SUBMITED THESIS

W O R D C O U N T : 1 5 , 0 0 0
Effectiveness of demand-
incentives on uptake and coverage
of basic child immunisation in low-
income-settings
YAHAYA H. OLORIEGBE
MSc. PublicHealth, School of health, University of Northampton.
SLSM 007

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

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Copyright
“The author and the supervisor give permission to put this Master’s 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 Master’s dissertation”.
University of Northampton, 7th July 2014
------------------------------------------- -----------------------------------------
Yahaya H. Oloriegbe Kirsty Mason
-----------------------------------------------
Karen Beaulieu

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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.

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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 master’s 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!

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TABLE OF CONTENT
CHAPTER ONE............................................................................................................................................................................2
INTRODUCTION........................................................................................................................................................................2
1.0 INTRODUCTION.............................................................................................................................................................2
1.1 RESEARCH OVERVIEW:..............................................................................................................................................2
1.2 JUSTIFICATIONOFSTUDY.........................................................................................................................................5
CHAPTER TWO..........................................................................................................................................................................6
BACKGROUND............................................................................................................................................................................6
2.0 INTRODUCTION.............................................................................................................................................................6
2.1 NEED FORDEMAND INCENTIVES STRATEGY:EFFECTONUNIMMUNISED CHILDREN...............6
2.2 FACTORS UNDERLYING SUBOPTIMALIMMUNISATION COVERAGE.....................................................8
2.3 EVIDENCE OFUSE OFINCENTIVES GLOBALLY...............................................................................................9
2.4 CURRENTSTUDIESTHATHAVE ACCESSEDTHE EFFECTIVENESSOFDEMANDINCENTIVES
ON IMMUNISATIONANDOTHERPREVENTIVE HEALTH BEHAVIOURS...................................................10
2.5 TYPESOFDEMAND-INCENTIVES........................................................................................................................11
2.6 SUMMARY ANDTAKING IT FORWARD..............................................................................................................11
CHAPTER THREE...................................................................................................................................................................12
RESEARCH AIM, OBJECTIVE AND QUESTIONS......................................................................................................12
3.0 INTRODUCTION...........................................................................................................................................................12
3.1 RESEARCH AIM.............................................................................................................................................................12
3.2 RESEARCH OBJECTIVE..............................................................................................................................................12
3.3 RESEARCH QUESTIONS............................................................................................................................................12
CHAPTER FOUR......................................................................................................................................................................13
METHODOLOGY.....................................................................................................................................................................13
4.0 INTRODUCTION...........................................................................................................................................................13
4.1 GENERATING RESEARCH QUESTION.............................................................................................................13
Figure1.0: Illustrationofthe useof standardPICOT and mindmappingin focusingthe research
questions(Fineout-Overhott and Johnston 2005).............................................................................................14
4.2 SELECTINGRESEARCH METHODOLOGY.....................................................................................................15
4.3 RESEARCH PROCESS.............................................................................................................................................16
4.3.1 SELECTION CRITERIA........................................................................................................................................16
FIG 2.0: Table highlighting the inclusion and selection criteria for articles to be selected.........................................................16
4.3.2 DATABASE SEARCHING...................................................................................................................................19
Figure 3.0 Table highlighting the choice of database used with rationale for selection..........................................................20
4.3.3 KEYTERMS SEARCH..........................................................................................................................................21
Figure 4.0 Table highlighting key terms used in including and excluding journal articles...................................................22
4.3.4 SEARCHING THROUGHTHE DATABASE....................................................................................................23
4.4 SELECTION OF ARTICLES....................................................................................................................................24
4.4.1 DATA MANAGEMENT....................................................................................................................................24
4.5 DATA ENTRY AND ANALYSIS.................................................................................................................................25
4.6 DEVELOPMENT OF THEMES..................................................................................................................................25
Figure 5.0 Table highlighting the summary findings and study designs of the selected journal articles.................26
CHAPTER 5...............................................................................................................................................................................29
5.0 EVIDENCESONTHE EFFECTOFDEMANDINCENTIVESFORCHILDIMMUNISATIONUPTAKE
AND COVERAGE INLOW-INCOME-SETTINGS.......................................................................................................29
CHAPTER SIX...........................................................................................................................................................................36
6.0 EVIDENCESONTHE FACTORSAFFECTINGTHE EFFECTIVENESSOFDEMANDINCENTIVES
ON CHILDIMMUNIZATIONUPTAKE AND COVERAGE INLOW-INCOME-SETTINGS............................36

