Randomized Controlled Trial of Text Message Reminders for Increasing Influenza Vaccination

Barriers and facilitators of immunisation in refugees and migrants in Australia: an east-African case study

BACKGROUND

Immunisation programs available in low and middle-income countries include fewer vaccines in comparison to Australia's National Immunisation Program. As a result, refugees and migrants may have a heightened risk of being inadequately immunised upon arrival to Australia. Several studies have suggested that East African immigrants have low vaccination coverage. As such, the aim of this study was to explore the underlying attitudes, barriers and facilitators to immunisation in east African communities in two states of Australia: New South Wales and Victoria.

METHODS

A qualitative study involving 17 semi-structured, in-depth interviews were undertaken with East African refugees and migrants living in two states of Australia: New South Wales and Victoria. These refugees and migrants were from four key East African countries: Kenya, Somalia, Ethiopia and South Sudan. Thematic analysis was undertaken to analyse and interpret the results.

RESULTS

Language barriers, low risk perception and a lack of education were the key barriers identified by participants. Facilitators mentioned included the development of resources in participants' languages and the implementation of reminder systems consistently across all GP practices. There was also a unanimous agreement amongst participants that community organisations need to play a greater role in the dissemination of information about immunisation.

CONCLUSIONS

Further research needs to be undertaken with regards to how education about immunisation is delivered and disseminated to refugee and migrant communities. Current findings also support the need to improve the health literacy of refugees and migrants by providing culturally and linguistically appropriate resources in participants' respective languages.

Lessons to be learned: Using National Immunisation strategies to improve adherence to acute rheumatic fever secondary prophylaxis

Rheumatic heart disease, as a result of a single or recurrent episode of acute rheumatic fever (ARF), remains a significant cause of morbidity and mortality in northern and remote Australia; ARF has a peak incidence among 5-14-year-old Aboriginal and Torres Strait Islander children. Long-term regular benzathine penicillin G injections are the only currently successful secondary prevention strategy; however, rates of adherence remain critically low. In contrast, rates of adherence to immunisations on the National Immunisation Program (NIP) Schedule are high, even among this target population. This article compares strategies used to implement and improve ARF secondary prophylaxis with those used in the NIP. Some successful NIP strategies, such as Service Incentive Payment for health providers, home-visiting delivery models and integration into the National Immunisation Register, if applied to ARF secondary prophylaxis have the potential to improve benzathine penicillin G adherence.

Klug S, Gensichen J. Increasing Influenza Vaccination Rates in People With Chronic Illness

BACKGROUND

The safety and efficacy of influenza vaccination for the chronically ill are clearly supported by the evidence, yet vaccination rates in this vulnerable popu- lation remain low. This leads to many avoidable hospitalizations and deaths in Germany every year. The goal of this systematic review is to identify measures in primary care medicine that can be used to increase influenza vaccination rates among the chronically ill.

METHODS

This review was carried out as recommended in the PRISMA statement. A systematic literature search was performed. Only randomized, controlled trials were included in the analysis. Details can be found in the study protocol (PROSPERO, CRD42018114163).

RESULTS

15 trials were included in the analysis. Training sessions for medical practice teams focusing on a particular disease raised the vaccination rates by as much as 22%. A financial incentive had the greatest effect (relative risk [RR]: 2.79; 95% confidence interval: [1.18; 6.62]). Reminders via text message yielded a maximum 3.8% absolute increase in vaccination rates. Complex interventions were not found to be of any greater benefit than simple ones.

CONCLUSION

A variety of approaches can be effective. Focusing training sessions for medical practice teams on certain diseases may be of greater benefit than vacci- nation-centered training sessions. Reminder systems for doctors should be more reliably implemented. Simple strategies are perhaps the most suitable ones in the heterogeneous population of chronically ill persons. The limitations of this system- atic review include the heterogeneity of the studies that we examined and the small number of studies in each category.

Randomised controlled trial of a theory-based intervention to prompt front-line staff to take up the seasonal influenza vaccine

OBJECTIVE

To evaluate the effectiveness of reminder letters informed by social normative theory (a type of 'nudge theory') on uptake of seasonal influenza vaccination by front-line hospital staff.

DESIGN

Individually randomised controlled trial.

SETTING

A large acute care hospital in England.

PARTICIPANTS

Front-line staff employed by the hospital (n=7540) were randomly allocated to one of four reminder types in a factorial design.

INTERVENTIONS

The standard letter included only general information directing the staff to take up the vaccine. A second letter highlighted a type of social norm based on peer comparisons. A third letter highlighted a type of social norm based on an appeal to authority. A fourth letter included a combination of the social norms.

MAIN OUTCOME MEASURE

The proportion of hospital staff vaccinated on-site.

