Impact of patient education on influenza vaccine uptake among community-dwelling elderly: a randomized controlled trial

Strategies to increase the coverage of influenza and pneumonia vaccination in older adults: a systematic review and network meta-analysis

BACKGROUND

It is urgent to implement interventions to increase vaccination rates of influenza/pneumonia vaccines in older adults, yet the effectiveness of different intervention strategies has not been thoroughly evaluated.

OBJECTIVE

We aimed to assess the effectiveness of intervention strategies for increasing the coverage of influenza/pneumonia vaccination in older adults.

METHODS

PubMed, Web of Science, Cochrane Library, Embase, China Biology Medicine disc, China National Knowledge Infrastructure and Wanfang were searched from 1 January 2000 to 1 October 2022. RCTs that assessed any intervention strategies for increasing influenza/pneumonia vaccination coverage or willingness in older adults were included. A series of random-effects network meta-analysis was conducted by using frequentist frameworks.

RESULTS

Twenty-two RCTs involving 385,182 older participants were eligible for further analysis. Eight types of intervention strategies were evaluated. Compared with routine notification, health education (odds ratio [OR], 1.85 [95%CI, 1.19 to 2.88]), centralised reminder (OR, 1.63 [95%CI, 1.07 to 2.47]), health education + onsite vaccination (OR, 2.89 [95%CI, 1.30 to 6.39]), and health education + centralised reminder + onsite vaccination (OR, 20.76 [95%CI, 7.33 to 58.74]) could effectively improve the vaccination rate. The evidence grade was low or very low due to the substantial heterogeneity among studies.

CONCLUSIONS

Our findings suggest that health education + centralised reminder + onsite vaccination may potentially be an effective strategy regardless of cost, but the evidence level was low. More rigorous trials are needed to identify the association between strategies and vaccination rates among older adults and to integrate such evidence into clinical care to improve vaccination rates.

A review of factors influencing vaccination policies and programs for older adults globally

Policies and programs to increase vaccine coverage rates among adults 50 years of age or older are limited and vaccine uptake is often suboptimal. Our review evaluated evidence on the effectiveness and success of adult-targeted vaccination interventions and identified literature gaps. Literature was retrieved (2021) from PubMed, Embase, and Google Scholar databases. Outcomes assessed included data on an intervention's effectiveness and impact on vaccine uptake. Interventions were characterized thematically: affordability (n = 9), awareness (n = 25), and vaccination access (n = 6); and included influenza, pneumococcal, tetanus-containing, and herpes zoster vaccines. Interactive interventions directed toward patients, including provider-led educational initiatives and provider recommendations showed more positive associations than less interactive interventions, such as posters and reminder-recall letters. Provider interventions, including awareness campaigns, incentives, affordability efforts, or vaccination site expansion generally showed positive associations. Combining interventions was found to be successful across several studies. Barriers and interventions varied for population subgroups, therefore, tailoring programs is critical.

Herpes zoster vaccine awareness and acceptance among adults in Saudi Arabia: a survey-based cross-sectional study

BACKGROUND

Herpes zoster (shingles) is caused by reactivation of the varicella-zoster virus. Despite the recommended herpes zoster vaccine for individuals aged ≥ 50 years, its uptake remains low in Saudi Arabia.

METHODS

This cross-sectional study assessed knowledge and awareness of herpes zoster and its vaccine in individuals aged ≥ 50 years in Saudi Arabia. Data were collected through an online survey distributed via social media.

RESULTS

Among 402 participants, 57.2% had heard of the shingles vaccine, but only 7.7% received it. However, 53.2% expressed willingness to be vaccinated. Multivariable analysis revealed that those aged 56-60 were 1.8 times more likely to accept the vaccine than those aged 50-55 years (p = 0.03). Men were 1.9 times more likely to accept the vaccine than women (p = 0.01). Additionally, participants with a primary education were 16.1 times more likely to accept the vaccine than those with a higher education (p = 0.01).

CONCLUSION

This study highlights the need for increased awareness and education among healthcare providers and the public in Saudi Arabia regarding shingles and its vaccine. The low vaccine uptake calls for effective strategies, such as awareness campaigns and provider reminders. Primary education and vaccine hesitancy influence willingness to be vaccinated.