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6.1 INTEGRATING DEMAND-INCENTIVE(S) WITHOTHER INTERVENTIONS........................................36
6.2 BASELINE IMMUNIZATION COVERAGE RATES.............................................................................................37
6.3 BASELINE CHARACTERISTICS OFSETTLEMENT AREA.............................................................................38
6.4 OTHERFACTORS.........................................................................................................................................................40
CHAPTER SEVEN....................................................................................................................................................................42
7.0 EVIDENCE ONTHE MOSTEFFECTIVETYPE OFDEMAND-INCENTIVE(S) FORBASICCHILD
IMMUNISATION UPTAKE AND COVERGAE INLOW-INCOME-SETTINGS..................................................42
CHAPTER EIGTH....................................................................................................................................................................44
DISCUSSION..............................................................................................................................................................................44
8.0 INTRODUCTION...........................................................................................................................................................44
8.1 SYNTHESES AND SUMMARY OF THE REVIEW FINDINGS.........................................................................44
8.2 OVERALLCOMPLETENESS AND GENERALIZABILITY OF EVIDENCE..................................................47
8.3 QUALITY OFEVIDENCE GENERATED FROM THE REVIEW......................................................................48
8.4 POTENTIAL BIASOF THE REVIEW PROCESS..................................................................................................49
8.5 AGREEMENT ANDDISAGREEMENTS WITHPREVIOUS STUDIES.........................................................50
CHAPTER NINE.......................................................................................................................................................................51
CONCLUSION............................................................................................................................................................................51
9.0 INTRODUCTION...........................................................................................................................................................51
9.1 KEY FINDINGS...............................................................................................................................................................51
9.2 IMPLICATION FORPRACTICE................................................................................................................................52
9.4 RECOMMENDATIONFORFUTURE RESEARCH..............................................................................................53
9.5 DISSEMINATIONOF FINDINGS.............................................................................................................................54
REFERENCES............................................................................................................................................................................55
APPENDIX.................................................................................................................................................................................61
APPENDIX 2:FLOW CHARTOF THE SELECTIONPROCESS OFJOURNAL ARTICLES............................61
APPENDIX 3:CASP CRITIQUING TOOL............................................................................................................................62

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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

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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.

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

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Acronyms and Abbreviations
BCG Bacilli, Calmette and Guerin
CASP Critical Appraisal tools
CI Confidence interval
CDC Centre for diseases control
CCTs Conditional cash transfer
CRD Centre for Review and Dissemination
CRCTs Cluster randomised control trials
EPOC
EU European Union
SSA Sub-Sahara Africa
GPEI Global eradication initiative
DTP3 Third dose of diphtheria, pertussis and tetanus
FMOH Federal Ministry of health
GAVI Global alliance for vaccine security
Hib Haemophilia influenza vaccine
Hep-B Hepatitis B
LMIC Low-middle-income country
MDG Millennium development goal
MCV Measles vaccine
OPV3 Third dose of Oral polio vaccine
OR Odds Ratio
PICOT Population, Intervention, Comparison, Outcome, Time
PENTA Pentavalent (diphtheria + Pertussis + Tetanus + haemophilia
influenza + hepatitis B)
RR Relative Risk
RCTs Randomised Controlled trials
USA United States of America
UCTs Unconditional cash transfer
UNICEF United Nations children’s fund
U5MR Under-five Mortality rate
WHO World Health Organisation

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“With the exception of safe water, no other modality not even antibiotics,
has had such a major effect on mortality reduction as immunisation…”
Plotkin et al., 2008;

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CHAPTER ONE
INTRODUCTION
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 research’s 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 body’s 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.,

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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

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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 (Mexico’s 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 people’s 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

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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.

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CHAPTER TWO
BACKGROUND
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 diseases1
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).
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).
1 These include measles, tuberculosis, polio, diphtheria, pertussis and tetanus.

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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’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.
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 Heard immunity is the coverage required to eradicate vaccine preventable diseases.

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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

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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 mother’s 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

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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 children’s 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).

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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 FORWARD
Having 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.

12
CHAPTER THREE
RESEARCH AIM, OBJECTIVE AND QUESTIONS
3.0 INTRODUCTION
This 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.

13
CHAPTER FOUR
METHODOLOGY
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.
4.1 GENERATING 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

14
identified gaps in the literature into research questions, the diagram below
illustrates how the mind map and the PICOT were used in doing this.
Figure 1.0: Illustration of the use of standard PICOT and mind mapping in focusing the
research questions (Fineout-Overhott and Johnston 2005).
Evidences not
exploring the
efficacy of
different types
of demand
incentives
The need to
improve the
uptake and
coverage of
basic
immunisation
The need to
explore the
factors
affecting the
efficacy of the
use 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 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)?
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)?

15
4.2 SELECTING 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

16
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.
4.3 RESEARCH 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 Criteria Justification Exclusion
Criteria
Justification
Primary research
articles accessing
the outcome of
incentives on
immunization
Primary articles
Provides higher
level of validity
and robust
evidence
(Hawker’s et al.,
2002)
Study conducted
in high or middle
income countries
according to the
world bank
income
classification
An EPOC criterion
guides the use of
studies in low-
income settings
for incentives
intervention
(EPOC, 2012).

17
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 language
Although 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
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)

18
easily
comprehendible
by this author
(Tod et al., 2004)
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

19
24months (WHO,
2012)
Intervention must
be
consumer/demand
incentives
This 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)
PUBMED The database provides free access to full
digital text archive of life science journal

20
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).
HIGHWIRE Full text science archive, specializing in
life science, medicine and physical
science.
JOURNAL @ OVID Database 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 DIRECT This 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 3.0 Table highlighting the choice of database used with rationale for selection.

