Large-scale influenza vaccination promotion on a mobile app platform: A randomized controlled trial

Digital Gamification Tools to Enhance Vaccine Uptake: Scoping Review

BACKGROUND

Gamification has been used successfully to promote various desired health behaviors. Previous studies have used gamification to achieve desired health behaviors or facilitate their learning about health.

OBJECTIVE

In this scoping review, we aimed to describe digital gamified tools that have been implemented or evaluated across various populations to encourage vaccination, as well as any reported effects of identified tools.

METHODS

We searched Medline, Embase, CINAHL, the Web of Science Core Collection, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Academic Search Premier, PsycInfo, Global Health, and ERIC for peer-reviewed papers describing digital gamified tools with or without evaluations. We also conducted web searches with Google to identify digital gamified tools lacking associated publications. We consulted 12 experts in the field of gamification and health behavior to identify any papers or tools we might have missed. We extracted data about the target population of the tools, the interventions themselves (eg, type of digital gamified tool platform, type of disease/vaccine, type and design of study), and any effects of evaluated tools, and we synthesized data narratively.

RESULTS

Of 1402 records, we included 28 (2%) peer-reviewed papers and 10 digital gamified tools lacking associated publications. The experts added 1 digital gamified tool that met the inclusion criteria. Our final data set therefore included 28 peer-reviewed papers and 11 digital gamified tools. Of the 28 peer-reviewed papers, 7 (25%) explained the development of the tool, 16 (57%) described evaluation, and 2 (7%) reported both development and evaluation of the tool. The 28 peer-reviewed papers reported on 25 different tools. Of these 25 digital gamified tools, 11 (44%) were web-based tools, 8 (32%) mobile (native mobile or mobile-enabled web) apps, and 6 (24%) virtual reality tools. Overall, tools that were evaluated showed increases in knowledge and intentions to receive vaccines, mixed effects on attitudes, and positive effects on beliefs. We did not observe discernible advantages of one type of digital gamified tool (web based, mobile, virtual reality) over the others. However, a few studies were randomized controlled trials, and publication bias may have led to such positive effects having a higher likelihood of appearing in the peer-reviewed literature.

CONCLUSIONS

Digital gamified tools appear to have potential for improving vaccine uptake by fostering positive beliefs and increasing vaccine-related knowledge and intentions. Encouraging comparative studies of different features or different types of digital gamified tools could advance the field by identifying features or types of tools that yield more positive effects across populations and contexts. Further work in this area should seek to inform the implementation of gamification for vaccine acceptance and promote effective health communication, thus yielding meaningful health and social impacts.

Effectiveness of chatbots on COVID vaccine confidence and acceptance in Thailand, Hong Kong, and Singapore

Chatbots have become an increasingly popular tool in the field of health services and communications. Despite chatbots' significance amid the COVID-19 pandemic, few studies have performed a rigorous evaluation of the effectiveness of chatbots in improving vaccine confidence and acceptance. In Thailand, Hong Kong, and Singapore, from February 11th to June 30th, 2022, we conducted multisite randomised controlled trials (RCT) on 2,045 adult guardians of children and seniors who were unvaccinated or had delayed vaccinations. After a week of using COVID-19 vaccine chatbots, the differences in vaccine confidence and acceptance were compared between the intervention and control groups. Compared to non-users, fewer chatbot users reported decreased confidence in vaccine effectiveness in the Thailand child group [Intervention: 4.3 % vs. Control: 17%, P = 0.023]. However, more chatbot users reported decreased vaccine acceptance [26% vs. 12%, P = 0.028] in Hong Kong child group and decreased vaccine confidence in safety [29% vs. 10%, P = 0.041] in Singapore child group. There was no statistically significant change in vaccine confidence or acceptance in the Hong Kong senior group. Employing the RE-AIM framework, process evaluation indicated strong acceptance and implementation support for vaccine chatbots from stakeholders, with high levels of sustainability and scalability. This multisite, parallel RCT study on vaccine chatbots found mixed success in improving vaccine confidence and acceptance among unvaccinated Asian subpopulations. Further studies that link chatbot usage and real-world vaccine uptake are needed to augment evidence for employing vaccine chatbots to advance vaccine confidence and acceptance.

Influenza Vaccine Hesitancy: Scope, Influencing Factors, and Strategic Interventions

Influenza vaccination rates in children are suboptimal. One underlying reason is influenza vaccine hesitancy. Tools such as the Parent Attitudes about Childhood Vaccines survey and the Vaccine Hesitancy Scale can be used to measure influenza vaccine hesitancy. The adapted Increasing Vaccination Model from Brewer and colleagues can help identify factors that influence influenza vaccine hesitancy, motivation, and uptake. Several strategies can be used to address influenza vaccine hesitancy, which we discuss further in this review.