Evaluating the impact of using mobile vaccination units to increase COVID-19 vaccination uptake in Cheshire and Merseyside, UK: a synthetic control analysis

OBJECTIVE

To evaluate the impact of mobile vaccination units on COVID-19 vaccine uptake of the first dose, the percentage of vaccinated people among the total eligible population. We further investigate whether such an effect differed by deprivation, ethnicity and age.

DESIGN

Synthetic control analysis.

SETTING

The population registered with general practices (GPs) in nine local authority areas in Cheshire and Merseyside in Northwest England, UK.

INTERVENTION

Mobile vaccination units that visited 37 sites on 54 occasions between 12 April 2021 and 28 June 2021. We defined intervention neighbourhoods as having their population weighted centroid located within 1 km of mobile vaccination sites (338 006 individuals). A weighted combination of neighbourhoods that had not received the intervention (1 495 582 individuals) was used to construct a synthetic control group.

OUTCOME

The weekly number of first-dose vaccines received among people aged 18 years and over as a proportion of the population.

RESULTS

The introduction of a mobile vaccination unit into a neighbourhood increased the number of first vaccinations conducted in the neighbourhood by 25% (95% CI 21% to 28%) within 3 weeks after the first visit to a neighbourhood, compared with the synthetic control group. Interaction analyses showed smaller or no effect among older age groups, Asian and black ethnic groups, and the most socioeconomically deprived populations.

CONCLUSIONS

Mobile vaccination units are effective interventions for increasing vaccination uptake, at least in the short term. While mobile units can be geographically targeted to reduce inequalities, we found evidence that they may increase inequalities in vaccine uptake within targeted areas, as the intervention was less effective among groups that tended to have lower vaccination uptake. Mobile vaccination units should be used in combination with activities to maximise outreach with black and Asian communities and socioeconomically disadvantaged groups.

Chatbot-Delivered Online Intervention to Promote Seasonal Influenza Vaccination During the COVID-19 Pandemic: A Randomized Clinical Trial

Importance

Receiving seasonal influenza vaccination (SIV) is important for adults during the COVID-19 pandemic. There are few robust evaluations of tailored interventions for improving SIV uptake among adults 65 years or older.

Objective

To evaluate the relative efficacy of a stages of change (SOC)-tailored online intervention compared with a standard, non-SOC-tailored online intervention in increasing SIV uptake among Hong Kong residents 65 years or older.

Design, Setting, and Participants

This nonblinded parallel-group randomized clinical trial was conducted between December 1, 2021, and July 31, 2022, in Hong Kong, China. Eligible participants were 65 years or older, had Cantonese- and/or Mandarin-speaking skills, were community-dwelling, had Hong Kong residency, were smartphone users, and had not received SIV for the 2021 to 2022 influenza season. Participants were recruited through random telephone calls, and those who completed the baseline telephone survey were randomized to either the intervention or control group. Both complete case and intention-to-treat (ITT) analyses were performed.

Intervention

In the intervention group, a simplified rule-based chatbot first assessed participants' SOC related to SIV uptake and then automatically selected and sent participants SOC-tailored online health promotion messages (videos) through a messaging application (WhatsApp; Meta) once every 2 weeks for 4 sessions. In the control group, the chatbot sent a link to access through the messaging application a standard online health promotion message (video) covering general SIV information every 2 weeks for 4 sessions.

Main Outcomes and Measures

The primary outcome was self-reported SIV uptake at month 6, which was validated by the research team. The secondary outcome was SOC measured at both baseline and month 6 by validated questions.

Results

A total of 396 participants (mean [SD] age of 70.2 [4.3] years; 249 females [62.9%]) were randomized to the intervention (n = 198) or control (n = 198) group. The ITT analysis showed that the validated SIV uptake rate was higher in the intervention group than the control group at month 6 (50.5% vs 35.3%; P = .002). The mean (SD) SOC score was higher in the intervention group than the control group (2.8 [1.4] vs 2.4 [1.4]; P = .02). More participants in the intervention group completed at least 1 episode of intervention than in the control group (77.3% vs 62.6%; P < .001).