21
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.

22
Figure 4.0 Table highlighting key terms used in including and excluding journal articles
Included as ‘AND’, ‘OR’ Excluded 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
(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”

23
independent states”
(30) Pacific Island
(31) “Indian Ocean Island”
(32) “ Eastern Europe”
(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, children’s, 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.

24
4.4 SELECTION 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?
4.4.1 DATA 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

25
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.

26
Figure 5.0 Table highlighting the summary findings and study designs of the selected
journal articles.
S/N Author/year/Country Aim of study Outcome Study design
1 Abhijit 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
2 Elizabeth 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
3 Hotenzia et al.(2012)
Kenya
(Financial Incentives)
Access the effect
of SMS based
reminders and
mobile-based
CCTs on timely
Out Of the 63% of 77
mothers enrolled, 86%
were reported to have
come back for Penta 2.
(There was a high return
Cohort study

27
uptake of
immunization.
as a result of
incentives).
Result is questionable
due to non-availability
of comparison group &
incomplete follow up of
study group.
4 Chandir 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,
P<0.001) compared to
the non-incentives
cohort.
coverage)
Cohort study
5 Saul et al. (2004)
Honduras
Accessed the
differential impact
of monetary
incentives to
households
compared with
incentives to
health services
providers on
immunization
coverage
(secondary
outcome)
No clear impact of
incentives on
immunization rates was
reported, rather the
result suggested an
opportune increase in
immunization due to
increase in access to
health centers as a
result of the incentives.
(No clear impact)
Cluster
randomized trial
6 Tania and John
(2013)
Nicaragua
Assess the
efficiency of
conditional cash
transfer on
On time vaccination
coverage rose in the
treatment group from
68/77% to 87/97% in 2
Cluster
randomized trial

28
vaccination rates
among mothers
with infants
(Under 2 years).
years.
rates)
7 Laura et al. (2013)
Zimbabwe
Investigate the
effects of
unconditional cash
transfer (UCT) and
conditional cash
transfer (CCTs) on
vaccination uptake
and other
outcomes (both
registration and
school
attendance)
Proportion of children
age 0-4 years with
complete vaccination
was 3.1% greater in the
UCT and 1.8% (5.0 –
8.7) greater in the CCT
group than in the
control group.
coverage) although no
clear impact of the
intervention.
Cluster
randomized trial

CHAPTER 5
5.0 EVIDENCES ON THE EFFECT OF DEMAND INCENTIVES FOR CHILD IMMUNISATION
UPTAKE AND COVERAGE IN LOW-INCOME-SETTINGS
Incentives has been widely used by countries to improve predetermined health
outcomes such as increased access to healthcare, vaccination uptake etc., however
very few studies has evaluated the significant effect of such demand driven
incentives on immunisation uptake in low-income settings. This chapter is aimed at
helping program managers understand the effect of demand- incentives on
immunization uptake and coverage and an analysis on the significance of its impact
in eradicating the target disease. Following the selection of the journal articles that
showed evidence of the use of demand- incentives for the purpose of improving
vaccination uptake in low-income communities, there will be a review of studies
published in the articles.
Abhijit et al. (2013) randomised 134 villages with 1640 children aged 1-3 years into
one of three groups to compare the efficacy of non-monetary incentives using food
and medicine vouchers and a reliable health service on the uptake of immunisation
in rural India. The randomisation of participants ensures participants were of similar
characteristics across the groups and thus reduces selection bias. However,
participants were allocated to groups without blinding effectively taken place. This
may have introduced response bias since the participant’s may want to sustain the
continuance of the program by giving a positive response. More so, outcomes from
the intervention were accessed through parent self-reporting, which might have
introduced recall or misclassification bias. Although, in order to improve the validity
of their findings, Abhijit et al. (2013) made use of a robust administrative data to
supplement result obtained from the parent self-report, the use of large sample
size (n=2188) in their study also increases the generalizability of their findings. In
addition, blinding was executed between the accessor and the participants thus
reducing information bias.
Their findings showed that non-monetary incentives integrated with a reliable
health supply service had a significant impact on the immunisation rates 39% (95%

