SummaryDuring a single influenza season (2010-2011), New York-Presbyterian/Columbia University Medical Center sent a series of automated text messages to predominantly low-income, Latino parents who bring their children to any of four community-based pediatric clinics affiliated with the hospital. The messages educated them about influenza and the influenza vaccine, and encouraged them to get their children vaccinated. The program led to a small but meaningful increase in the percentage of children vaccinated, including those vaccinated before peak influenza season (the most effective time to administer the influenza shot). Because the program was conducted as part of a broader effort to analyze the potential of text messaging to boost childhood immunizations, it was not repeated during the subsequent influenza season. Once the broader analysis has been completed, program leaders will decide whether to use the same or a similar program on an ongoing basis.Strong: The evidence consists of a randomized controlled trial that compared vaccination rates among children whose parents received the text messages with rates in children whose parents did not.
Developing OrganizationsNew York-Presbyterian/Columbia University Medical Center
Date First Implemented2010
Patient PopulationThe program served the parents of children who used the four clinics, roughly 43 percent of whom were Latino, 12 percent African American, and 2 percent white, with the remainder being of another or unknown racial/ethnic background.Age > Adolescent (13-18 years); Race and Ethnicity > Black or African American; Age > Child (6-12 years); Vulnerable Populations > Children; Race and Ethnicity > Hispanic/Latino-Latina; Vulnerable Populations > Impoverished; Age > Infant (1-23 months); Vulnerable Populations > Non-English speaking/Limited English proficiency; Age > Preschooler (2-5 years); Vulnerable Populations > Racial minorities; Urban populations
Problem AddressedBecause of common misconceptions, children in low-income and minority families often fail to get annual influenza vaccinations, putting them at increased risk of influenza and its accompanying problems, including missed school days and in some cases more serious illness that requires hospitalization. Text messages can serve as an effective reminder for parents to immunize their children, but they have generally not been used with annual influenza shots.
- Low vaccination rates among low-income, minority children: Timely vaccination significantly reduces an individual's risk of getting influenza and also helps prevent influenza epidemics. The Centers for Disease Control and Prevention (CDC) recommends vaccination for all children and adolescents aged 6 months to 18 years.1 Despite this recommendation, low-income children (who are at higher risk of influenza due to crowded living conditions) and minorities are less likely to be vaccinated against influenza than other children.2 Before implementation of this program, the annual influenza vaccination rate among the predominantly low-income, minority children served by the four community clinics that tested it was low.
- Driven by lack of knowledge and misconceptions: Low vaccination rates stem in large part from parents' mistaken beliefs about influenza and the influenza vaccine, including that children are unlikely to get influenza, that the illness will not be serious if they do get it, and that vaccinations can cause influenza or other serious health problems. They also may not be aware of the availability of free or discounted vaccinations.3
- Leading to missed school, more serious illness, transmission to others: Children and adolescents who get influenza commonly miss several days of school. They also are at increased risk for influenza-related morbidity, which in turn can lead to the need for hospitalization (influenza remains one of the most common causes of hospitalization in children and adolescents) and even death. In addition, school-aged children and adolescents who get influenza often transmit the disease to others, particularly those at highest risk for severe disease.4
- Unrealized potential of text messages: Text messages offer an easy, inexpensive way to reach large numbers of people, including low-income populations. In fact, one study found that 92 percent of low-income families had cellular telephones, and that 96 percent of these families could receive text messages.5 In addition, cellular telephone numbers tend to be more stable than land-line numbers and home addresses in low-income populations.6 Text message reminders have been effective in increasing pediatric and adolescent vaccination rates for three vaccines (against human papillomavirus; meningitis; and tetanus, diphtheria, and pertussis).7,8 However, before this program, they had generally not been used to encouragement for annual influenza shots.
Description of the Innovative ActivityDuring a single influenza season, NewYork-Presbyterian/Columbia University Medical Center sent a series of automated text messages to the predominantly Latino, low-income parents of children who receive care at four community-based pediatric clinics. The messages educated them about influenza and the influenza shot, and encouraged them to get their children vaccinated. A detailed description of the program follows:
- Target population: Parents could receive the text messages if they had a cellular telephone number recorded in the hospital's registration system and had 1 or more children between the ages of 6 months and 18 years who had visited 1 of the 4 clinics in the past year. Roughly 95 percent of families served by the clinics qualify for free vaccines through the federal Vaccines for Children Program.
- Immunization information system: The hospital has an immunization information system (called EzVac) that collects information on vaccine administration from the electronic health record (EHR) system used in the four clinics and from the New York Citywide Immunization Registry. As a result, this system can track any vaccine administered to clinic patients, even those received at other sites.
