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Atta S, Brown RB, Wasser LM, Mayer N, Cassidy J, Liu PJ, Williams AM. Effect of a Patient Portal Reminder Message After No-Show on Appointment Reattendance in Ophthalmology: A Randomized Clinical Trial. Am J Ophthalmol 2024; 263:93-98. [PMID: 38403099 PMCID: PMC11162931 DOI: 10.1016/j.ajo.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 01/29/2024] [Accepted: 02/19/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE To assess the efficacy of electronic health record (EHR) messaging for re-engaging patients with ophthalmology care after a missed appointment. DESIGN Prospective, randomized clinical trial. METHODS The study setting was an academic ophthalmology department. The patient population comprised of return patients age 18 years or older with an appointment "no show," or missed appointment. Over 2 phases of recruitment, 362 patients with an active patient portal in the EHR were selected consecutively each business day. Patients were randomized using a web-based tool to receive a reminder to reschedule via a standard mailed letter only (control) or the mailed letter plus an electronic message through the EHR within 1 business day of the missed appointment (intervention). Reengagement with eye care was defined as attendance of a rescheduled appointment within 30 days of the no-show visit. Patient charts were reviewed for demographic and clinical data. RESULTS The average age of recruited patients was 59.9 years, just under half of the sample was male (42.5%, 154/362), and most patients were White (56.9%, 206/362) or Black (36.2%, 131/362). Patients were most commonly recruited from the retina service (39.2%, 142/362) followed by the glaucoma service (29.3%, 106/362). Many patients in this study had previous no-show appointments, with an average no-show rate of 18.8% out of all scheduled visits across our health system. In total, 22.2% (42/189) of patients in the intervention group attended a follow-up appointment within 30 days of their no-show visit compared to 11.6% (20/173) of the control group (OR, 2.186; 95% CI, 1.225-3.898; P = .008). When including only the 74 patients in the intervention group who read the intervention message in the patient portal, 28.4% (21/74) attended a follow-up compared to 11.6% (20/173) of the control group (P = .001). CONCLUSIONS EHR-based reminder messages sent within a business day of a missed appointment may promote re-engagement in ophthalmology care after appointment no-show.
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Affiliation(s)
- Sarah Atta
- From the Department of Ophthalmology (S.A., R.B., L.W., N.M., J.C., A.W.,), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Cleveland Clinic (S.A.), Cole Eye Institute, Cleveland, Ohio, USA
| | - Richard B Brown
- From the Department of Ophthalmology (S.A., R.B., L.W., N.M., J.C., A.W.,), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lauren M Wasser
- From the Department of Ophthalmology (S.A., R.B., L.W., N.M., J.C., A.W.,), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Ophthalmology, Shaare Zedek Medical Center (L.W.), Hebrew University, Hadassah School of Medicine, Jerusalem, Israel
| | - Natasha Mayer
- From the Department of Ophthalmology (S.A., R.B., L.W., N.M., J.C., A.W.,), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Julie Cassidy
- From the Department of Ophthalmology (S.A., R.B., L.W., N.M., J.C., A.W.,), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Peggy J Liu
- Department of Business Administration - Marketing and Business Economics Area, Joseph M. Katz Graduate School of Business (P.L.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew M Williams
- From the Department of Ophthalmology (S.A., R.B., L.W., N.M., J.C., A.W.,), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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De Guzman C, Thomas CA, Wiwanto L, Hu D, Henriquez-Rivera J, Gage L, Perreault JC, Harris E, Rastas C, McCormick D, Gaffney A. Health Care Access and COVID-19 Vaccination in the United States: A Cross-Sectional Analysis. Med Care 2024; 62:380-387. [PMID: 38728678 DOI: 10.1097/mlr.0000000000002005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND Although federal legislation made COVID-19 vaccines free, inequities in access to medical care may affect vaccine uptake. OBJECTIVE To assess whether health care access was associated with uptake and timeliness of COVID-19 vaccination in the United States. DESIGN A cross-sectional study. SETTING 2021 National Health Interview Survey (Q2-Q4). SUBJECTS In all, 21,532 adults aged≥18 were included in the study. MEASURES Exposures included 4 metrics of health care access: health insurance, having an established place for medical