RESULTS

Vaccine coverage was 43% (812/1885) in the standard letter group, 43% (818/1885) in the descriptive norms group, 43% (814/1885) in the injunctive norms group and 43% (812/1885) in the combination group. There were no statistically significant effects of either norm or the interaction. The OR for the descriptive norms factor is 1.01 (0.89-1.15) in the absence of the injunctive norms factor and 1.00 (0.88-1.13) in its presence. The OR for the injunctive norms factor is 1.00 (0.88-1.14) in the absence of the descriptive norms factor and 0.99 (0.87-1.12) in its presence.

CONCLUSIONS

We find no evidence that the uptake of the seasonal influenza vaccination is affected by reminders using social norms to motivate uptake.

Randomised controlled trial of a theory-based intervention to prompt front-line staff to take up the seasonal influenza vaccine

Objective

To evaluate the effectiveness of reminder letters informed by social normative theory (a type of ‘nudge theory’) on uptake of seasonal influenza vaccination by front-line hospital staff.

Design

Individually randomised controlled trial.

Setting

A large acute care hospital in England.

Participants

Front-line staff employed by the hospital (n=7540) were randomly allocated to one of four reminder types in a factorial design.

Interventions

The standard letter included only general information directing the staff to take up the vaccine. A second letter highlighted a type of social norm based on peer comparisons. A third letter highlighted a type of social norm based on an appeal to authority. A fourth letter included a combination of the social norms.

Main outcome measure

The proportion of hospital staff vaccinated on-site.

Results

Vaccine coverage was 43% (812/1885) in the standard letter group, 43% (818/1885) in the descriptive norms group, 43% (814/1885) in the injunctive norms group and 43% (812/1885) in the combination group. There were no statistically significant effects of either norm or the interaction. The OR for the descriptive norms factor is 1.01 (0.89–1.15) in the absence of the injunctive norms factor and 1.00 (0.88–1.13) in its presence. The OR for the injunctive norms factor is 1.00 (0.88–1.14) in the absence of the descriptive norms factor and 0.99 (0.87–1.12) in its presence.

Conclusions

We find no evidence that the uptake of the seasonal influenza vaccination is affected by reminders using social norms to motivate uptake.

An Editorial Review of Mobile Health: Implications for the US Military Health System

Introduction

The United States Military Health System provides healthcare to a diverse patient population throughout the world. There are three distinct challenges that the Military Health System faces. (1) Providers have varying degrees of clinical training expertise and may be called upon to practice outside their usual scope of care. (2) There is geographic isolation of patients and providers with limited resources while stationed overseas. (3) Patients are at higher risk of breaks in continuity of care because of permanent change of duty stations, deployments, and retirement.

Materials and Methods

In this article we review the history of mobile health in both the civilian and military sectors, and how mobile health may be used to address the challenges unique to the United States Military Health System.

Results

There are many good initiatives in military mobile health, however they are decentralized and different across the services and military treatment facilities. We describe some military specific success stories with improving patient access to care and disease specific mobile health applications implemented.

Conclusions

Mobile health is a powerful platform which can help deliver standardized care in missions around the world and improve access to care for patients at military treatment facilities in the United States. The United States Military Health System would benefit greatly from creating universal mobile health applications to assist providers in patient access to care, military mission readiness, and disease specific modules. Future resources should be dedicated to the development of a mobile health application pool that is universally implemented across services to improve quality of care delivered at home and in theater by military providers.

Text Message Reminders for Child Influenza Vaccination in the Setting of School-Located Influenza Vaccination: A Randomized Clinical Trial

Half of US school children receive influenza vaccine. In our previous trials, school-located influenza vaccination (SLIV) raised vaccination rates by 5 to 8 percentage points. We assessed whether text message reminders to parents could raise vaccination rates above those observed with SLIV. Within urban elementary schools we randomized families into text message + SLIV (intervention) versus SLIV alone (comparison). All parents were sent 2 backpack notifications plus 2 autodialer phone reminders about SLIV at a single SLIV clinic. Intervention group parents also were sent 3 text messages from the school nurse encouraging flu vaccination via either primary care or SLIV. Among 15 768 children at 32 schools, vaccination rates were text + SLIV (40%) and SLIV control (40%); 4% of students per group received influenza vaccination at SLIV. Text message reminders did not raise influenza vaccination rates above those observed with SLIV alone. More intensive interventions are needed to raise influenza vaccination rates.