30
CI 30% - 47%) compared to only a reliable supply side 18% (95% CI 11% - 23%)
and the control without any of the package 6% (95% CI 3% - 9%). However,
caution should be exercised in generalizing this result since the precise estimate of
the treatment effect was not reported.
In a similar study conducted in rural Kenya by Elizabeth et al. (2012), Non-
monetary incentives in the form of Hygiene kits were distributed during routine
immunisation to evaluate its impact on increased immunisation coverage and also
household hygiene behaviour. A large sample size of 3501 children aged 2 -
20months was randomly selected into two groups. However, despite the large
sample size and the randomisation, characteristics of both the treatment and
control group were not controlled, thus introducing confounding bias. First, there
was dissimilar composition of the participants in both the treatment and the control
group. The treatment group was composed of more urban (46%) than the control
group (14%). Secondly, there were more educated participants in the treatment
group (57%) than the control group (46%). This may have introduced classification
bias, as there is a tendency that these factors (urbanisation and education) will
influence the outcome of the intervention. Furthermore, hygiene kit distribution was
not concurrent with routine immunisation as planned, which means any outcome
observed from the study might not be a direct result of the incentives. Results from
the study showed there was an overall improvement in immunisation coverage
from 61% to 70% (p= 0.007) in the intervention group. There was however a
similar improvement observed in the non-intervention group with an increase from
47% to 58% P= 0.005. But the increase in the control group was more significant
than the treatment group, which is however contrasting with Abhijit et al., (2013)
findings. Therefore, caution should be taken in interpreting Elizabeth et al. findings.
Findings from Chandir et al. (2010) indicate non-monetary incentives in the form of
food coupon increased vaccine coverage by two folds (RR, 2.20, 95% CI: 1.95-
2.48, P<0.001) when compared with the non-incentives cohort. Therefore,
strengthening a similar result obtained in Abhijit et al. (2013) and Elizabeth et al.
(2012). The generalizability of the Chandir et al. (2010) finding is questionable due
to the following reasons. The study aimed at evaluating the effect of food/medicine
coupon on vaccine coverage among mothers of infants (6-18 weeks) visiting EPI
centres in Karachi, Pakistan using a cohort study design. First, the use of cohort

31
design was inappropriate for an effectiveness study; cohort designs limit the
inference of a causal relationship between the incentives and the immunisation
coverage. More so, confounding factors were hardly adjusted for in the study as
baseline characteristics were different from the characteristics of those excluded vs.
included from the analysis, and as such introduced confounding bias into the study.
Secondly, selection of study sites were not done randomly; rather EPI centres were
selected based on the volume of visiting mothers and the geographical location,
which then introduced selection bias as this might have influenced the outcome of
the result. Thirdly, implementation was non-concurrent in both groups, as weeks of
wash out period were introduced between the treatment and the control group and
as a result of the outcome of the study may have been influenced by changes in the
delivery or acceptance of vaccine overtime. Finally, there was no mention of
blinding in selection or assessment of participants; therefore caution should be
exercised in generalizing Chandir et al. (2010) findings as the assessor might have
influenced the outcome
A different form of incentives was used in a similar study conducted in Zimbabwe.
Laura et al. (2013) used a cluster-randomized design to access the effect of
unconditional cash transfer and conditional cash transfer (monetary) on
immunization uptake and two other health outcomes such as birth certification and
school attendance. In terms of immunization uptakes, their result showed there
was no significant difference across the groups (UCT and CCT) uptake. Result
showed the proportion of children age 0-4 years with complete vaccination was 3.1
% greater in the UCT and 1.8% greater in the CCT group than in the control group.
However, caution should be highly exhibited in generalizing this finding. These
study findings were flawed due to the following reasons; first, although
randomization of participatory villages was carried out including participating
households however, selection of household was biased as community heads were
asked to select eligible household based on household wealth quintile. This may
have introduced selection bias as community leader may select household based on
favours.
Secondly, implementing this intervention might have been biased: all groups
including UCT, CCT and the control group were all offered a form of incentives
therefore limit a causal relation of the actual impact of the incentive. Moreover,

32
participants in the conditioned group were rarely penalized for not meeting the
conditions and as such created outcome bias.
Thirdly, the inability to compare the effect of the intervention across groups
introduced measurement bias. Although, it could be argued that this was right from
an ethical view point as they had to consider not harming participants. However,
the decision affects the quality of the study
Finally, there were mixtures in the UCT group with the CCT groups. Follow up study
revealed 31% of participants in the UCT group reported to have met conditionality
when it had not required them to do so. In addition, two cohorts from the control
group were also mistakenly enrolled in the UCT group. Therefore, all these errors
might have biased the outcome hence findings from this paper cannot be
generalized. Laura et al. (2013) findings is however conflicting with the context of
this theme as it does not indicate if the outcome was a direct impact of the
incentives.
Tania and John (2009) accessed the effect of conditional cash transfer to
households on immunization coverage of children aged 0-24months in rural
Nicaragua. Their findings showed an increase in timely vaccination of children age 0
– 24 months from a previous rate of 68/77% to 81/97% in the treatment group.
However, the generalisation of their findings is questionable due to the following:
There was no mention of the blinding study personnel or data collectors to the
treatment, which might thus introduce measurement bias to the study. Also, there
was interference with the treatment group, as health care providers were trained
and paid to increase supply side, as such the outcome of the study cannot be
directly linked to the effect of the incentives. However, there were other factors
that validated their findings. Randomization of participants at cluster and household
level reduces the risk of selection and classification bias. More so, the use of
administrative data to back up survey date reduces the risk of recall bias from
participants. Furthermore, besides randomization of participant to balance the
group’s characteristics, the author controlled for other confiding factors such as
education, status, and age of mother by statistical adjustment to reduce
classification bias. In summary, Tania and John, findings are similar to that
recorded in Abhijit et al. (2013); Chandir et al. (2010) as such, it can be concluded

