURES

Figure 1.0Illustration of the use of standard PICOT and mind mapping in focusing the research questions.Figure 2.0Table highlighting the inclusion and selection criteria for articles to be selected.Figure 3.0Table highlighting the choice of database used with rationale for selection.Figure 4.0Table highlighting key terms used in including and excluding journal articles.Figure 5.0Table highlighting the summary findings and study designs of the selected journal articles.

Acronyms and AbbreviationsBCGBacilli, Calmette and GuerinCASPCritical Appraisal toolsCIConfidence intervalCDCCentre for diseases controlCCTsConditional cash transferCRDCentre for Review and DisseminationCRCTsCluster randomised control trialsEPOCEUEuropean UnionSSASub-Sahara AfricaGPEIGlobal eradication initiative DTP3Third dose of diphtheria, pertussis and tetanusFMOHFederal Ministry of healthGAVIGlobal alliance for vaccine securityHibHaemophilia influenza vaccineHep-BHepatitis BLMICLow-middle-income countryMDGMillennium development goalMCVMeasles vaccineOPV3 Third dose of Oral polio vaccineOROdds RatioPICOTPopulation, Intervention, Comparison, Outcome, TimePENTAPentavalent (diphtheria + Pertussis + Tetanus + haemophilia influenza + hepatitis B)RRRelative RiskRCTsRandomised Controlled trialsUSA United States of AmericaUCTsUnconditional cash transferUNICEFUnited Nations childrens fundU5MRUnder-five Mortality rateWHOWorld Health Organisation

With the exception of safe water, no other modality not even antibiotics, has had such a major effect on mortality reduction as immunisation

DRAFT

DRAFT

DRAFT

Plotkin et al., 2008;

4

CHAPTER ONEINTRODUCTION

1.0 INTRODUCTION

This paper will evaluate the effectiveness of the use of incentives on the uptake and increase in coverage of basic child immunisation in low-income settings. The thesis is divided into nine chapters for easy navigation and comprehension. Chapter 1 provides an overview of the research structure; it includes a description of the focus of the research with emphasis on the importance of the research. Chapter 2 explores the existing literature on the use of incentives for driving up the uptake and coverage of immunisation in a development programme setting. Chapter 3 Outlines the researchs aims and objectives while also setting out the key research questions that forms the basis of conducting the research. Chapter 4 describes the methodological process undertaken in collecting, collating and analysing primary data for the purpose of developing findings for this study. The following Chapters 5 7 present the findings of the study and its analysis discussed through a standard process. Chapter 8 presents a comprehensive synthesis of the findings generated from the study while Chapter 9 presents recommendations for practice, which could form the basis of future research work.

1.1 RESEARCH OVERVIEW:

A key component of any public health policy is reducing the burden of illness and mortality especially from preventable causes (Tania and John, 2009). One of such methods that aimed at the reduction of morbidity prevalence and mortality rate from preventable causes is Vaccination. According to the world health organisation (2014), Vaccination/Immunisation is the process of making a person immune/resistant to an infection/diseases through administration of antigenic material known as vaccines. Vaccines trigger the bodys immune system to safeguard the person against subsequent infections by developing adaptive immunity (WHO, 2014). Several research findings have showed vaccination to be an efficient and cost effective method for improving child survival (Miller et al., 2006). For example, The eradication of small pox in 1977 and global vaccination rates of 75% against major childhood diseases such as diphtheria, pertussis, tetanus and measles in the mid 1990s saved more than a billion lives since then (Quadros et al., 2003; Miller et al., 2006).

Despite available evidences (Quadros et al., 2003; Miller et al., 2006) that immunisation is a cost efficient and effective intervention for improving child survival, Children in many parts of the world especially in the developing nations are either unvaccinated or vaccinated late (Clark, 2009). Hotenzia et al. (2012) would argue that this setback has been much due to the fact that much concentration has been on improving the supply side of immunisation without much consideration on the demand side. The supply side includes the vaccine Cold chain, transportation, procurement and staff training. However, despite this perceived improvement on the supply side, it has not resulted in optimal immunization coverage (Hotenzia et al., 2012). Demand side barriers such as lack of knowledge, forgetfulness, prohibitive transport cost and other competing priorities all play prominent role in low vaccine uptake, especially in low-income population and these groups contribute the highest percentage of the unvaccinated population. The peculiarity of low uptake of vaccination amongst low-income communities reflects the effect of socio-economic characteristics on population health behaviour. These disadvantaged populations present negative health outcomes at a constantly high level (Boerma et al., 2008). For example, the under-five mortality rate has dropped by 47% from 90 deaths per 1000 live births in 1990 to 48 in 2002; this trend has been observed in all regions where under-five mortality rate has dropped 50% except sub-Saharan Africa and the Oceania (UNICEF, 2013). According to Malqvist et al. (2013), general economic development is not enough for improving health for all, rather health care managers and policy makers need to take health of this disadvantaged groups into consideration to ensure sustainable development. Further more, Malqvist et al. (2013) identified striving for universal coverage of health care interventions with special focus on the most vulnerable groups or applying target intervention directed at marginalised population groups. Although, universal health care coverage may be a prerequisite for an equitable health system. However, to disallow the structural drivers of inequity and ensure equity, it is essential to make policies that promote health of the disadvantaged group under a clear context of factors causing inequity (Malqvist et al., 2013). Thus, universal intervention like free vaccination for all may need to be supplemented by targeted intervention focusing on special needs and obstacles to equitable care. For example, countries in the Latin American (Mexicos program for education and health-PROGESSA and Nicaragua red de proteccion social) transfers cash to poor families to alleviate obstacles such as transport cost or competing priorities and with this, they aimed to boost demand for health services such as vaccination and growth monitoring (Gertler and Boyce, 2003; Inter American development Bank, 2003).

Health care Incentive is one of such social-economic targeted intervention. Health Incentives could be targeted at either the providers such as General Practitioners (GPs), health facility managers for performance-based reward or to consumers such as parents and adults to facilitate change in a health related behaviour such as the uptake of vaccine. These mechanisms are increasingly being considered and adopted in health care settings in many nations (e.g. Australia, Mexico and Kenya), in an attempt to change health related behaviour (Legrads, 2008; Lagarde et al., 2007). Their effectiveness is presumably for simple one off behaviour such as getting vaccinated (Achat et al., 1999; Seal et al., 2003). However, the effectiveness of incentives has been proven to vary with recipients level of social deprivation (Eleni et al., 2012). In addition, Sutherland et al. (2008) argued that higher response to financial incentives should be expected from the more socially deprived groups. Nonetheless, if incentives are effective in promoting behavioural change, there are concerns regarding the adverse effect they may have on the quality and depth of peoples decisions to engage in incentivized behaviours. For example, findings from a study revealed that beneficiaries of incentives might loose interest in the incentives as times goes on or as the perceived value of such incentives may reduce, as such sustainability of the behavioural change achieved through the use of incentives becomes a challenge. In addition there are concerns about the impact of such interventions and possible significance in contributing to the eradication of diseases. An understanding of the factors that may inhibit or augment this process will help health managers to understand how to effectively manage this type of intervention. Finally, following the identification of several types of incentives ranging from incentives for providers, consumers or monetary, non-monetary incentives; it is still unclear as to what type of incentives will be most effective for low-income settings. 1.2 JUSTIFICATION OF STUDY

Nigeria accounts for 13% of the global under-five mortality after India (22%), Pakistan, Congo and China (UNICEF, 2013); all the five countries accounts for half of the under-five deaths globally (UNICEF). However, almost half of the leading cause of these deaths are diseases such as pneumonia (17%), Diarrhoea (9%) and malaria (7%) majority of which are preventable through administration of technologies such vaccination (UNICEF, 2013). One of the major problems as highlighted in the previous section (Chapter 1.1) is how to increase demand for these vaccines. The author thus, hopes understanding how incentives works in improving immunisation will aid health managers in increasing child immunisation coverage which may help a country like Nigeria out of its child mortality situation and subsequently other like countries. Therefore, the major problem this study aimed to address is reducing the number of children unvaccinated as a result of lack of demand from their mothers or guardians.

