Increasing influenza immunization among high-risk patients: education or financial incentive?

Effectiveness of Multifaceted Strategies to Increase Influenza Vaccination Uptake: A Cluster Randomized Trial

Importance

Influenza vaccination rates remain low among primary school students and vary by school in Beijing, China. Theory-informed, multifaceted strategies are needed to improve influenza vaccination uptake.

Objective

To evaluate the effectiveness of multifaceted strategies in improving influenza vaccination uptake among primary school students.

Design, Setting, and Participants

This cluster randomized trial was conducted from September 2022 to May 2023 across primary schools in Beijing, China. Schools were allocated randomly in a 1:1 ratio to multifaceted strategies or usual practice. Schools were deemed eligible if the vaccination rates in the 2019 to 2020 season fell at or below the district-wide average for primary schools. Eligible participants included students in grades 2 and 3 with no medical contraindications for influenza vaccination.

Intervention

The multifaceted strategies intervention involved system-level planning and coordination (eg, developing an implementation blueprint, building social norms, and enhancing supervision), school-level training and educating school implementers (eg, conducting a 1-hour training and developing educational materials), and individual-level educating and reminding students and parents (eg, conducting educational activities and sending 4 reminders about vaccination).

Main Outcomes and Measures

The primary outcomes were influenza vaccination uptake at school reported by school clinicians as well as overall vaccine uptake either at school or outside of school as reported by parents at 3 months. Generalized linear mixed models were used for analysis.

Results

A total of 20 schools were randomized. One intervention school and 2 control schools did not administer vaccination on school grounds due to COVID-19, resulting in a total of 17 schools (9 intervention and 8 control). There was a total of 1691 students aged 7 to 8 years (890 male [52.6%]; 801 female [47.4%]) including 915 in the intervention group and 776 in the control group. Of all participants, 848 (50.1%) were in grade 2, and 1209 (71.5%) were vaccinated in the 2021 to 2022 season. Participants in the intervention and control groups shared similar characteristics. At follow-up, of the 915 students in the intervention group, 679 (74.5%) received a vaccination at school, and of the 776 students in the control group, 556 (71.7%) received a vaccination at school. The overall vaccination rates were 76.0% (695 of 915 students) for the intervention group and 71.3% (553 of 776 students) for the control group. Compared with the control group, there was significant improvement of vaccination uptake at school (odds ratio, 1.40; 95% CI, 1.06-1.85; P = .02) and overall uptake (odds ratio, 1.49; 95% CI, 1.12-1.99; P = .01) for the intervention group.

Conclusions and Relevance

In this study, multifaceted strategies showed modest effectiveness in improving influenza vaccination uptake among primary school students, which provides a basis for the implementation of school-located vaccination programs of other vaccines in China, and in other countries with comparable programs.

Trial registration

Chinese Clinical Trial Registry: ChiCTR2200062449.

Determinants of COVID-19 vaccine fatigue

There is growing concern that Coronavirus Disease 2019 (COVID-19) vaccine fatigue will be a major obstacle in maintaining immunity in the general population. In this study, we assessed vaccine acceptance in future scenarios in two conjoint experiments, investigating determinants such as new vaccines, communication, costs/incentives and legal rules. The experiments were embedded in an online survey (n = 6,357 participants) conducted in two European countries (Austria and Italy). Our results suggest that vaccination campaigns should be tailored to subgroups based on their vaccination status. Among the unvaccinated, campaign messages conveying community spirit had a positive effect (0.343, confidence interval (CI) 0.019-0.666), whereas offering positive incentives, such as a cash reward (0.722, CI 0.429-1.014) or voucher (0.670, CI 0.373-0.967), was pivotal to the decision-making of those vaccinated once or twice. Among the triple vaccinated, vaccination readiness increased when adapted vaccines were offered (0.279, CI 0.182-0.377), but costs (-0.795, CI -0.935 to -0.654) and medical dissensus (-0.161, CI -0.293 to -0.030) reduced their likelihood to get vaccinated. We conclude that failing to mobilize the triple vaccinated is likely to result in booster vaccination rates falling short of expectations. For long-term success, measures fostering institutional trust should be considered. These results provide guidance to those responsible for future COVID-19 vaccination campaigns.

Assessing the effectiveness of COVID-19 vaccine lotteries: A cross-state synthetic control methods approach

Vaccines are the most effective means at combating sickness and death caused by COVID-19. Yet, there are significant populations within the United States who are vaccine-hesitant, some due to ideological or pseudo-scientific motivations, others due to significant perceived and real costs from vaccination. Given this vaccine hesitancy, twenty state governors from May 12th to July 21st 2021 implemented some form of vaccination lottery aiming to increase low vaccination rates. In the aftermath of these programs, however, the critical question of whether these lotteries had a direct effect on vaccination remains. Previous literature on financial incentives for public health behaviors is consistent: Financial incentives significantly increase incentivized behaviors. Yet, work done specifically on state vaccine lotteries is both limited in scope and mixed in its conclusions. To help fill this gap in the literature, we use synthetic control methods to analyze all 20 states and causally identify, for eighteen states, the effects of their lotteries on both first-dose and complete vaccination rates. Within those eighteen states, we find strong evidence that all but three states’ lotteries had positive effects on first-dose vaccination. We find for complete vaccinations, however, over half the states analyzed had negative or null effects. We explore possibilities related to these mixed results including the states’ overall partisanship, vaccine hesitancy, and the size of their lotteries finding null effects for each of these explanations. Therefore, we conclude that the design of these programs is likely to blame: Every state lottery only incentivized first-doses with no additional or contingent incentive based on a second dose. Our findings suggest that the design of financial incentives is critical to their success, or failure, but generally, these programs can induce an uptake in vaccination across diverse demographic, ideological, and geographic contexts in the United States.