- Series of personalized text messages: Through a customized text-messaging platform integrated into the information system described above, parents of children who had not yet been immunized received a series of five personalized weekly, automated reminders. The first three provided educational information on vaccine safety and the seriousness of influenza infection, such as: "The flu vaccine is considered safe and protects millions of children yearly. It's a smart way to keep [child's name] healthy!" The final two messages told families about upcoming dates and times when their children could receive free vaccinations, which were offered weekly (on Saturdays) at one clinic site. Texts also included a telephone number parents could call if they had questions. Additional features designed to maximize the effectiveness of the messages are outlined below:
- Staggered start: To avoid overloading the clinic with patients during the first few Saturdays, not all parents began receiving messages at the same time. Parents of children age 6 to 23 months received their first message in early October; those with children age 2 to 4 began receiving them a few weeks later; and those with children age 5 to 18 began receiving them a few weeks after that.
- Personalized messages in English or Spanish: The text messages included the child's name and the name of the clinic, and were tailored to the child's age. For example, parents of children younger than age 5 received a message stating that: "Children age 6 to 59 months like [child's name] have the highest risk of getting sick from the flu and should be vaccinated." Parents of children age 5 to 18 received a message stating that: "Flu is often seen as mild. But 20,000 children are hospitalized yearly with flu. All children are at risk and need the vaccine." Messages appeared in either English or Spanish, according to the parent's language preference (as specified in the registration system). Text messages sent in English also included an option to automatically switch to Spanish.
- Additional messages: In January, families of children who had still not been vaccinated received two additional text messages. One reminded them about the importance of vaccination and the other provided the remaining Saturday clinic dates.
- Stopping delivery: All text messages included information on how parents could decline to receive further text messages. Also, the messages ceased once a child or adolescent had been vaccinated (as recorded in the immunization information system).
- Telephone reminders: Parents also received an automated telephone message in early November with information similar to that offered in the text messages. Also, each of the four clinic sites posted flyers advertising the Saturday vaccination clinics.
References/Related ArticlesStockwell MS, Kharbanda EO, Martinez RA, et al. Effect of a text messaging intervention on influenza vaccination in an urban, low-income pediatric and adolescent population: a randomized controlled trial. JAMA. 2012;307(16):1702-8. [PubMed]
Szilagyi PG, Adams WG. Text messaging: a new tool for improving preventive services. JAMA. 2012;307(16):1748-9. [PubMed]
Contact the InnovatorMelissa Stockwell, MD, MPH
Florence Irving Assistant Professor of Pediatrics and Population and Family Health
622 W. 168th St., VC 417
New York, NY 10032
Innovator DisclosuresDr. Stockwell reported receiving a series of grants from the Health Resources and Services Administration (HRSA), CDC, and the Agency for Healthcare Research and Quality for other work in the area of immunizations. She also reported receiving honorariums from HRSA and CDC for serving on grant review panels; in addition, information on funders is available in the Funding Sources section.
ResultsThe program led to a small but meaningful increase in the percentage of children vaccinated against influenza, including the proportion receiving the vaccine when it is most effective (before peak influenza season).
Strong: The evidence consists of a randomized controlled trial that compared vaccination rates among children whose parents received the text messages with rates in children whose parents did not.
- Meaningful increase early in influenza season: A randomized controlled trial found that 6 weeks after the program's launch, 27.1 percent of children whose parents received the text message reminders had been vaccinated, compared with 22.8 percent in a control group of children whose parents did not (a difference of 4.3 percentage points). An increase in rates at this stage can have a disproportionately positive impact, since the vaccine is more effective when administered before the start of peak influenza season.
- Sustained over whole influenza season: Six months after the program's launch, 43.6 percent of children whose parents received the text messages had been vaccinated, compared with 39.9 percent in the control group (a difference of 3.7 percentage points).
Context of the InnovationNewYork-Presbyterian/Columbia University Medical Center is a large academic hospital system affiliated with multiple outpatient clinics, including the four community-based pediatric clinics that participated in the text message pilot program. As noted, the clinics serve a primarily Latino population including many families who are Dominican; most patients are eligible for public insurance. The four clinics operate as part of a centrally administered ambulatory care network staffed by one pediatric group practice that uses a common EHR.
The impetus for this program came from a team of hospital-based researchers who wanted to boost historically low influenza vaccination rates among pediatric patients. These rates had remained low in spite of traditional mail and telephone-based reminders to parents. In 2009, the researchers began a series of studies to test the effectiveness of text message reminders on various types of childhood immunizations. After two such studies (one on the vaccine against human papillomavirus and one on the vaccination against meningitis and the combined vaccination against tetanus, diphtheria, and pertussis) produced positive results, the team decided to see if the same approach could boost influenza vaccination rates.
Planning and Development ProcessKey steps included the following:
- Securing funding: In early 2010, the research team received a grant from the Department of Health and Human Services' Maternal and Child Health Bureau (which also funded the earlier studies).
- Adapting technology: The team met with its programmer, who adapted the existing text messaging platform for the new pilot project. This programmer enhanced the platform based on input from the researchers, including making it easier to send messages, delete recipients who do not wish to receive subsequent messages, and track which families have had their children vaccinated.