Thus, the author aims to conduct this study by utilising a systemic review as a research methodology. This involves generating data from published primary empirical studies and afterwards analysing them to generate findings that will aid in improving demand for child vaccination in Nigeria and other low-middle income countries.

CHAPTER TWOBACKGROUND

2.0 INTRODUCTION

This chapter will discuss issues on, the need for demand incentives as a strategy to reduce the number of unimmunised children, the current body of knowledge on the use of incentives and studies conducted to explore its effectiveness will be analysed. Finally, research gaps on the subject and how it may be taken forward will be discussed. 2.1 NEED FOR DEMAND INCENTIVES STRATEGY: EFFECT ON UNIMMUNISED CHILDREN

Vaccination is one of the key components of public health policy used in reducing the burden of illness and mortality from preventable diseases (Tania and John, 2009). Eradication of small pox in 1977 and reaching global vaccination rates of 75% for major childhood diseases[footnoteRef:1] in the mid-1990s market some of the pivotal moments for vaccination (Global polio eradication initiative-GPEI, 2013). In 2012, India celebrated one year without any case of wild poliovirus, thus ending a difficult trend of several decades (GPEI, 2013). Presently efforts are underway to eradicate polio in the remaining endemic countries (Nigeria, Pakistan and Afghanistan). Although, eradicating diseases may be a costly program to implement and sustained, long-term financial gain from such intervention tends to be of large impact especially in developing countries (Tania and John, 2009; World health organisation WHO, 2005; UNCEF, 2005; Bloom et al., 2005). For example, it is estimated that as high as $1billion per annum will be saved from the eradication of polio globally, since future expenditure on prevention and treatment of polio victims are eliminated (GPEI, 2013; Khan and Ehreth, 2003). [1: These include measles, tuberculosis, polio, diphtheria, pertussis and tetanus.]

Despite the recorded successes from vaccination, the World health organisation estimated about two million children to have died as a result of vaccine preventable diseases (WHO, 2008). Part of the factors hindering prevention was low and static level of immunisation coverage rates across the globe (Foster et al., 2006). According to the United Nation Children fund (UNICEF, 2008), about 26 million children are left unprotected as a result of the hindering low level of immunisation coverage. However, countries are expected to plateau above coverage rates close to 95% to reach heard immunity[footnoteRef:2] (Barrett and Hoel, 2003). New strategies are however required to achieve eradication coverage. According to Geoffard and Philipson (1997), demand-side strategy is important in eradicating disease because demand for vaccination reduces as the prevalence of a disease decline, therefore, facilitating the resurgence of diseases in an environment. As such, Tania and John (2009) argues that despite the provision of price subsidies such as free vaccination at health facilities and compulsory immunisation programs, these may not be effective enough to eradicate diseases. In a study by Xie and Dow (2005), demand-side and supply side factor was empirically explored. Price of vaccine, health services from supply side and maternal education amongst other demand-side factors determines household level of immunisation coverage. [2: Heard immunity is the coverage required to eradicate vaccine preventable diseases.]

However, Tania and John argued that most national strategies are supply side focused, including door-door service delivery during mass campaigns. On the contrary, demand-side strategies are limited to awareness, which sometimes miss some vulnerable group such as children of poor illiterate mothers. Therefore, strengthening demand side strategies are essential to reduce the number of child mortality from vaccine preventable diseases.

According to the Centre for disease control (CDC), 1998, children from poor, ethnic minority or living far away from the urban area tend to record low vaccination rates compared to the general populations. (shefer et al., 1999; Kerpelman et al., 2000; Minkovtz et al., 1999) emphasised that mixed results have been obtained when incentives was provided to parent to achieve high immunisation coverage in developed countries with only few similar strategies observed in the developing region. Therefore, it is evident that only few studies have explored the effectiveness of demand incentives in low-income settings.

2.2 FACTORS UNDERLYING SUBOPTIMAL IMMUNISATION COVERAGE

According to Sidsel et al., (2013), most unimmunized or incompletely immunized children live in the poorest countries, where many factors combine to thwart attempts to raise vaccine coverage rates, such factors as; fragile or non-existent health service infrastructure, difficult geographical terrain, and armed conflict, to mention just a few. Other unaccounted numbers of unimmunized children are refugees or homeless children, who are usually beyond the reach of routine immunization. Failure to reach these different groups of children with vaccines is jeopardizing the massive efforts and funding being invested in expanding the use of currently underused vaccines (such as the Hib, hepatitis B, and yellow fever vaccines), as well as in major disease-defeating drives, such as eradicating polio, reducing child deaths from measles, and eliminating maternal and neonatal tetanus

A study by Owino et al. (2009) in Nairobi-Kenya noted that although, immunisation services are accessible but utilization is poor. Some of the major factors leading to poor utilization includes ignorance on the need for immunisation and on return dates, fear of adverse event following immunisation, negative attitude of health care providers and missed opportunities. Another study associated the low uptake of child vaccination to low level of education and relative lack of knowledge on immunization (Kamau and Esamai, 2001). According to Ruhul et al. (2013), a study in urban Dili noted that apart from caregivers knowledge and attitude towards immunization, access to services and information, particularly in the city periphery, health workers' attitudes and practices, caregivers' fears of side effects, conflicting priorities, large family size, lack of support from husbands and paternal grandmothers, and seasonal migration all contributes to low uptake of vaccine.

Similarly, Hotenzia et al., 2012 identified lack of knowledge, forgetfulness, high transport cost, with other competing priorities as demand side barriers that limits the uptake of vaccination by parents in especially low-income settings.

Finally, it is evident that developing strategies to uplift demand side barriers will improve immunisation uptake and coverage in low-income settings. (Shefer et al., 1999). Task force community preventive service, 2000) identified various demand strategies that are being piloted to improve immunisation outcome, these include health education, out-reach services, facilitating easy access to heath facilities and monetary incentives. For this reason, it is evident that use of incentives is paramount to improvement of immunisation uptake and achieving higher coverage. 2.3 EVIDENCE OF USE OF INCENTIVES GLOBALLY

The uses of economic incentives have been widely accepted with several countries recording positive health outcome as a result of the increased behavioural change. For example, In Latin American countries, Mexico PROGRESA program, Nicaragua (the red de proteccion) and Honduras have improved immunisation coverage rates including other health outcomes using cash incentives and food vouchers (Inter-American development bank, 2003; Gertler and Boyce, 2003). Similar findings were observed in Australia, USA and also UK where cash incentives were paid to general practitioners to improve immunisation coverage (Loevinsohn and Loevinsohn, 1986; Achat et al., 1999; Hoekstra et al., 1998).

Incentives have also been widely used for other health outcomes asides immunisation. This include, cash transfer, transport voucher sand food coupons for increased compliance to tuberculosis treatment in the Latin America and Eastern Europe (e.g. Russia) (Eichler, 2009). Likewise in the Americas (Brazil, Mexico and USA) provides cash transfer to low-income communities to improve health, education and nutritional outcome (Rawlings, 2009; Rockefeller foundation, 2009). Similarly, cash transfer to mothers improved antenatal care in France and Austria (Hoekstra et al, 1998).

From the examples given above, it is evident that incentives is a widely use intervention for improving preventive health outcome, however, most of the studies obtained were conducted in developed countries, therefore necessitating a need to conduct more studies in low-income settings. More so, none of the studies have explored what type of incentives is most effective for use in low-income settings. Therefore it is important to fill in this knowledge gaps

2.4 CURRENT STUDIES THAT HAVE ACCESSED THE EFFECTIVENESS OF DEMAND INCENTIVES ON IMMUNISATION AND OTHER PREVENTIVE HEALTH BEHAVIOURS.A non-randomised trial conducted in Africa to access the impact of bed nets coupled with vaccination showed increased ownership of bed nets (Grabowski et al., 2005; Wynsonge et al., 2006), however estimate of the impact of the program on measles coverage was not demonstrated. Another study conducted in Nicaragua showed food incentives increased attendance at immunisation campaign from 77% to 94% (Loevinsohn and Loevinsohn, 1987), however the study treatment were sequential instead of contemporaneous because it was an observational study.