care, having a physician visit within the past year, and medical care affordability. Outcomes included receipt of 1 or more COVID-19 vaccines and receipt of a first vaccine within 6 months of vaccine availability. We examined the association between each health care access metric and outcome using logistic regression, unadjusted and adjusted for demographic, geographic, and socioeconomic covariates. RESULTS In unadjusted analyses, each metric of health care access was associated with the uptake of COVID-19 vaccination and (among those vaccinated) early vaccination. In adjusted analyses, having health coverage (adjusted odds ratio [AOR] 1.60; 95% CI: 1.39, 1.84), a usual place of care (AOR 1.58; 95% CI: 1.42, 1.75), and a doctor visit within the past year (AOR 1.45, 95% CI: 1.31, 1.62) remained associated with higher rates of COVID-19 vaccination. Only having a usual place of care was associated with early vaccine uptake in adjusted analyses. LIMITATIONS Receipt of COVID-19 vaccination was self-reported. CONCLUSIONS Several metrics of health care access are associated with the uptake of COVID-19 vaccines. Policies that achieve universal coverage, and facilitate long-term relationships with trusted providers, may be an important component of pandemic responses.
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Affiliation(s)
- Charles De Guzman
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Chloe A Thomas
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Lynn Wiwanto
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Dier Hu
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Jose Henriquez-Rivera
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Lily Gage
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Jaclyn C Perreault
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Emily Harris
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Charlotte Rastas
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
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Keegan G, Zhu M, Paz M, Kang H, Patel A, Baig AA. Neighborhood-level factors associated with COVID-19 vaccination rates: a case study in Chicago. BMC Public Health 2024; 24:889. [PMID: 38528490 PMCID: PMC10962191 DOI: 10.1186/s12889-024-18352-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 03/13/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Chicago's deeply-rooted racial and socioeconomic residential segregation is a pattern mirrored in other major cities, making it a prototype for studying the uptake of public health interventions across the US. Residential segregation is related to availability of primary care, sense of community, and trust in the healthcare system, components which are essential in the response to crises like Covid-19 in which vaccine rollout was primarily community-based. We aimed to evaluate the association between rates of access to primary care and community-belonging with Covid-19 vaccination within Chicago's neighborhoods. METHODS Data from Chicago Department of Public Health (12/2020-6/2022) on Covid-19 vaccination rates, race/ethnicity (% Black and % Hispanic/Latinx residents), age (% >65), gender (% female), socioeconomic status (% below the federal poverty line), access to needed care rate, and rate of self-reported sense of community-belonging on the neighborhood level were analyzed. Linear mixed models (LMMs) were used to study the impact of variables on vaccination; each neighborhood was added as a random effect to account for with-community association. RESULTS The average Covid-19 vaccination rates across Chicago's neighborhoods was 79%, ranging from 37 to 100%, with median 81%. We found that Covid-19 vaccination rates were positively correlated with access to needed care (p < 0.001) and community-belonging (p < 0.001). Community areas that had lower vaccination rates had greater percentage of Black residents (p < 0.0001) and greater poverty rates (p < 0.0001). After adjusting for poverty, race, gender and age in the models, the association between vaccination rates and access to care or community-belonging were no longer significant, but % Black residents and poverty remained significant. CONCLUSIONS Though access to needed primary care and community-belonging are correlated with vaccination rates, this association was not significant when controlling for demographic factors. The association between poverty, race and vaccination status remained significant, indicating that socioeconomic and racial disparities across Chicago drive Covid-19 vaccine recommendation adherence regardless of care access. Understanding how poverty, and its intersectional relation to race and primary care access, affects vaccination should be a priority for public health efforts broadly.
