Celibell Y. Vargas

Effect of a Text Messaging Intervention on Influenza Vaccination in an Urban, Low-Income Pediatric and Adolescent Population: A Randomized Controlled Trial

CONTEXT Influenza infection results in substantial costs, morbidity, and mortality. Vaccination against influenza is particularly important in children and adolescents who are a significant source of transmission to other high-risk populations, yet pediatric and adolescent vaccine coverage remains low. Traditional vaccine reminders have had a limited effect on low-income populations; however, text messaging is a novel, scalable approach to promote influenza vaccination. OBJECTIVE To evaluate targeted text message reminders for low-income, urban parents to promote receipt of influenza vaccination among children and adolescents. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial of 9213 children and adolescents aged 6 months to 18 years receiving care at 4 community-based clinics in the United States during the 2010-2011 influenza season. Of the 9213 children and adolescents, 7574 had not received influenza vaccine prior to the intervention start date and were included in the primary analysis. INTERVENTION Parents of children assigned to the intervention received up to 5 weekly immunization registry-linked text messages providing educational information and instructions regarding Saturday clinics. Both the intervention and usual care groups received the usual care, an automated telephone reminder, and access to informational flyers posted at the study sites. MAIN OUTCOME MEASURES Receipt of an influenza vaccine dose recorded in the immunization registry via an electronic health record by March 31, 2011. Receipt was secondarily assessed at an earlier fall review date prior to typical widespread influenza activity. RESULTS Study children and adolescents were primarily minority, 88% were publicly insured, and 58% were from Spanish-speaking families. As of March 31, 2011, a higher proportion of children and adolescents in the intervention group (43.6%; n = 1653) compared with the usual care group (39.9%; n = 1509) had received influenza vaccine (difference, 3.7% [95% CI, 1.5%-5.9%]; relative rate ratio [RRR], 1.09 [95% CI, 1.04-1.15]; P = .001). At the fall review date, 27.1% (n = 1026) of the intervention group compared with 22.8% (n = 864) of the usual care group had received influenza vaccine (difference, 4.3% [95% CI, 2.3%-6.3%]; RRR, 1.19 [95% CI, 1.10-1.28]; P < .001). CONCLUSIONS Among children and adolescents in a low-income, urban population, a text messaging intervention compared with usual care was associated with an increased rate of influenza vaccination. However, the overall influenza vaccination rate remained low. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01146912.

Influenza Vaccine Text Message Reminders for Urban, Low-Income Pregnant Women: A Randomized Controlled Trial

OBJECTIVES We evaluated the impact of influenza vaccine text message reminders in a low-income obstetric population. METHODS We conducted a randomized controlled trial that enrolled 1187 obstetric patients from 5 community-based clinics in New York City. The intervention group received 5 weekly text messages regarding influenza vaccination starting mid-September 2011 and 2 text message appointment reminders. Both groups received standard automated telephone appointment reminders. The prespecified endpoints were receipt of either pre- or postpartum influenza vaccination calculated cumulatively at the end of each month (September-December 2011). RESULTS After adjusting for gestational age and number of clinic visits, women who received the intervention were 30% more likely to be vaccinated as of December 2011 (adjusted odds ratio [AOR] = 1.30; 95% confidence interval [CI] = 1.003, 1.69 end of September: AOR = 1.34; 95% CI = 0.98, 1.85; October: AOR = 1.35; 95% CI = 1.05, 1.75; November: AOR = 1.27; 95% CI = 0.98, 1.65). The subgroup of women early in the third trimester at randomization showed the greatest intervention effect (December 31: 61.9% intervention vs 49.0% control; AOR = 1.88; 95% CI = 1.12, 3.15). CONCLUSIONS In this low-income obstetric population, text messaging was associated with increased influenza vaccination, especially in those who received messages early in their third trimester.

Exploring pregnant women's views on influenza vaccination and educational text messages

BACKGROUND The influenza vaccine has the potential to reduce morbidity among pregnant women and newborns but immunization coverage remains low. Effective interventions are needed to promote vaccine uptake in this population. PURPOSE The goal of this study was to explore attitudes toward influenza vaccination and interest in targeted educational text messages among urban pregnant women. METHODS English and Spanish language focus groups were conducted with pregnant women in New York City in April 2010. Transcripts were independently coded using content analysis. RESULTS The 40 participants ranged in age from 19-35 years (mean=26, SD=5). Their gestational age ranged from 8-40 weeks (mean=27, SD=8). Most were Latina (85%), had other children (70%), and were publicly insured (78%). Nearly half had received the seasonal influenza or influenza A (H1N1) 2009 monovalent vaccine. Barriers to vaccination included concerns regarding vaccine safety and efficacy, misperceptions regarding risks for influenza, and lack of provider recommendation. Pregnant women expressed interest in receiving educational text messages regarding influenza. Even women who had refused the influenza vaccine thought the text messages would encourage vaccine-related discussions during prenatal visits. CONCLUSION Among urban pregnant women, educational text messages regarding influenza would be well received and may effectively address current barriers to vaccination.