Similarly, conditional cash transfer program implemented in Latin American countries showed that incentives have been effective in facilitating the uptake of various preventive health care services (e.g. antenatal care, birth weight) including positive outcome on women and childrens health (Rivera et al., 2004; Lagarde et al., 2007; Fernald et al., 2008; Glassman et al., 2009). However, Malucio and Flores (2004) argued that impact of these program were of less impact. Abhijit et al. (2013) suggested the lack of impact might have been attributed to the initial high immunisation rates in the implementation area.

On the contrary there are studies (Loevinsohn and Loevinsohn, 1987; Morris et al., 2004) that argues ensuring reliable supply of health services and educating mothers on the advantages of immunisation are of importance than incentives in low income settings. Nonetheless, several previous studies have showed that low valued incentives do increase the uptake of preventive behaviours (Loevinsohn and Loevinsohn, 1987; Thornton R., 2008; Kremer and Miguel, 2007; Cohen and Dupas, 2007).

2.5 TYPES OF DEMAND-INCENTIVES Several programmes and studies have explored the use of different kind of demand-incentives. Monetary incentives in the form of cash transfer are frequently used in health and development programmes to aid vulnerable population (Shibuya, 2008; Adato and Bassett, 2009; Fiszbein and Schady, 2009). Conditionality is attached in Conditional Cash Transfer (CCTs) to encourage parents to comply with certain outcomes. However, Debrauw and Hoddinot suggested that Unconditional Cash Transfer (UCTs) compared to CCTs is easier to implement and more appropriate in resource constrained settings. Certain Sub-Saharan African countries (e.g. Zambia and South Africa) with high HIV prevalence have piloted the use of UCTs, with studies from Malawi showing that HIV infections and Herpes in female adolescent significantly declined as a result of use of both CCTS and UCTs (Adato and Bassett, 2009; Baird et al., 2012). Adato and Bassett (2008) however noted that the Malawi study was the only study to have compared UCT with CCT and subsequently Laura et al., (2013) also conducted a randomised trial to compare the effect of UCT versus CCT.

2.6 SUMMARY AND TAKING IT FORWARDHaving considered the effect of lingering unimmunised children globally and also identifying the potential of the use of incentives in improving this deficit, it is still inconclusive as to the weather impact of incentives is significant enough to eradicate disease. Also, none of the study has vividly explored the programmatic factors that affect the effectiveness of demand-incentives on immunisation uptake and coverage. Finally, asides the study comparing the efficacy of unconditional cash transfer and conditional cash transfer, no study have explored what type of demand incentives is most effective. Therefore, this study will aim to feel these knowledge gap identified for practice purpose.

CHAPTER THREERESEARCH AIM, OBJECTIVE AND QUESTIONS3.0 INTRODUCTIONThis chapter provides the aim and objective of this research in line with predefined research questions. The research questions have been formulated to address current gaps identified in currently available literature on the effectiveness of using incentives to improve immunisation coverage.3.1 RESEARCH AIM To explore available evidence on the effectiveness of using demand incentives to improve child immunisation uptake and coverage.3.2 RESEARCH OBJECTIVE To identify how policy makers and health planners can deliver incentive strategy to increase vaccination uptake ad coverage among the public.3.3 RESEARCH QUESTIONS The following research questions will guide the scope of this research in achieving the above stated aim and objective

Research question 1: What is the effect of demand incentives on timely uptake and coverage of basic child immunisation in low-income settings?Research question 2: What are the factors affecting the effectiveness of the use of demand incentives on timely uptake (or take-up) and coverage of basic child immunisation in low-income settings?Research question 3: What type of demand incentives is most effective in improving timely uptake and coverage of basic child immunisation in low-income settings?

Thus, with the research aim, objective and research questions outlined, the next chapter will describe the methodological process undertaken to collect, collate and analysis the primary source of data.

CHAPTER FOURMETHODOLOGY

4.0 INTRODUCTION

This chapter will explore the methodological process taken in identifying relevant articles that will help in providing answers to the research aim and objective hence providing answers to the research questions. In doing this, the first section addresses the process used in generating the research question, followed by an exploration of the different research methodology and a discussion of rationale for choosing the choice of methodology. The second section details the process of undertaking a literature search and also highlights the rationale for selecting articles. Finally, Procedure undertaken in analysing the final selected articles will be explored.

4.1GENERATING RESEARCH QUESTION

Using elicitation technique and visual records such as mind mapping, the author created visual representation around the topic area (Plotik, 2001). This method aided clarification of associations between the different aspects of the topic and identifies gaps around the topic area. Furthermore, in narrowing the research question, the author made use of the standard PICOT (Population, Intention, Comparison, Outcome and Time), as standard PICOT helps in structuring a research topic into question (Fineout-Overhott and Johnston, 2005)

Having explored in the background (see chapter 2.4), the use of incentives in immunization programs, the weight of evidence remains inconclusive as to the types of demand incentives that have higher impact on the uptake of immunization services and why. Furthermore, it remains inconclusive as to the effect of demand incentives on immunization uptake. More so, understanding the factors that affect the efficacy of the use of demand side incentives in immunisation program will fill in the knowledge gap identified in the background. Therefore, to structure the identified gaps in the literature into research questions, the diagram below illustrates how the mind map and the PICOT were used in doing this.The need to explore the factors affecting the efficacy of the use of demand incentivesThe need to improve the uptake and coverage of basic immunisation

Evidences not exploring the efficacy of different types of demand incentives

Evidence not exploring the efficacy of demand incentives

What is the effect of demand incentives (Incentives) on timely (Time) uptake and coverage (Coverage) of basic child (population) immunisation in low-income settings (Population)?

What type of demand incentives (intervention) is most effective in improving timely (Time) uptake and coverage (outcome) of basic child immunisation coverage in low-income settings (Population)?

What are the factors affecting the efficacy of the use of demand incentives (Intervention) on timely (time) uptake and coverage (Outcome) of basic child immunisation in low-income settings (Population)?

Figure 1.0: Illustration of the use of standard PICOT and mind mapping in focusing the research questions (Fineout-Overhott and Johnston 2005).

4.2SELECTING RESEARCH METHODOLOGY

Research involves a process of steps and techniques used to collect process and analyse information to generate relevant conclusions or increase previous understanding of a topic. (Boyton and Greenhalgh, 2004, Creswell, 2008). However, appropriate methods must be chosen based on the research design. Research design may be Qualitative, Quantitative or Mixed method (Polit and Beck, 2005).

Both quantitative and qualitative method involves collections of primary empirical data. These studies report description of the methods, sampling and data collection strategies, and data analysis and results. They allow for collection of new information from primary source. And if well conducted, gives room for valid and reproducible result (Aveyard, 2010). However, this form of research may be time consuming and costly. Thus, a valid alternative is the systemic review. According to Aveyard (2010) a literature review is the comprehensive study and interpretation of a collection of primary research studies, which provides a summary of information on a topic. However, a literature review may be systematic, if the methodology is described to provide opportunity for reproducibility and as such makes it a research methodology (Centre for Review and Dissemination (CRD), 2008; Contrell, 2005; Aveyard, 2010). Furthermore, systemic review aims to summarize and make sense of a large body of available research literature, which aids reader to get the best possible information on a topic area in concise manner (Aveyard, 2010). In addition, a literature review does not require the formal approval of a research ethics committee, which is usually a lengthy process (Aveyard, 2010, Brow et al., 2008).