Conditional cash lotteries increase COVID-19 vaccination rates

Conditional cash lotteries (CCLs) provide people with opportunities to win monetary prizes only if they make specific behavioral changes. We conduct a case study of Ohio's Vax-A-Million initiative, the first CCL targeting COVID-19 vaccinations. Forming a synthetic control from other states, we find that Ohios incentive scheme increases the vaccinated share of state population by 1.5 percent (0.7 pp), costing sixty-eight dollars per person persuaded to vaccinate. We show this causes significant reductions in COVID-19, preventing at least one infection for every six vaccinations that the lottery had successfully encouraged. These findings are promising for similar CCL public health initiatives.

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

Impfen gegen Influenza – Internationale Bestandsaufnahme und Perspektiven für Deutschland

Hintergrund

Die aktuelle SARS-CoV-2-Pandemie erfordert hohe Durchimpfungsraten von chronisch Kranken gegen Influenza, um das Gesundheitssystem nicht zusätzlich zu belasten. Trotz klarer Evidenz für Sicherheit und Wirksamkeit der Influenza-Impfung sind die Impfquoten in den vergangenen Jahren international auf insuffizientem Niveau verblieben. Der Hausarzt hat eine zentrale Bedeutung für die Versorgung dieser Population. Ziel dieser systematischen Übersichtsarbeit war daher die Evaluation verschiedener Maßnahmen in der Allgemeinmedizin zur Steigerung der saisonalen Influenza-Impfquoten bei chronisch Kranken unter Berücksichtigung verschiedener internationaler Gesundheitssysteme.

Methoden

Eine systematische Literaturrecherche wurde in MEDLINE, CENTRAL, EMBASE und ERIC sowie manuell in Studienregistern und Literaturlisten durchgeführt. Dabei wurden ausschließlich randomisierte kontrollierte Studien berücksichtigt. Die Methodik wurde im Vorfeld in einem Studienprotokoll festgelegt (PROSPERO CRD42018114163).

Ergebnisse

Insgesamt wurden 14 Studien im Rahmen eines nationalen Gesundheitsdienstes (Großbritannien), einer staatlichen (Australien) und sozialen (Schweiz) Krankenversicherung und eines privaten Gesundheitssystems (USA) in unsere Übersichtsarbeit eingeschlossen. Analoge Patientenerinnerungen und automatisierte Arzterinnerungen sowie Veränderungen der beruflichen Rollen führten ausschließlich im privaten Gesundheitssystem zu einem deutlichen Anstieg der Influenzaimpfquoten. Im nationalen Gesundheitsdienst konnte keine der analysierten Interventionen einen signifikanten Anstieg der Impfquoten erreichen, wobei im nationalen Gesundheitsdienst Großbritanniens verhältnismäßig gute Basisimpfraten gegen Influenza bereits vor Durchführung der Studien interventionsunabhängig vorlagen. Fortbildungsveranstaltungen für Praxisteams und Erinnerungs-SMS zeigten in den sozialen und staatlichen Krankenversicherungssystemen der Schweiz und in Australien gute Resultate.

Schlussfolgerungen

In Deutschland könnten vor allem Fortbildungsveranstaltungen für medizinische Teams und sowie zentral organisierte Einladungs- und Monitoringsysteme zur Verbesserung der Impfquoten bei chronisch Kranken geeignet sein. Eine staatliche Kostenübernahme der Impfkosten scheint in verschiedenen Gesundheitssystemen für eine gute Basisimpfquote gegen Influenza bei Indikationspatienten zu sorgen.

Utilization of influenza vaccination among chronically ill individuals in Germany: A nationwide claims-based analysis

BACKGROUND

Individuals with chronic diseases have a higher risk of serious complications or even death in case of influenza infection. The European Union (EU) set a goal to reach a vaccination coverage of 75% in seniors and chronically ill individuals. The aim of this study was to assess influenza vaccination uptake among individuals with a wide spectrum of chronic diseases and examine its regional variations and temporal trends over a period of the last ten years.

METHODS

We used nationwide SHI-physician outpatient claims data from the years 2009 to 2018 covering 87% of the total German population to assess influenza vaccination uptake among individuals over 1 year of age with at least one of the following chronic diseases: pulmonary, cardiovascular, liver, kidney, metabolic, neurological and musculoskeletal diseases, as well as immune deficiency disorders, including HIV infection.

RESULTS

Influenza vaccination coverage varied across patient populations between 19% (multiple sclerosis) and 44% (chronic kidney disease) in the influenza season 2017/18. Vaccination coverage was slightly higher among females than males, except for HIV/AIDS patients. Among HIV-patients vaccination coverage was higher by 7 percent points among males (43%) than females (37%). The coverage was higher nearly for all patient groups in the eastern than western federal states. Over the observation period vaccination uptake showed decreasing trends in most of the target groups. Among patients with HIV/AIDS and immune deficiency disorders a stagnating trend was observed.

CONCLUSIONS

Vaccination uptake among chronically ill individuals is suboptimal and far from the EU-defined target of 75%. There were substantial variations in coverage by disease groups, individual factors and regions. The disease-specific evaluation of the current study allows identification of populations at higher risk with considerable vaccination gaps. Further efforts are needed to improve vaccination uptake in these vulnerable population groups.

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.

