Increasing influenza vaccination rates via low cost messaging interventions

"How" Versus "Why" Messaging to Increase Uptake of Booster Vaccination Against COVID-19: Results of a Pragmatic Randomized Trial

BACKGROUND

Messages aimed at increasing uptake of vaccines have been modestly successful, perhaps in part because they often focus on why individuals should receive a vaccine. Construal Level Theory posits that messages emphasizing "how" to get a vaccine may be more effective at encouraging vaccination than emphasizing "why." This message framing may be particularly important for COVID-19 booster acceptance.

OBJECTIVE

To determine if pre-visit patient portal messages designed using Construal Level Theory increase rates of COVID-19 booster vaccination.

DESIGN AND INTERVENTIONS

This 3-arm randomized trial was conducted across three large, diverse primary care clinics in Massachusetts between February and May 2022, testing the impact of "how" versus "why" framed pre-visit messages versus no messages ("usual care"). Messages were sent by patient portal two business days before a visit.

PARTICIPANTS

Adults with upcoming primary care visits who had electronic health record evidence of receiving their initial COVID-19 vaccination series but not a booster dose.

MAIN MEASURES

Receipt of a COVID-19 booster vaccination after the message was sent through the visit date (primary outcome) or 6 weeks (secondary outcome).

KEY RESULTS

A total of 3665 patients were randomized (mean age: 53.5 years (SD: 17.3), 59% female, 65.2% White, 26.6% Hispanic), with 1249 to "how" 1199 to "why," and 1217 to usual care arms. Except for clinic and preferred language, characteristics were well balanced across arms. Rates of COVID-19 booster were 13.6% (usual care), 11.7% ("how") (odds ratio (OR) "how" vs usual care: 0.87, 95%CI: 0.67-1.14), and 13.7% ("why") ("why" vs usual care: OR: 1.01, 95%CI: 0.81-1.28). At 6 weeks, "why" outperformed "how" for vaccination (OR: 1.26, 95%CI: 1.06-1.49), with no difference versus usual care.

CONCLUSIONS

We found no differences on visit booster receipt after single pre-visit portal messages designed using Construal Level Theory. Further studies to identify effective messaging interventions are needed, especially as additional doses are recommended.

CLINICAL TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov, ID: NCT04871776 . Initial release occurred 04/30/2021.

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Factors influencing the decision to receive seasonal influenza vaccination among US corporate non-healthcare workers

Influenza causes significant mortality and morbidity in the United States (US). Employees are exposed to influenza at work and can spread it to others. The influenza vaccine is safe, effective, and prevents severe outcomes; however, coverage among US adults (50.2%) is below Healthy People 2030 target of 70%. These highlights need for more effective vaccination promotion interventions. Understanding predictors of vaccination acceptance could inform vaccine promotion messages, improve coverage, and reduce illness-related work absences. We aimed to identify factors influencing influenza vaccination among US non-healthcare workers. Using mixed-methods approach, we evaluated factors influencing influenza vaccination among employees in three US companies during April-June 2020. Survey questions were adapted from the WHO seasonal influenza survey. Most respondents (n = 454) were women (272, 59.9%), 20-39 years old (n = 250, 55.1%); white (n = 254, 56.0%); had a college degree (n = 431, 95.0%); and reported receiving influenza vaccine in preceding influenza season (n = 297, 65.4%). Logistic regression model was statistically significant, X (16, N = 450) = 31.6, p = .01. Education [(OR) = 0.3, 95%CI = 0.1-0.6)] and race (OR = 0.4, 95%CI = 0.2-0.8) were significant predictors of influenza vaccine acceptance among participants. The majority had favorable attitudes toward influenza vaccination and reported that physician recommendation would influence their vaccination decisions. Seven themes were identified in qualitative analysis: "Protecting others" (109, 24.0%), "Protecting self" (105, 23.1%), "Vaccine accessibility" (94, 20.7%), "Education/messaging" (71, 15.6%), "Policies/requirements" (15, 3.3%), "Reminders" (9, 2.0%), and "Incentives" (3, 0.7%). Our findings could facilitate the development of effective influenza vaccination promotion messages and programs for employers, and workplace vaccination programs for other diseases such as COVID-19, by public health authorities.

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

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

COVID-19 Immunisation, Willingness to Be Vaccinated and Vaccination Strategies to Improve Vaccine Uptake in Australia

The COVID-19 vaccine rollout is crucial to lifting community and economic restrictions. This cross-sectional study aimed to assess: (a) COVID-19 vaccine uptake and associated factors; (b) COVID-19 vaccine intentions and associated factors; (c) community support for COVID-19 vaccination strategies and associated factors. The survey was conducted between May and July 2021 in Australia. Of 3003 participants, 30% reported they were already vaccinated and 39% indicated they would get vaccinated. Low socioeconomic and education levels, non-English speaking backgrounds and being parents were associated with decreased vaccine willingness and/or vaccination rates. High levels of support for vaccination strategies were demonstrated with mandatory vaccination being less preferable. Respondents from non-English speaking backgrounds were more likely to support a mandatory vaccination policy. Respondents with the highest socioeconomic level were more likely to support vaccination requirements for international travel, visiting nursing homes and working in healthcare settings. Respondents who were aged ≥70 years were more likely to support all proposed vaccination strategies. Targeted campaigns should be implemented for parents and those who live in socioeconomic disadvantaged areas and have lower educational attainment. Concise and clear vaccine information should be provided in lay and multiple languages to improve vaccine confidence. Vaccine enforcement policies should be considered and implemented with caution.