However, the most important rationales for the choice of literature review as a form of research methodology are the time frame and cost. The time frame for conducting a systemic review may be shorter compared to primary data collection i.e. Qualitative and Quantitative (Burls, 2009). Furthermore, it is cost effective, as it does not involve payment for logistics such as participants incentives, transport, development of questionnaire etc. (Chalmers and Altman, 1995). Although, there may be a requirement to purchase some relevant online journal articles

In summary, the choice of using a systemic review for this thesis can be justified as a valid and reliable method of research methodology. Thus, as a result of these advantages, the author decided to conduct this research by utilizing a systemic review as a research method. This will involve generation of primary data from previously published journal articles. The next section will hence, describe the process taken in collecting the primary data.4.3RESEARCH PROCESS

This section describes the process of search strategy used; this includes the development of selection criteria, development of key terms, database searching, article selection, data management, data synthesis and finally exploring the coding system.4.3.1 SELECTION CRITERIA

This section will describe the rationale for inclusion and exclusion criteria. Developing selection in a research helps in in identifying appropriate literature to be taken forward while providing justification for the rejected articles, in addition, selection criteria ease search strategy by limiting time and energy spent on selecting relevant journal articles (Haynes, 2007). However, since this study is accessing the effectiveness of an intervention, some criteria from the effective practice and organisation of care (EPOC, 2012) standards were utilised. Therefore, The Table below will highlights the rationale for the inclusion and exclusion criteria FIG 2.0: Table highlighting the inclusion and selection criteria for articles to be selected.

Inclusion CriteriaJustification Exclusion Criteria Justification

Primary research articles accessing the outcome of incentives on immunizationPrimary articles Provides higher level of validity and robust evidence (Hawkers et al., 2002)Study conducted in high or middle income countries according to the world bank income classificationAn EPOC criterion guides the use of studies in low-income settings for incentives intervention (EPOC, 2012). Moreover, improving immunization coverage is a dire focus of the low-income countries.

Full text, publishes and peer reviewed Full text articles allows for critique of study process; while published peer reviewed articles will have gone through expert review, thus validating its credibility for review purpose (Smith and Bird, 2010). Study accessing other outcome asides immunization uptake or coverage.There are other studies that have evaluated the effect of incentives on other preventive health service such as use of health facility or Tuberculosis treatment adherence (Martins et al., 2009).

Article published in English languageAlthough it is possible to translate other languages, however, it will require using software that is purchased and moreover some words might not be literarily translated. As such, English Language is easily comprehendible by this author (Tod et al., 2004)Articles with study design asides EPOC criteria, i.e. Randomized control trials, Nonrandomized controlled trials, Controlled before and after, and Interrupted time series studies.According to EPOC, only this range of study design gives a valid outcome for effectiveness study (EPOC, 2012)

Post 2005 articles Recent articles will provide contemporary evidence (Tod et al., 2004)

Intervention must be targeted at parents/guardian and children under the age of 3 years.Decision to access immunization service are taken by parent/guardian of a child, as such, incentives will be targeted at them. More so, there are studies that have shown Incentives program having different targets asides parent/guardian group (Martins et al., 2009). In addition, basic child immunization is for children from birth to 9months and catch up to 24months (WHO, 2012)

Intervention must be consumer/demand incentivesThis is to exclude studies accessing the effect of other type of incentives such pay-for-performance for service providers.

4.3.2 DATA BASE SEARCHING

Following the identification of the inclusion and exclusion criteria to select the relevant articles, the author made use of the university academic electronic database portal (NELSON). NELSON was utilised by the author as it provides free access to different subject specific database for journal articles searching. The entire databases were accessed from June13, 2014 to June 17, 2014. Thus, for clarity purpose, the table below will highlights the rationale for the choice of each database utilised.

Names of data base accessed(May 27-June 14)Rationale for the choice of database used

EBSCO (AMED, MEDLINE & CINHAL)The database is a single sign in resource for other database apart from the listed one. However, the three-listed database provides access to journal articles that are in the category of biomedical, allied and contemporary medicine and nursing articles (university of Northampton UON, 2014)

PUBMEDThe database provides free access to full digital text archive of life science journal articles that are useful for all aspects of medicine. In addition, it cover journal articles published since the 20th century (UON, 2014)

Applied Social Sciences Index and Abstracts (ASSIA)Database contains and provides access to indexing and abstracts for studies in social sciences and health (UON, 2014). Thus, helps the author in developing more relevant search terms (Glasziou, 2009).

HIGHWIREFull text science archive, specializing in life science, medicine and physical science.

JOURNAL @ OVIDDatabase provide free access to archive of wide range of full text journals titles in categories of clinical medicine, behavioral and social sciences (UON, 2014)

SCIENCE DIRECTThis database stores journal from all subject fields (Goldcine, 2008; UON, 2014). Hence, it will aid access to all science related journals in full text.

WEB OF SCIENCE Indexes over 14,000 funds titles in Art & Human Social Science and Science subject fields.

Figure 3.0Table highlighting the choice of database used with rationale for selection.

Furthermore, searches were undertaken using the key search terms by using a search engine such as Google scholar to widen result options. In addition, the reference list of key articles was scrutinized to provide further references (Thompson et al., 2005). Hand searching as suggested by Aveyard, 2010, Haynes 2001) would have helped in locating articles which might not have been in indexed in the database due to outcome bias. Therefore, having selected the database to be utilised, the next step is developing the search terms to be used. The next section will thus describe this process.4.3.3 KEY TERMS SEARCH

According to Tod et al., (2004), the use of Google scholar in lateral search of terms used to describe a topic gives a wide view around a topic and enables the identification of commonly used words. As such, the author made use of Google scholar search engine to identify how different terms were used in describing the topic. Furthermore, the thesaurus component of different subject specific databases (Medline, CINAHL, Web Science, Assia and PubMed) were searched and utilised to develop phrases and terms. According Thompson et al., (2005), the use of subject specific database thesaurus component are effective in generation of key terms since journal articles are indexed differently to aid identification. In addition, abstracts of randomly selected journal articles discussing topic area were searched and utilised (Tod et al., 2004). Below is a table listing the search terms generated from abstract, search engine and databases search. Key words and phrases needed in articles that will be included using the Boolean operator AND & OR while the words to be excluded using the NOT are all listed.

Figure 4.0Table highlighting key terms used in including and excluding journal articles

Included as AND, ORExcluded as NOT

(1) Incentives(2) Financial Incentives(3) Non Financial Incentives(4) Conditional cash transfer(5) Consumer based transfer(6) Demand side incentives(7) Demand side Financing(8) Output based financing(9) Voucher programs (10) Voucher scheme(11) Social scheme(12) Cash transfer(13) Consumer base incentives(14) Demand side incentive(15) Immunization(16) Vaccination(17) Immunization Uptake(18) Vaccination uptake(19) Immunization coverage(20) Vaccination Coverage(21) Developing Countries(22) Africa(23) Lower middle income countries(24) Central American(25) South American (26) Latin American(27) Mexico(28) Asia(29) Common Wealth of independent states(30) Pacific Island(31) Indian Ocean Island(32) Eastern Europe

(1) Pay FOR performance(2) Provider Incentives(3) personal Downsizing(4) Work place(5) Health Planning Guideline(6) Patient freedom of choice laws(7) Preferred provider organizations(8) Emergency Medical service communication system(9) Genetic services(10) Medical errors(11) Chemical and Drugs categories(12) Drug industry(13) Epidemiology(14) Patents(15) War(16) Anatomy category(17) Child Abuse(18) Obesity(19) Tuberculosis

4.3.4 SEARCHING THROUGH THE DATABASE

Boolean operators such as AND/OR commands were used to combine search terms in searching databases. According to Haynes (2005) and Rycroft (2008), the use of the command AND/OR allows for narrower search of terms. AND reduces the number of Hits generated from searches while OR enables generation of similar keywords in Hits generated. In addition, truncation (*) was used to identify keywords with different endings. Rycroft, (2008) identified that the use of truncation (*) in words such as child allow representation of words such as children, childrens, thus avoiding omission of relevant articles which might not have used the keywords specified in search boxes (Haynes, 2007). Appendix 1 provides a table of the process and combination of key search terms for reproducibly purpose.