Effects of vaccine registration on disease prophylaxis: a systematic review

BACKGROUND

The impact of the pandemic caused by the coronavirus (SARS-CoV-2), causing the disease COVID-19, has brought losses to the world in terms of deaths, economic and health problems. The expected return of the public to activities adapted to the new health situation led to discussions about the use of vaccination and its effects. However, the demand for proof of vaccination showed how inconsistent, unregistered, and uncontrolled this health process is with current technologies. Despite the proven effectiveness of vaccines in reducing infection rates, mortality, and morbidity, there are still doubts about their use in preventing certain infections and injuries, as well as the use of digital medical records for identification at public events and disease prevention. Therefore, this review aims to analyze the use of digital immunization cards in disease prevention in general.

METHODS

A systematic review of Science, PubMed/MEDLINE, LILACS /BSV, CINALH, and IEEE and Xplore was performed using PRISMA guidelines. The authors summarized the studies conducted over the last decade on the impacts of prophylaxis by control through immunization cards. Studies were selected using the following terms: Vaccination; Mobile Applications; Health Smarts Cards; Immunization Programs; Vaccination Coverage. For data analysis, we used Mendeley, Excel, RStudio, and Bibliometrix software among others.

RESULTS

A total of 1828 publications were found. After applying eligibility criteria (Articles published in Portuguese, Spanish or English in the last 10 years). Studies that only dealt with paper or physical records were excluded, as well as studies that were not linked to their country's health Department, as a possibility of bias exists with these types of information). After removing duplicates and applying filters 1 and 2, we included 18 studies in this review. This resulted in 18 papers that met our priori inclusion criteria; it was found that the most relevant sources were from the databases of the Institute of Electrical and Electronics Engineers (IEEE).

CONCLUSIONS

Considering the selected studies, we found that scientific evidence and epidemiological surveillance are essential tools to characterize the efficiency and effectiveness of immunization passport protection intervention and to ethically justify them. Technological development of digital vaccine passports can assist in vaccination programs and positively impact disease prophylaxis.

Can financial incentives and other nudges increase COVID-19 vaccinations among the vaccine hesitant? A randomized trial

Despite rapid initial uptake, COVID-19 vaccinations in the United States stalled within a few months of widespread rollout in 2021. In response, many state and local governments, employers and health systems used public health messaging, financial incentives and creative scheduling tools to increase vaccine uptake. Although these approaches drew on evidence from influenza and other vaccination efforts, they were largely untested in the context of SARS-CoV-2. In mid-2021, months after vaccines were widely available, we evaluated vaccination intentions and vaccine uptake using a randomized control trial. To do this, we recruited unvaccinated members of a Medicaid managed care plan in California (n = 2,701) and randomly assigned them to different public health messages, $10 or $50 financial incentives for vaccination, a simple vaccination appointment scheduler, or control. While messages increased vaccination intentions, none of the interventions increased vaccination rates. Estimates for financial incentives rule out even relatively small increases in vaccination rates. Small financial incentives and other behavioral nudges do not meaningfully increase COVID-19 vaccination rates amongst the vaccine hesitant.

Increasing Seasonal Influenza Vaccination among University Students: A Systematic Review of Programs Using a Social Marketing Perspective

The health and economic consequences of seasonal influenza present great costs to communities. Promoting voluntary uptake of the seasonal influenza vaccine among university students, particularly during the COVID-19 pandemic, can deliver protective effects for both individuals and the wider community. Vaccine uptake will be greatest when more of the social marketing benchmarks are applied. This systematic review summarizes evidence from programs aiming to increase seasonal influenza vaccination among university students. Six major electronic databases for health promotion studies (PubMed, EBSCO, ProQuest, Ovid, Web of Science, and ScienceDirect) were searched in November 2021 to capture peer-reviewed studies reporting field trials that have sought to increase seasonal influenza vaccination in university student populations, without any restrictions regarding the publication period. Following PRISMA guidelines, this paper identified 12 peer-reviewed studies that were conducted in the field in the United States, Australia, and Spain. Three studies were targeted at healthcare students and the rest focused on wider university student populations. Studies were narratively summarized, evidence of social marketing principles were identified, and quantitative outcomes were meta-analyzed. The findings indicate that none of the field studies, even a self-classified social marketing study, had adopted all eight of the social marketing benchmarks in program design and implementation. The two studies that only used promotion, but not other marketing-mix and social marketing principles, reported increases in students’ intention to be vaccinated but not actual behavior. Given that change is more likely when more social benchmarks are applied, this paper identifies activities that can be included in flu vaccine programs to improve flu vaccine uptake rates. The analysis highlights a lack of field studies focusing on increasing rates of vaccination behavior as research outcomes in countries beyond the United States.

A meta-analysis of influenza vaccination following correspondence: Considerations for COVID-19

Background

High vaccination rates are needed to protect against influenza and to end the COVID-19 pandemic. Health authorities need to know if supplementing mass communications with direct correspondence to the community would increase uptake.

Objectives

The primary objective is to determine if sending a single written message directly to individuals increases influenza vaccine uptake, and a secondary objective is to identify any identified content shown to increase influenza vaccine uptake.

Methods

MEDLINE, Embase, Cochrane CENTRAL, PsycINFO, and PubMed were searched for RCTs testing a single correspondence for members of the community in OECD countries to obtain influenza vaccination. A meta-analysis with inverse-variance, random-effects modelling was used to estimate a mean, weighted risk ratio effect size measure of vaccine uptake. Studies were quality assessed and analysis was undertaken to account for potential publication bias.

