Vaccination Programs: Monetary Sanction Policies

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.

The systematic review included two studies.

• One study evaluated vaccination outcomes for 1,324 young children in families who receive assistance from the Aid to Families with Dependent Children (AFDC) program in Maryland. The program showed a 0.7 percentage point decrease in vaccination rates.
• Another study of 2,500 families on AFDC assistance in Georgia reported an 11.8 percentage point increase in vaccination rates among children.

• Are there circumstances when monetary sanction policies are effective and beneficial?

• Both of the included studies were from the United States and evaluated the use of state monetary sanction policies for families receiving assistance through the Aid to Families with Dependent Children (AFDC) program.
• Both studies used randomized controlled trials.
• One study was conducted over two years, one was over three years.

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.

Effectiveness Review

Summary Evidence Table

Effectiveness Review

Kerpelman LC, Connell DB, Gunn WJ. Effect of a monetary sanction on immunization rates of recipients of aid to families with dependent children. JAMA 2000;284:53-9.

Minkovitz C, Holt E, Hughart N, Hou W, Thomas L, Dini E et al. The effect of parental monetary sanctions on the vaccination status of young children: an evaluation of welfare reform in Maryland. Archives of Pediatrics & Adolescent Medicine 1999;153:1242-7.

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

• It has been suggested that policies on monetary sanctions may increase clients’ contact with healthcare providers which may increase receipt of other recommended preventive services. The Maryland study considered this possibility, however, and found no difference in receipt of well-child visits.
• Potential harms include the loss of financial support for families in need of assistance, whether through sanction, program drop-out, or reductions in applications for assistance.
• Monetary sanction policies may negatively affect other program activities and interactions between program staff and families in need of assistance.
• Agencies might not adopt or enforce these policies because of concerns about harms to families.