4.4SELECTION OF ARTICLES

With the selection criteria in mind, initial screenings of articles were done through abstract and title reading. Selecting articles through title and abstract reading helps researchers in managing the high volume of Hits generated from the search, as such the author used this method in saving time. However, over reliance on abstract reading to save time may sometimes bias the selection of relevant articles, this is because certain journal articles are titled and abstracted differently from their content (Elliot, 2003). Thus, chances are that relevant articles are missed while some may contain relevant contents. Therefore, Elliot, (2003); Evans, (2002) recommend the full text reading of articles that passed the abstract and title screening to have better comprehension of the content in relevance to the choice of research focus. Furthermore, using EPOC criteria in further streaming down the number of selected papers, quality assessment according to EPOC criteria where utilised. Below is the list of criterion used in streaming down the number of papers selected for this study.

Was the purpose stated clearly? Was relevant background literature reviewed? Was the sample described in detail? Was there randomization of selection of participants? Were results reported in terms of statistical significance? Was the conclusion appropriate considering study methods and results?

4.4.1DATA MANAGEMENT

For relevant articles selected, the reference software (Endnote x 7) was utilized in electronic record keeping of relevant articles. The rationale for the choice of software was due to its ability to aid easy referencing during write up. For, repeatability purpose, a diary was kept on the search process (Burls, 2009). In addition, the author backed up and saved all search records in an electronic folder for security purpose (Brown et al., 2008). Furthermore, electronic folder was emailed to the author email address to prevent data loss (Brown et al., 2008). Following the storage of relevant article, duplicates from different databases were deleted (see appendix 2 for a flow diagram showing the streamlining process of selected articles). Finally, a total of 18 articles were streamlined to Seven (7) quality journal articles. Hence, the seven journal articles were then taken forward for data appraisal and quality evaluation. 4.5 DATA ENTRY AND ANALYSIS

Following the selection of relevant articles, Data were extracted from articles and entered into Excel 2010 for further analysis. Furthermore, to access the methodological quality of the selected papers, a standard critique tools known as the critical appraisal tools (CASP) were utilised. However, there are other appraisal tools that could have been use; the CASP tools provide appraisal guideline for study designs relevant for efficacy studies (Public Health Resources Unit, 2012). Furthermore, the CASP tools allow for a fair assessment of all kind of study design with the same rigour (Polit and Beck, 2005). Appendix 3 shows the questions asked of papers been appraised, while appendix four gives examples of how some of the papers were critiqued using the CASP tools. 4.6 DEVELOPMENT OF THEMES

Having collated and analysed the evidence generated from the journal articles. Coding system was utilised in developing themes to aid the author in reviewing similar evidences. According to Newman et al., (2006), Coding aids the process of grouping journal articles with similar evidences into groups to facilitate the review process. Therefore the author coded similar findings from each journal articles by designating them with both alphabetical and numerical values for easy referrals during review process.

Three major themes were developed from the coding process. (a) evidences on the effect of demand-incentives on immunisation in low-income-settings (b) evidence on the factors affecting the effectiveness of demand-incentives on immunisation rates (c) evidence on the most effective type of demand incentives in low-income settings. Hence, the next chapter will begin the review process.Following the extraction of relevant information from all the selected articles, the table below presents the summary findings and study designs of each paper for comprehension purpose.

Figure 5.0Table highlighting the summary findings and study designs of the selected journal articles.S/NAuthor/year/CountryAim of studyOutcome Study design

1Abhijit et al. (2013)India(Non-financial Incentives)Aimed to compare the efficacy of non-financial incentives (raw lentils and silver plate) and only a reliable service on immunization rates in children aged 1-3.Non-financial incentives had larger impact on immunization rates 39% (30-47% 95% CI), compared to only a reliable service 18% (11-23% 95% CI) and control without any treatment 6% (3-9% 95% CI)Randomized trial

2Elizabeth et al. (2012)Kenya(Non-financial Incentives)Aimed to evaluate the efficacy of non-financial incentive (Hygiene kit distribution) on immunization rates and household hygiene behavior.There was an increase in immunization coverage for children from (2-20 months) 61% to 70% p = .007 in the treatment group while there was also a similar result in the control group which experience an increase from 47% to 58% P=. 005(Improved immunization rates with a similar results obtained in the control group)Cluster randomized trial

3Hotenzia et al.(2012)Kenya(Financial Incentives)Access the effect of SMS based reminders and mobile-based CCTs on timely uptake of immunization.Out Of the 63% of 77 mothers enrolled, 86% were reported to have come back for Penta 2.(There was a high return as a result of incentives).Result is questionable due to non-availability of comparison group & incomplete follow up of study group.Cohort study

4Chandir et al. (2010)Pakistan(Non-financial Incentives)Evaluate the impact of food /medicine coupon on vaccine coverage among mothers of infants (6-18 weeks) visiting EPI centers.Incentives increased immunization coverage at 18 weeks by Two folds (i.e. RR 2.20, 95% CI: 1.95 2.48, P95%) required to eradicate vaccine preventable diseases]

On the contrary, (Abhijit et al., 2013; Laura et al., 2013; Tania and john, 2009) suggested that gains from the incentive program can be improved when other factors are considered. Ensuring a reliable health supply side such as paying staffs for performance, adequate cold chain facility, avoiding vaccine stock-out[footnoteRef:8] can improve gains from incentives program (Abhijit et al., 2013; Tania and john, 2009; Laura et al., 2013). Also, integrating demand side strategies such as social mobilisation, recruiting social worker in identification of missed children and educating mothers on the benefit of immunisation might all improve the gains recorded. [8: Stock-out is the unavailability of required vaccine at required time frame.]

Furthermore, (Chandir et al., 2010; Abhijit et al., 2013; Elizabeth et al., 2012) suggested that demand incentives might not be as effective when implemented in an environment with high baseline coverage. Also, factors such as the baseline socio-economic characteristics of the implementation environment do influence the outcome of demand incentives on immunisation rates. Evidence from (Tania and john, 2009; Elizabeth et al. 2012) suggested that distance from health facilitates may limits mothers from accessing health facility, regardless of the presence of incentives. However, (Saul et al., 2004; Elizabeth et al., 2012) showed that accessibility barrier can be overcome if the value of incentives is high enough to cover household costs such as transport cost, living cost and feeding cost. Conversely, Abhijit et al. (2013) argued that the value of incentives may not be a factor in parent decision to vaccinate their child, rather parent are influenced with the sense of presence of a positive transfer. However small, it is only natural that individuals will only be motivated if the cost benefit of an intervention is of advantage.

Furthermore, other factors such as ensuring adequate budgeting and implementation time frame were revealed to influence the effectiveness of the use incentives. 6 of the 7 journal articles revealed that inadequate implementation budget might negatively affect the efficacy of the use of incentives in immunisation program. Their findings showed that incomplete implementation and incomplete follow up resulting from funding stoppage largely affect the required timeline to access the increase in immunisation coverage. This is because immunisation coverage measurement requires follow-up of children age 0 up-till 9months for measles vaccination; in addition, additional year is allowed to follow up for catchment group age 1year to 2years. Therefore, when funding halts the complete implementation and follow-up of participants, standard measurement for full effect of incentive is impossible.

Finally, it is unclear as to which type of demand incentives is most effective in low-income settings. The two basic types of demand incentives retrieved from the review; non-monetary and monetary incentives both had varied advantages in improving immunisation in low-income-settings. 3 of the study used non-monetary incentives while 4 of the 7 accessed the effect of monetary incentives. (Abhijit et al., 2013; Elizabeth et al., 2012; Chandir et al., 2010) showed that non-financial or non-monetary incentives such as food vouchers, hygiene kits, or insecticide treated have multiple benefits when integrated with implementation of demand incentives. For example, Elizabeth et al., (2012) showed that hygiene kit distribution increased household hygiene behaviour coupled with increase in immunization uptake among Kenyan mothers. However, despite this positive outcome, the effect of non-monetary incentives may not have larger impact. This is because there concerns as to low perception of the value of non-monetary incentives by the consumers (mothers). Therefore, non-monetary incentives effectiveness is limited by low perceived value by the participants.

