NIHR Signal Sending patient reminders improves immunisation uptake

Published on 24 April 2018

Contacting patients by telephone or mail about recommended immunisations leads to eight more people in every 100 being immunised. Text messages, postcards or automatic dialling techniques and recorded voices are the reminder methods that have the highest certainty of being effective.

In the UK over 90% of children currently receive the recommended immunisation programme, but this is still below optimal to prevent infection. The uptake of the influenza vaccination in over 65s is also below national coverage goals.

This updated Cochrane review identified 75 studies measuring the effect of contacting patients when immunisations are due or overdue. There was evidence for improved uptake of child and adolescent vaccinations, and for adults having the influenza vaccine.

The international studies covered a variety of settings across different countries with relatively low baseline vaccination rates. The evidence reinforces the benefit of recalls and reminders.

Even small increases in vaccination uptake could make a difference in population coverage and so could have a meaningful public health impact.

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Why was this study needed?

Immunisations are important to protect individuals and communities from serious infections. People who cannot have immunisations for health reasons are protected because of the high level of immunity in the population which stops unimmunised people from coming into contact with infections. This is known as herd immunity. If the level of immunisation drops, then diseases can spread among unimmunised individuals.

In 2016-17, 93.4% of children completed the three-course immunisation for diphtheria, tetanus, pertussis, polio and haemophilus influenzae type B before their first birthday. 91.6% received the measles, mumps and rubella vaccination before their second birthday. However, these rates present a small decline on previous years. 

Uptake of the influenza vaccination among over 65s is much lower at 70.5% from September 2016 to January 2017.

This update of a Cochrane review last published in 2008 adds 28 new studies assessing how contacting patients about due (reminders) or overdue immunisations (recalls) affects uptake.

What did this study do?

This update identified a total of 75 studies, which were mostly randomised controlled trials, although five used a before-and-after design. Meta-analysis was performed for 55 studies with 138,625 participants.

Fifty-eight studies came from the USA with others from a selection of mostly high-income countries. Two came from the UK. Settings were highly varied including schools, private practices and public health departments. Twenty-nine studies examined routine childhood vaccinations, 24 adult flu vaccines and five child flu vaccines.

Thirty-two studies assessed reminder or recall letters, 10 used postcards, 14 telephone calls, six text messages and seven interventions using automatic dialling techniques with recorded messages. The remainder used a combination of interventions. Interventions varied from one-off reminders/recalls to intermittent contact over one year. Highest possibility of bias seemed to be awareness of group allocation, either at randomisation or when outcomes were assessed.

What did it find?

  • Contacting patients about due or overdue immunisations increased uptake by eight percentage points. Thirty-seven per 100 people receiving recalls or reminders were immunised compared with 29 per 100 who were not contacted (relative risk [RR] 1.28, 95% confidence interval [CI] 1.23 to 1.35). This was based on 55 studies with 138,625 participants with moderate certainty of the evidence.
  • Similar effects were seen in subgroup analyses for contacting patients about childhood immunisations (41% immunised vs. 33%; RR 1.22, 95% CI 1.15 to 1.29; 23 studies, 31,099 participants) and adolescent immunisations (31% vs 24%; RR 1.29, 95% CI 1.17 to 1.42, 10 studies, 30,868 participants), both with high certainty of the evidence.
  • There was moderate certainty that contacting patients about adult influenza vaccination was effective (38% vs 29%; RR 1.29, 95% CI 1.17 to 1.43; 15 studies, 59,328 participants). There was an even larger effect for childhood influenza vaccination, though this was based on fewer studies (65% vs 43%; RR 1.51, 95% CI 1.14 to 1.99; 5 studies, 9,265 participants).
  • By specific method, there was highest certainty of evidence for the effectiveness of post cards (RR 1.18, 95% CI 1.08 to 1.30; eight studies, 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44, six studies, 7,772 participants) and autodialer messages (RR 1.17, 95% CI 1.03 to 1.32; five studies, 11,947 participants). Telephone calls and letters are also likely to be effective based on moderate certainty evidence.

Uptake of immunisations with or without reminders

What does current guidance say on this issue?

NICE’s public health guideline on reducing the difference in uptake of immunisations in under 19s notes: “Send tailored invitations for immunisation. When a child or young person does not attend appointments, send tailored reminders and recall invitations and follow them up by telephone or text message.”