Attractive Flu Shot: A Behavioral Approach to Increasing Influenza Vaccination Uptake Rates

Background. We suggest and examine a behavioral approach to increasing seasonal influenza vaccine uptake. Our idea combines behavioral effects generated by a dominated option, together with more traditional tools, such as providing information and recommendations. Methods. Making use of the seasonal nature of the flu, our treatments present participants with 2 options to receive the shot: early in the season, which is recommended and hence "attractive," or later. Three additional layers are examined: 1) mentioning that the vaccine is more likely to run out of stock late in the season, 2) the early shot is free while the late one costs a fee, and 3) the early shot carries a monetary benefit. We compare vaccination intentions in these treatments to those of a control group who were invited to receive the shot regardless of timing. Results. Using a sample of the Israeli adult population (n = 3271), we found positive effects of all treatments on vaccination intentions, and these effects were significant for 3 of the 4 treatments. In addition, the vast majority of those who are willing to vaccinate intend to get the early shot. Conclusions. Introducing 2 options to get vaccinated against influenza (early or late) positively affects intentions to receive the flu shot. In addition, this approach nudges participants to take the shot in early winter, a timing that has been shown to be more cost-effective.

Multiple mail reminders to increase adherence to influenza vaccination

INTRODUCTION

Different interventions have been proposed to reinforce the use of the influenza vaccine. The use of reminders, whether through letters, phone calls, pamphlets or technological applications, among others, has stood out among those aimed at increasing ad-herence to treatment. However, its effectiveness is not clear. In this summary, which is part of a series of reminder evaluations, we assess the use of multiple mail reminders.

METHODS

We conducted a search in Epistemonikos, the largest database of systematic health reviews, which is maintained by screening multiple sources of information, including MEDLINE, EMBASE, Cochrane, among others. We extracted the data from the identified reviews, analyzed the data from the primary studies, performed a meta-analysis and prepared a summary table of the results using the GRADE method.

RESULTS AND CONCLUSIONS

We identified eight systematic reviews including 35 primary studies, of which four analyze the use of more than one letter as a reminder. We conclude that the use of multiple mail reminders probably increase adherence to influenza vaccination in patients over 60; while it may make little or no difference in children under 6 years, but the certainty of the evidence is low.

Increasing Influenza Vaccination Rates in People With Chronic Illness

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Disparities in uptake of 13-valent pneumococcal conjugate vaccine among older adults in the United States

BACKGROUND

In September 2014, 13-valent pneumococcal conjugate vaccine (PCV13) was universally recommended for all US adults aged ≥65 years. Adult PCV13 coverage, including whether disparities in uptake exist, however, is not well-described.

METHODS

We used a monthly series of cross-sectional analyses of administrative medical and prescription claims data collected by IQVIA and linked to sociodemographic data collected by Experian to estimate overall and subpopulation-level uptake of PCV13 among US adults aged ≥65 years.

RESULTS

Among adults aged ≥65 years, 43.3% received PCV13 by the end of November 2017. Race/ethnicity, annual household income, education status, and neighborhood urbanicity were strongly related to PCV13 uptake among adults aged ≥65 years. Lower uptake of PCV13 was observed for non-Hispanic black (36.3%) and Hispanic (30.0%) adults (vs 45.6% for non-Hispanic whites, P < .01), the poor (30.7% vs 54.2% among lowest vs highest income deciles, P < .01), adults with low educational status (33.0% vs 49.0% among those without high school education vs college educated, P < .01), and those living in rural communities (22.9%) or urban/inner-city (33.8%) areas (vs 45.8% in suburban areas, P < .01).

CONCLUSIONS

PCV13 uptake among adults aged ≥65 occurred rapidly in the three years after universal recommendation in September 2014. Yet, poor and minority communities, rural and urban/inner-city areas, and communities with low educational attainment had substantially lower PCV13 coverage. These same populations are at increased risk of pneumococcal disease. In order to maximize the benefits of pneumococcal vaccination, further targeted and tailored interventions to increase PCV13 uptake in these underserved populations are still necessary.

Low-cost approaches to increasing gym attendance

We investigate the effect of two low-cost experimental interventions designed to increase physical exercise: a lottery based financial incentive and a social norming treatment. The lottery intervention provides a financial incentive to increase physical activity whereas the social norming intervention attempts to increase physical activity by providing feedback to individuals on their own and their peers' physical exercise activity. We find the larger of our two lottery treatments yields a positive and statistically significant effect on physical activity at modest cost, whereas our social norming treatment has no detectable effect.

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.

Community health workers on a college campus: Effects on influenza vaccination

OBJECTIVE

To assess the impact of a campus community health worker program (HealthPALs) on student influenza vaccination.

PARTICIPANTS

Undergraduate students at a northeastern US university (enrollment 6650), influenza seasons 2011-2012 through 2015-2016.

METHODS

Study design: Difference-in-differences analysis of student vaccination at campus dormitory influenza clinics during intervention vs. baseline.

INTERVENTION

In the first intervention year, HealthPALs conducted in-person peer outreach at several campus dormitory flu clinics. Subsequent years, HealthPALs conducted an enhanced intervention, with the addition of a personalized, dormitory-specific social media campaign appealing to students' community identity.

RESULTS

The initial intervention increased vaccinations by 66% (IRR = 1.66, 95%CI 1.39-1.97) at intervention clinics relative to control. The enhanced intervention increased vaccinations by 85% (IRR = 1.85, 95%CI 1.75-1.96).

CONCLUSION

Community health workers can be a highly effective, low-cost strategy for increasing influenza vaccination among college students. This model could also be used to address other campus health challenges where student engagement is key.

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

Increasing influenza vaccination rates via low cost messaging interventions

This article tests low cost interventions to increase influenza vaccination rates. By changing an email announcement sent out to employees in 2014 (n > 30,000), the following interventions are tested: incentives, attention to the negative impacts of not get vaccinated, and showing a map to the vaccination centers at the end of the email announcement. Only the map condition helped increase influenza vaccination rates. The use of low-cost interventions can improve influenza vaccination rates though not all interventions work as well as others in the field. In particular, while including maps helped increase vaccination rates, other factors such as negative impact reminders and incentives, which previous studies have found to be successful in the laboratory, did not.