On the contrary, cash incentive is usually implemented with the aim of supplementing the cost of transportation and other household living cost to alleviate abject poverty. Therefore, participants perceived cash incentives to be of higher value. However, the cost of sustaining such method limits the use of cash method. Although, 4 of 7 the studies used cash incentives but only one was able to complete implementation of treatment.

Overall, it cannot be concluded as to the type of demand incentives that is most effective for use in low-income setting for immunization uptake. what can however be deduced from the analysis is that when either are implemented in the right condition such as a reliable supply side with adequate funding, demand incentives does have a significant positive effect on the uptake and coverage of child immunization.8.2 OVERALL COMPLETENESS AND GENERALIZABILITY OF EVIDENCE

5 of the 7 journal articles selected were randomized trial with the remaining two been cohort studies. The strength of evidence generated from this review may be adjudged to be moderate. EPOC reviews (2013) suggest that randomised trial is of the highest hierarchy in effectiveness study. As such, the findings of this review, which is an effectiveness study, can be generalised.

However, the two Cohorts study might have limited the generalizability of this review. This is because Cohort studies are affected when con-founding factors are un-adjusted for. And one of the studies (Chandir et al. 2010) had confounding factors incompletely adjusted for. Therefore, the two-cohort studies limit causal relationship of demand-incentives with immunisation rates as they fail to emphasise direct impact of incentives on immunisation rates.

Nevertheless, findings from this review can be generalised as the study samples covers a wide and similar ranger of participants. For example, the selection criteria ensured only country categorised as low-income or middle income were selected for review. More so, the study areas of the selected journals reviewed cut across all racial groups ranging from Sub-Sahara Africa, South-east Asia and Latin American. To further appraise the generalizability of this review, the next section will explore the quality of the evidences (journal articles) used.8.3 QUALITY OF EVIDENCE GENERATED FROM THE REVIEW

The qualities of the evidence were assessed based on the methodological process of the studies. 5 of the 7 of the reviewed journal articles collected data through parent self -report. The use of self-reporting may increase the tendency of misclassification or recall bias. However, to limit the misclassification and recall bias the researchers used various other means of verifications; one (Abhijit et al., 2013) study made use of physical evidence of injection sites on children to ascertain vaccine was administered. Another study (Tania and Braham, 2009) made use of administrative record to validate parents report, while the remaining four made use of immunisation cards. Also, only 2 of the seven effectively blinded the accessor for the participants. Therefore, classification bias might have been introduced as participants gives socially desirable response. More so, the two-cohort study (Hotenzia et al., 2012; Chandir et al. 2010) failed to match the characteristics of cohorts examined and as such prevent drawing conclusion on the precise effect of demand incentives on immunisation rate. Chandir et al., 2010 however used multivariate analysis to account for the differences between their cohorts. There are also concerns on the standard range of measurement for both age and vaccine dose at endpoint survey. The age at which follow-up for immunisation coverage was conducted varied across all the studies. 2 of the 7 journal articles marked their endpoint at 18 weeks for DPT3 coverage. 3 of the papers accessed the end-point at 3years for measles and catch-up group. While only one (Saul et al. 2004) failed to accessed immunisation rates at the recommended age. However, WHO recommends standard immunisation coverage rates to be reported for the third dose of OPV3, DTP3 at 14weeks or measles at 9months. Therefore, studies that measure follow-up asides the recommended age and vaccine dose introduce misclassification bias.

Nevertheless, 5 of the 7 journal articles reported using randomisation in sample selection, therefore limiting confounding bias. In view of all the above, findings in this review can be generalised. Although caution should also be exercised due to the limitation stated above. Hence the next section will explore the potential bias of this review to appraise the generalizability.8.4 POTENTIAL BIAS OF THE REVIEW PROCESS

Having selected and used a small sample size of seven journal articles, the generalizability of this review may be considers limited. However selected factors can be attributed to have caused this. The selection criteria (see table 4.1) such as dates of publication (2005 and above), place of study (low-income communities study) and selection of articles studying effectiveness of demand incentives alone may have limited the number of relevant hits generated. More so, it should be noted that not much studies have been conducted to access the effectiveness of the use of demand incentives due to the required cost and the ethical issue of not preventing any child from accessing or using immunization services.

Furthermore, not all relevant journal articles might have been included despite doing an electronic search and hand searching through reference picking in the journals. There is also high probability of missing out relevant articles due to pre-selected criteria such as published article only. Aveyard, 2010 noted that journal tends to only publish articles that show positive finding. Therefore, relevant articles might have been missed as a result of been unpublished. Also screening through abstract reading might have also contributed to omission of relevant journals that may have relevant information in the contents.

Finally, a meta-analysis was not done to ascertain the significant of the impact of the incentives on the uptake/coverage of child immunization. Therefore limiting how precise the positive significance of incentives reported in this study. In summary, caution was taking to ensure that the methodological process used was rigorous and systemic enough to ensure reliability and validity. To further, validate this review, it is worth accessing studies that agreed and disagreed with this review findings. 8.5AGREEMENTS AND DISSAGREEMENT WITH PREVIOUS STUDIESIn line with previously published studies around the effect of demand incentives on uptake and coverage of preventive health service including immunisation (Grabowski et al., 2005; Wynsonge et al., 2006), which all recorded an increase in the uptake and coverage of preventive health services as a result of demand incentives, this review tentatively suggest that demand incentives also increase immunisation uptake in low income settings. However, as suggested by Malucio and Flores (2004), who argued that demand incentives programs had less impact on the uptake of immunisation, this review clarify the probable factors that may have lead to Malucio and Flores (2004) conclusions. As such, conclusions from this review suggest that Malucio and Flores (2004) may be right as studies (Saul et al., 2004) in this review showed. However, this review showed that factors such as integrating demand incentives with other intervention, implementing in a previously low immunisation coverage rates and ensuring reliable supply side could increase the impact of the program.

On the contrary, studies from (Loevinsohn and Loevinsohn, 1987; Morris et al., 2004) revealed that ensuring reliable supply of health services and educating mothers where of more importance than incentives, however, this present review begs to differ with (Loevinsohn and Loevinsohn, 1987; Morris et al., 2004). This is because, conclusions from this review shows that when other interventions such as (ensuring reliable supply of health services and educating mothers) are integrated with the incentives programs, positive result are rather recorded.

Finally, studies from (Loevinsohn and Loevinsohn, 1987; Thornton R., 2008; Kremer and Miguel, 2007; Cohen and Dupas, 2007) all suggested that low valued incentives do increase the uptake of preventive behaviour. There findings are in agreement with the findings from the present review, however this review further goes to highlight that low value incentives are only effective if factors such as distance to health facilities are minimal, implemented in a population of less educated mothers/guardians or implemented in low-income settings.CHAPTER NINECONCLUSION9.0 INTRODUCTION

This chapter will summarize the findings from the review in making conclusive remarks on the effectiveness of demand incentives on child immunization uptake and coverage in low-income settings. Finally, the chapter will highlight the implications of the findings from this review for practice purpose while also making recommendation for future research.9.1 KEY FINDINGS

Following rigorous review of 7 journal articles on the effect of demand incentive on the uptake and coverage of child immunization in low-income settings, it can be concluded that both monetary and non-monetary incentives for mothers/guardians of infants aged 0-2yrs does improve their decision to take their child for immunization. However, the positive impact of the incentives is not substantial enough to eradicate vaccine preventable diseases in low-income settings except when integrated with reliable supply side interventions such as close proximity of health facilities, adequate trained staffs with substantial payment to motivate them and also avoiding vaccine stock out as well as additional demand side activities like social mobilization .