33
that incentives had significant increase impact on immunization uptake and
coverage in low-income settings.
Hotenzia et al. (2012) also revealed some inconclusive findings. Although, their
result showed there was significant increase in timely immunization uptake, but the
generalization of their finding is highly controversial due to certain factors. Hotenzia
et al. (2012) accessed the effect of SMS based reminder for vaccination schedule
integrated with a conditional cash transfer for time uptake of vaccination. The study
design was however flawed, as there was no comparison group drawn to ascertain
differential effect of their intervention. Furthermore, a small sample size of 72
mothers with children age 0 – 3 weeks were enrolled into the study, therefore limits
the ability to replicate their findings to any locality. In addition, their result showed
there was only follow up to the second dose of Penta, this is however contrasting
with their set aim of accessing complete timely uptake of vaccination at third dose,
thus, making their result inconclusive and unreliable.
Nonetheless, the findings of the study showed that of the 63 children followed up,
90% received first dose Penta vaccine while 86% received Penta 2, with no report
for Penta 3. Their findings was however contrasting to other papers reviewed as
their results showed 47% of mother reported that SMS influenced their decision to
vaccinate their child while only 4% reported CCT to have influenced their decision
and 36% reported neither influenced them. Therefore, it is inconclusive as to
whether the increase recorded was a result of the cash transfer.
Finally, Saul et al. (2004) evaluated 5600 households with pregnant women and
children in rural Honduras using a clustered randomised trial. They aimed at
comparing the effect of improving service alone or unconditional money transfer to
household on use and coverage of primary health care interventions. A stratified
and blocked sampling was done at the municipal and household level, which
ensured constant baseline characteristics. Three groups of treatment, a direct
household payment (intervention A), service alone package (B), both packages (C)
and a control group were surveyed using both children immunisation card and
government record after two years of implementation. Their result showed that
direct payment to household had a significant impact on the uptake of antenatal
care and routine well child check with an increase of 18- 21percentage point. Cash

34
incentives also increased the coverage of first dose DTP 1/Pentavalent vaccine at
the right age but no significant difference with measles coverage and mothers’
tetanus immunisation coverage.
Their findings suggested that increased use of health facility by mothers through
incentives program exposes the child to opportunely immunisation series. However,
the result did not account for DPT3 coverage in its outcome as done in Abhijit et al.,
2010 study. Therefore, making it difficult to access the true impact of the cash
based incentives on immunisation coverage. In addition, the external validity of
their finding is questionable for the following reasons; a) the result didn’t present
any statistical result to show the impact nor its preciseness, b) there was
incomplete implementation of intervention as only 17% of planned transfer was
done to the service alone group (group B). Previous DTP uptake rate at baseline
was different in all the groups, therefore introducing confounding bias. In addition,
there was no effective blinding of the study to the investigators as they had to be
aware of government plan to compensate the control group, as such treatment bias
might have been introduced. Also, courtesy bias was also noted in the study during
the baseline survey, participants were not blinded from the treatment, as such,
there were possibilities of participants giving answer that will favour them being
assigned to cash transfer group.
However, the investigators ensured there was blinding of the data collector to the
treatment group by ensuring interviewers identified themselves as independent
consultants and were themselves unaware of the primary objective of the study.
Furthermore, selection bias was kept to a minimum by ensuring randomization at
both cluster level and also household level. Finally, the investigators ensured
effective follow up of participants by tracing migrating participants to other
treatment cluster, therefore limiting measurement bias. In summary, Saul et al.
(2004) findings did reveal a possible increase in immunization uptake as a result of
household cash transfer. It is however unclear as to the extent which the findings
of this study can be generalized. The finding of the Saul et al. (2004) study is
similar to other papers (Abhijit et al. 2013), Chandir et al. (2010), Laura et al.
(2013).

35
Evidence from the reviewed papers showed that demand driven incentives does
have a significant impact by increasing the uptake and coverage of basic child
immunization in low-income countries. However, finding also showed similar results
in-some situations without incentives due to some factors that will be analysed in
the following chapter. In addition, evidence from the review also revealed that
incentives might not have that such great impact on the uptake and coverage child
immunization except otherwise if other factors are present. As such, it is evident
from this review that there are factors which affect the effectiveness of the use of
demand incentives in child immunization program. Therefore, the next section will
explore these evidences to get a better understanding of how these factors affect
incentives efficacy.