Increasing Coverage of Appropriate Vaccinations: A Community Guide Systematic Economic Review

CONTEXT

Population-level coverage for immunization against many vaccine-preventable diseases remains below optimal rates in the U.S. The Community Preventive Services Task Force recently recommended several interventions to increase vaccination coverage based on systematic reviews of the evaluation literature. The present study provides the economic results from those reviews.

EVIDENCE ACQUISITION

A systematic review was conducted (search period, January 1980 through February 2012) to identify economic evaluations of 12 interventions recommended by the Task Force. Evidence was drawn from included studies; estimates were constructed for the population reach of each strategy, cost of implementation, and cost per additional vaccinated person because of the intervention. Analyses were conducted in 2014.

EVIDENCE SYNTHESIS

Reminder systems, whether for clients or providers, were among the lowest-cost strategies to implement and the most cost effective in terms of additional people vaccinated. Strategies involving home visits and combination strategies in community settings were both costly and less cost effective. Strategies based in settings such as schools and MCOs that reached the target population achieved additional vaccinations in the middle range of cost effectiveness.

CONCLUSIONS

The interventions recommended by the Task Force differed in reach, cost, and cost effectiveness. This systematic review presents the economic information for 12 effective strategies to increase vaccination coverage that can guide implementers in their choice of interventions to fit their local needs, available resources, and budget.

The impact of non-financial and financial encouragements on participation in non school-based human papillomavirus vaccination: a retrospective cohort study

OBJECTIVE

Adolescent vaccination coverage under a system of non school-based vaccination is likely to be suboptimal, but might be increased by targeted encouragement campaigns. We analysed the effect on human papillomavirus (HPV) vaccination initiation by girls aged 12-18 of two campaigns set up in Flanders (Belgium) in 2007 and 2009: a personal information campaign and a combined personal information and financial incentive campaign.

METHODS

We analysed (objective) data on HPV vaccination behaviour from the National Alliance of Christian Mutualities (NACM), Flanders' largest sickness fund. We used z-scores to compare the monthly proportion of girls initiating HPV vaccination over time between carefully selected intervention and control groups. Separate analyses were done for older and younger girls. Total sample sizes of the intervention (control) groups were 221 (243) for the personal information campaign and 629 (5,322) for the combined personal information and financial incentive campaign.

RESULTS

The personal information campaign significantly increased vaccination initiation, with older girls reacting faster. One year after the campaign the percentages of vaccination initiation for the oldest girls were 64.6 and 42.8 % in the intervention and control group, respectively (z = 3.35, p = 0.0008); for the youngest girls the percentages were 78.4 and 68.1 % (z = 1.71, p = 0.09). The combined personal information and financial incentive campaign increased vaccination initiation among certain age groups. One year after the campaign the difference in percentage points for HPV vaccination initiation between intervention and control groups varied between 18.5 % (z = 3.65, p = 0.0002) and 5.1 % (z = 1.12, p = 0.26).

CONCLUSION

Under a non school-based vaccination system, personal information and removing out-of-pocket costs had a significant positive effect on HPV vaccination initiation, although the effect substantially varied in magnitude. Overall, the obtained vaccination rates remained far below those realised under school-based HPV vaccination.

Health education and factors influencing acceptance of and willingness to pay for influenza vaccination among older adults

Background

The influenza vaccine is recommended in older population. However the immunization coverage varies globally. It has been reported as low as 10–20 % in some countries. This study explored the acceptance of and willingness to pay for influenza vaccination, comparing acceptance and willingness to pay before and after health education.

Methods

The study was conducted with 2693 older people in Bangkok, Thailand. Participants were divided into an education group (n = 1402) and a control group (n = 1291). A validated questionnaire measuring acceptance of and willingness to pay for vaccination was administered during semi-structured interviews before and after education. Data on factors influencing acceptance were analyzed.

Results

Participants’ mean age was 69.5 years, 80 % were women and 82.1 % had at least one co-morbidity. Of the participants, 43.5 % had previously received vaccination more than once, although 92.8 % expressed acceptance of vaccination. Acceptance was associated with a positive attitude toward vaccination (OR 2.1, 95 % CI 1.5–2.9) and a history of receiving vaccination (OR 4.1, 95 % CI 2.8–6.1). At baseline, there were no differences between the education and control groups in terms of work status (p = 0.457), co-morbidities (p = 0.07), medical status (p = 0.243), and previous vaccination (p = 0.62), except for educational background (p = 0.004). Acceptance of vaccination increased to 95.8 % (p < 0.001) after education and willingness to pay increased to 82.1 % (p < 0.001). Education significantly affected those with primary school-level education and no previous vaccination history, with acceptance increasing from 83.3 to 92.6 % (p < 0.001); more than twice as high as the control group (OR 2.4, 95 % CI 1.2–4.7). Viewing an educational video increased the proportion of participants with a high level of knowledge from 29.2 to 49.2 % (p < 0.001), and increased the proportion of participants with a positive attitude from 52.4 to 70.7 % (p <0.001). No significant difference was found in any parameter between the first and second assessment in the control group.

Conclusions

The strategies to increase positive attitudes may enhance the acceptance of vaccination. Health education using an educational video demonstrated a significant impact on acceptance, willingness to pay, knowledge and attitude in older people. This may lead to increased sustainability of the immunization program in older people.