Conclusions

Results of this trial indicate that the SOC-tailored online intervention was more effective than the non-SOC-tailored intervention and may be a sustainable new method in increasing SIV uptake among adults 65 years or older.

Trial Registration

ClinicalTrials.gov Identifier: NCT05155241.

Influenza vaccine uptake among children and older adults in China: a secondary analysis of a quasi-experimental study

BACKGROUND

Influenza vaccination is the key to prevent influenza-related disease, especially among high-risk populations. However, influenza vaccine uptake in China is low. This secondary analysis of a quasi-experimental trial aimed to understand factors associated with influenza vaccine uptake among children and older people stratified by funding context.

METHODS

A total of 225 children (aged 0.5-8 years) and 225 older people (aged 60 years or above) were recruited from three clinics (rural, suburban and urban) in Guangdong Province. Participants were allocated into two groups based on funding contexts: a self-paid group (N = 150, 75 children and 75 older adults) in which participants paid full price for their vaccination; and a subsidized group (N = 300, 150 children and 150 older adults) in which varying levels of financial support was provided. Univariate and multivariable logistic regressions were conducted stratified by funding contexts.

RESULTS

Overall, 75.0% (225/300) of participants in the subsidized group and 36.7% (55/150) in the self-paid group got vaccinated. Older adults had lower vaccination rates than children in both funding groups, while both age groups showed much higher uptake in the subsidized group than in the self-paid group (aOR = 5.96, 95% CI: 3.77-9.42, p = 0.001). In the self-paid group, having prior influenza vaccination history of children (aOR:2.61, 95%CI: 1.06-6.42) or older people (aOR:4.76, 95%CI: 1.08-20.90) was associated with increased influenza vaccine uptake compared to those who had no prior vaccination experiences in the family. While in the subsidized group, participants who got married or lived with partners (aOR = 0.32, 0.10-0.98) had lower vaccination uptake than single ones. Trust in providers' advice (aOR = 4.95, 95%CI:1.99, 12.43), perceived effectiveness of the vaccine (aOR: 12.18, 95%CI: 5.21-28.50), and experienced influenza-like illnesses in the family in the past year (aOR = 46.52, 4.10, 533.78) were associated with higher vaccine uptake.

CONCLUSIONS

Older people had suboptimal vaccine uptake compared to children in both contexts and need more attention to enhance influenza vaccination. Tailoring interventions to different vaccine funding contexts may help improve influenza vaccination: In self-paid context, motivating people to accept their first ever influenza vaccination may be a promising strategy. In subsidized context, improving public confidence in vaccine effectiveness and providers' advice would be useful.

Education increases COVID-19 vaccine uptake among people in Canadian federal prisons in a prospective randomized controlled trial: The EDUCATE study

Education is key to behavioural adoption and acceptability of health interventions. We evaluated the impact of an educational intervention administered 1:1 to individuals incarcerated in four Canadian federal prisons on COVID-19 vaccine uptake. Eligible individuals (those who had refused all COVID-19 vaccines) were randomized 2:1 to receive the educational intervention or not (control group); those who received the intervention completed questionnaires assessing COVID-19 vaccine-related knowledge, attitudes, and beliefs pre- and post-educational intervention. The primary and secondary outcome measures were COVID-19 vaccine uptake and vaccine confidence, respectively. Between May 3 and September 9, 2022, 202 participants were randomized to receive the intervention, of whom 127 (63 %) agreed to participate. Participants who were randomized to the intervention had higher COVID-19 vaccine uptake vs. the control group (5 % vs 1 %, p = 0.046). COVID-19 vaccine-related knowledge, attitudes, and beliefs improved post-intervention. Education increases COVID-19 vaccine uptake and confidence among people in Canadian federal correctional facilities.