- Developing text message content: The research team, which included pediatric clinicians, drafted the text messages. In addition to stressing brevity to remain below the 160-character limit for texts, the researchers wanted the messages to create a sense of urgency without coming across as pushy. Clinicians of Dominican descent helped with this effort and also helped translate the messages into Spanish.
- Tweaking messages based on informal testing: Before launching the program, researchers tested the messages' content and functionality with several parent volunteers who reviewed the messages on their cellular telephones after bringing their children in for appointments. Feedback from these parents led to minor adjustments in the phrasing of some messages.
- Conducting 1-year pilot: The researchers conducted a 1-year pilot test of the program during the 2010-2011 influenza season. The same program was not used during the 2011-2012 season because researchers wanted to test text messages with a different population—parents of children between the ages of 6 months and 18 years who had yet to be vaccinated by the middle of the fall. Depending on the results of this pilot test and other factors, the hospital may relaunch the program (or something quite similar to it) in the future.
Resources Used and Skills Needed
- Staffing: The program did not require the hiring of any additional clinic-based nurses, as existing staff provided the vaccinations during regular office hours and the Saturday clinics as part of their regular responsibilities. (The clinics were already open on these Saturdays for influenza shots so their hours did not change.) The computer programmer spent some upfront time configuring the text-messaging system. During the pilot test, a research team consisting of investigators, research staff, a programmer, and a statistician dedicated some of their time to this program.
- Costs: The upfront programming time cost roughly $7,000. Ongoing expenses include programmer time to prepare and monitor message delivery ($270 per week) and to send the text messages ($165 for 23,000 messages). The cost of vaccines is minimal because most are covered by the federally funded Vaccines for Children program.
Funding SourcesDepartment of Health and Human Services, Maternal and Child Health Bureau
The Department of Health and Human Services' Maternal and Child Health Bureau supported the project through a $866,000 grant.
Getting Started with This Innovation
- Set up system to allow collection of cellular telephone numbers: Health systems that do not already do so should include space on the standard patient registration form where parents can list their cellular telephone number(s) and indicate their willingness to receive occasional text messages.
- Include auto-response feature: Organizations that serve a large patient population will generally not be able to have a live person available to respond to parents who reply to text messages asking for further details. To avoid frustrating these parents, set up the system with an auto-reply feature that responds to such requests with a brief message that includes clinic telephone numbers and operating hours.
- Do not discontinue other efforts to boost rates: Text messages can modestly improve vaccination rates but are not likely to boost them to optimal levels on their own. As a result, pediatric clinics should continue using traditional methods of raising awareness about the importance of annual immunization, such as having physicians and nurses discuss the issue during appointments.
Sustaining This Innovation
- Coordinate closely with clinicians: Effective upfront and ongoing communication with clinic leaders can help to ensure the program runs smoothly. Clinicians need to be aware of the dates each message will go out, thus allowing them to ensure they have sufficient vaccine and staff to deliver influenza shots to all who request them.
- Update database promptly: Set up the messaging system so that parents whose children have received all their needed influenza vaccinations for that season do not receive additional reminders. Failing to do so risks confusion, since parents may think they need to bring their child in for another influenza shot. In addition, unnecessary messages may reduce the response rate for future initiatives, since parents may begin to disregard the messages.
- Consider additional uses: Once a text-messaging system is in place, it can easily be used for other purposes. For example, text messages can remind parents whose children are overdue for other types of vaccinations and/or can disseminate information about important public health issues, such as a measles outbreak.
Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011;60(33):1128-32. [PubMed]
Vlahov D, Coady MH, Ompad DC, et al. Strategies for improving influenza immunization rates among hard-to-reach populations. J Urban Health. 2007;84(4):615-31. [PubMed]
Bhatt P, Block SL, Toback SL, et al. Timing of the availability and administration of influenza vaccine through the Vaccines for Children program. Pediatr Infect Dis J. 2011;30(2):100-6. [PubMed]
Fiore AE, Uyeki TM, Broder K, et al. Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Recomm Rep. 2010;59(RR-8):1-62. [PubMed]
Ahlers-Schmidt CR, Chesser A, Hart T, et al. Text messaging immunization reminders: feasibility of implementation with low-income parents. Prev Med. 2010;50(5-6):306-7. [PubMed]
Clark SJ, Butchart A, Kennedy A, et al. Parents’ experiences with and preferences for immunization reminder/recall technologies. Pediatrics. 2011;128(5):e1100-5. [PubMed]
Kharbanda EO, Stockwell MS, Fox HW, et al. Text message reminders to promote human papillomavirus vaccination. Vaccine. 2011;29(14):2537-41. [PubMed]
Stockwell MS, Kharbanda EO, Martinez RA, et al. Text4Health: impact of text message reminder-recalls for pediatric and adolescent immunizations. Am J Public Health. 2012;102(2):e15-21. Epub 2011 Dec 15. [PubMed]
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Service Delivery Innovation Profile
Original publication: December 19, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: December 04, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.