Additionally, there were some unaccountable factors, such as polio campaign during which either the EPI staff would be out on campaign signaling pathway or would only administer polio vaccine. Other than this study, no out-reach efforts or mass campaigns were carried out for immunization coverage in the study area. There were also some differences in the baseline characteristics and characteristics of those included vs. excluded from the analysis. The differences could be due to the sampling method as the study utilized consecutive sampling for the cohorts. The characteristics could be better matched by randomization used in intervention trials. To
account for the differences between the two cohorts, the multivariate analysis was used that included all of the variables; however, the primary endpoint estimates
were qualitatively similar to those obtained from the bivariate analysis. However, there may be residual selection bias and limitations of generalizability due to differences in characteristics of the children included vs. those excluded from the study. The high number of excluded infants from control cohort was a result of discontinuation of the pneumonia surveillance project due to discontinued funding. This led to a short follow-up period for many subjects resulting in exclusion from the up-to-date data analysis at 18 weeks of age. Another limitation may be due to the non-concurrent intervention and control arms. Although the wash-out period of 6 weeks was given at the end of follow-up of intervention cohort, incentives learn more in the prior time might have affected the enrollment and follow-up of control cohort. Economic incentives have been used to improve coverage
of public health interventions in various settings. For example, cash incentives and food vouchers for mothers resulted in improved immunization coverage in Nicaragua, Australia and the USA [22], [29] and [30]. Cash incentives for General Practitioners in the UK have also been used for improving immunization coverage [31]. Examples of effective economic incentives for public health outcomes other than immunization include: (a) money, transport Cediranib (AZD2171) vouchers and food baskets to improve Tuberculosis (TB) treatment compliance in Russia, Latin America and some Eastern Europe countries [32]; (b) conditional cash transfers (CCT) to provide financial support to low socio-economic status families and improve health, nutrition and education status in Mexico, Brazil and USA [33] and [34]; and (c) cash incentives to mothers for antenatal visits in France and Austria [30]. All these programs have shown positive results. Presently, large-scale economic incentives for immunizations are offered by two programs: the National Immunization Program, Australia and the Women, Infant and Children (WIC) Nutrition Supplementary Program in the United States. The Australian program has been associated with increasing immunization coverage [26].
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