Inattention or reluctance? Parental responses to vaccination reminder letters

This paper studies non-adherence in the Danish Childhood Vaccination Program using a nationwide introduction of a vaccination reminder letter policy and administrative data from 2011-2017. First, I provide causal estimates of how the reminder letter policy affects vaccination adherence using a Regression Discontinuity Design (RDD). Second, I link parental responses to the reminder letter to parents' causes for being non-adherent. I find that the reminder letter policy positively affects adherence. However, 72% of non-adherent parents are non-responsive to the reminder letter indicating that reluctance and not inattention is the leading cause for non-adherence. Thus, other policies beyond reminder letters - such as mandatory vaccination laws - are necessary to substantially increase vaccination coverage.

A Rapid Systematic Review of Public Responses to Health Messages Encouraging Vaccination against Infectious Diseases in a Pandemic or Epidemic

Public health teams need to understand how the public responds to vaccination messages in a pandemic or epidemic to inform successful campaigns encouraging the uptake of new vaccines as they become available. A rapid systematic review was performed by searching PsycINFO, MEDLINE, healthevidence.org, OSF Preprints and PsyArXiv Preprints in May 2020 for studies including at least one health message promoting vaccine uptake of airborne-, droplet- and fomite-spread viruses. Included studies were assessed for quality using the Mixed Methods Appraisal Tool (MMAT) or the Assessment of Multiple Systematic Reviews (AMSTAR), and for patient and public involvement (PPI) in the research. Thirty-five articles were included. Most reported messages for seasonal influenza (n = 11; 31%) or H1N1 (n = 11; 31%). Evidence from moderate to high quality studies for improving vaccine uptake included providing information about virus risks and vaccination safety, as well as addressing vaccine misunderstandings, offering vaccination reminders, including vaccination clinic details, and delivering mixed media campaigns across hospitals or communities. Behavioural influences (beliefs and intentions) were improved when: shorter, risk-reducing or relative risk framing messages were used; the benefits of vaccination to society were emphasised; and beliefs about capability and concerns among target populations (e.g., vaccine safety) were addressed. Clear, credible, messages in a language target groups can understand were associated with higher acceptability. Two studies (6%) described PPI in the research process. Future campaigns should consider the beliefs and information needs of target populations in their design, including ensuring that vaccine eligibility and availability is clear, and messages are accessible. More high quality research is needed to demonstrate the effects of messaging interventions on actual vaccine uptake.

Be inFLUential: Evaluation of a multifaceted intervention to increase influenza vaccination rates among pediatric inpatients

BACKGROUND AND OBJECTIVE

Annual influenza vaccination is recommended for individual ≥6 months of age, yet vaccination rates remain below national targets in the US. Hospitalization provides another medical setting for influenza vaccination, but the effectiveness of inpatient interventions has not been well studied. Our objective was to evaluate the effectiveness of a multifaceted intervention to increase influenza vaccination rates among pediatric inpatients.

METHODS

We conducted a pre-post interventional study on medical inpatient units at Children's Hospital Colorado from September 2016-April 2017 (pre-intervention) and September 2017-April 2018 (intervention). The intervention targeted nurses (web-based education modules, huddles and reminders) and providers (vaccination lists in the electronic health record, reminders, vaccination reports and financial incentives for residents). Outcomes were influenza vaccine ordering rates, and influenza vaccination rates at discharge. We analyzed data using descriptive statistics, bivariate and logistic regression.

RESULTS

Among 4,050 inpatients in 2016-2017 and 4,523 inpatients in 2017 aged ≥ 6 months, vaccination status was documented for 2,902/4,050 (71.7%) and 3,431/4,523 (75.9%) children aged > 6 months of age hospitalized during the study period. The vaccine ordering rate among eligible children was 28.8% in the pre-intervention season versus 50.2% in the intervention season (p < 0.001). The intervention was associated with 1.23 (95% CI 1.11-1.35) times higher odds of appropriate vaccination screening on admission, 2.27 (95% CI 2.01-2.56) times higher odds of a vaccination being ordered, and 1.39 (95% CI 1.27-1.53) times higher odds of a child being vaccinated against influenza at discharge (all p < 0.001). Residents (56%) and medical providers (39%) were more likely to order vaccines compared with nurses (5%), p = 0.014).

CONCLUSION

A multifaceted intervention targeting nurses, residents and providers comprising education, visual reminders, vaccination reports and financial incentives is an effective way of improving influenza vaccine ordering, resulting in higher inpatient influenza vaccination rates.