Text Messaging Program May Increase Flu Vaccination Rate

Larry Hand

April 24, 2012

April 24, 2012 — Using a text messaging intervention system to educate and remind parents about influenza vaccination increased the rate of child and adolescent vaccinations in a low-income urban population, according to an article published April 25 in JAMA.

Melissa S. Stockwell, MD, MPH, from Columbia University, New York, and colleagues analyzed results of a randomized trial in which targeted text messages were sent to an intervention group of parents to promote flu vaccinations in their children aged 6 months to 18 years, compared with a group of parents who were sent just the usual mail or telephone messages, during the 2010-2011 flu season.

Although the overall vaccination rate remained low, a higher percentage of the children and adolescents whose parents received the text messages received flu vaccinations. As of March 31, 2011, 43.6% (1653 persons) of the text message group had been vaccinated, compared with 39% (1509) of the usual care group, for a difference of 3.7 percentage points (95% confidence interval [CI], 1.5 - 5.9 percentage points) and a relative rate ratio (RRR) of 1.09 (95% CI, 1.04 - 1.15; P = .001).

For a secondary end point of November 30, 2010, 27.1% (1026) of the text message group had been vaccinated, compared with 22.8% (864) of the usual care group (difference, 4.3 percentage points [95% CI, 2.3 - 6.3 percentage points]; RRR, 1.19 [95% CI, 1.10 - 1.28]; P < .001).

A total of 9213 children and adolescents were randomly assigned, and 7574 of them who had not been vaccinated before the first text message were included in the primary analysis. The clinics sent a total of more than 23,000 text messages to parents of 4607 children in the intervention group, of which 11.1% were undeliverable.

The study population included people served by 4 community-based pediatric clinics affiliated with New York-Presbyterian Hospital/Columbia University Medical Center, centrally managed by 1 pediatric group practice and sharing a common electronic health record (EHR). About 95% of the primarily Latino population was eligible for free vaccines through the Vaccines for Children Program.

The clinics used a customized text messaging program, integrated with their immunization information system that collects vaccine administrations from the clinics' EHRs and from the New York City registry, to send 5 weekly text messages on a staggered basis to avoid producing excessive clinic volume at one time. The messages were personalized and in English or Spanish, based on parents' language preferences. The first 3 messages were educational and the last 2 advised the parents of Saturday flu clinics, October 2010 through March 2011.

"We found that a text messaging intervention increased the rate of influenza vaccination compared with usual care in a low-income population of children and adolescents with low underlying rates of influenza vaccination," the researchers write.

Texts Are Brief and Cost-Effective and Dispel Vaccine Misperceptions

"One possible factor contributing to the effectiveness of text message reminders in our study was the incorporation of education targeting common vaccine misperceptions," the researchers write. "Of note, text messages also may be particularly useful in lower-literacy populations because they are limited to 160 characters and therefore usually use short, uncomplicated words."

In an accompanying JAMA editorial, Peter G. Szilagyi, MD, MPH, from the University of Rochester School of Medicine and Dentistry, Rochester, New York, and William G. Adams, MD, from the Boston University School of Medicine and Boston Medical Center in Massachusetts, wrote that even a small improvement such as 3.7 percentage points can make a big difference when applied to a large population.

"Modest steps are the norm when complex behaviors and systems are targeted such as receipt of preventive services," they write. "Nonetheless, these [text messaging] systems have substantial potential, particularly when the technologies are tailored to individual patients and families, delivered in an actionable way, and driven toward important health behaviors. There can be little doubt that in the next decade there will be an increasing use of such systems and their application to additional services."

Limitations of the study — believed to be the first large trial on effectiveness of text message reminders — included possible underreporting of vaccinations, the fact that 18% of the overall population had been vaccinated before the start of the intervention, and directing of the intervention to parents, some with more than 1 child, that could have altered the results. Also, all parents received 1 telephone call regardless of which group they were in.

Nevertheless, the researchers concluded, "Immunization registry-linked text messaging with education-related messages increased influenza vaccination coverage compared with usual care in a traditionally hard-to-reach, low-income, urban, minority population."

Direct costs of the study were relatively low. The researchers reported $7000 in programming costs, $270/week for message preparation and monitoring, and an estimated $165 in message costs for the entire study. "Once the system is set up, the only variable cost is the sending of the text messages, which, even with use of commercial platforms, usually cost pennies per message," the researchers write.

This study was supported by a grant from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services. The authors have disclosed no relevant financial relationships.

JAMA. 2012;307:1702-1708, 1748-1749.

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