IMMUNIZATIONS: Chicago Links Food Vouchers, Shots

      A collaborative program in Chicago "has significantly improved the dangerously low immunization rates among the city's poor children" by using federal food vouchers as an incentive, the New York Times reports. The study, published in this week's Journal of the American Medical Association, "for the first time links local immunization efforts to federal food distribution." Prior to the inception of the program, recipients of Special Supplemental Nutrition Program for Women, Infants and Children (WIC) received a three-month supply of food vouchers during a single visit. Parents of unvaccinated children received counseling about the health risks children face without vaccination and were referred to clinics for free shots. However, the new program requires parents to report to authorities monthly until their children receives the appropriate vaccinations, at which point parents are allowed to return to quarterly vouchers. As a result, immunization rates among the city's children under age two "increased to 89% from 56% over the 15 months when parents ... were required to report monthly" (Noble, 10/7). By contrast, immunization rates remained constant at centers offering counseling and provider referrals, but without voucher incentives (Hoekstra et al., JAMA, 10/7 issue). Study author Charles LeBaron said, "It started raising immunization rates about as fast as any intervention we've ever seen" (Que, NPR, 10/6).

Details, Details
      Chicago's immunization project was run by the city's Department of Public Health and targeted all 47 Chicago WIC sites in an effort to expand services to 37,000 infant enrollees, a target population "hit hard" by measles outbreaks "in the nation's inner cities" (AP/Baltimore Sun, 10/7). Indeed, lead researcher Dr. Edward Hoekstra noted that children in the Chicago-area were particularly impacted by the measles resurgence, "with data indicating that city-wide vaccination coverage was 16% to 25% over eight years, despite the epidemic." The authors conclude that the costs associated with the joint program were not prohibitive; the "annual labor cost of providing voucher incentives in Chicago was relatively modest." However, the Centers for Disease Control and Prevention says it knows of only seven states that offer WIC voucher incentive programs (Hoekstra et al., JAMA, 10/7 issue).

A Long Shot?
      An accompanying JAMA editorial commends the researchers for their "stunning accomplishment," noting that in the inner cities of Los Angeles, Chicago and New York City, "only about 50% of one and two-year olds are up-to-date with immunizations." Drs. David Wood and Neil Halfon attribute the disappointing immunization rates in inner cities to "inadequately distributed" child health services which fail to provide quality care. Furthermore, they note that "inner- city families can have problems that impede their use of preventive care, including a lack of understanding of the immunization schedule, difficulties with transportation and limited social support." The authors praise the Chicago model for "attacking a number of these barriers" by providing immunization during each center visit, offering free services at the WIC clinic and providing "powerful negative incentives" which proved effective. Despite their praise for the program's results, Wood and Halfon warn that "the use of financial sanctions against families that are poor and often struggling to provide their children with basic necessities raises ethical and moral issues" (10/7 issue). Hoekstra noted that there was no decline in WIC participation as a result of the incentive program (10/7 issue). In an interview with NPR's Vicki Que, Wood advocated expanding the program, saying, "If they can do it with that many kids in inner-city Chicago, it can probably be taken to a number of our other cities." Que added that researchers say they also want to see if the approach works for children enrolled in other programs, such as food stamps ("All Things Considered," 10/6).