Second flu vaccine doses, however, did seem influenced by the messaging

Influenza vaccination rates for children and adolescents remain suboptimal and efforts to improve flu jab uptake rates continue to be an uphill battle. As previously reported by BreakingMED, an effort to use a clinical decision support strategy did not help increase vaccination rates for hospitalized children despite improving orders for the vaccines.

Another tactic could be reminders in patient portals, but, in an intention-to-treat randomized trial that used flu vaccine reminder messages for portal users did not increase vaccine rates over controls. However, the researchers did see an increase in uptake of second vaccine doses, according to a study published in Pediatrics.

The study, conducted by Carlos Lerner, MD, MPhil, from Department of Pediatrics, Mattel Children’s Hospital in Los Angeles, and colleagues, conducted a 3-arm trial to assess what could influence vaccine uptake via patient portal messaging:

  • Reminders for the first vaccine where the portal users were assigned to either not receive a reminder (n=7,391), receive 3 gain-frame reminders (the benefit of getting the vaccine; n=7,318), or 3 loss-frame reminders (the consequence of not getting the flu vaccine; n=7,337).
  • Precommitment messaging where patients were randomized to either receive a precommitment message (n=11,068) that reminded them that the flu season was upon them and asked them to answer the question whether or not they were planning on having their children vaccinated or were randomized to not receive this message (10,978).
  • The third arm of the trial involved reminders for the second flu vaccine and included patients ages 6 to <36 months who were overdue for their second vaccine. This group was randomized to either no reminder (n=347) or 1 reminder (n=342).

“[W]e found no significant increases in vaccination rates after portal reminders for the first influenza vaccine, with vaccination rates of 56.9% in the control group (no reminders), 58.0% in the loss-frame portal reminders group (P=0.07), and 58.0% in the gain-frame reminder group (P=0.47),” Lerner and colleagues wrote. “Additionally, a portal-based precommitment survey, intended to capitalize on the principle that individuals seek a consistent and continuous self-image, did not significantly increase vaccination rates, with 57.0% receiving ≥1 vaccines in the control group and 58.3% in the precommitment group (P=0.11). In our previous work, we found limited effectiveness of a generic influenza vaccine reminder. In this study, despite the implementation of a message targeted specifically at pediatric patients and the use of additional behavioral science concepts to enhance message effectiveness, the portal reminders for the first influenza vaccine had no significant impact on immunization rates.”

“Adjusted risk ratios for first vaccination were 1.02 (95% confidence interval [CI]: 1.00–1.04) for loss-frame reminders, 1.01 (95% CI: 0.98–1.05) for gain-frame reminders, and 1.02 (95% CI: 1.00–1.04) for precommitment messages versus controls. Second-dose vaccination rates were 44.1% in the control group and 55.0% in the reminder group, with an adjusted risk ratio of 1.25 (95% CI: 1.07–1.45),” the study authors wrote.

Lerner and colleagues noted that while they hypothesized that loss-frame messaging might be more persuasive in getting parents to get their children vaccinated as “they may possibly arouse emotions of guilt or regret,” this was not the case in the trial. The framing of the message did not seem to matter.

“Likewise, the precommitment message did not increase vaccination rates,” Lerner and colleagues noted. “Plausible reasons for the lack of efficacy include the low percentage (6.9%) of patients and proxies that read the precommitment message and the private nature of the precommitment responses. Commitments that are made publicly, for example, may be more effective, because the individual seeks to avoid reputational damage, a dimension we were unable to incorporate in our intervention.”

In all their study was comprised of 22,046 children age 6 months to <18 years in 53 UCLA primary care practices and whose parents/proxies were active portal users. The messaging was based on the Health belief model and principles of health literacy and incorporated behavioral science principles. They were in English and were at a below-seventh-grade reading level. Just under half of all the participants were female; nearly 92% had private health insurance; 41.3% were White, 3,9% were Black, 12.8% were Asian, and just over 40% were or another or unknown race; most were not Hispanic or their ethnicity was no known, and 63.7% had a history of ≥1 vaccine in the last two seasons, with 36.3% not having received a vaccine during that time.

“Overall, this study demonstrated the ability of portal messages to increase influenza vaccination in children for those in need of a second dose,” Chelsea S. Wynne, MPH, Ashley B. Stephens, MD, and Melissa S. Stockwell, MD, MPH, all from Columbia University and New York Presbyterian Hospital, in New York wrote in a commentary accompanying the study. However, they noted that while one of the strengths of the study is its large sample size, they suggested that the intervention could be optimized the messaging if it is sent in the patient’s “preferred language and that providers and other pediatric clinical staff are active in encouraging [portal] use.” For instance, they noted that the portal messages could complement text messaging or phone calls, “to address other barriers to first-dose influenza vaccination. Moreover, for families that are hesitant about vaccination, the decision to obtain the influenza vaccine may still need to be a conversation.”

The study authors acknowledged several limitations of their study, including that it took place in a single health system and may not be generalizable, particularly for underserved populations and the fact that portal-based interventions are limited to those who use portals.

  1. An intention-to-treat randomized trial that used flu vaccine reminder messages for portal users did not increase vaccine rates over controls. The researchers did see an increase in uptake of second vaccine doses.

  2. Neither gain or loss messaging appeared to increase the flu vaccine uptake among patient portal users.

Candace Hoffmann, Managing Editor, BreakingMED™

Lerner disclosed no relevant relationships.

Stockwell has received grants from the National Institutes of Health and Centers for Disease Control and Prevention; and Wynn and Stephens have indicated they have no financial relationships relevant to this article to disclose.

Cat ID: 138

Topic ID: 85,138,730,125,30,31,138,139,43,44,561,653,151,924,925