Differences in Demographics of Vaccinees, Access to, and Satisfaction with SARS-CoV-2 Vaccination Procedures between German General Practices and Mass Vaccination Centers

In the European Union, SARS-CoV-2 vaccines became available in December 2020. The vaccination campaign in Germany was initially implemented through mass vaccination centers and later joined by general practitioners (GPs) in spring 2021. This study compared population characteristics, perceived access barriers, and satisfaction with the vaccination procedure between vaccination centers and GP practices. A paper-based survey was distributed (07/2021-10/2021) among newly vaccinated individuals in ten GP practices (n = 364) and two vaccine centers (n = 474). Participants in vaccine centers were younger compared to participants in GP practices. GP preference was higher in older participants and those with pre-existing illnesses. Wait time at vaccination site was longer in GP practices, whereas travel distance to site was longer for participants in vaccine centers. However, satisfaction with patient education and recommendation of site were more likely with increasing comprehensibility of the vaccination procedure and physicians' information as well as perceived sufficiency of patient education duration, factors that can be easily modified by all vaccination sites. Our results demonstrate that both types of vaccination sites complement each other in terms of accessibility and target population and that satisfaction with the vaccination procedure can be promoted at all sites by an easy-to-understand process.

Impact of video-led educational intervention on uptake of influenza vaccine among the elderly in western China: a community-based randomized controlled trial

BACKGROUND

Influenza vaccination coverage rate among the elderly is low in China. We aimed to evaluate the impact of video-led educational intervention on influenza vaccine uptake among the Chinese elderly.

METHODS

A randomized controlled trial was conducted in 8 communities of Xi'an, a representative city in western China. Elderly aged over 60 years were randomized to the control group and intervention group (12-minute video education on influenza and its vaccination). Participants' knowledge, attitudes, and practices (KAP) of influenza was assessed by using a questionnaire survey before and after the intervention. The primary outcomes were participants' willingness to get influenza vaccinated and their actual uptake rates in the 2020-21 flu season. Secondary outcomes were the variations of pre- and post-intervention KAP scores. Intention-to-treat analysis was performed to analyze the data, and sensitivity analyses were conducted to examine the robustness of the results.

RESULTS

A total of 350 people were enrolled, with 175 individuals for each group. Participants in the intervention group were more willing to receive influenza vaccination than those in the control group (64.6% vs. 51.4%, p<0.05). The influenza vaccination uptake rate occurred in 10.3% of participants in the intervention group and 3.4% in the control group (odds ratio, 3.23; 95% CI 1.25-8.32, p<0.001). The post-intervention KAP scores in the intervention group were significantly higher compared to those in the control group (p<0.001).

CONCLUSION

Video-led education was an effective and feasible approach to improve old people's willingness and uptake of influenza vaccination in western China.

Shifting the Demand for Vaccines: A Review of Strategies

Vaccines prevent millions of deaths, and yet millions of people die each year from vaccine-preventable diseases. The primary reason for these deaths is that a significant fraction of the population chooses not to vaccinate. Why don't people vaccinate, and what can be done to increase vaccination rates besides providing free and easy access to vaccines? This review presents a conceptual framework, motivated by economic theory, of which factors shift the demand for vaccines. Next, it critically examines the literature on these demand shifters and interventions that target these demand shifters. The review concludes with offering directions for future research and lessons for public health decision-making. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Influenza vaccination uptake and its determinants during the 2019-2020 and early 2020-2021 flu seasons among migrants in Shanghai, China: a cross-sectional survey

Influenza vaccination coverage has generally been low in mainland China. However, few studies have attempted to measure influenza vaccination coverage among internal migrants in China who are at an increased risk of influenza infections. This study assessed influenza vaccination coverage and the factors associated with vaccination uptake among internal migrants in Shanghai, China. We conducted a cross-sectional online survey among a sample of migrants residing in Shanghai during November 1–20, 2020, to investigate vaccination uptake during the 2019–20 and early 2020–21 flu seasons (September to November 2020). Multivariable logistic regression was used to examine the factors associated with influenza vaccination uptake for the two flu seasons. About a quarter, 26.3%, and 24.4% of respondents reported receiving an influenza vaccination during the 2019–20 and early 2020–2021 flu seasons, respectively. Respondents who were divorced or widowed, had more household members (2 or ≥ 3), and considered themselves in good health were more likely to receive an influenza vaccine, regardless of the season. Respondents who perceived that they were highly susceptible to influenza and COVID-19 and those who reported ever consulting a medical professional about COVID-19 were more likely to have received a flu vaccination in the early 2020–21 flu season. The uptake of influenza vaccination among internal migrants in Shanghai was suboptimal. We found a range of factors linked to influenza vaccination uptake, pointing to the need for more in-depth evaluations on the underlying reasons driving the vaccination uptake among vulnerable populations in China, especially during the COVID-19 pandemic.