36
CHAPTER SIX
6.0 EVIDENCES ON THE FACTORS AFFECTING THE EFFECTIVENESS OF DEMAND
INCENTIVES ON CHILD IMMUNIZATION UPTAKE AND COVERAGE IN LOW-INCOME-
SETTINGS
From the previous section, it was evident that immunisation outcome from the
provision of demand incentives may vary. Therefore, understanding what factors
varies the outcomes will help health managers understand how to effectively utilise
the use of incentives for the purpose of increasing basic child immunisation uptake
in low income communities.
Three subthemes summarize the major factors with a fourth theme describing other
general factors that affect the use of incentives in immunisation program. The next
section will therefore explore the evidence showing the factors that affect the
effectiveness of incentives
6.1 INTEGRATING DEMAND-INCENTIVE(s) WITH OTHER INTERVENTIONS
Abhijit et al. (2013) compared the efficacy of integrating a reliable supply side with
a non-monetary incentive3
and only a reliable service. Their result indicated that,
by integrating a reliable service side such as setting up of regular immunization
camps, the use of social mobilization identifying missed children and educating
mothers and regular monitoring of immunization centres/camps, they all improve
the effectiveness of the incentive. As the result show there was 39% (148/382,
95% CI 30-47%) full immunization coverage in the group with both reliable service
alone and 6% in the control group without any of the treatment.
Similarly in a study conducted by Laura et al (2013), they aimed at accessing the
differential impact of using unconditional cash transfer compared with conditional
payment to improve health outcomes such as up to-date immunization coverage in
Zimbabwe. In the study, it was described that to ensure conditionality, participants
had to be supported through social mobilization activities such as education in local
meetings, attachment of community volunteer. Their findings revealed that 35% of
3 Non monetary incentives involvesthe use of material incentives asides cash, e.g. food vouchers,
medicine and insecticide net

37
the participant in the CCT4
had to be supported to meet the condition. However, as
reported in chapter 5 (see 5.1), their findings revealed there was greater impact of
the UCT5
on immunization than the CCT camped to the control i.e. (3.1% >1.8% in
the CCT group camped to the control). Thus, their findings were similar to Abhijit et
al. (2013) by improving immunisation uptake through integration with other
interventions.
Also, a study conducted by Tania & John (2009) in rural Nicaragua to access the
efficacy of conditional cash transfer on vaccination coverage. In comparing two
groups, treatment and control, the study revealed that, in ensuring vaccination was
delivered despite incentives provided to increase demand, providers had to be paid
to deliver this service. Furthermore, the study revealed that the study coordinato r
had to recruit and train more workers to meet the increased demand for services.
In summary, the 3 papers showed that integrating other interventions such as
ensuring a reliable supply through, social mobilization, training of health workers to
meet demand, paying providers and educating mothers improves the effectiveness
of using demand incentives for child immunization in low-income settings.
6.2 BASELINE IMMUNIZATION COVERAGE RATES
Abhijit et al (2013) findings showed that previous low immunisation coverage rate
might have confounded the increased outcome recorded in the study. As part of the
limitation of their findings, Abhijit et al. (2013) noted that conducting the study in
an environment with low density where initial immunisation rates were extremely
low might have increased the effectiveness of the incentives. However, Abhijit et al.
(2013) was cautious by reiterating that much higher increase could be recorded
from a high-density population with higher immunisation coverage. Therefore
conceding to the conclusion that more research is needed to validate their
observation.
4 Conditional cash transfer are cash transfer based on the condition of parent meeting certain
health outcomesuch as immunization uptake, seeking antenatal care before they are been paid.
5 Unconditional cash transfer is cash given forhealth outcomes without any conditionality attached.

38
Nonetheless, findings from Elizabeth et al. (2012) strengthened Abhijit et al (2013)
observation on the effect of baseline coverage. Elizabeth et al. (2012) in a cluster-
randomized trial evaluated the effect of hygiene kit distribution on vaccination
coverage and other hygiene outcome. Their study finding revealed there was less
increase in immunization coverage for group with the incentives (Hygiene kits)
compared to the group without incentives. The data showed immunisation coverage
increased by 16% from baseline coverage of 37% to an endpoint coverage of 53%
in group without incentives, whereas, an unexpected low effect was observed in the
group with incentives at 9% increase from a baseline coverage of 57%. The
dramatic increase in the group without incentives was linked to the low baseline
coverage rates of 37% compared to the treatment group who had baseline
coverage of 57%. This finding is however similar to that observed in Abhijit et al.
(2013).
Therefore, from the two papers reviewed, it can be concluded that demand driven
incentives are more effective when implemented in an environment with low
baseline immunisation coverage. However, caution should be taken in generalising
this finding, as more evidences are required to validate this claim.
6.3 BASELINE CHARACTERISTICS OF SETTLEMENT AREA
Elizabeth et al (2012) accessed the impact of hygiene kit distribution on up to-date
immunization coverage in both urban and rural enumeration area of Kenya. In
other to ensure the sample in the highly rural populated study site included urban
enumeration areas, they stratified enumeration areas by Urban and rural with
varying numbers across the two study groups (treatment and Control). Finding
from the study showed that the urban-rural stratification might have confounded
the outcome of their study. Result showed there was increased implementation
coverage (68% -84%, p< .0001) and up-to date coverage (69% - 82%, p< .0001)
in the urban area of the treatment group where an incentive was distributed.
Whereas, there was no change recorded for both implementation and up-to-date
coverage in the rural area of the treatment group. A conflicting result was however
recorded in the control group, with increased implementation (46%-57%, P= .01)
and up-to-date coverage (36%-52%, P= .0003) in the rural area with no statistical
change in the urban area.

