Vaccination Programs: Client or Family Incentive Rewards

This review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to increasing appropriate vaccination.

Seven studies were included in the systematic review.

• Overall vaccination rates increased by a median of 8 percentage points.
• Incentive rewards used alone led to similar changes in vaccination rates (8.5 and 9.0 percentage points; 2 studies).

Economic evidence indicates even small incentives can increase vaccination rates, and the reach can be substantial when incentives are provided within health plans.

Seven studies were included in the review (search period: 1980 2012). Monetary values are reported in 2013 U.S. dollars.

• Median sample size: 774 (6 studies)
• Median intervention cost per person per year: $372 (4 studies)
• Cost estimates per additional vaccinated person ranged from $248 to $2,447.
• Studies were conducted in the United States (4 studies), Germany (2 studies), and Australia (1 study).
• Studies evaluated programs to address hepatitis B (4 studies), influenza (1 study), and childhood vaccination series (2 studies).
• Incentives included gift certificates, cash awards, and substantial credits for child care and maternity benefits.

• How effective are client or family incentive rewards when used alone?
• What is the relationship between the size of the incentive reward and intervention effectiveness? Are there potential thresholds for effectiveness?
• How long do program effects last?
• How effective are interventions on vaccination rates among adolescents, adults, or older adults?
• How effective are interventions in communities with disparities in vaccination rates?

• Studies evaluated use of client incentive rewards alone (2 studies) or in combination with additional interventions (6 studies).
• Evaluated programs were conducted mostly in public health settings, although several involved coordinated efforts with public and private partners.
• Targeted client populations included adults and families with children.
• Vaccines delivered in the included studies were seasonal influenza (1 study); tetanus, diphtheria, pertussis (1 study); and vaccines recommended as part of the childhood series (5 studies).
• The type of incentive reward offered to clients included government payments (i.e., of $208 Australian dollars and childcare assistance), lottery prizes (i.e., $50 grocery voucher or $175 in monetary prizes), gift cards (i.e., $10 for baby products), baby products, and food vouchers.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

Economic Review

No content is available for this section.

Effectiveness Review

Bond L, Davie G, Carlin JB, Lester R, Nolan T. Increases in vaccination coverage for children in child care, 1997 to 2000: An evaluation of the impact of government incentives and initiatives. Aust New Zealand J Public Health 2002;26(1):58-64.

Browngoehl K, Kennedy K, Krotki K, Mainzer H. Increasing immunization: a Medicaid managed care model. Pediatrics 1997;99(1):E4.

LeBaron CW, Starnes D, Dini EF, Chambliss JW, Chaney M. The impact of interventions by a community-based organization on inner-city vaccination coverage: Fulton County, Georgia, 1992-1993. Archives of Pediatrics & Adolescent Medicine 1998;152(4):327-32.

Luthy KE, Thorpe A, Dymock LC, Connely S. Evaluation of an intervention program to increase immunization compliance among school children. Journal of School Nursing 2011; 27(4):252-7.

Moran WP, Nelson K, Wofford JL, Velez R, Case LD. Increasing influenza immunization among high-risk patients: education or financial incentive. American Journal of Medicine 1996;101:612 20.

Tweed SA. Virginia’s stay on track daycare initiative. Managed Care 2007;16(8 Suppl 8):15-6; discussion 17-9.

Yokley JM, Glenwick DS. Increasing the immunization of preschool children: an evaluation of applied community interventions. Journal of Applied Behavior Analysis 1984;17:313 25.

Economic Review

Bond L, Davie G, Carlin JB, Lester R, Nolan T. Infectious disease: increases in vaccination coverage for children in child care, 1997 to 2000: an evaluation of the impact of government incentives and initiatives. Aust N Z J Public Health. 2002;26(1):58-64. http://dx.doi.org/10.1111/j.1467-842X.2002.tb00272.x.

Greengold B, Nyamathi A, Kominski G, et al. Cost-effectiveness analysis of behavioral interventions to improve vaccination compliance in homeless adults. Vaccine. 2009;27(5):718-725. http://dx.doi.org/10.1016/j.vaccine.2008.11.031.

Hwang LY, Grimes CZ, Tran TQ, et al. Accelerated hepatitis B vaccination schedule among drug users: a randomized controlled trial. J Infect Dis. 2010;202(10):1500-1509. http://dx.doi.org/10.1086/656776.

Lawrence GL, MacIntyre CR, Hull BP, McIntyre PB. Effectiveness of the linkage of child care and maternity payments to childhood immunisation. Vaccine. 2004;22(17):2345-2350. http://dx.doi.org/10.1016/j.vaccine.2003.10.038.