Public Interest in Distribution and Determinants of Influenza and Pneumonia Vaccination during the COVID-19 Pandemic: An Infodemiology and Cross-Sectional Study from China

Background: Following the COVID-19 pandemic, global interest in influenza vaccines and pneumonia vaccines has increased significantly. We aimed to examine public interest in and actual market circulation of influenza and pneumonia vaccines before and after the initial outbreak of COVID-19 and estimate the coverage and determinants of influenza and pneumonia vaccination uptake following the COVID-19 pandemic. Methods: We obtained search volume data for vaccines using the Baidu search index and collected the numbers of vaccines issued from the National Institutes for Food and Drug Control. We also conducted a cross-sectional survey among 3346 adult residents to evaluate the coverage and determinants of influenza and pneumonia vaccination uptake in the Yangtze River delta, China, from 29 January to 4 February 2021. Results: Public searches and the number of vaccines issued for the influenza vaccines and pneumonia vaccines obviously increased after the initial outbreak of COVID-19. In the total sample, 12.5% were vaccinated against influenza, and 21.5% had at least one family member vaccinated against pneumonia. A minority of participants perceived that they were highly or very highly susceptible to influenza (15.9%) and COVID-19 (6.7%). A range of socio-economic factors and perceived susceptibility to COVID-19 were associated with influenza and pneumonia vaccination uptake. Conclusions: Public interest in and issued volumes of influenza and pneumonia vaccines increased nationally following the COVID-19 pandemic. Perceptions of high susceptibility to COVID-19 were associated with the uptake of the influenza and pneumonia vaccines. Targeted interventions were needed to improve vaccination coverage.

The role of health determinants in the influenza vaccination uptake among older adults (65+): a scope review

Background

Although the burden of influenza infection is the highest in older adults, vaccination coverage remains low, despite this age group being more vulnerable than others.

Aims

Given the current pandemic of SARS-CoV-2, it was the aim of this scope review to update knowledge on factors affecting seasonal influenza vaccine uptake among older adults to strengthen prevention approaches in the context of an overall burden of infectious diseases.

Methods

We searched bibliographic databases from 2012 to 2019. All studies reviewed one or more social determinant of health listed by WHO, or factors affecting the decision-making process whether to accept influenza vaccine or not.

Results

Overall, 44 studies were included, 41 determinants were extracted and summarized into six categories. Older age and constitutional factors including multiple chronic diseases as well as preventive lifestyle and frequent routine healthcare utilization positively affected vaccination uptake (VU). Living and working conditions are also researched determinants of influenza vaccine uptake. A small number of studies explored the role of social inclusion and system-based interventions.

Discussion and conclusions

This scope review provides a comprehensive overview on factors affecting seasonal influenza vaccination uptake among older citizens. The review also clearly shows gaps for evidence on system-based level or political strategies to improve vaccination uptake.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01793-3.

Impact of video-led educational intervention on the uptake of influenza vaccine among adults aged 60 years and above in China: a study protocol for a randomized controlled trial

Background

Influenza is a global health threat to older adults, and the influenza vaccine is the most effective approach to prevent influenza infection. However, influenza vaccination coverage among Chinese older adults is far less than in developed countries such as the United States (4.0% vs. 64.9%). This study aims to increase influenza vaccination coverage in Chinese adults ≥60 years using a video-led educational intervention conducted by medical students.

Methods

A cluster randomized controlled trial will be conducted in 4 districts of Xi’an city, Shaanxi Province, China, using a stratified sampling approach. Adults aged ≥60 years will be recruited from 8 community hospitals. A self-administered questionnaire of knowledge, attitudes, and practices (KAP) will be employed to record the KAP score. During the 6-month interventional period, participants in the intervention group will receive educational videos focused on influenza and influenza vaccination, coupled with a group discussion conducted by the medical students. For those in the control group, no intervention will be provided. The outcomes measured in both groups will be the influenza vaccination coverage and the KAP scores of all participants.