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Affiliation(s)
- Grace Keegan
- Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Ave. MC 2007, 60637, Chicago, IL, USA.
| | - Mengqi Zhu
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, USA
| | - Maria Paz
- Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Ave. MC 2007, 60637, Chicago, IL, USA
| | - Hyojung Kang
- Department of Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Ajanta Patel
- Chicago Department of Public Health, Chicago, IL, USA
| | - Arshiya A Baig
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, USA
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Rabin Y, Kohler RE. COVID-19 Vaccination Messengers, Communication Channels, and Messages Trusted Among Black Communities in the USA: a Review. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01858-1. [PMID: 37947953 DOI: 10.1007/s40615-023-01858-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
Black and African American adults exhibited higher levels of mistrust and vaccine hesitancy and lower levels of vaccination throughout the COVID-19 pandemic. Vaccination and booster uptake remains disproportionately low among Black adults. We conducted a systematic review of empirical research published between February 2021 and July 2022 from five electronic databases and the grey literature. We screened studies that assessed COVID-19 vaccination information needs and preferences as well as communication strategies among Black adults in the USA. We extracted data, then analyzed and synthesized results narratively. Twenty-two articles were included: 2 interventions, 3 experimental surveys, 7 observational surveys, 8 qualitative inquiries, and 2 mixed methods studies. Studies reported credible and preferred COVID-19 vaccination information sources/messengers, channels, and content. Commonly trusted messengers included personal health care providers, social network connections, and church/faith leaders. Electronic outreach (e.g., email, text messages), community events (e.g., forums, canvassing), and social media were popular. Black communities wanted hopeful, fact-based messages that address racism and mistrust; persuasive messages using collective appeals about protecting others may be more influential in changing behavior. Future communication strategies aiming to increase vaccine confidence and encourage COVID-19 booster vaccination among Black communities should be developed in partnership with community leaders and local health care providers to disseminate trauma-informed messages with transparent facts and collective action appeals across multiple in-person and electronic channels.
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Affiliation(s)
- Yael Rabin
- Department of Health Behavior Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Racquel E Kohler
- Department of Health Behavior Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA.
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
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Kuwahara K, Sakamoto M, Ishizuka R, Kato M, Akiyama M, Ishikawa H, Kiyohara K. Effect of digital messages from health professionals on COVID-19-related outcomes: A systematic review of randomized controlled trials. J Infect Public Health 2023; 16:1682-1689. [PMID: 37634322 DOI: 10.1016/j.jiph.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/28/2023] [Accepted: 08/16/2023] [Indexed: 08/29/2023] Open
Abstract
Effectiveness of health professionals' messages via digital tools on COVID-19-related outcomes remains unknown. In this systematic review, we examined this issue by searching randomized controlled trials in six databases until August, 2022 (PROSPERO, CRD 42022350788). Risk of bias was assessed using revised Cochrane risk-of-bias tool. Primary outcomes were COVID-19 infections, preventive behaviors, and factors that support behavioral change. Seven trials with 16 reports (some reported two or more outcomes) were included. One trial showed that physician videos distributed by Facebook ads significantly reduced COVID-19 infections. Five of 6 reports showed that interventions can promote non-pharmaceutical preventive behaviors, vaccination, or information-seeking behaviors and half of the results were significant. Interventions improved the factors that support behavioral change. 14 reports had some concerns of bias risk and 2 had high risk of bias. Our findings suggest that digital messages by health professionals may help reduce COVID-19 infections through promoting behavioral change.