Seal KH, Kral AH, Lorvick J, McNees A, Gee L, Edlin BR. A randomized controlled trial of monetary incentives vs. outreach to enhance adherence to the hepatitis B vaccine series among injection drug users. Drug Alcohol Depend. 2003;71(2):127-131. http://dx.doi.org/10.1016/S0376-8716(03)00074-7.

Stitzer ML, Polk T, Bowles S, Kosten T. Drug users’ adherence to a 6-month vaccination protocol: effects of motivational incentives. Drug Alcohol Depend. 2010;107(1):76-79. http://dx.doi.org/10.1016/j.drugalcdep.2009.09.006.

Stock S, Schmidt H, B scher G, et al. Financial incentives in the German Statutory Health Insurance: New findings, new questions. Health Policy. 2010;96(1):51-56. http://dx.doi.org/10.1016/j.healthpol.2009.12.015.

Stock S, Stollenwerk B, Klever-Deichert G, et al. Preliminary analysis of short term financial implications of a prevention bonus program: First results from the German statutory health insurance. Int J Public Health. 2008;53(2):78-86. http://dx.doi.org/10.1007/s00038-008-7026-0.

Effectiveness Review

The CPSTF findings are based on studies included in the original review (search period 1980-1997) combined with studies identified in the updated search (search period 1997- February 2012). Reference lists of articles reviewed as well as lists in review articles were also searched, and members of our coordination team were consulted for additional references.

Details of the original search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included in the review, a study had to:

• have a publication date of 1980 1997;
• address universally recommended adult, adolescent, or childhood vaccinations;
• be a primary study rather than, for example, a guideline or review;
• take place in an industrialized country or countries;
• be written in English;
• meet the evidence review and Guide chapter development team’s definition of the interventions; provide information on one or more outcomes related to the analytic frameworks; and
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

Details of the update search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing the effectiveness of Vaccine Preventable Disease interventions in improving vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. Reference lists of articles reviewed as well as lists in review articles were also searched, and subject matter experts consulted for additional references. To be included in the updated review, a study had to:

• have a publication date of 1997- February 2012;
• evaluate vaccinations with universal recommendations;
• meet the evidence review and Guide chapter development team’s definition of the interventions;
• be a primary research study with one or more outcomes related to the analytic frameworks;
• take place in an high income country or countries;
• be written in English
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive

Search Terms

1. Immunization
2. Vaccination
3. Immunization Programs

Economic Review

The present review included studies that reported economic outcomes from the 2000 review (search period 1980-1997) combined with studies identified from updated searches (search period 1997- February 2012) within the standard medical and health-related research databases, Google Scholar, and databases specialized to economics and social sciences. The details of the two sets of searches are provided below.

Details of the Updated Search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing interventions to improve vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. In addition, Google Scholar and specialized databases (CRD-University of York: NHS EED, EconLit, and JSTOR), were also searched. Reference lists of articles reviewed as well as lists in review articles were also considered, and subject matter experts consulted for additional references.

Search Terms

• Immunization
• Vaccination
• Immunization Programs

To be included in the updated review, a study had to do the following:

• Have a publication date of 1997- February 2012
• Evaluate vaccinations with universal recommendations
• Meet the evidence review and Community Guide review team’s definition of the interventions
• Be a primary research study with one or more outcomes related to the analytic framework(s)
• Take place in a high income country or countries
• Be written in English; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed.

Details of the Original Search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included, a study had to do the following:

• Have a publication date of 1980 1997
• Address universally recommended adult, adolescent, or childhood vaccinations
• Be a primary study rather than, for example, a guideline or review
• Take place in an industrialized country or countries
• Be written in English
• Meet the definition of the interventions
• Provide information on one or more outcomes related to the analytic frameworks; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

• Client or family incentive rewards can be included in two multicomponent intervention approaches recommended by the CPSTF:
  • Health care system-based interventions implemented in combination
  • Community-based interventions implemented in combination
• Incentive rewards may increase contact between clients and healthcare providers, providing opportunities for additional preventive care.
• Incentive rewards may be considered coercive and could influence the process when clients are deciding whether to accept vaccination.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of children who get no recommended vaccines by age 2 years — IID‑02
• Maintain the vaccination coverage level of 1 dose of the MMR vaccine in children by age 2 years — IID‑03
• Maintain the vaccination coverage level of 2 doses of the MMR vaccine for children in kindergarten — IID‑04
• Increase the coverage level of 4 doses of the DTaP vaccine in children by age 2 years — IID‑06
• Increase the proportion of people who get the flu vaccine every year — IID‑09
• Increase the proportion of adults age 19 years or older who get recommended vaccines — IID‑D03