Although this guideline was published in 2009, in August 2017 a check of this guideline found no update was necessary. NICE is developing guidance on increasing uptake of influenza vaccination.

The Public Health England green book Immunisation against infectious disease does not mention reminder or recall interventions.

What are the implications?

The large body of evidence supports recommendations around recalls and reminders for child immunisations. It suggests the strategy may also benefit other age groups, such as adult influenza vaccination.

The baseline immunisation rate across these pooled international studies was fairly low at around a third, much lower than UK coverage, even with declining rates. Increased uptake by about eight percentage points could make a big difference here, but it's uncertain if this would apply to the UK.

It may be helpful to consider how reminder and recall methods can be tailored to meet the needs of specific patient groups.

Citation and Funding

Jacobson Vann JC, Jacobson RM, Coyne-Beasley T, et al. Patient reminder and recall interventions to improve immunization rates. Cochrane Database Syst Rev. 2018;CD003941.

This project was funded by the NIHR, via Cochrane Infrastructure funding to the Effective Practice and Organisation of Care Group.

Bibliography

Caan W. Telephone first consultations may discriminate against people with disabilities. BMJ. 2017;359:j4905.

NICE. Flu vaccination: increasing uptake. GID-PHG96. London: National Institute for Health and Care Excellence; in development.

NICE. Immunisations: reducing differences in uptake in under 19s. PH21. London: National Institute for Health and Care Excellence; 2009.Public Health England. Immunisation against infectious disease: the green book. London: Public Health England; 2013.

Public Health England. Seasonal influenza vaccine uptake in GP patients in England: winter season 2016 to 2017. London: Public Health England; 2017.

Khan R. Polio vaccination team ambushed and two members killed in remote tribal region of Pakistan. London: The Independent; 19 March 2018.

Screening & Immunisations Team, NHS Digital. Child vaccination coverage statistics, England, 2016-17. Richmond: Health and Social Care Information Centre; 2017.

Why was this study needed?

Immunisations are important to protect individuals and communities from serious infections. People who cannot have immunisations for health reasons are protected because of the high level of immunity in the population which stops unimmunised people from coming into contact with infections. This is known as herd immunity. If the level of immunisation drops, then diseases can spread among unimmunised individuals.

In 2016-17, 93.4% of children completed the three-course immunisation for diphtheria, tetanus, pertussis, polio and haemophilus influenzae type B before their first birthday. 91.6% received the measles, mumps and rubella vaccination before their second birthday. However, these rates present a small decline on previous years. 

Uptake of the influenza vaccination among over 65s is much lower at 70.5% from September 2016 to January 2017.

This update of a Cochrane review last published in 2008 adds 28 new studies assessing how contacting patients about due (reminders) or overdue immunisations (recalls) affects uptake.

What did this study do?

This update identified a total of 75 studies, which were mostly randomised controlled trials, although five used a before-and-after design. Meta-analysis was performed for 55 studies with 138,625 participants.

Fifty-eight studies came from the USA with others from a selection of mostly high-income countries. Two came from the UK. Settings were highly varied including schools, private practices and public health departments. Twenty-nine studies examined routine childhood vaccinations, 24 adult flu vaccines and five child flu vaccines.

Thirty-two studies assessed reminder or recall letters, 10 used postcards, 14 telephone calls, six text messages and seven interventions using automatic dialling techniques with recorded messages. The remainder used a combination of interventions. Interventions varied from one-off reminders/recalls to intermittent contact over one year. Highest possibility of bias seemed to be awareness of group allocation, either at randomisation or when outcomes were assessed.

What did it find?