Using Behavioral Insights to Increase Vaccination Policy Effectiveness

Even though there are policies in place, and safe and effective vaccines available, almost every country struggles with vaccine hesitancy, that is, a delay in acceptance or refusal of vaccination. Consequently, it is important to understand the determinants of individual vaccination decisions to establish effective strategies to support the success of country-specific public health policies. Vaccine refusal can result from complacency, inconvenience, a lack of confidence, and a rational calculation of pros and cons. Interventions should, therefore, be carefully targeted to focus on the reason for non-vaccination. We suggest that there are several interventions that may be effective for complacent, convenient, and calculating individuals whereas interventions that might be effective for those who lack confidence are scarce. Thus, efforts should be concentrated on motivating the complacent, removing barriers for those for whom vaccination is inconvenient, and adding incentives and additional utility for the calculating. These strategies might be more promising, economic, and effective than convincing those who lack confidence in vaccination.

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

BACKGROUND

The effectiveness of interventions to increase the uptake of influenza vaccination in people aged 60 and older is uncertain.

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 (2014, Issue 5), MEDLINE (January 1950 to May week 3 2014), EMBASE (1980 to June 2014), AgeLine (1978 to 4 June 2014), ERIC (1965 to June 2014) and CINAHL (1982 to June 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase influenza vaccination uptake in people aged 60 and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted influenza vaccine uptake data.

MAIN RESULTS

This update identified 13 new RCTs; the review now includes a total of 57 RCTs with 896,531 participants. The trials included community-dwelling seniors in high-income countries. Heterogeneity limited meta-analysis. The percentage of trials with low risk of bias for each domain was as follows: randomisation (33%); allocation concealment (11%); blinding (44%); missing data (49%) and selective reporting (100%). Increasing community demand (32 trials, 10 strategies)The interventions with a statistically significant result were: three trials (n = 64,200) of letter plus leaflet/postcard compared to letter (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15); two trials (n = 614) of nurses/pharmacists educating plus vaccinating patients (OR 3.29, 95% CI 1.91 to 5.66); single trials of a phone call from a senior (n = 193) (OR 3.33, 95% CI 1.79 to 6.22), a telephone invitation versus clinic drop-in (n = 243) (OR 2.72, 95% CI 1.55 to 4.76), a free groceries lottery (n = 291) (OR 1.04, 95% CI 0.62 to 1.76) and nurses educating and vaccinating patients (n = 485) (OR 152.95, 95% CI 9.39 to 2490.67).We did not pool the following trials due to considerable heterogeneity: postcard/letter/pamphlets (16 trials, n = 592,165); tailored communications (16 trials, n = 388,164); customised letter/phone-call (four trials, n = 82,465) and client-based appraisals (three trials, n = 4016), although several trials showed the interventions were effective. Enhancing vaccination access (10 trials, six strategies)The interventions with a statistically significant result were: two trials (n = 2112) of home visits compared to clinic invitation (OR 1.30, 95% CI 1.05 to 1.61); two trials (n = 2251) of free vaccine (OR 2.36, 95% CI 1.98 to 2.82) and one trial (n = 321) of patient group visits (OR 24.85, 95% CI 1.45 to 425.32). One trial (n = 350) of a home visit plus vaccine encouragement compared to a home visit plus safety advice was non-significant.We did not pool the following trials due to considerable heterogeneity: nurse home visits (two trials, n = 2069) and free vaccine compared to no intervention (two trials, n = 2250). Provider- or system-based interventions (17 trials, 11 strategies)The interventions with a statistically significant result were: two trials (n = 2815) of paying physicians (OR 2.22, 95% CI 1.77 to 2.77); one trial (n = 316) of reminding physicians about all their patients (OR 2.47, 95% CI 1.53 to 3.99); one trial (n = 8376) of posters plus postcards (OR 2.03, 95% CI 1.86 to 2.22); one trial (n = 1360) of chart review/feedback (OR 3.43, 95% CI 2.37 to 4.97) and one trial (n = 27,580) of educational outreach/feedback (OR 0.77, 95% CI 0.72 to 0.81).Trials of posters plus postcards versus posters (n = 5753), academic detailing (n = 1400) and increasing staff vaccination rates (n = 26,432) were non-significant.We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators (three trials, n = 2183), although several trials showed the interventions were effective. Interventions at the societal level We identified no RCTs of interventions at the societal level.

AUTHORS' CONCLUSIONS

There are interventions that are effective for increasing community demand for vaccination, enhancing access and improving provider/system response. Heterogeneity limited pooling of trials.

Interventions to improve influenza and pneumococcal vaccination rates among community-dwelling adults: a systematic review and meta-analysis

PURPOSE

Influenza and pneumococcal vaccination rates remain below national targets. We systematically reviewed the effectiveness of quality improvement interventions for increasing the rates of influenza and pneumococcal vaccinations among community-dwelling adults.

METHODS

We included randomized and nonrandomized studies with a concurrent control group. We estimated pooled odds ratios using random effects models, and used the Downs and Black tool to assess the quality of included studies.

RESULTS

Most studies involved elderly primary care patients. Interventions were associated with improvements in the rates of any vaccination (111 comparisons in 77 studies, pooled odds ratio [OR] = 1.61, 95% CI, 1.49-1.75), and influenza (93 comparisons, 65 studies, OR = 1.46, 95% CI, 1.35-1.57) and pneumococcal (58 comparisons, 35 studies, OR = 2.01, 95% CI, 1.72-2.3) vaccinations. Interventions that appeared effective were patient financial incentives (influenza only), audit and feedback (influenza only), clinician reminders, clinician financial incentives (influenza only), team change, patient outreach, delivery site changes (influenza only), clinician education (pneumococcus only), and case management (pneumococcus only). Patient outreach was more effective if personal contact was involved. Team changes were more effective where nurses administered influenza vaccinations independently. Heterogeneity in some pooled odds ratios was high, however, and funnel plots showed signs of potential publication bias. Study quality varied but was not associated with outcomes.

