Can social incentives increase timely and complete immunizations? How much do people care to signal to others that they look after their and their children’s health? How much do people learn from observing others’ actions? In Sierra Leone, Innovations for Poverty Action is working with researchers to conduct a randomized evaluation testing the impact of social incentives—in the form of highly visible bracelets for children, signaling they have been immunized—on adherence to children’s immunization schedules. 

Policy Issue 

Reducing under-five mortality is a public health priority in many sub-Saharan African countries, but finding cost-effective ways to improve service delivery and improve health outcomes for young children has been a challenge. One barrier is that many people do not seek preventive healthcare, or they only partially do; for example, many caregivers bring their children to health facilities for the first round or two of immunizations, but fail to complete the full immunization schedule. Difficulty reaching or paying for transportation to clinics is one barrier, but other likely barriers include lack of trust in health institutions and/or the human tendency to be “present-biased,” i.e., to weight current desires and demands on our time higher than future ones, which may lead people to put-off seeking preventive care, even when they want to.

Small incentives that motivate people to seek care for themselves and their children may help people overcome present-bias, build trust in health institutions, and spur more care seeking behavior. While there is ample evidence on the role of financial incentives (as well as consumption incentives, like food), less is known about how social incentives, such as public recognition and peer influence, influence health behavior. Yet given the low-cost of such incentives, shedding light on this question is very important from a policy perspective. This research aims to contribute to our understanding of the role of social incentives in encouraging pro-social behavior.

Context of the Evaluation 

Sierra Leone has one of the highest rates of infant mortality in the world with under-five mortality at 156 per 1,000 live births.1 2 The Government of Sierra Leone, together with development partners is heavily investing in strengthening health services. However, there is a shortage of information on cost-effective ways to do this in a state with weak capacity.

This study is taking place in four out of the country’s 14 districts: Kambia, Bombali, Tonkolili and Western Area Rural as districts, which have among the highest dropout and lowest full immunization rates. In the selected districts less than 60 percent of children completed all routine immunizations.3

Details of the Intervention 

Innovations for Poverty Action is working with researchers to rigorously measure the impact of social incentives, in the form of colored bracelets, on caregivers’ decisions to immunize their children. The design enables researchers to test both the effectiveness of the bracelets and to understand if behavior change is driven by social signaling or learning.

Researchers randomly assigned 120 government clinics into four different groups. In program clinics, government health workers give colored bracelets to children under the age of 15 months when they come for routine immunizations. Clinics are assigned to one of the following groups:

  1. One color, uninformative bracelets: Every child receives a yellow or green bracelet when coming for the first vaccine visit. Caregivers can choose their preferred color. The bracelet is exchanged for a bracelet of the same color at the 4th and 5th vaccine visit. It is unobservable whether a child has progressed past the first vaccine visit or completed the immunization schedule. (30 clinics)
  2. Two color, partially informative bracelets: Every child receives a yellow bracelet when coming for the first vaccine visit. The bracelet is exchanged to a green bracelet if the child comes timely for the 4th vaccine visit. It is now observable whether a child has progressed to the 4th vaccine visit. (30 clinics)
  3. Two color, fully informative bracelets: Every child receives a yellow bracelet when coming for the first vaccine visit. The bracelet is exchanged to a green bracelet if the child comes timely for the 5th vaccine visit. It is now observable whether a child has come for all vaccine visits and completed the schedule on time. (30 clinics)
  4. Comparison group: No bracelets are given for immunization. It is not observable whether a child has received any or all vaccinations. (30 clinics)

The research team is measuring impacts on timely and complete immunization, caregivers’ knowledge about immunization and their beliefs about other children’s immunization status. The endline survey will be conducted 12 months after the start of the program. 

Results and Policy Lessons 

Project ongoing; results forthcoming.

 

See IPA's Juliette Finetti explain randomized controlled trials and the study design here:

 

Sources

[1] World Health Organization, UNICEF, World Bank, United Nations Population Division. Trends in maternal mortality: 1990 to 2013. Geneva, Switzerland: World Health Organization; 2014. http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en.

[2] Save the Children. Surviving the first day: state of the world's mothers 2013. http://www.refworld.org/docid/51a5ad654.html.

[3] Sierra Leone Demographic and Health Survey, 2013, http://dhsprogram.com/publications/publication-FR297-DHS-Final-Reports.cfm.