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Affiliation(s)
- Keisuke Kuwahara
- Teikyo University Graduate School of Public Health, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan; Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa-ku, Yokohama, Kanagawa, Japan.
| | - Masahiko Sakamoto
- Teikyo University Graduate School of Public Health, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Ryohei Ishizuka
- Teikyo University Graduate School of Public Health, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Mio Kato
- Office of Crisis Communication, Center for Emergency Preparedness and Response, National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, Tokyo, Japan
| | - Miki Akiyama
- Faculty of Environment and Information Studies, Keio University, 5322, Endo, Fujisawa, Kanagawa, Japan
| | - Hirono Ishikawa
- Teikyo University Graduate School of Public Health, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Faculty of Home Economics, Otsuma Women's University, 12 Sanban-cho, Chiyoda-ku, Tokyo, Japan
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Terrell R, Alami A, Krewski D. Interventions for COVID-19 Vaccine Hesitancy: A Systematic Review and Narrative Synthesis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6082. [PMID: 37372669 DOI: 10.3390/ijerph20126082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
Vaccines effectively protect against COVID-19, but vaccine hesitancy and refusal hinder vaccination rates. This systematic review aimed to (1) review and describe current interventions for addressing COVID-19 vaccine hesitancy/refusal and (2) assess whether these interventions are effective for increasing vaccine uptake. The protocol was registered prospectively on PROSPERO and comprehensive search included Medline, Embase, CINAHL, PsycInfo, and Web of Science databases. Only studies that evaluated the effectiveness of non-financial interventions to address COVID-19 vaccine hesitancy were included, while those focusing intentions or financial incentive were excluded. Risk of bias for all included studies was evaluated using Cochrane risk of bias tools. In total, six articles were included in the review (total participants n = 200,720). A narrative synthesis was performed due to the absence of common quantitative metrics. Except for one randomized controlled trial, all studies reported that interventions were effective, increasing COVID-19 vaccination rates. However, non-randomized studies were subject to confounding biases. Evidence on the effectiveness of COVID-19 vaccine hesitancy interventions remains limited and further evidence is needed for the development of clear guidance on effective interventions to increase vaccine uptake.
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Affiliation(s)
- Rowan Terrell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1S 5B6, Canada
| | - Abdallah Alami
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1S 5B6, Canada
| | - Daniel Krewski
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1S 5B6, Canada
- Risk Sciences International, Ottawa, ON K1P 5J6, Canada
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Kandasamy S, Manoharan B, Khan Z, Stennett R, Desai D, Nocos R, Wahi G, Banner D, de Souza RJ, Lear SA, Anand SS. Perceptions of COVID-19 risk, vaccine access and confidence: a qualitative description of South Asians in Canada. BMJ Open 2023; 13:e070433. [PMID: 37015794 PMCID: PMC10083522 DOI: 10.1136/bmjopen-2022-070433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023] Open
Abstract
OBJECTIVES In the first full year of the COVID-19 pandemic (2020), South Asians living in the Greater Toronto and Hamilton Area (GTHA) and Greater Vancouver area (GVA) experienced specific barriers to accessing SARS-CoV-2 testing and reliable health information. However, between June 2021 and February 2022, the proportion of people having received at least one COVID-19 vaccine dose was higher among this group (96%) than among individuals who were not visible minorities (93%). A better understanding of successful approaches and the challenges experienced by those who remain unvaccinated among this highly vaccinated group may improve public health outreach in subsequent waves of the current pandemic or for future pandemic planning. Using qualitative methods, we sought to explore the perceptions of COVID-19 risk, vaccine access, uptake and confidence among South Asians living in Canada. DESIGN Semistructured interviews conducted with 25 participants analysed using thematic analysis. Throughout this process, we held frequent discussions with members of the study's advisory group to guide data collection (community engagement, recruitment and data analysis). SETTING Communities of the GTHA and GVA with interviews conducted virtually over Zoom or telephone. PARTICIPANTS 25 participants (15 from Ontario and 10 from British Columbia) were interviewed between July 2021 and January 2022. 10 individuals were community members, 9 were advocacy group leaders and 6 were public health staff. RESULTS Access to and confidence in the COVID-19 vaccine was impacted by individual risk perceptions; sources of trusted information (ethnic and non-ethnic); impact of COVID-19 and the pandemic on individuals, families and society; and experiences with COVID-19 mandates and policies (including temporal and generational differences). Approaches that include community-level awareness and tailored outreach (language and cultural context) were considered successful. CONCLUSIONS Understanding factors and developing strategies that build vaccine confidence and improve access can guide approaches that increase vaccine acceptance in the current and future pandemics.Visual abstract can be found at https://drive.google.com/file/d/1iXdnJj9ssc3hXCllZxP0QA9DhHH-7uwB/view.