CONCLUSIONS

Quality improvement interventions, especially those that assign vaccination responsibilities to nonphysician personnel or that activate patients through personal contact, can modestly improve vaccination rates in community-dwelling adults. To meet national policy targets, more-potent interventions should be developed and evaluated.

Using financial incentives to increase initial uptake and completion of HPV vaccinations: protocol for a randomised controlled trial

BACKGROUND

HPV vaccination reduces the risk of cervical cancer. Uptake however, of the 'catch-up' campaign in England for 17-18 year old girls is below the 80% NHS target. The aim of this randomized controlled trial is to assess the impact of financial incentives on (a) the uptake and completion of an HPV vaccination programme and (b) the quality of the decisions to undertake the vaccination.

METHOD/DESIGN

One thousand (n = 1000) 16-18 year-old girls will be invited to participate in an HPV vaccination programme: Five-hundred (n = 500) will have received a previous invitation to get vaccinated but will have failed to do so (previous non-attenders) and 500 will not have previously received an invitation (first-time invitees). Girls will be randomly selected from eligible participants who are registered with a GP in areas covered by the Birmingham East and North (BEN) and Heart of Birmingham Primary Care Trusts. The two samples of girls will be randomised to receive either a standard vaccination invitation letter or an invitation letter including the offer of vouchers worth £45 for receiving three vaccinations. Girls will also complete a questionnaire to assess the quality of their decisions to be vaccinated. The primary outcome will be uptake of the 1st and 3rd vaccinations. The secondary outcome will be the quality of the decisions to undertake the vaccination, measured by assessing attitudes towards and knowledge of the HPV vaccination.

DISCUSSION

The key results will be: a) the effectiveness of financial incentives in increasing uptake of the 1st and 3rd vaccinations; b) the role of participants' socio-economic status in the moderation of the impact of incentives on uptake; and c) the impact of incentives on the quality of decisions to undertake the HPV vaccinations.

A consideration of user financial incentives to address health inequalities

Health inequalities and user financial incentives to encourage health-related behavior change are two topical issues in the health policy discourse, and this article attempts to combine the two; namely, we try to address whether the latter can be used to reduce the former in the contexts of the United Kingdom and the United States. Payments for some aspects of medical adherence may offer a promising way to address, to some extent, inequalities in health and health care in both countries. However, payments for more sustained behavior change, such as that associated with smoking cessation and weight loss, have thus far shown little long-term effect, although more research that tests the effectiveness of different incentive mechanism designs, informed by the findings of behavioral economics, ought to be undertaken. Many practical, political, ethical, and ideological objections can be waged against user financial incentives in health, and this article reviews a number of them, but the justifiability of and limits to these incentives require more academic and public discourse so as to gain a better understanding of the circumstances in which they can legitimately be used.

New opportunity for vaccinating older people: well-child clinic visits

BACKGROUND

Streptococcus pneumoniae causes considerable morbidity and mortality in the elderly. As aging of the population is making the health of the elderly a universal priority, preventive measures, such as vaccination, will become increasingly important.

METHODS

We designed a prospective interventional study to determine whether recommendations to vaccinate grandparents of children attending well-child clinics would increase the pneumococcal vaccination rate in the elderly. Children younger than 5 years of age, attending a university well-child clinic from 1 May to 31 September 2008 who had grandparents over 65 years of age were eligible. A survey including the questions about the demographic characteristics of children, their parents and grandparents over 65 was carried out by face-to-face interview with the parents. High-risk medical conditions and vaccination history of grandparents was also noted and the benefits and necessity of pneumococcal vaccination (23vPPV) for the elderly was emphasized. Four months later these families were contacted to determine whether this intervention had increased the pneumococcal vaccination rates of the elderly.

RESULTS

Information was obtained from 938 grandparents of 545 children. Before the interview, among all grandparents, only 0.9% were vaccinated with 23vPPV. Four months after this intervention, immunization coverage increased to 19.1%. The sex of the grandchild (OR: 1.99) and previous hepatitis B or influenza immunization of the grandparents (OR: 2.73) were the significant parameters accounting for higher immunization rates.

CONCLUSION

Reminding elderly grandparents about vaccines in well-child clinics could be an opportunity in this field.

Estimating the cost-effectiveness of a national program to eliminate disparities in influenza vaccination rates among elderly minority groups

Influenza is a major cause of preventable morbidity and mortality in the United States, particularly among the elderly. Yet, there remain large disparities in influenza vaccination rates across elderly Caucasian (70%), African-American (50%) and Hispanic (55%) populations, with substantial mortality consequences. In this study, we built a decision-analysis model to estimate the cost-effectiveness of a hypothetical national vaccination program designed to eliminate these disparities in influenza vaccination rates. Taking a societal perspective, we developed a Markov model with a one-year cycle length and lifetime time horizon. In the base case, we conservatively assumed that the cost of promoting the vaccination program was $10 per targeted elder per year and that by year 10, the vaccination rate of the elderly African-American and Hispanic populations would equal the vaccination rate of the elderly Caucasian population (70%). The cost-effectiveness of the vaccination program compared to no vaccination program was $48,617 per QALY saved. Probabilistic sensitivity analyses suggested that at willingness-to-pay thresholds of $50,000 and $100,000 per QALY saved, the likelihood of the vaccination program being cost-effective was 38% and 92%, respectively. In an analysis using conservative assumptions, we found that a hypothetical program to ameliorate disparities in influenza vaccination rates has a moderate to high likelihood of being cost-effective.

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

BACKGROUND

Although the evidence to support influenza vaccination is poor, it is promoted by many health authorities. There is uncertainty about the effectiveness of interventions to increase influenza vaccination rates in those 60 years or older.