Text Message Reminders for Second Dose of Influenza Vaccine: A Randomized Controlled Trial

OBJECTIVE: To determine whether provision of vaccine-health-literacy-promoting information in text message vaccine reminders improves receipt and timeliness of the second dose of influenza vaccine within a season for children in need of 2 doses. METHODS: During the 2012–2013 season, families of eligible 6-month through 8-year-old children were recruited at the time of their first influenza vaccination from 3 community clinics in New York City. Children (n = 660) were randomly assigned to “educational” text message, “conventional” text message, and “written reminder-only” arms. At enrollment, all arms received a written reminder with next dose due date. Conventional messages included second dose due date and clinic walk-in hours. Educational messages added information regarding the need for a timely second dose. Receipt of second dose by April 30 was assessed by using χ2 tests. Timeliness was assessed by receipt of second dose by 2 weeks after due date (day 42) using χ2 and over time using a Kaplan-Meier analysis. RESULTS: Most families were Latino and publicly insured with no significant between-arm differences between groups. Children in the educational arm were more likely to receive a second dose by April 30 (72.7%) versus conventional (66.7%) versus written reminder-only arm (57.1%; P = .003). They also had more timely receipt by day 42 (P < .001) and over time (P < .001). CONCLUSIONS: In this low-income, urban, minority population, embedding health literacy information improved the effectiveness of text message reminders in promoting timely delivery of a second dose of influenza vaccine, compared with conventional text messages and written reminder only.

Parental and provider preferences and concerns regarding text message reminder/recall for early childhood vaccinations

OBJECTIVE To assess parental, provider, and medical staff opinions about text message reminder/recall for early childhood vaccination. METHODS A cross-sectional survey was conducted between January and March 2011 among 200 parents of 6-59 month-old children, 26 providers, and 20 medical staff at four academically-affiliated pediatric practices in New York City with text messaging experience. Survey questions addressed interest in, preferences for, and concerns/barriers related to vaccine-related text message reminder/recall. RESULTS Parents were primarily Latino, Spanish-speaking, and had a high school education or less. Most parents owned a text message-enabled cell phone (89%) and used text messaging services (97%). While 84% had never received health-related text messages, 88% were comfortable receiving them. Nearly all parents reported interest in receiving reminder/recall text messages, many endorsing them over phone calls and/or letters. Preferences included personalization, interactivity, and multiple messages. While 25% of parents had no concerns, 38% were concerned about incorrect numbers; only 6% worried about cost. Providers and staff were also supportive of vaccine-related text messages. Their biggest concerns were correct cell phone numbers, appointment availability, and increased call volume. CONCLUSION Text message reminder/recall for early childhood vaccination was widely supported. Important barriers were identified that should be addressed to maximize their effectiveness.

Text message reminders for timely routine MMR vaccination: A randomized controlled trial ☆

OBJECTIVE Measles-mumps-rubella (MMR) vaccination is important for preventing disease outbreaks, yet pockets of under-vaccination persist. Text message reminders have been employed successfully for other pediatric vaccines, but studies examining their use for MMR vaccination are limited. This study assessed the impact of text message reminders on timely MMR vaccination. STUDY DESIGN Parents (n=2054) of 9.5-10.5-month-old children from four urban academically-affiliated pediatric clinics were randomized to scheduling plus appointment text message reminders, appointment text message reminder-only, or usual care. The former included up to three text reminders to schedule the one-year preventive care visit. Both text messaging arms included a text reminder sent 2 days before that visit. Outcomes included appointment scheduling, appointment attendance, and MMR vaccination by age 13 months, the standard of care at study sites. RESULTS Children of parents in the scheduling plus appointment text message reminders arm were more likely to have a scheduled one-year visit than those in the other arms (71.9% vs. 67.4%, relative risk ratio (RRR) 1.07 [95% CI 1.005-1.13]), particularly if no appointment was scheduled before randomization (i.e., no baseline appointment) (62.1% vs. 54.7%, RRR 1.14 [95% CI 1.04-1.24]). One-year visit attendance and timely MMR vaccination were similar between arms. However, among children without a baseline appointment, those with parents in the scheduling plus appointment text message reminders arm were more likely to undergo timely MMR vaccination (61.1% vs. 55.1%, RRR 1.11 [95% CI 1.01-1.21]). CONCLUSION Text message reminders improved timely MMR vaccination of high-risk children without a baseline one-year visit.

