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.

Identifying factors behind the general practice use of the term 'decline' for the childhood immunisation programme in New Zealand

INTRODUCTION The role of healthcare providers and their use of systems is one of the most important factors in vaccination uptake. AIM To identify reasons and find patterns behind why immunisation providers code the word 'decline' in their system for childhood immunisation events. METHODS A qualitative study involving face-to-face semi-structured interviews with staff members involved in immunisation delivery. General practices were purposively selected for having either high or low rates of registered children coded on the electronic practice management system as having declined immunisation events. Thematic analysis was undertaken using an inductive approach to link themes to the data. RESULTS A total of 35 interviews were conducted with practice nurses; 21 were from practices with high rates of registered children recorded as having declining immunisation events, and 14 practices with low rates of declining. Common themes were: effective use of systems, early and ongoing engagement, adequate health care practitioner time and practitioner experience. Practices with low rates of coded decliners had stronger approaches for early and ongoing engagement, and were less likely to use formalised decline forms. As practice immunisation coverage rates improved over time, there was perceived to be less expressed vaccine hesitancy from families. CONCLUSIONS The reasons for coding individuals as 'decliners' are a complex mixture of individual, community, practitioner and practice systems. Front-line providers need adequate tools, time and resourcing to support effective and ongoing engagement with families. Community factors have influence but can change over time.

Patient reminder and recall interventions to improve immunization rates

BACKGROUND

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.

OBJECTIVES

To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017.

SELECTION CRITERIA

We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model.

MAIN RESULTS

The 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).

AUTHORS' CONCLUSIONS

Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

Closing the gap in Australian Aboriginal infant immunisation rates -- the development and review of a pre-call strategy

Background

Improving timely immunisation is key to closing the inequitable gap in immunisation rates between Aboriginal children and non-Indigenous children. Aboriginal Immunisation Officers were employed in Hunter New England Local Health District (HNELHD), New South Wales (NSW), Australia, to telephone the families of all Aboriginal infants prior to the due date for their first scheduled vaccination.

Methods

Aboriginal Immunisation Officers contacted the families of Aboriginal children born in the Hunter New England Local Health District (HNELHD) by telephone before their due immunisation date (pre-call) to provide the rationale for timely immunisation, and to facilitate contact with culturally safe local immunisation services if this was required. The impact of this strategy on immunisation coverage rates is reviewed.

Results

For the period March 2010 to September 2014 there was a significant increase in immunisation coverage rate for Aboriginal children at 12 months of age in HNELHD (p < 0.0001). The coverage in the rest of NSW Aboriginal children also increased but not significantly (p = 0.218). Over the full study period there was a significant decrease in the immunisation coverage gap between Aboriginal children and non-Indigenous children in HNELHD (p < 0.0001) and the rest of NSW (p = 0.004). The immunisation coverage gap between Aboriginal and non-Indigenous infants decreased at a significantly faster rate in HNELHD than the rest of NSW (p = 0.0001). By the end of the study period in 2014, immunisation coverage in HNELHD Aboriginal infants had surpassed that of non-Indigenous infants by 0.8 %.

Conclusions

The employment of Aboriginal immunisation officers may be associated with closing of the gap between Aboriginal and non-Indigenous infants’ immunisation coverage in HNELHD and NSW. The pre-call telephone strategy provided accelerated benefit in closing this gap in HNELHD.