OBJECTIVES

To assess effects of interventions to increase influenza vaccination rates in those 60 or older.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 3), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1950 to July 2010), PubMed (January 1950 to July 2010), EMBASE (1980 to 2010 Week 28), AgeLine (1978 to July 2010), ERIC (1965 to July 2010) and CINAHL (1982 to July 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) to increase influenza vaccination rates in those aged 60 years and older, recording influenza vaccination status either through clinic records, billing data or local/national vaccination registers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data.

MAIN RESULTS

Forty-four RCTs were included. All included RCTs studied seniors in the community and in high-income countries. No RCTs of society-level interventions were included. Heterogeneity was marked and meta-analysis was limited. Only five RCTs were graded at low and six at moderate risk of bias. They included three of 13 personalized postcard interventions (all three with the 95% confidence interval (CI) above unity), two of the four home visit interventions (both with 95% CI above unity, but one a small study), three of the four reminder to physicians interventions (none with 95% CI above unity) and three of the four facilitator interventions (one with 95% CI above unity, and one P < 0.01). The other 33 RCTs were at high risk of bias and no recommendations for practice can be drawn.

AUTHORS' CONCLUSIONS

Personalized postcards or phone calls are effective, and home visits, and facilitators, may be effective. Reminders to physicians are not. There is insufficient good evidence for other interventions.

The timing of influenza vaccination for older adults (65 years and older)

While studies have found influenza vaccination to be cost-effective in older adults (65 years or older), they have not looked at how the vaccine's economic value may vary with the timing of vaccine administration. We developed a set of computer simulation models to evaluate the economic impact of vaccinating older adults at different months. Our models delineated the costs and utility losses in delaying vaccination past October and suggest that policy makers and payors may consider structuring incentives (< or =$2.50 per patient) to vaccinate in October. Our results also suggest that vaccination is still cost-effective through the end of February.

Impact of influenza vaccination disparities on elderly mortality in the United States

PURPOSE

Racial and ethnic disparities in influenza vaccination among the elderly are well documented, but their impact on minority mortality is unknown.

METHODS

We model racial and ethnic parity in influenza vaccination on reduction in annual minority deaths among the elderly using age-, sex-, race-, and ethnicity-specific influenza vaccination data from the 2002 Medicare Current Beneficiary Survey, national mortality data and a relative risk (0.89; 95% confidence interval 0.80-0.98) for all-cause mortality during influenza season associated with vaccination. We also estimate the impact of 90% influenza coverage (Healthy People 2010 objective) on annual minority and white deaths. Lastly, we estimate years of minority lives saved from parity in annual vaccination beginning at age 65.

RESULTS

Parity in influenza vaccination would reduce elderly minority deaths by 1880 annually. Achievement of 90% vaccination coverage would reduce minority and White deaths by 3750 and 11,840 annually. Parity in vaccination beginning at age 65 and continuing through out life would save more than 33,000 minority years of life.

CONCLUSIONS

Based on conservative estimates, elimination of racial and ethnic disparities in influenza vaccination would significantly reduce elderly minority mortality and save substantial years of minority life.

Interventions to increase influenza vaccination rates in veterans with spinal cord injuries and disorders

OBJECTIVE

To increase the percentage of veterans with spinal cord injuries and disorders (SCI&D) who receive annual influenza vaccinations.

DESIGN

A repeated measures quality improvement project using several integrated evidence-based interventions.

SETTING

23 Veterans Affairs (VA) SCI Centers.

PATIENTS

Veterans with SCI&D average age = 57.3 years (range 21-102 y).

INTERVENTIONS

Patient reminder letters and education; provider reminders and posters; computerized clinical reminders for vaccination targeted to SCI & D; standing orders.

MAIN OUTCOME MEASURES

Patient self-reported vaccination status.

RESULTS

Baseline vaccination rate was 33% in fiscal year (FY) 2001. The percentage of veterans with SCI&D who reported receiving vaccinations increased from 62.5% in year 1 (FY2002) to 67.4% in FY2003 (P = 0.004); for individuals younger than 50 years of age, rates increased from 50% to 54%. Predictors of vaccination were age 65 years of age or older, VA health care visit in past year, nonsmoker, believing vaccination is important, having a health condition that may contribute to respiratory complications, and self-reported influenza in prior year.

CONCLUSIONS

Vaccination rates were higher than baseline and higher than reported for other high-risk groups. Interventions that incorporate system-wide approaches plus patient and provider education and reminders were moderately effective in increasing vaccination rates. Targeting younger persons, smokers, and those who do not use VA care may further improve rates.

A structured review of the effect of economic incentives on consumers' preventive behavior

Improving participation in preventive activities will require finding methods to encourage consumers to engage in and remain in such efforts. This review assesses the effects of economic incentives on consumers' preventive health behaviors. A study was classified as complex preventive health if a sustained behavior change was required of the consumer; if it could be accomplished directly (e.g., immunizations), it was considered simple. A systematic literature review identified 111 randomized controlled trials of which 47 (published between 1966 and 2002) met the criteria for review. The economic incentives worked 73% of the time (74% for simple, and 72% for complex). Rates varied by the goal of the incentive. Incentives that increased ability to purchase the preventive service worked better than more diffuse incentives, but the type matters less than the nature of the incentive. Economic incentives are effective in the short run for simple preventive care, and distinct, well-defined behavioral goals. Small incentives can produce finite changes, but it is not clear what size of incentive is needed to yield a major sustained effect.

Effectiveness of individually tailored calendars in promoting childhood immunization in urban public health centers

OBJECTIVES

We examined the effectiveness of tailored calendars in increasing childhood immunization rates.