Furthermore, demand incentives are more effective in environment with low baseline immunization coverage rates thus; program managers need to find other ways to improve coverage in environment with high baseline immunization coverage rate. Also, findings from the review suggest that the value of the incentive is an important consideration when implementing demand incentives program for immunisation, as mother/guardians may be less influenced if the perceived value of the incentive fails to cover for other burdens such as transportation or household living cost.

Finally, for incentives to be effective, adequate budgeting that will sustain the complete implementation of intervention (full immunization period) should be ensured in allowing full benefit of the intervention. This review was conducted to aid health managers on the effective use of demand incentives in improving immunisation uptake and coverage; hence the next section will explore some of the implication of the findings in this review for practice purpose.9.2 IMPLICATION FOR PRACTICE

With high rates of children still missing immunisations in low income countries such as Nigeria, Pakistan and Afghanistan where polio cases still prevails, program managers need to employ strategies such as demand incentive to motivate parents to bring their child for immunization. However, policy makers need to ensure that adequate provision is made for health workers to ensure optimal performance interms of service delivery. In addition, health facilities should be adequately equipped with infrastructure such as uninterrupted cold chain and adequate space to encourage mothers to revisit. Aside this, policy to fast track easy access to health facilities such as good roads, innovations such as mobile health clinic or setup of camps with constant availability of a nurse should be developed.

Program implementers however need to consider integrating demand incentives with other interventions to allow multiple benefits derived from such integration. For example, integrating nutrition program with immunization will ensure malnourished children are catered for while also ensuring the intervention is cost effective. Cost of implementing two vertical programs separately reduces when they are implemented together, because certain cost such as human resource cost and other logistic cost (transport, accommodation) are been shared by both programs, thus interventions are cost effective.

Finally, since incentive intervention is meant to improve immunisation rates overtime, both policy makers and program implementers needs to find other ways to sustain the effect of demand incentives in improving immunization uptake after it has been withdrawn.

9.4 RECOMMENDATION FOR FUTURE RESEARCH

Having initially set out to access the best type of demand incentives to be used by program implementers, however, the unavailability of conclusive evidence on the most effective type of incentives that produced best effect and inability of the author to do a meta-analysis to ascertain what type of incentives has the most significant impact? It does remain unclear as to what type of demand incentives has the most significant impact.

Also, only 1 of the 7 (Abhijit et al., 2013) reported on the cost effectiveness of using demand incentives for immunisation coverage, however with un-generalizable finding; there is need for more robust study including a meta-analysis to access the cost effectiveness of demand incentives in improving immunisation coverage.

Finally, there is a gap in understanding how the effect of incentives on immunization uptake and coverage can be sustained after the intervention is withdrawn. Therefore, there is a need to find alternative ways such as enforcement strategies to encourage demand by mothers in communities with low-immunisation coverage rates.

9.5 DISSEMINATION OF FINDINGS

The findings from this critical review aimed to help immunisation program officer and policy makers on how to improve child immunisation uptake especially in low-income settings. Therefore, on completing this critical review, the author will share findings from this review with co-workers and senior officers in previous place of employment (National Primary health care development agency- NPHCDA), which happen to be a government institution responsible for the development and implementation primary health care programs including immunisation in Nigeria. As such, the author hopes findings from the review will be utilised as evidence in developing effective policy and programs that will improve child immunisation coverage in Nigeria.

Furthermore, the author hopes to pursue a further third degree as a doctorate in immunisation policy and interventions. Therefore, to aid this purpose, a summary of the review including findings from the study will be edited and forwarded for publishing in immunisation journals. As such, the author hopes publishing the findings will facilitate scholarship funding to further pursue a specialisation in immunisation policy and interventions.

REFERENCES

Abhijit V. B., Esther D., Abdulatif J., Rachel G., Dhurva K. (2010) Improving Immunisation coverage in rural india: clustered randomised controlled evaluation of immunisation campaigns with and without incentives. British Medical Journal BMJ 340:c2220 doi:10.1136/bmj.c2220

Achat, H., Mcintyre, P., Burgess M. (1999) Health care incentives in immunization. Journal of Public Health. 23(3):285-288. Adato M, Bassett L. Social protection to support orphans and vulnerable children and families: the potential of cash transfers to protect education, health and nutrition. AIDS Care 2009; 21: 6075.

Adato M, Bassett L. What is the potential of cash transfers to strengthen families aff ected by HIV and AIDS? A review of the evidence on impacts and key policy debates. Washington, DC: Joint Learning Initiative on Children and AIDS, International Food Policy Research Institute, 2008.

Aveyard H. (2010) doing a literature review in Health and Social care; a practical guide (3rd ed.). England: Open University press

Baird SJ, Garfein RS, McIntosh CT, .zler B. Eff ect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet 2012; 379: 132029.

Boyton PM and Greenhalgh T (2004) Hands-on Guide to questionnaire research: Selecting, designing and developing your questionnaire, British medical Journal 328:1312-15

Boerma, J.T, Bryce J, Kinfu Y, Axelson H, Victora CG (2008) Mind the gap:equity and trends in coverage of maternal, newborn, and child health services in54 Countdown countries. Lancet. 371:12591267.

Celina M.H., Eliane F., Nina S., Seth B. (2013) Prediction of immunization performance. The Lancet, [Online]. 381(9864), 349-350. Available at: http://www.sciencedirect.com/science/article/pii/S0140673612621655# [Accessed 17 February 2014]

Chandir S., Khan A. J., Hussain H., Usman H.R., Khowaja S., Halsey N.A., Omer S.B. (2009) Effect of food coupoun incentives on timely completion of DTP immunization series in children from a low- income area in Karachi, Pakistan: A longitudinal intervention study. ELSEVIER 28: 3473-3478

Centers for Disease Control and Prevention. Vaccination coverage by race/ethnicity and poverty level among children aged 1935 months: United States, 1997. MMWR Morb Mortal Wkly Rep 1998;47:9569.

Cohen J, Dupas P. Free distribution or cost-sharing? Evidence from a randomized malaria prevention experiment. Brookings Global Economy and Development Working Paper No 11. Brookings Institute, 2007.

Crombie I. (2006) Pocket Guide to Critical Appraisal. London: BMJ Publishing Group.

Duclos P., okwo-Bele J.M., Gacic-Dobo M., Cherian T. (2009) Global immunization status, progress, challenges and future. BMC int Health rigths, vol 9:s2

de Brauw A, Hoddinott J. Must conditional cash transfer programs be conditioned to be eff ective? The impact of conditioning transfers on school enrollment in Mexico. Washington, DC: International Food Policy Research Institute, 2007.

Elizabeth et al (2012) Impact of integration of Hygiene kit distribution with routine immunisation on infant vaccine coverage and water treatment and hand washing practices, Journal of infectious Diseases. 205:S56-64

Edmund A.S. & Damian G.W. (2011) Reaching MDG 4 in India: A Role for Rotavirus Vaccine? Oxford Journals, [Online]. 52 (2/doi: 10.1093/cid/ciq095), 178-179. Available at: http://cid.oxfordjournals.org/content/52/2/178.full.pdf+html [Accessed 17 February 2014].

Eichler R. Can Pay for Performance Increase Utilization by the Poor and Improve the Quality of Health Services? Washington, DC: Center for Global Development, Working Gro*up on Performance-Based Incentives; 2006 February. Available online at: http://www.cgdev.org/doc/ghprn/PBI%20Background %20Paper.pdf [accessed October 15, 2009].

Fernald LCH, Gertler PJ, Neufeld LM. Role of cash in conditional cash transfer programmes for child health, growth, and development: an analysis of Mexicos Oportunidades. Lancet 2008;371:828-37.Fairbrother G., Hanson K.L., S. Friedman, and G. C. Butts (1999) The impact of physician bonuses, enhanced fees and feedback on childhood immunization coverage rates. American Journal of Public Health 89(2): 71-175.