39
Their findings suggested that the increase recorded in the urban area of the
treatment group might have been due to shorter distances to health facilities, lower
transport costs and better roads and access to public transportation, therefore
facilitating easy access to the health facility. In comparison to the rural areas, their
findings suggested long distance from rural areas to the health facilities might have
reduced the effect of the incentives, as the perceived value of the incentives was
not high enough to supplement the transport cost. The study also showed that
larger concentration of educated mothers in the urban area of the treatment group
might have facilitated increased decision to vaccinate their child.
However, Tania and John argued that demand side strategy limited to awareness or
social mobilization6
are less effective for improving immunisation in rural areas as
they tend to miss poor uneducated women. They therefore examine the effect of
larger incentives on immunisation rates by providing conditional cash transfer
coupled with social mobilisation in rural Nicaragua. Interestingly, their finding
showed a contrasting result to Elizabeth et al. (2013). Their finding indicated there
was increased OPV3 and DPT3 coverage from <65%- >95% for those living far
from the health facility in the CCT group compared to 85% in the control group.
They also revealed there was larger effect of the CCT on mothers with less
education. Therefore, they concluded that the CCT program was more effective for
children hard to reach with further positive effect on children with less educated
mothers
In summary, the two papers however contrasting their findings may be, revealed
that baseline characteristics of an environment such as distance to health facility,
composition of educated Vs. uneducated, good road access and urban-rural
composition do have effect on the outcome of a demand driven incentive for
immunisation rates.
6 Social mobilization strategy includes activities taken to improve parents decision to vaccinate
their child e.g. poster campaign, public role play or public announcement via the community leader.

40
6.4 OTHER FACTORS
Having explored the major factors that may affect the effectiveness of using
demand incentives on child immunization uptake/coverage, the author will go
further in exploring other factors that appear to be minor but also have effect on
the use of this intervention.
One of the factors that appear to be consistent in all the papers is funding. 5 out of
7 (Elizabeth et al., 2013; Chandir et al., 2010; Laura et al., 2013; Saul et al.,
2004; Abhijit et al., 2013) articles showed that restriction in funding might inhibit
sustenance of the intervention. They revealed that immunisation coverage are
effectively monitored when children are followed up till 9months for Measles
vaccination and up to 2years for catch-up groups with missed vaccination are also
monitored, therefore indicating a minimum of two years for an incentives to be
effective. As such, when funding for incentive program failed to be sustained,
complete implementation and follow-up are halted and therefore affect the outcome
of the intervention.
Another factor consistent in the review was the perceived value of the incentives.
Findings by Abhijit et al (2013) suggested that high valued incentives might not
mean a larger impact on the increased outcome of immunisation rates, beyond the
fact that parent are more sensitive to a positive transfer. However finding from
Elizabeth et al. (2013) was contrasting with that of Abhijit et al. (2013), Elizabeth
et al. (2013) argued that incentives with low perceived value failed to motivate
parents living far away from the health facilities as the value fails to supplement
their transport cost.
Nevertheless, Hotenzia et al (2012) finding was in agreement with that of Elizabeth
et al. (2013). They both suggested that high value incentive increased the tendency
of parent vaccinating their children. In a cohort study conducted by Hotenzia et al.
(2012) in rural Kenya to access the efficacy of SMS based reminders integrated
with money transfer or call credit transfer on immunisation rates. Their result
showed that 54 mothers in the follow-up survey stated they would prefer money
transfer to call-credit transfer; in addition 61% participant at the follow-up stated
money transfer “worth more” with 9% claiming it was “easier”. When asked of the

41
least amount of transfer that would motivate then to bring their child for
immunization, 40% was okay with the value given in the study ($2.00) while the
remain 59% preferred something above the value given in the study. Therefore,
their result suggested parents are more motivated with high value incentives.
However, as noted in chapter 5 (see chapter 5.1), caution should be taken in
generalising Hotenzia et al. (2012) finding as the sample size was small for
universal applicability.
Also, a similar result was obtained in Saul et al (2004) study. They aimed to access
the effect of monetary vouchers on immunization uptake as a part of their outcome
in rural Honduras. To facilitate the effect of their incentive, they ensured the value
of the incentives was enough to feed an average household per month. Therefore,
their finding suggest that incentive must be able to alleviate common house hold
barrier such as transport cost, household living expenses or feeding cost to have
positive effect on immunisation outcome.
Finally, another factor that appeared to affect the effectiveness of the use of
demand driven incentives is ethical consideration. Considering ‘Intent-not-to-do-
harm’ might be a factor that affects the outcome of using incentives to improve
immunisation rates. In a cluster-randomised trial conducted by Laura et al. (2013),
they aimed to access the effect of conditionality attached to incentives on
immunisation outcome in Zimbabwe. Their findings suggested that the
implementers were unable to infer conditionality on the participant, as they
consider not leaving out the opportunity of vaccinating children. Therefore, ethical
consideration on ensuring no child was missed thus have spill over effect on other
camps asides implementation environment.
In summary, it can be concluded from the review that incentives increases
immunisation rates in low-income communities. However, incentive is more
effective when funding is available to sustain the full implementation of the
intervention. Also, high valued incentives have more impact on the increased
outcome of immunisation rates in low-income communities as this alleviate
household financial barrier to clinic access. Finally, intent not to miss any child
influences spill over effect of incentives program to other neighbouring
environment.

