Information nudges for influenza vaccination: Evidence from a large-scale cluster-randomized controlled trial in Finland

Lauri Sääksvuori, Cornelia Betsch, Hanna Nohynek, Heini Salo, Jonas Sivelä, Robert Böhm, Lauri Sääksvuori, Cornelia Betsch, Hanna Nohynek, Heini Salo, Jonas Sivelä, Robert Böhm

Abstract

Background: Vaccination is the most effective means of preventing the spread of infectious diseases. Despite the proven benefits of vaccination, vaccine hesitancy keeps many people from getting vaccinated.

Methods and findings: We conducted a large-scale cluster randomized controlled trial in Finland to test the effectiveness of centralized written reminders (distributed via mail) on influenza vaccination coverage. The study included the entire older adult population (aged 65 years and above) in 2 culturally and geographically distinct regions with historically low (31.8%, n = 7,398, mean age 75.5 years) and high (57.7%, n = 40,727, mean age 74.0 years) influenza vaccination coverage. The study population was randomized into 3 treatments: (i) no reminder (only in the region with low vaccination coverage); (ii) an individual-benefits reminder, informing recipients about the individual benefits of vaccination; and (iii) an individual- and social-benefits reminder, informing recipients about the additional social benefits of vaccination in the form of herd immunity. There was no control treatment group in the region with high vaccination coverage as general reminders had been sent in previous years. The primary endpoint was a record of influenza vaccination in the Finnish National Vaccination Register during a 5-month follow-up period (from October 18, 2018 to March 18, 2019). Vaccination coverage after the intervention in the region with historically low coverage was 41.8% in the individual-benefits treatment, 38.9% in the individual- and social-benefits treatment and 34.0% in the control treatment group. Vaccination coverage after the intervention in the region with historically high coverage was 59.0% in the individual-benefits treatment and 59.2% in the individual- and social-benefits treatment. The effect of receiving any type of reminder letter in comparison to control treatment group (no reminder) was 6.4 percentage points (95% CI: 3.6 to 9.1, p < 0.001). The effect of reminders was particularly large among individuals with no prior influenza vaccination (8.8 pp, 95% CI: 6.5 to 11.1, p < 0.001). There was a substantial positive effect (5.3 pp, 95% CI: 2.8 to 7.8, p < 0.001) among the most consistently unvaccinated individuals who had not received any type of vaccine during the 9 years prior to the study. There was no difference in influenza vaccination coverage between the individual-benefit reminder and the individual- and social-benefit reminder (region with low vaccination coverage: 2.9 pp, 95% CI: -0.4 to 6.1, p = 0.087, region with high vaccination coverage: 0.2 pp, 95% CI: -1.0 to 1.3, p = 0.724). Study limitations included potential contamination between the treatments due to information spillovers and the lack of control treatment group in the region with high vaccination coverage.

Conclusions: In this study, we found that sending reminders was an effective and scalable intervention strategy to increase vaccination coverage in an older adult population with low vaccination coverage. Communicating the social benefits of vaccinations, in addition to individual benefits, did not enhance vaccination coverage. The effectiveness of letter reminders about the benefits of vaccination to improve influenza vaccination coverage may depend on the prior vaccination history of the population.

Trial registration: AEA RCT registry AEARCTR-0003520 and ClinicalTrials.gov NCT03748160.

Conflict of interest statement

I have read the journal’s policy and the authors of this manuscript have the following competing interests: LS, HN, HS and JS declare grants to their employer, but no personal support or financial relationship, from Sanofi Pasteur and Innovative Medicines Initiative IMI during the conduct of the study. HN and HS declare membership in the National Advisory Committee on Vaccination in Finland. CB and RB declare no support from any organization or financial relationships with any organizations that might have an interest in the submitted work. All authors declare no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1. Study regions and randomization scheme.
Fig 1. Study regions and randomization scheme.
The map in Fig 1 was created for this article in R software using open source data (CC BY 4.0) from Statistics Finland. The base layer of the map used in Fig 1 is available at Statistics Finland’s map service (https://tilastokeskus-kartta.swgis.fi/?lang=en). The R code and shapefiles to reproduce the map in Fig 1 are available at https://osf.io/v453z/. Control = no reminder, Treatment I = individual-benefit reminder, Treatment I + S = individual- and social-benefit reminder.
Fig 2. Vaccination coverage by region and…
Fig 2. Vaccination coverage by region and treatment.
Control = No reminder, Treatment I = individual-benefit reminder, and Treatment I + S = individual- and social-benefit reminder. Bar graphs denote influenza vaccination coverage. Error bars denote 95% confidence intervals.
Fig 3. Vaccination coverage by treatment in…
Fig 3. Vaccination coverage by treatment in the western region.
Panel A: Full sample (No reminder vs. Any type of reminder, pooling the I and I + S treatments); Panel B: Vaccination coverage by treatment in the western region stratified by prior vaccination status (No reminder vs. Any type of reminder). Error bars denote 95% confidence intervals.

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Source: PubMed

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