METHODS

Parents of babies aged birth to 1 year (n = 321) received individually tailored calendars promoting immunization from 2 urban public health centers. For each baby, an age- and sex-matched control was selected from the same center. Immunization status was tracked through age 24 months.

RESULTS

A higher proportion of intervention than of control babies were up to date at the end of a 9-month enrollment period (82% vs 65%, P <.001) and at age 24 months (66% vs 47%, P <.001). The younger the baby's age at enrollment in the program, the greater was the intervention effect.

CONCLUSIONS

Tailored immunization calendars can help increase child immunization rates.

Tracking and Improving Influenza Immunization Rates in a High-Risk Medicare Beneficiary Population

Immunization rates for end stage renal disease (ESRD) patients were well below the 80% target set by Healthy People 2000 and Centers for Medicare and Medicaid Services. The authors sought to increase documentation of immunization status, and influenza immunization rates of these patients. A survey was distributed to dialysis facilities to determine immunization practices. Facilities were provided with an immunization toolbox and spreadsheets to document the immunization status of patients. A total of 102 facilities (53%) provided data for three collection periods (1999, 2000, and 2001). Immunization rates for each influenza season increased significantly from 62.1% and 61.4% in 1998-1999 to 80.3% and 80.0% in 2000-2001 (Pennsylvania and Delaware respectively).

Cost-benefit analysis of a new HEDIS performance measure for pneumococcal vaccination

OBJECTIVES

Measurement of the quality of care provided by managed care organizations (MCOs) has achieved national prominence, though there is controversy regarding its value. This article assesses the economic implications of a new Health Plan Employer Data and Information Set (HEDIS) measure for pneumococcal vaccination.

METHODS

A Markov decision model, with Monte Carlo simulations, was utilized to conduct a cost-benefit analysis of annual HEDIS-associated interventions, which were repeated for 5 consecutive years, in an average Medicare MCO, using a societal perspective and a 3% annual discount rate.

RESULTS

Compared with the status quo, the HEDIS intervention will be cost saving 99.8% of the time, with an average net savings of $3.80 per enrollee (95% probability interval: $0.73-$6.87).

CONCLUSIONS

The new HEDIS measure will save societal dollars. This type of analysis is essential if performance measurement is to become a legitimate part of our health care landscape.

Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services

This paper presents the results of systematic reviews of the effectiveness, applicability, other effects, economic impact, and barriers to use of selected population-based interventions intended to improve vaccination coverage. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis for recommendations by the Task Force on Community Preventive Services (the Task Force) regarding the use of these selected interventions. The Task Force recommendations are presented on pp. 92-96 of this issue.

Educational content and the effectiveness of influenza vaccination reminders

OBJECTIVE

To determine if a mailed patient education brochure (addressing demonstrated reasons for vaccination refusal) would result in a higher rate of influenza vaccination than a mailed postcard reminder without educational content.

DESIGN

Randomized, controlled trial.

SETTING

Urban, predominantly African-American, low-income community.

PARTICIPANTS

There were 740 community-dwelling individuals aged 65 years and older in the study.

MEASUREMENTS

Receipt of influenza vaccination and beliefs about influenza and influenza vaccination were measured by telephone survey self-report.

MAIN RESULTS

We successfully contacted 202 individuals (69.9%) who received the postcard reminder and 229 individuals (71.1%) who received the educational brochure. People receiving the educational brochure were more likely to report influenza vaccination during the previous vaccination season than those who received the postcard reminder (66.4% vs 56.9%, p =.04). They also reported more interest in influenza vaccination in the coming year. (66.5% vs 57.1%, p =.05).

CONCLUSIONS

A mailed educational brochure is more effective than a simple reminder in increasing influenza vaccination rates among inner-city, elderly patients.

Public health in managed care: a randomized controlled trial of the effectiveness of postcard reminders

OBJECTIVES

This study evaluated the effectiveness of an annual public health intervention in a managed care setting.

METHODS

Managed care organization members 65 years and older who received influenza immunization in 1996 were randomized to an intervention group (mailed a postcard reminder to receive an influenza vaccination in 1997) or a control group (no postcard). Vaccination rates for both groups were assessed monthly.

RESULTS

Members receiving the intervention were no more likely to be immunized (78.6%) than members of the control group (77.2%, P = .222). Members were vaccinated at the same pace regardless of vaccination history and postcard intervention status.

CONCLUSIONS

Postcard reminders were not an effective intervention among seniors who had been vaccinated the previous year.

Health care incentives in immunisation

BACKGROUND

Australia has introduced a nationwide immunisation incentive scheme. This yet to be evaluated two-year program offers financial rewards to providers and parents to encourage childhood immunisations.

OBJECTIVES

To review the use of incentives in immunisation uptake, identify issues in developing an incentive program for childhood immunisation and examine the findings within the context of the Australian scheme.

METHOD

Medline was searched under 'immunization and financial incentive' and 'immunization and incentive' in English 1966 to 1998.

RESULTS

The search identified six and 93 articles respectively, of which six examined the role of material incentives influencing coverage of immunisation. References and reviews identified a further three studies. Among these nine studies (two British, six American, one Nicaraguan), two reported the same intervention. Of the eight incentives examined, four referred to non-financial incentives such as food vouchers and four to monetary incentives for parents (1) or providers (3). Groups receiving the incentives were up to three times more likely to be immunised and had overall immunisation rates up to 17% higher than comparison groups.

CONCLUSIONS

Effective incentives require collaboration of key players, using a program appropriate to the characteristics of the population. Although varying in cost-effectiveness, both monetary and non-monetary incentives can improve childhood immunisation uptake. Evaluation of current programs including the Australian ones will assist future allocation of resources.