Understanding the unique characteristics of seasonal influenza illness to improve vaccine uptake in the US

Seasonal influenza results in substantial morbidity, mortality and socio-economic burden. The US Advisory Committee on Immunization Practices recommends vaccination of everyone over 6 months of age, but coverage remains substantially below the Healthy People 2020 target of 70% in most age groups. Influenza is different from other vaccine-preventable diseases in several ways that influence vaccine uptake. Although the incidence of most vaccine-preventable diseases is low, there is a perception that these diseases result in significant illness or death. In contrast, seasonal influenza has a relatively high incidence, but there is an incorrect perception of a lower disease severity. The vaccine effectiveness of seasonal influenza vaccines is less than other routine vaccines, varies from season to season between northern and southern hemispheres, and can be low in some seasons. It is also not well recognized that vaccination can attenuate the severity of influenza illness. Finally, the need for annual vaccination is perceived as a burden to busy people. Understanding these differences from the perspective of caregivers and vaccinees might help to improve influenza vaccine uptake. Presenting vaccine effectiveness in terms of clinical outcomes that have the most impact might help to overcome the perceptions that influenza is a non-serious disease and that the vaccine is not effective. The benefits of disease attenuation need to be emphasized in terms of reduced mortality, hospitalization, absenteeism and disruption to daily life. Innovative communication strategies should be adopted, including stronger recommendations from and to healthcare providers, continuous patient education, and social media initiatives employing more emotional and narrative approaches than traditionally used. Finally, access to seasonal influenza vaccination needs to be improved, and barriers such as cost and inconvenience removed. Multiple initiatives have already been successful. The remaining challenge is to translate individual successes into public health policies with corresponding funding and implementation.

Letters designed with behavioural science increase influenza vaccination in Medicare beneficiaries

The influenza ('flu') vaccination is low cost¹ and effective, typically reducing the likelihood of infection by 50-60%². It is recommended for nearly everyone older than 6 months of age³; yet, only 40% of Americans are immunized each year. Vaccination rates are higher among at-risk groups, such as those ≥65 years of age, but still only 6 in 10 receive it⁴. There have been numerous attempts to improve vaccination rates using strategies such as school-based programmes, financial incentives and reminders, but these have generally had limited success^5-7. Of the attempts that are successful, most are expensive-limiting scalability-and have not been evaluated in the elderly⁸. Conversely, lower-cost interventions, such as mailed information, hold promise for a scalable solution, but their limited effectiveness may result from how they have been designed. We randomly assigned 228,000 individuals ≥66 years of age to one of five versions of letters intended to motivate vaccination, including versions with an implementation intention prompt and an enhanced active choice implementation prompt. We found that a single mailed letter significantly increased influenza vaccination rates compared with no letter. However, there was no difference in vaccination rates across the four different letters tailored with behavioural science techniques.

Coverage and predictors of influenza vaccination in patients with cystic fibrosis in a campaign with a mobile phone text messaging intervention

Annual influenza vaccination is considered the best protection against influenza infection. We analyzed the influenza vaccine coverage (IVC) in cystic fibrosis (CF) patients and evaluated the factors associated with the IVC, including the effect of text-message/SMS reminders.

We performed a cross-sectional study in the Community of Madrid (Spain) in 2015. The target population was people with CF older than 6 months of age at the beginning of the flu vaccination campaign. The IVC was calculated according to the study variables.

A total of 445 CF patients were analyzed. In 2015, IVC reached 67.9% and was higher in children and women. The main factor associated with flu vaccination was having been vaccinated in the previous campaign (aOR 14.36; IC95%: 8.48–24.32).

The probability of being vaccinated after receiving the SMS was more than twice than for those who did not receive it, although no statistical significance was reached.

In conclusion the IVC of patients with CF is high, but it still has room for improvement. SMS reminders sent to CF patients might improve influenza vaccine uptake.

Effect of a Remotely Delivered Tailored Multicomponent Approach to Enhance Medication Taking for Patients With Hyperlipidemia, Hypertension, and Diabetes: The STIC2IT Cluster Randomized Clinical Trial

IMPORTANCE

Approximately half of patients with chronic conditions are nonadherent to prescribed medications, and interventions have been only modestly effective.

OBJECTIVE

To evaluate the effect of a remotely delivered multicomponent behaviorally tailored intervention on adherence to medications for hyperlipidemia, hypertension, and diabetes.

DESIGN, SETTING, AND PARTICIPANTS

Two-arm pragmatic cluster randomized controlled trial at a multispecialty group practice including participants 18 to 85 years old with suboptimal hyperlipidemia, hypertension, or diabetes disease control, and who were nonadherent to prescribed medications for these conditions.

INTERVENTIONS

Usual care or a multicomponent intervention using telephone-delivered behavioral interviewing by trained clinical pharmacists, text messaging, pillboxes, and mailed progress reports. The intervention was tailored to individual barriers and level of activation.