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Affiliation(s)
- Sujane Kandasamy
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Baanu Manoharan
- Master of Public Health (MPH) Program, McMaster University, Hamilton, Ontario, Canada
| | - Zainab Khan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Rosain Stennett
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dipika Desai
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Rochelle Nocos
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Davina Banner
- School of Nursing, University of Northern British Columbia, Prince George, British Columbia, Canada
| | - Russell J de Souza
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Sonia S Anand
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Johansen ND, Vaduganathan M, Bhatt AS, Lee SG, Modin D, Claggett BL, Dueger EL, Samson SI, Loiacono MM, Køber L, Solomon SD, Sivapalan P, Jensen JUS, Martel CJM, Valentiner-Branth P, Krause TG, Biering-Sørensen T. Electronic nudges to increase influenza vaccination uptake in Denmark: a nationwide, pragmatic, registry-based, randomised implementation trial. Lancet 2023; 401:1103-1114. [PMID: 36889332 DOI: 10.1016/s0140-6736(23)00349-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Influenza vaccination rates remain suboptimal despite effectiveness in preventing influenza infection and related complications. We investigated whether behavioural nudges, delivered via a governmental electronic letter system, would increase influenza vaccination uptake among older adults in Denmark. METHODS We did a nationwide, pragmatic, registry-based, cluster-randomised implementation trial during the 2022-23 influenza season in Denmark. All Danish citizens aged 65 years or older or turning 65 years by Jan 15, 2023 were included. We excluded individuals living in nursing homes and individuals who had an exemption from the Danish mandatory governmental electronic letter system. Households were randomly assigned (9:1:1:1:1:1:1:1:1:1) to usual care or nine different electronic letters designed on the basis of different behavioural nudging concepts. Data were sourced from nationwide Danish administrative health registries. The primary endpoint was receipt of influenza vaccination on or before Jan 1, 2023. The primary analysis assessed an analytical set of one randomly selected individual per household, and a sensitivity analysis included all randomly assigned individuals and accounted for within-household correlation. The trial is registered with ClinicalTrials.gov, NCT05542004. FINDINGS We identified 1 232 938 individuals aged 65 years or older in Denmark and excluded 56 436 (4·6%) individuals living in nursing homes and 211 632 (17·2%) with an exemption from the electronic letter system. We randomly assigned 964 870 (78·3%) participants across 691 820 households. Compared with usual care, influenza vaccination rates were higher in the group receiving an electronic letter highlighting potential cardiovascular benefits of vaccination (81·00% vs 80·12%; difference 0·89 percentage points [99·55% CI 0·29-1·48]; p<0·0001) and the group receiving repeated letters at randomisation and at day 14 (80·85% vs 80·12%; difference 0·73 percentage points [0·13-1·34]; p=0·0006). These strategies improved vaccination rates across major subgroups including those with and without established cardiovascular disease. The cardiovascular gain-framed letter was particularly effective among participants who had not been vaccinated for influenza in the previous season (pinteraction=0·0002). A sensitivity analysis of all randomly assigned individuals accounting for within-household clustering yielded similar findings. INTERPRETATION Electronically delivered letters highlighting potential cardiovascular benefits of influenza vaccination or sent again as a reminder significantly increased vaccination uptake across Denmark. Although the magnitude of effectiveness was modest, the low-touch, inexpensive, and highly scalable nature of these electronic letters might be informative for future public health campaigns. FUNDING Sanofi.
