Mobile Phone Incentives for Childhood Immunizations in Rural India

Abstract

Objectives: Young children in resource-poor settings remain inadequately immunized. We evaluated the role of compliance-linked incentives versus mobile phone messaging to improve childhood immunizations.

Methods: Children aged ≤24 months from a rural community in India were randomly assigned to either a control group or 1 of 2 study groups. A cloud-based, biometric-linked software platform was used for positive identification, record keeping for all groups, and delivery of automated mobile phone reminders with or without compliance-linked incentives (Indian rupee Rs30 or US dollar $0.50 of phone talk time) for the study groups. Immunization coverage was analyzed by using multivariable Poisson regression.

Results: Between July 11, 2016, and July 20, 2017, 608 children were randomly assigned to the study groups. Five hundred and forty-nine (90.3%) children fulfilled eligibility criteria, with a median age of 5 months; 51.4% were girls, 83.6% of their mothers had no schooling, and they were in the study for a median duration of 292 days. Median immunization coverage at enrollment was 33% in all groups and increased to 41.7% (interquartile range [IQR]: 23.1%-69.2%), 40.1% (IQR: 30.8%-69.2%), and 50.0% (IQR: 30.8%-76.9%) by the end of the study in the control group, the group with mobile phone reminders, and the compliance-linked incentives group, respectively. The administration of compliance-linked incentives was independently associated with improvement in immunization coverage and a modest increase in timeliness of immunizations.

Conclusions: Compliance-linked incentives are an important intervention for improving the coverage and timeliness of immunizations in young children in resource-poor settings.

Trial registration: ClinicalTrials.gov NCT03180138.

FIGURE 1

Consolidated Standards of Reporting Trials diagram.

FIGURE 2

Immunization coverage and number of doses administered over the course of the study. A, Median immunization coverage over the course of the study period in the control (white square), automated mobile phone reminders alone (white triangle), and automated reminders with compliance-linked incentives (black triangle) groups are shown. The dotted line represents the overall rates. Immunization coverage is defined as the proportion of the total number of immunizations received divided by the total number of immunizations required for each child at the time of measurement. B, We show the cumulative number of doses administered from the time of enrollment in the control (brown), automated mobile phone reminders alone (purple), and automated reminders with compliance-linked incentives (green) groups.

FIGURE 3

Real-time information on immunization status. Overall or vaccine-specific immunization of the community can be obtained in real time. Each dot on this satellite map of the community represents a single subject’s GPS location at the time of enrollment. The color represents the immunization status of each subject: red represents no immunization, green represents full immunization.