MAIN OUTCOMES AND MEASURES

The primary outcome was medication adherence from pharmacy claims data. Secondary outcomes were disease control based on achieved levels of low-density lipoprotein cholesterol, systolic blood pressure, and hemoglobin A1c from electronic health records, and health care resource use from claims data. Outcomes were evaluated using intention-to-treat principles and multiple imputation for missing values.

RESULTS

Fourteen practice sites with 4078 participants had a mean (SD) age of 59.8 (11.6) years; 45.1% were female. Seven sites were each randomized to intervention or usual care. The intervention resulted in a 4.7% (95% CI, 3.0%-6.4%) improvement in adherence vs usual care but no difference in the odds of achieving good disease control for at least 1 (odds ratio [OR], 1.10; 95% CI, 0.94-1.28) or all eligible conditions (OR, 1.05; 95% CI, 0.91-1.22), hospitalization (OR, 1.02; 95% CI, 0.78-1.34), or having a physician office visit (OR, 1.11; 95% CI, 0.91-1.36). However, intervention participants were significantly less likely to have an emergency department visit (OR, 0.62; 95% CI, 0.45-0.85). In as-treated analyses, the intervention was associated with a 10.4% (95% CI, 8.2%-12.5%) increase in adherence, a significant increase in patients achieving disease control for at least 1 eligible condition (OR, 1.24; 95% CI, 1.03-1.50), and nonsignificantly improved disease control for all eligible conditions (OR, 1.18; 95% CI, 0.99-1.41).

CONCLUSIONS AND RELEVANCE

A remotely delivered multicomponent behaviorally tailored intervention resulted in a statistically significant increase in medication adherence but did not change clinical outcomes. Future work should focus on identifying which groups derive the most clinical benefit from adherence improvement efforts.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02512276.

The use of technology to promote vaccination: A social ecological model based framework

Vaccinations are an important and effective cornerstone of preventive medical care. Growing technologic capabilities and use by both patients and providers present critical opportunities to leverage these tools to improve vaccination rates and public health. We propose the Social Ecological Model as a useful theoretical framework to identify areas in which technology has been or may be leveraged to target undervaccination across the individual, interpersonal, organizational, community, and society levels and the ways in which these levels interact.

Using text message reminders in health care services: A narrative literature review

INTRODUCTION

Despite the extensive use of mHealth behavior change interventions, questions remain about the use of technology-based reminders in delivering health care services. Text messaging, or short message service (SMS), is one reminder method that has been extensively researched. Most SMS-reminder research is distributed across a range of health care outcomes. The aim of this article is to systematically review the aggregate impact of these reminders on overall health care outcomes.

METHODS

A systematic literature review was conducted and yielded 2316 articles. Studies were included if they used SMS reminders to support patient health care outcomes. Study methodology was aligned with the PRISMA guidelines for systematic reviews.

RESULTS

Following screening, 162 articles met inclusion criteria. Of these studies, 93 investigated medical compliance reminders and 56 investigated appointment reminders. The review found that nearly all the SMS-reminder studies helped improve patient medical compliance and appointment reminders. Additionally, researchers reported numerous benefits from using SMS reminders, including ease of use, relative inexpensiveness, and rapid and automated message delivery. Minimal risks were reported and most participants found the reminders to be acceptable.

DISCUSSION

Text messages appear to be an effective reminder mechanism to promote improved patient appointment and medical compliance. Reminders should continue to be evaluated and improved to determine the most effective timing and frequency of messages for improving outcomes.

[Analysis of the refusal of the flu vaccination (REGRIVI study)]

INTRODUCTION

The objective of this study is to determine the reasons for refusing the flu vaccination in the Primary Care Health Centre of Vilanova de Arousa, Spain, as well as to evaluate the flu vaccination coverage after an educational intervention.

MATERIAL AND METHODS

A quasi-experimental before and after study was conducted after an educational intervention on a total of 73 people that included those Primary Care Health Centre patients from Vilanova de Arousa who had refused the flu vaccination in 2014, and who did not meet the exclusion criteria (death during 2014 and 2015 campaigns, non-acceptance of participation, vaccine registration mistakes, contraindication or no indication for the vaccine, inability to contact). After a brief educational intervention, vaccination data from those patients in the 2015 and 2016 campaigns were checked. A descriptive analysis of the variables under study was then carried out. Of the 73 patients initially included, 72 completed the study.

RESULTS

The main reasons for refusing a vaccination were the concerns about the adverse effects and patient perception of good health. Vaccination coverage was 50.7% in 2015, and 48.6% in 2016.

CONCLUSIONS

The reasons for refusing vaccination are approachable with a brief intervention since the refusal decreases by half in the long-term.