MoSAIC: Mobile Surveillance for Acute Respiratory Infections and Influenza-Like Illness in the Community

Surveillance for acute respiratory infection (ARI) and influenza-like illness (ILI) relies primarily on reports of medically attended illness. Community surveillance could mitigate delays in reporting, allow for timely collection of respiratory tract samples, and characterize cases of non–medically attended ILI representing substantial personal and economic burden. Text messaging could be utilized to perform longitudinal ILI surveillance in a community-based sample but has not been assessed. We recruited 161 households (789 people) in New York City for a study of mobile ARI/ILI surveillance, and selected reporters received text messages twice weekly inquiring whether anyone in the household was ill. Home visits were conducted to obtain nasal swabs from persons with ARI/ILI. Participants were primarily female, Latino, and publicly insured. During the 44-week period from December 2012 through September 2013, 11,282 text messages were sent. In responses to 8,250 (73.1%) messages, a household reported either that someone was ill or no one was ill; 88.9% of responses were received within 4 hours. Swabs were obtained for 361 of 363 reported ARI/ILI episodes. The median time from symptom onset to nasal swab was 2 days; 65.4% of samples were positive for a respiratory pathogen by reverse-transcriptase polymerase chain reaction. In summary, text messaging promoted rapid ARI/ILI reporting and specimen collection and could represent a promising approach to timely, community-based surveillance.

Impacting Delayed Pediatric Influenza Vaccination: A Randomized Controlled Trial of Text Message Reminders

BACKGROUND Influenza vaccination coverage is low, especially among low-income populations. Most doses are generally administered early in the influenza season, yet sustained vaccination efforts are crucial for achieving optimal coverage. The impact of text message influenza vaccination reminders was recently demonstrated in a low-income population. Little is known about their effect on children with delayed influenza vaccination or the most effective message type. PURPOSE To determine the impact of educational plus interactive text message reminders on influenza vaccination of urban low-income children unvaccinated by late fall. DESIGN Randomized controlled trial. SETTING/PARTICIPANTS Parents of 5,462 children aged 6 months-17 years from four academically affiliated pediatric clinics who were unvaccinated by mid-November 2011. INTERVENTION Eligible parents were stratified by their childs age and pediatric clinic site and randomized using a 1:1:1 allocation to educational plus interactive text message reminders, educational-only text message reminders, or usual care. Using an immunization registry-linked text messaging system, parents of intervention children received up to seven weekly text message reminders. One of the messages sent to parents in the educational plus interactive text message arm allowed selection of more information about influenza and influenza vaccination. MAIN OUTCOME MEASURES Influenza vaccination by March 31, 2012. Data were collected and analyzed between 2012 and 2014. RESULTS Most children were publicly insured and Spanish speaking. Baseline demographics were similar between groups. More children of parents in the educational plus interactive text message arm were vaccinated (38.5%) versus those in the educational-only text message (35.3%; difference=3.3%, 95% CI=0.02%, 6.5%; relative risk ratio (RRR)=1.09, 95% CI=1.002, 1.19) and usual care (34.8%; difference=3.8%, 95% CI=0.6%, 7.0%; RRR=1.11, 95% CI=1.02-1.21) arms. CONCLUSIONS Text message reminders with embedded educational information and options for interactivity have a small positive effect on influenza vaccination of urban, low-income, minority children who remain unvaccinated by late fall.

Influenza vaccine effectiveness in a low-income, urban community cohort

In this community-based cohort study of 275 primarily low-income, urban households in New York City, overall 2013-2014 influenza vaccine effectiveness (VE) was 62.5% (95% confidence interval, 21.7%-82.0%). VE point estimates were highest against 2009 H1N1 and for those who were vaccinated in 2013-2014 but not in 2012-2013.

Pilot study of participant-collected nasal swabs for acute respiratory infections in a low-income, urban population.

Objective To assess the feasibility and validity of unsupervised participant-collected nasal swabs to detect respiratory pathogens in a low-income, urban minority population. Methods This project was conducted as part of an ongoing community-based surveillance study in New York City to identify viral etiologies of acute respiratory infection. In January 2014, following sample collection by trained research assistants, participants with acute respiratory infection from 30 households subsequently collected and returned a self-collected/parent-collected nasal swab via mail. Self/parental swabs corresponding with positive reverse transcription polymerase chain reaction primary research samples were analyzed. Results Nearly all (96.8%, n=30/31) households agreed to participate; 100% reported returning the sample and 29 were received (median time: 8 days). Most (18; 62.1%) of the primary research samples were positive. For eight influenza-positive research samples, seven (87.5%) self-swabs were also positive. For ten other respiratory pathogen-positive research samples, eight (80.0%) self-swabs were positive. Sensitivity of self-swabs for any respiratory pathogen was 83.3% and 87.5% for influenza, and specificity for both was 100%. There was no relationship between level of education and concordance of results between positive research samples and their matching participant swab. Conclusion In this pilot study, self-swabbing was feasible and valid in a low-income, urban minority population.