Results

Twenty-eight randomized controlled trials were included, covering 45 interventions. Of the 45 interventions, 37 (82.2%) report an increase in influenza vaccination rates. A formal meta-analysis shows that sending a single written message increased influenza vaccine uptake by 16%, relative to the no contact comparator group (RR = 1.16, 95% CI [1.13-1.20], Z = 9.25, p < .001). Analysis shows that the intervention is effective across correspondence type, age group, time, and location, and after allowing for risk of publication bias.

Limitations

The generalizability of results across the OECD may be questioned.

Conclusions and implications

The implication for public health authorities organizing vaccination programs for influenza, and arguably also for COVID-19, is that sending written vaccination correspondence to members of the community is likely to increase uptake. Keywords: vaccine uptake, COVID-19, influenza, direct correspondence, meta-analysis.

This study is pre-registered on osf.io; details can be found at https://osf.io/98mr7

A rapid global review of strategies to improve influenza vaccination uptake in Australia

This study aimed to identify effective strategies for improving the uptake of influenza vaccination and to inform recommendations for influenza vaccination programs in Australia. A rapid systematic review was conducted to assimilate and synthesize peer-reviewed articles identified in PubMed. The National Health and Medical Research Council (NHMRC) Hierarchy of Evidence was used to appraise the quality of evidence. A systematic search identified 4373 articles and 52 that met the inclusion criteria were included. The evidence suggests influenza vaccination uptake may be improved by interventions that (1) increase community/patient demand and access to influenza vaccine and overcome practice-related barriers; (2) reinforce the critical role healthcare providers play in driving influenza vaccination uptake. Strategies such as standing orders, reminder and recall efforts were successful in improving influenza vaccination rates. Community pharmacies, particularly in regional/remote areas, are well positioned to improve influenza vaccine coverage. The findings of this rapid review can be utilized to improve the performance of influenza immunization programs in Australia and other countries with comparable programs; and recommend priorities for future evaluation of interventions to improve influenza vaccination uptake.

Digital intervention increases influenza vaccination rates for people with diabetes in a decentralized randomized trial

People with diabetes (PWD) have an increased risk of developing influenza-related complications, including pneumonia, abnormal glycemic events, and hospitalization. Annual influenza vaccination is recommended for PWD, but vaccination rates are suboptimal. The study aimed to increase influenza vaccination rate in people with self-reported diabetes. This study was a prospective, 1:1 randomized controlled trial of a 6-month Digital Diabetes Intervention in U.S. adults with diabetes. The intervention group received monthly messages through an online health platform. The control group received no intervention. Difference in self-reported vaccination rates was tested using multivariable logistic regression controlling for demographics and comorbidities. The study was registered at clinicaltrials.gov: NCT03870997. A total of 10,429 participants reported influenza vaccination status (5158 intervention, mean age (±SD) = 46.8 (11.1), 78.5% female; 5271 control, Mean age (±SD) = 46.7 (11.2), 79.4% female). After a 6-month intervention, 64.2% of the intervention arm reported influenza vaccination, vers us 61.1% in the control arm (diff = 3.1, RR = 1.05, 95% CI [1.02, 1.08], p = 0.0013, number needed to treat = 33 to obtain 1 additional vaccination). Completion of one or more intervention messages was associated with up to an 8% increase in vaccination rate (OR 1.27, 95% CI [1.17, 1.38], p < 0.0001). The intervention improved influenza vaccination rates in PWD, suggesting that leveraging new technology to deliver knowledge and information can improve influenza vaccination rates in high-risk populations to reduce public health burden of influenza. Rapid cycle innovation could maximize the effects of these digital interventions in the future with other populations and vaccines.

Knowledge and practice toward seasonal influenza vaccine and its barriers at the community level in Riyadh, Saudi Arabia

BACKGROUND

The important role of vaccination and preventive health care has been shown in several studies conducted worldwide. Despite the annual high infection rate of influenza, there are still many people who opt not to get vaccinated and be protected. We conducted this study to explore the knowledge, practices, and barriers of a Saudi Arabian population toward influenza vaccination.

METHODS

We conducted a community-based cross-sectional study using a questionnaire that was distributed online through social media to adult males and females aged 18 years old and above in Riyadh, Saudi Arabia.

RESULTS

A total of 778 individuals responded to the survey, 193 (24.8%) males and 585 (75.2%) females. Male respondents tended to have a better knowledge of influenza and flu vaccine than females. However, there were more females who have been vaccinated. More males believed that they do not belong to the high-risk group compared to females (P < 0.001). The younger age group of respondents significantly had a better knowledge of flu vaccine and influenza (P < 0.05). On the other hand, the older age group of respondents (age 45-60 and age >60 years old) have more reasons and barriers to have the vaccine.

CONCLUSION

Knowledge of influenza and flu vaccine is relatively high, but the translation of this knowledge into practice is poor. The paradigm shift should be focused not only on knowledge of vaccines and vaccination but to attitudes and practices that will address barriers to getting the vaccine.