Discussion

Medical students are more likely to educate older adults about scientific knowledge of influenza and its vaccine compared to clinical practitioners, who, most of the time, remain over-occupied due to the extensive workload. Video-led counseling and education could be a useful option to optimize older adults’ understanding of influenza and influenza vaccination. This eventually could improve the uptake of influenza vaccine among Chinese older adults.

Trial registration

Chinese Clinical Trial Registry; ChiCTR2000034330; Registered 3rd July 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10220-1.

Assessing the impact of shared decision making processes on influenza vaccination rates in adult patients in outpatient care: A systematic review and meta-analysis

BACKGROUND

Shared decision making (SDM) is a promising approach, to bridge major barriers concerning vaccination by patient education and personal interaction of health care provider (HCP) and patient. SDM affects patient adherence, enhances patient knowledge, decreases decisional conflict and improves trust in the physician in most areas of health care. The shared decision making process (SDM process) is characterised by three key components: patient activation, bi-directional exchange of information and bi-directional deliberation of options.

OBJECTIVES

To assess the impact of SDM processes on influenza vaccination rates in outpatient care patients.

METHODS

A systematic literature search in MEDLINE, CENTRAL, EMBASE, PsycINFO and ERIC was conducted (2020-02-05). Randomized controlled trials (RCTs) and cluster RCTs, that aimed to improve influenza vaccination rates in adult patients in outpatient care were included. We examined effects of SDM processes on influenza vaccination rates by meta-analysis, and considered the extent of SDM processes in the analysed interventions and possible effect modifiers in subgroup analyses.

RESULTS

We included 21 studies, with interventions including face-to-face sessions, telephone outreach, home visits, Health Care Practitioner (HCP) trainings and supporting educational material. In 12 studies, interventions included all elements of a SDM process. A meta-analysis of 15 studies showed a positive effect on vaccination rates (OR of 1.96 (95% CI: 1.31 to 2.95)). Findings further suggest that interventions are effective across different patients groups and could increase effectiveness when the interaction is facilitated by multidisciplinary teams of HCP in comparison to interventions delivered by individual HCP.

DISCUSSION

This systematic review and meta-analysis provide evidence that SDM processes can be an effective strategy to increase influenza vaccination rates. Further research with more detailed descriptions of SDM implementation modalities is necessary to better understand which components of SDM are most effective.

TRIAL REGISTRATION

PROSPERO: CRD42020175555.

Office-Based Educational Handout for Influenza Vaccination: A Randomized Controlled Trial

OBJECTIVES

To assess the impact of a parent educational intervention about influenza disease on child vaccine receipt.

METHODS

A convenience sample of parents of children ≥6 months old with a visit at 2 New York City pediatric clinics between August 2016 and March 2017 were randomly assigned (1:1:1) to receive either usual care, an educational handout about influenza disease that was based on local data, or an educational handout about influenza disease that was based on national data. Parents received the handout in the waiting room before their visit. Primary outcomes were child influenza vaccine receipt on the day of the clinic visit and by the end of the season. A multivariable logistic regression was used to assess associations between intervention and vaccination, with adjustment for variables that were significantly different between arms.

RESULTS

Parents who received an intervention (versus usual care) had greater odds of child influenza vaccine receipt by the end of the season (74.9% vs 65.4%; adjusted odds ratio 1.68; 95% confidence interval: 1.06-2.67) but not on the day of the clinic visit. Parents who received the national data handout (versus usual care) had greater odds of child influenza vaccine receipt on the day of the clinic visit (59.0% vs 52.6%; adjusted odds ratio 1.79; 95% confidence interval: 1.04-3.08) but not by the end of the season.

CONCLUSIONS

Providing an educational intervention in the waiting room before a pediatric provider visit may help increase child influenza vaccine receipt.

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.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014.

OBJECTIVES

To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as specified by Cochrane.

MAIN RESULTS

We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources.

AUTHORS' CONCLUSIONS

We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.