By: Matias Busso and Julian Cristia
Take a moment to recall the last time you forgot someone’s birthday. When was the last time you were at the grocery store and forgot that one crucial ingredient for dinner? How many times have you been locked out in the past year? A good memory is undoubtedly important for anyone. The memory of faces, names, facts and many other things concerning our everyday life is a measure of our ability to prevail in today’s fast-paced society.
The consequences of oblivion may vary; perhaps only a fine if we forget the deadline for paying taxes, or a sincere apology if we forget our partner’s birthday. But what are the potential consequences of forgetting the date to vaccinate our children? Why would we forget something so important?
Over 1.5 million children die of vaccine-preventable diseases every year, representing 29 percent of all child deaths under the age of five; the majority of these deaths occur among poor populations in developing countries. In recent decades, countries have implemented different supply-side interventions to boost vaccination rates, which have surely contributed to increased vaccination rates. Nonetheless, in 2013 about 21.8 million children worldwide did not receive the recommended package of vaccines.
In a scenario like this one, where supply is available, a critical question is how to further boost the demand for vaccines in developing countries? Mani, Mullainathan, Shafir and Zhao suggest that individuals living in poverty must constantly manage limited resources and face difficult trade-offs; these constant preoccupations leave fewer cognitive resources available. This approach infers that certain simple public interventions, such as providing reminders, could be particularly helpful for individuals living in poverty to make better health decisions.
Bearing this in mind, between 2011 and 2012, we conducted a field experiment in Guatemala, using administrative and survey data from 130 rural communities to assess the effects of a reminder intervention after six months of implementation.
As in other developing countries, in Guatemala coverage rates for vaccines due in the first months of life are high, but they decrease markedly for vaccines due after children turn one year old. That is, 86 percent of children 12 months old or younger received all vaccines recommended for their age, but this rate decreases to 67 percent for children between the ages of 18 and 48 months and to 42 percent for children between the ages of 48 and 53 months. Nonetheless, the decline in complete vaccination rates with a child’s age shows that most families fail to follow through with their plans, suggesting that reminders may aid families in achieving full vaccination.
The government hired nongovernmental organizations (NGOs) to provide a package of child and maternal health preventive services in clinics, which in turn employed community health workers to promote attendance at the clinics. We randomly assigned clinics in our sample to either a treatment or a control group. In treatment communities, health workers received lists of children who were due to receive a vaccine at the clinic in the following month.
The results were encouraging. The intervention produced an increase in vaccinations among children that were due for a vaccine during the implementation of almost 5 percentage points. Furthermore, the “reminder strategy” results efficient and highly cost-effective. We estimate that the total cost of scaling up this intervention in Guatemala is only $0.17 per child for the six-month intervention. These costs per additional child vaccinated are much lower than those of typical conditional cash transfer programs implemented in other Latin American countries.
Reminders are rarely used in developing countries and definitely represent a big opportunity to achieve further improvements in vaccination rates at a moderate cost. Moreover, reminders could potentially be used not only to increase vaccination levels, but also to spur demand for other preventive health care measures. Still, further research about how best to use reminders in developing countries is needed and important questions remain regarding different aspects of the use of reminders. How to reach people in a more efficient way? Should we use more sophisticated methods? Incorporate technology?
As in any other field of public policy, knowing the setting is crucial, but in any case, it seems that the lesson worth remembering is that in any of its variations —an App, a Post-it or a friend— reminders of what needs to be done and when can have a profound impact on health.
To know more about the experiment visit: Did You Get Your Shots? Experimental Evidence on the Role of Reminders
Related blogs: Vaccination: Infectious Misinformation by Carlos Scartascini