Fernald L. Gentler P.J., Nufield L.M. (2008) Role of cash in condition cash transfer programmes for child health, growth and development: an analysis of Mexico opportunidades. Lancets 371:828-37.

Fiszbein A, Schady N. Conditional cash transfers: reducing present and future poverty. Washington, DC: World Bank, 2009.

Glassman A, Todd J, Gaarder M. Latin America: cash transfers to support better household decisions. In: Eichler R, Levine R, eds. Performance-based incentives working group. Performance incentives for global health: potential and pitfalls. Brookings Institution Press, 2009:89-121.

Grabowski M., Farell N., Chimumbwa J., Nobiya T., Ahun M. (2005) Achieving equity in the distribution of insecticides treated bednets through links with measles vaccination campaigns In; Health, nutrition and population (HNP) discussion paper. World bank.

Glender et al. (2003) Effectiveness of the linkage of childcare and maternity payments to childhood immunization, ELSEVIER. 22: 2345-2350.

Hanson K., Ranson K., Oliveira Cruz V., Mills A. (2000) Constraints to scaling up health interventions: a conceptual framework and empirical analysis; CMH Working paper series. WG5 paper no.14. Geneva: WHO press.

Hotenzia et al. (2012) The feasibility of using mobile phone based SMS reminders and conditional cash transfers to improve immunisation in rural Kenya, ELSEVIER. 31:987-993

Hoekstra EJ, LeBaron CW, Megaloeconomou Y, Guerrero H, Byers C, Johnson- Partlow T, et al. Impact of a large-scale immunization initiative in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). JAMA 1998;280(13):11437.

Kerpelman LC, Connell DB, Gunn WJ. Effect of a monetary sanction on immunization rates of recipients of aid to families with dependent children. JAMA 2000;284(1):539.

Kerplan L.C., Connel D.B., Gunn W.J. (2000) Effect of monetary Sanction on immunisation rates of recipients of aid to families with dependent children. JAMA 284(1): 53-9.

Kremer M, Miguel E. The illusion of sustainability. Q J Econ 2007;122:1007-65.

Laura R., Phyllis M., Jefferey W.E., Lovemore D., Gideo M., Jeremiah M., Christina S., Tom C., Roeland M., Lorraine S., Geoffrey P.G., Constance N., Simon G (2013). Lancet 381: 1283-92

Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review. JAMA 2007;298:1900-10.

Loevinsohn BP, Loevinsohn ME. Improvement in coverage of primary health care in a developing country through use of food incentives. Lancet 1986;1(8493):13146.

Maluccio J, Flores R. Impact evaluation of a conditional cash transfer program: the Nicaraguan Red de Proteccion Social. Food Consumption and Nutrition Division (FCND) Discussion Paper No 184. International Food Policy Research Institute, 2004.

Miller, M., Barrett, S., Henderson, D.A. (2006) control and eradication. In; Disease control priorities in developing Countries, 2nd edition. Oxford University Press, New york (chapter 62) pp. 1163-1176

Minkovitz C., Holt E., Hughart N., Hou W., Thomas L., Dini E. (1999) The effect of Parental monetary sanctions on the vaccination status of young children: an evaluation of welfare reform in Maryland. Arch Pediatr Adolesc Med 153(12): 1242-7

Morris SS, Flores F, Olinto P, Medina JM.Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: cluster randomized trial. Lancet 2004;364:2030-7.

Oppenheim A.N. (1992) Questionnaire Design, Interviewing and attitude Measurement. London: Continuum

Plotkin, S., Orenstein, W., Offit, P. (2008) Vaccines 5th ed. Saunders.

Rawlings LB. A New Approach to Social Assistance: Latin Americas Experience with Conditional Cash Transfer Programs. Washington, DC: The World Bank, Human Development Network, Social Protection Unit; 2004 August. Report No.: 0416. Available online at: http://siteresources.worldbank.org/ SOCIALPROTECTION/Resources/SP-Discussion-papers/Safety-Nets-DP/0416. pdf [accessed October 15, 2009].

Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA 2004;291:2563-70.

The Rockefeller Foundation. Opportunity NYC: Recognizing the Day-to-Day Challenges Faced by the Poor; 2009. http://www.rockfound.org/efforts/nycof/ opportunity nyc.shtml; undates [accessed October 15, 2009].

Saul M., Rafeal F., Pedro O., Juan M. M. (2004) Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: Cluster randomised trial. Lancet 364: 2030-37

Shefer A., Briss P., Rodeward L., Bernier R., Strikas R., Yusuf H, et al. (1999). Improving Immunisation coverage rates: an evidence-based review of the literature. Epidemiology Review 21(1): 92-6.

Shibuya K. Conditional cash transfer: a magic bullet for health? Lancet 2008; 371: 78991.

Sutherland K., Christianson J.B., Leatherman S. (2008) Impact of targeted financial incentives on personal health behavior; a review of the literature. Med care Res Rev. 65 (6):36s-78.

Tania Barham (2010) A healthier start: the effect of conditional cash transfers on neonatal and infant mortality in rural Mexico. ELSERVIER, 94:74-85

UNICEF (2013) At a glance: Nigeria; Statistics and Monitoring [online]. Available from http://www.unicef.org/infobycountry/nigeria_statistics.html [18th September, 2013].

United Nations (2007) World population prospects: the 2006 revision. Population Division, Department of Economic and Social Affairs, New York.

World Health organisation WHO (2013) Polio Eradication and endgame strategic plan 2013-2014.WHO Press: Geneva.http://www.polioeradication.org/Portals/0/Document/Resources/StrategyWork/PEESP_EN_A4.pdf.

Winsonye C.S., Nomo E., Mawo J.N., Ticha J.M. (2006) Accelerated measles Control in sub-Saharan Africa. Lancet 367: 394-5.

WHO, UNICEF, Global immunization data-summary (2012) Global immunization coverage in 2011. http:/www.who.int/immunization-monioring/global_immunization-data.pdf [accessed 18 February 2014].

WHO (2014) Health Topic: Immunization. Available at: http://www.who.int/topics/immunization/en/ [accessed 22 February 2014].Quadros , C.A., Izurieta, H., Carraso, P., Brana M., Tambini g., 2003. Progress towards Measles eradication in the region of the Americas. The Journal of infectious Diseases. 187:102-11

WHO, UNICEF, World Bank (2009) State of the worlds vaccines and immunization, 3rd ed. Geneva, World Health Organization, 2009.immunization, 3rd ed. Geneva, World Health Organization.

APPENDIXAPPENDIX 2: FLOW CHART OF THE SELECTION PROCESS OF JOURNAL ARTICLES

APPENDIX 3: CASP Critiquing Tool

Appraisal of Randomised Control trials

Did the study address a clearly focused issue?

Was the assignment of patients to treatments randomised

Were all patients to treatments who entered the trial properly accounted for at its conclusion

Where patients, health workers and study personnel blind to treatment?

Were the groups similar at the start of the trial?

Aside from the experimental intervention, were the groups treated equally?

How large was the treatment effect?

How precise was the estimate of the treatment effect?

Can the result be applied to the local population?

Were all clinically important outcomes considered?

Are the benefits worth the harm and cost?

Appraisal of Cohort Studies

Did the study address a clearly focused issue?

Did the authors use an appropriate method to answer their question?

Was the Cohort recruited in an acceptable way?

Was the exposure accurately measured to minimize bias?

Was the outcome measured to minimize bias?

Have the authors identified all-important confounding factors?

Have they taken account of the confounding factors in the design and/or analysis?

Was the follow up of subjects complete enough?

Was the follow up of subjects long enough?

What are the results of the study in terms of the association between exposure and outcomes?

How precise were the results in terms of the confidence interval?

How reliable the results are in terms of the methodology or biases?

Can the results be applied to the local population (infants or children)?

Do the results of the study fits with other available evidence?