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Influenza Vaccination Text Message Reminders for Pregnant Women

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Michelle Liu

on 2 June 2014

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Transcript of Influenza Vaccination Text Message Reminders for Pregnant Women

Text Message Reminders as an aid for Influenza Vaccinations

The study seeks to evaluate the impact of influenza vaccine text message reminders in a low-income obstetric population
Study Design
The randomized controlled trial included women who initiated prenatal care at 1 of 5 multispecialty community-based clinics affiliated with an academic medical center in New York City, New York during the 2011-2012 influenza season
The study used a 2-step inclusion process
eligibility for a screening text message included
(1) having a first trimester visit between February 1 and August 15, 2011 at 1 of the 5 clinical sites
(2) having an estimated date of delivery after August 31, 2011
(3) having a cellphone number recorded on the registration system
Women meeting these criterias were sent an introductory message
The Current Situation
There are an estimated 226, 000 hospitalizations annually in the United States caused by influenza, with 3000 to 49 000 deaths annually over the past 3 decades. A study by Stockwell, Westhoff, Kharbanda, Vargas, Camargo et al. in 2014 examined the the impact of influenza vaccine text message remindrs in a low-income obstetric population. This research article focuses on a clinical/medical intervention that has successfully proven to be beneficial to the public heath. If implemented on larger scales, it should act as a regulatory system to encourage more individuals to receive the influenza vaccine.
A Critical Appraisal
After analyzing this study, I believe that the article is of good quality. The theoretical question was built upon previous research but also offers something new. The authors had previously conducted alternative studies that examined the same text messaging reminder service to a different population and had produced significant results . With the current study, it has a good potential to provide directions for future research. It also directly addresses to the real world problem of individuals (especially pregnant women) not receiving the influenza vaccination. A selection bias did exist since the text messages were only available in two languages: English and Spanish. Participants who were not fluent in either languages may have felt discouraged by the reminder service. As well, the study was completed only in a single low-income population which may have affected generalizability. Otherwise, the study was well designed and could easily be adjusted to be reused in a different context.
Influenza Vaccination Text Message Reminders for Pregnant Women
Influenza vaccination is extremely important for pregnant mothers and their newborns. This study had seek to observe the impact of text message reminders for vaccinations and had successfully obtained positive results. Although vaccination coverage is still low, coverage in the intervention group in this study was higher than national coverage during the same time period (43.2% by November 2011)
The impact of influenza vaccine text message reminders in low-income urban obstetric patients have been assessed and the study hypothesizes that these text messages would be more effective compared to usual care since most adults in the U.S. have a cell phone and cell phone use is higher in low income populations
Challenges and opportunities
Pregnant women are at higher risk for influenza morbiditiy and mortality
Although pregnant women represent a mere 1% of the U.S. population, during the H1N1 pandemic in 2009 they were at a disproportionately higher mortality risk

The Problem
Along with pregnant women, infants are also more likely to experience influenza related morbidity and mortality compared to other age groups
infants younger than 6 months of age are too young to be vaccinated
The Solution
Routine immunization of pregnant women (in all trimesters) has been recommended by the World Health Organization (WHO)
mothers who receive the vaccination during pregnancy will protect newborns through both passive transfer of immunity and by protecting the newborn from exposure by vaccinating those in close proximity
Possible Implications?
Who Else?
Although this particular study explained the need for pregnant and newborn mothers to get immunized, other populations such as young children are noticeably needing attention as well when it comes to getting vaccinated.
The Clinics
the sites routinely provide vaccination administration to pregnant women
all 5 sites used a common electronic health record (EHR)
primarily serve a publicly insured, Latina population
women who were uninsured were routinely enrolled in Medicaid (which covers vaccinations)
The Population
the intervention group received 5 weekly text messages regarding influenza vaccinations starting mid-September 2011 and two text message reminders
both groups received automated telephone appointment reminders
23.2% of women who were not vaccinated by December 31, 2011 had an influenza vaccine order written but the vaccine was never administered. This statistic did not differ between intervention and usual care groups
Women in the third trimester at randomization showed the greatest intervention effect
Text messaging services are easy to direct and utilize. When immunization data is easily accessible in a registry or EHR system, large numbers of text messages can be sent rapidly, simultaneously and inexpensively. This in turn can decrease costs compared to other methods of communication. Results from this study suggests the possibility of yielding even greater public health benefits if the service was provided at a national level
Areas to Improve
Vaccine safety fears were still found within some of the pregnant women. Despite the sent text messages had provided educational information regarding the benefits of vaccinations for both mother and child, future interventions should further emphasize on this message
Noticeable Patterns
Participants who were seen by a family medical practitioner were more likely to get vaccinated compared to those seen by obstetrics and gynecology physicians
Based on Jim Harvey's speech structures
Despite recommendations, only 47% of pregnant women in the U.S. had chosen to receive the influenza vaccine in the 2011-2012 season
Text Messaging
the implementation of text messages used as reminders to increase vaccination coverage in pediatric and adolescent populations have been proven successful in the past .
Unfortunately vaccine text message reminders have been limited for pregnant women despite their expressed interest in this type of service
The use of text messages within the study included (1) reminders for vaccinations, (2) reminded those who remain unvaccinated and (3) provided educational information about influenza and the vaccine
The Pew Research Center's Internet and American Life Project has found that cell phone ownership among adults in the U.S. has grown over 90%
Protection from influenza is especially important for individuals within low-income populations as the rate of influenza transmission is higher compared to other groups
1187 obstetric patients from the 5 clinics were enrolled
women were eligible if they had a cell phone able to receive text messages with no automated bounce response within the first 2 attempts
Messages were discontinued for a woman once she was vaccinated