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Affiliation(s)
- Niklas Dyrby Johansen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital, Boston, MA, USA
| | - Ankeet S Bhatt
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital, Boston, MA, USA; Kaiser Permanente San Francisco Medical Center & Division of Research, San Francisco, CA, USA
| | - Simin Gharib Lee
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Modin
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Lars Køber
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pradeesh Sivapalan
- Respiratory Medicine Section, Department of Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Jens Ulrik Stæhr Jensen
- Respiratory Medicine Section, Department of Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Cyril Jean-Marie Martel
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Palle Valentiner-Branth
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Tyra Grove Krause
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
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Spees LP, Biddell CB, Angove RSM, Gallagher KD, Anderson E, Christenbury A, Rocque G, Wheeler SB. Barriers to COVID-19 vaccine uptake among resource-limited adults diagnosed with chronic illness. Front Public Health 2023; 11:1046515. [PMID: 36844843 PMCID: PMC9948023 DOI: 10.3389/fpubh.2023.1046515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/20/2023] [Indexed: 02/11/2023] Open
Abstract
Background Despite the use of interventions (e.g., monetary incentives, educational campaigns, on-site workplace vaccination) to increase COVID-19 vaccination, differences in uptake persist by poverty level, insurance status, geography, race, and ethnicity, suggesting that these interventions may not be adequately addressing the barriers faced by these populations. Among a sample of resource-limited individuals with chronic illnesses, we (1) described the prevalence of different types of barriers to the COVID-19 vaccination and (2) identified associations between patients' sociodemographic characteristics and barriers to vaccination. Methods We surveyed a national sample of patients with chronic illness and demonstrated healthcare affordability and/or access challenges about barriers to COVID-19 vaccination in July 2021. We categorized participant responses into cost, transportation, informational, and attitudinal barrier domains and assessed the prevalence of each domain, both overall and by self-reported vaccination status. Using logistic regression models, we examined unadjusted and adjusted associations between respondent characteristics (sociodemographic, geographic, and healthcare access) and self-reported barriers to vaccination. Results Of 1,342 respondents in the analytic sample, 20% (264/1,342) reported informational barriers and 9% (126/1,342) reported attitudinal barriers to COVID-19 vaccination. Transportation and cost barriers were reported much less commonly, by only 1.1% (15/1,342) and 0.7% (10/1,342) of the sample, respectively. Controlling for all other characteristics, respondents with either a specialist as their usual source of care or no usual source of care had an 8.4 (95% CI: 1.7-15.1) and 18.1 (95% CI: 4.3-32.0) percentage point higher predicted probability, respectively, of reporting informational barriers to care. Compared to females, males had an 8.4% point (95% CI: 5.5-11.4) lower predicted probability of reporting attitudinal barriers. Only attitudinal barriers were associated with COVID-19 vaccine uptake. Conclusion Among a sample of adults with chronic illnesses who had received financial assistance and case management services from a national non-profit, informational and attitudinal barriers were more commonly reported than logistical or structural access barriers (i.e., transportation and cost barriers). Interventions should target attitudinal barriers among patients with chronic illness, who may have particular concerns about the interaction of the vaccine with ongoing medical care. Additionally, interventions targeting informational barriers are particularly needed among individuals without a usual source of care.