42
CHAPTER SEVEN
7.0 EVIDENCE ON THE MOST EFFECTIVE TYPE OF DEMAND-INCENTIVE(s) FOR BASIC
CHILD IMMUNISATION UPTAKE AND COVERGAE IN LOW-INCOME-SETTINGS
Having explored the effect of demand incentives and the factors that may affect its
effectiveness in the uptake and coverage of immunization in low-income setting;
understanding the type of demand-incentive(s) that would be most effective for use
by health managers is important. Therefore, the next section will explore evidences
that show the most effective demand incentive(s).
Following the review of the seven-selected journal article, two major types of
incentives were consistent. Three of the selected papers (Abhijit et al., 2013;
Elizabeth et al., 2012; Chandir et al., 2010) made use of Non- monetary incentives.
Abhijit et al (2013) made use of raw lentils and metal plates as incentives. Their
result revealed an increased impact of 39% immunization coverage as a result of
the incentives. Also Elizabeth et al. (2012) and Chandir et al (2010) used hygiene
kit and food coupon respectively. They both reported an increase in immunization
coverage due to the incentives. However their finding suggested that non-monetary
incentive might command less impact as the perceived value is lower in motivating
parent.
Nonetheless, positive findings were recorded from the use of non-monetary
incentive. Elizabeth et al. (2012) finding suggested that integrating hygiene kit
distribution with routine immunisation increased the number in reported household
water treatment (30%-44%, P< .0001) and correct hand washing technique (25%-
51%, P< .0001) in the treatment group with no changes in the control group. A
similar impact was observed in Abhijit et al., (2013) study as their study suggested
raw lentils was preferred to cash by the programmers, as it inculcate nutritional
value. Similarly, Chandir et al. (2010) study preferred food/medicine incentives to
cash so as to generate integrated benefit.

43
However 4 of the 7 reviewed journal articles (Saul et al; 2004; Hotenzia, 2012;
Tania and John 2008, Laura) made use of monetary incentives. Their findings
showed that the value of cash transfer might have more impact on the decision of
parent to vaccinate their child. However, the cost of using cash incentive may be
unsustainable and as such halt the complete implementation and follow-up of
immunisation intervention.
Therefore, from the analysis of both types of incentives, it is unclear as to what
type of incentives is most effective. As a result, a Meta-analysis may reveal the
incentives with the most statistical significance, however the heterogeneity of the
results obtained from the selected papers makes this analysis a difficult one. In
summary, it is inconclusive as to what type of incentives is most effective.
Therefore, more research is needed to compare the effectiveness of different types
of incentives. A randomized control study that administer both forms of incentives
(monetary and non-monetary) and evaluate their impact will be useful to support
an objective conclusion on the most effective form for improving uptake and
coverage of child immunization.

44
CHAPTER EIGTH
DISCUSSION
8.0 INTRODUCTION
Having reviewed the pre-selected journals by exploring their methodological
strength and contribution to answering the predefined questions, this chapter will
synthesis findings from the three groups of evidences. Afterwards, an appraisal of
the reliability and applicability of the reviewed journals articles will be conducted.
Also, the quality of the reviewed journals and related bias with the review process
will be appraised. Finally, for generalizability purpose, a comparative analysis will
be conducted to access how much finding from this review conforms to other
findings.
8.1 SYNTHESES AND SUMMARY OF THE REVIEW FINDINGS
A total of 7 articles were reviewed to answer the predefined question, (see chapter
3.3 for the questions). Of the 7 journal articles reviewed, 5 studies were cluster-
randomized trial with the remaining two using cohort design. Three major themes
were developed from the synthesis and analysis of the 7 journal articles. Therefore,
findings from all the three themes will be synthesised to answer questions on (a)
significant effect of demand side incentives on immunisation uptake in low-income-
settings, (b) factors affecting the effectiveness of the use of demand incentives on
immunisation uptake in low-income-settings and (c) which type of incentives is
most effective in improving immunisation uptake in low-income-settings.
6 of the 7 reviewed journal articles concluded that demand incentives had a
significantly positive effect on child immunization uptake and coverage in low-
income settings. Abhijit et al. (2013) showed that raw lentils and silver plates
distributed to mothers of children age 1-3 years in rural India had higher impact on
immunisation coverage (39%) than the control group (6%) and the group with only
a reliable health service (18%), therefore suggesting that integration of reliable
health service with incentives might have confounded the positive increase
recorded in the treatment group. Also, hygiene kit distribution in Kenyan increased

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