Prespecified endpoints were receipt of either pre or postpartum vaccination calculated cumulatively at the end of each month (from September to December 2011)
those in the intervention group were sent 5 weekly automated text message reminders

1st Message: introductory message letting women know they were due for vaccination
next 3 messages provided educational information regarding: (1) that pregnant women and newborns are at an increased risk of contracting influenza, (2) vaccine safety and (3) vaccination is recommended by doctors
4th Message: suggested women to talk to their physicians about the vaccine during their next prenatal visit
5th Message: was interactive and asked women to select whether they would like to receive more information on influenza and vaccine misconceptions

A final message was sent to assess the satisfication of the text messaging service
Messages were written at at fourth grade level (per the Flesch-Kincaid readability statistic)
The 2011-2012 seasons was relatively mild for influenza which may have contributed to the overall lower vaccination rates
vaccinations may have been under reported (i.e. the participant may have chosen to receive the vaccination at an alternative site from the 5 chosen for this study and the vaccination information was not received)
those who responded to the satisfaction question enjoyed the service but the overall response rate was low
results may not be as generalizable because it focused on a solely on a single primarily low income population
Why getting the Influenza Vaccine is so Important
The findings of this study can easily be applied to numerous contexts. Influenza vaccination coverage is low among many different population groups not only in the U.S. but in Canada as well. Similar to the United States, the number of cell phone users in Canada are growing steadily. Text messaging has become very simple and easy to use. A text message reminder for immunizations should serve as an aid to the public health. Whether it is on a national scale or a more local scale (i.e. Ontario), findings from this study suggests potential benefit to all demographics and populations.
Looking at Canada
In 2012, only 25.3% of males and 32.3% of females in Canada were immunized. During that same year, 31.1% of reported individuals aged 12 and year had received immunization. Unfortunately these numbers are still very low.
A study by Campitelli, Inoue, Calzavara, Kwong & Guttmann (2012) looked at an urging issue in Ontario. Influenza vaccine coverage among children from 6 to 23 months of age is substantially low. Despite a universal vaccination program, full vaccination coverage for this population is less than 10% and has been declining since the 2006-2007 season .
Percentage of children aged 6 to 23 months in Ontario who have received full (dark shaded areas) or partial (lightly shaded areas) influenza vaccination coverage from the 2002-2003 to 2008-2009 influenza season
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
Looking at Our Local Context: Ontario
"Influenza Vaccine Text Message Reminders for Urban low-income Pregnant Women"
Stockwell, Westhoff, Kharbanda, Vargas, Camargo et al.
As mentioned previously, vaccination coverage is fairly low in Ontario. According to Stockwell, Westhoff, Kharbanda, Vargas, Camargo et al.'s study, pregnant women continued to fear the side effects/risks of receiving the flu vaccine . To help eliminate the myths circulating, more educational and informative text messages such be incorporated into the program/service. If individuals become more knowledgeable, the fear would subside, resulting in a higher rate of vaccination.
Busting Common Myths
Image retrieved from: http://www.medindia.net/news/healthwatch/Vaccination-During-Pregnancy-82727-1.htm
Image retrieved from: http://media.salon.com/2012/11/cell-phone-1101-620x412.jpg
Figure retrieved from: http://www.pewresearch.org/fact-tank/2013/06/06/cell-phone-ownership-hits-91-of-adults/
Statistics Canada. [Table] retrieved from: http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health102b-eng.htm
Campitelli, Inoue, Calzavara, Kwong & Guttmann (2012). Low rates of influenza immunization in young children under Ontario's universal influenza program. [Figure] retrieved from: http://pediatrics.aappublications.org/content/129/6/e1421.full.pdf
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