  • Contacting patients about due or overdue immunisations increased uptake by eight percentage points. Thirty-seven per 100 people receiving recalls or reminders were immunised compared with 29 per 100 who were not contacted (relative risk [RR] 1.28, 95% confidence interval [CI] 1.23 to 1.35). This was based on 55 studies with 138,625 participants with moderate certainty of the evidence.
  • Similar effects were seen in subgroup analyses for contacting patients about childhood immunisations (41% immunised vs. 33%; RR 1.22, 95% CI 1.15 to 1.29; 23 studies, 31,099 participants) and adolescent immunisations (31% vs 24%; RR 1.29, 95% CI 1.17 to 1.42, 10 studies, 30,868 participants), both with high certainty of the evidence.
  • There was moderate certainty that contacting patients about adult influenza vaccination was effective (38% vs 29%; RR 1.29, 95% CI 1.17 to 1.43; 15 studies, 59,328 participants). There was an even larger effect for childhood influenza vaccination, though this was based on fewer studies (65% vs 43%; RR 1.51, 95% CI 1.14 to 1.99; 5 studies, 9,265 participants).
  • By specific method, there was highest certainty of evidence for the effectiveness of post cards (RR 1.18, 95% CI 1.08 to 1.30; eight studies, 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44, six studies, 7,772 participants) and autodialer messages (RR 1.17, 95% CI 1.03 to 1.32; five studies, 11,947 participants). Telephone calls and letters are also likely to be effective based on moderate certainty evidence.

Uptake of immunisations with or without reminders

What does current guidance say on this issue?

NICE’s public health guideline on reducing the difference in uptake of immunisations in under 19s notes: “Send tailored invitations for immunisation. When a child or young person does not attend appointments, send tailored reminders and recall invitations and follow them up by telephone or text message.”

Although this guideline was published in 2009, in August 2017 a check of this guideline found no update was necessary. NICE is developing guidance on increasing uptake of influenza vaccination.

The Public Health England green book Immunisation against infectious disease does not mention reminder or recall interventions.

What are the implications?

The large body of evidence supports recommendations around recalls and reminders for child immunisations. It suggests the strategy may also benefit other age groups, such as adult influenza vaccination.

The baseline immunisation rate across these pooled international studies was fairly low at around a third, much lower than UK coverage, even with declining rates. Increased uptake by about eight percentage points could make a big difference here, but it's uncertain if this would apply to the UK.

It may be helpful to consider how reminder and recall methods can be tailored to meet the needs of specific patient groups.

Citation and Funding

Jacobson Vann JC, Jacobson RM, Coyne-Beasley T, et al. Patient reminder and recall interventions to improve immunization rates. Cochrane Database Syst Rev. 2018;CD003941.

This project was funded by the NIHR, via Cochrane Infrastructure funding to the Effective Practice and Organisation of Care Group.

Bibliography

Caan W. Telephone first consultations may discriminate against people with disabilities. BMJ. 2017;359:j4905.

NICE. Flu vaccination: increasing uptake. GID-PHG96. London: National Institute for Health and Care Excellence; in development.

NICE. Immunisations: reducing differences in uptake in under 19s. PH21. London: National Institute for Health and Care Excellence; 2009.Public Health England. Immunisation against infectious disease: the green book. London: Public Health England; 2013.

Public Health England. Seasonal influenza vaccine uptake in GP patients in England: winter season 2016 to 2017. London: Public Health England; 2017.

Khan R. Polio vaccination team ambushed and two members killed in remote tribal region of Pakistan. London: The Independent; 19 March 2018.

Screening & Immunisations Team, NHS Digital. Child vaccination coverage statistics, England, 2016-17. Richmond: Health and Social Care Information Centre; 2017.

Patient reminder and recall interventions to improve immunization rates

Published on 18 January 2018

Jacobson Vann, J. C.,Jacobson, R. M.,Coyne-Beasley, T.,Asafu-Adjei, J. K.,Szilagyi, P. G.

Cochrane Database Syst Rev Volume 1 , 2018

BACKGROUND: Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review. OBJECTIVES: To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017. SELECTION CRITERIA: We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model. MAIN RESULTS: The 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants). AUTHORS' CONCLUSIONS: Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

Expert commentary

Immunisation is a cornerstone of health protection. However, the evidence for this review came mainly from stable, high-income countries (USA 58/75): recently in the news from Pakistan was ‘Polio vaccination team ambushed and two members killed in remote tribal region of Pakistan’. Globally, it is important to consider both factors that promote and prevent immunisation.

Benefits from the patient reminder or recall approaches to individuals (involving phone, text or post) are confirmed. While increased uptake was reported for adults and children, not all populations can be reached by these approaches, for example, those without mobile phones may be disadvantaged.

Woody Caan, Professorial Fellow of the Royal Society for Public Health