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Affiliation(s)
- Lisa P. Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caitlin B. Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | | | - Eric Anderson
- Patient Advocate Foundation, Hampton, VA, United States
| | | | - Gabrielle Rocque
- Division of Hematology and Oncology, Department of Medicine, University of Alabama-Birmingham, Birmingham, AL, United States
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Gaffney A, Woolhandler S, Bor J, McCormick D, Himmelstein DU. Community Health, Health Care Access, And COVID-19 Booster Uptake In Massachusetts. Health Aff (Millwood) 2023; 42:268-276. [PMID: 36745834 DOI: 10.1377/hlthaff.2022.00835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Booster vaccination offers vital protection against COVID-19, particularly for communities in which many people have chronic conditions. Although vaccination has been widely and freely available, people who have experienced barriers to care might be deterred from being vaccinated. We examined the relationship between COVID-19 booster uptake and small area-level demographics, chronic disease prevalence, and measures of health care access in 462 Massachusetts communities during the period September 2021-April 2022. Unadjusted analyses found that booster uptake was higher in older and wealthier areas, lower in areas with more Hispanic and Black residents, and lower in areas with a high prevalence of chronic conditions. In both unadjusted and adjusted analyses, uptake was lower in communities with more uninsured residents and those in which fewer residents received routine medical check-ups. Adjusted analyses found that areas with more vaccine providers and primary care physicians had higher booster uptake, but this association was not significant in unadjusted analyses. Results suggest a need for innovative outreach efforts, as well as structural changes such as expansion of health care coverage and universal access to care to mitigate the inequitable burden of COVID-19.
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Affiliation(s)
- Adam Gaffney
- Adam Gaffney , Harvard University and Cambridge Health Alliance, Cambridge, Massachusetts
| | - Steffie Woolhandler
- Steffie Woolhandler, City University of New York, New York, New York; Harvard University; and Cambridge Health Alliance
| | - Jacob Bor
- Jacob Bor, Boston University, Boston, Massachusetts
| | - Danny McCormick
- Danny McCormick, Harvard University and Cambridge Health Alliance
| | - David U Himmelstein
- David U. Himmelstein, City University of New York, Harvard University, and Cambridge Health Alliance
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11
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Durojaiye C, Prausnitz S, Elkin EP, Escobar P, Finn L, Chen YFI, Lieu TA. Changes in COVID-19 Vaccine Intent Among a Diverse Population of Older Adults, June 2021-February 2022. Perm J 2022; 26:78-84. [PMID: 36530052 PMCID: PMC9761285 DOI: 10.7812/tpp/22.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction COVID-19 vaccination rates remain suboptimal in the United States. Clinicians and policymakers need to better understand how likely vaccine-hesitant individuals are to ultimately accept vaccination and what is associated with such changes. This study's aims were to 1) describe changes between vaccine intentions and actual uptake from June 2021 through February 2022, and 2) identify modifiable factors associated with vaccine uptake among those with initial hesitancy. Methods This cohort study included a stratified random sample of adults aged 65 years and older in an integrated health care system. The survey, conducted June through August 2021, elicited intent and perceptions regarding COVID-19 vaccination. Subsequent vaccine uptake through February 2022 was analyzed using electronic health records. Results Of 1195 individuals surveyed, 66% responded; 213 reported not yet having received a COVID-19 vaccine and were further analyzed. At baseline, most individuals said they would definitely not (42%) or probably not (5%) get the COVID-19 vaccine or were not sure (26%). During follow-up, 61 individuals (29%) were vaccinated, including 19% of those who initially said they would definitely not be vaccinated. Among vaccine-hesitant individuals, the rate of vaccination was highest for those who initially considered COVID-19 less dangerous than the vaccine (46%) or named short-term side effects (36%) as their most important concern. Conclusions COVID-19 vaccine intent among older adults was malleable during the pandemic's second year, even among those who initially said they would definitely not be vaccinated. Vaccine uptake could be enhanced by increasing awareness of COVID-19 risks and by addressing vaccine side effects.
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Affiliation(s)
- Cimone Durojaiye
- 1Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA,Cimone Durojaiye, MPH
| | - Stephanie Prausnitz
- 1Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Eric P Elkin
- 1Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA,2TPMG Consulting Services, Oakland, CA, USA
| | | | - Lucy Finn
- 2TPMG Consulting Services, Oakland, CA, USA
| | | | - Tracy A Lieu
- 1Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA,4The Permanente Medical Group, Oakland, CA, USA
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