Programs that Work
Healthy and Safe Children
Children experiencing good physical health
Age of Child
Early Childhood (0-8)
Type of Setting
Health Care Provider
Type of Service
Health Care Services
Type of Outcome Addressed
Evidence Level (What does this mean?)
FluText is a text messaging intervention that sent automated vaccination reminders to parents of children and adolescents aged six months to 18 years. The goal was to encourage seasonal influenza vaccination by educating parents about influenza vaccine safety and the seriousness of influenza infection among children and adolescents, providing recommendations for influenza vaccine uptake among children and adolescents, and informing parents about upcoming influenza vaccine clinics at their child's health care facility (Stockwell et al., 2012).
FluText has been used among parents of children and adolescents aged six months to 18 years, though it has been found to be effective at increasing influenza vaccine uptake only among children aged six months to less than five years. (Stockwell et al., 2012).
Stockwell et al. (2012) assessed the effect of FluText on receipt of seasonal influenza vaccine. Researchers utilized EzVac, an institutional immunization information system that automatically collects electronic vaccine administration on patients from the four study sites as well as from New York's Citywide Immunization Registry.
The four study sites were four clinics affiliated with New York-Presbyterian Hospital and Columbia University Medical Center (Stockwell et al., 2012). The clinics serve a population that is predominantly Latino and eligible for free vaccines through the federal Vaccines for Children Program. Children and adolescents aged six months to 18 years as of September 28, 2010, who had attended one of the four clinics in the past 12 months and had a parental cell phone number recorded in the hospital registration system were eligible for the evaluation. All eligible children aged six months to less than five years were randomized to intervention or control groups. A random sample of eligible children aged five to 18 years was also selected for randomization to intervention or control groups. (Not all children age 5-18 years were included due to clinic capacity constraints.) Randomization was stratified by age group and clinic to ensure an equal distribution of children in the intervention and control groups by age and clinic.
The baseline intervention consisted of a series of five weekly text messages sent to the cell phones of parents of children in the intervention group. The first three messages provided educational information on vaccine safety and the seriousness of influenza infection in children. The last two messages recommended that the target child receive the influenza vaccine and provided information about flu vaccine clinics held each Saturday from October through March at their health care clinic. If the target child was vaccinated before all five text messages were sent, the text messages were discontinued. Finally, if the target child remained unvaccinated by January 2011, two additional text messages were sent regarding the recommendation to receive the influenza vaccine and the remaining Saturday vaccine clinic dates. All text messages were sent in either English or Spanish based on the parent's preferred language recorded in the clinic electronic medical record. Both parents of children in the control group and the intervention group received standard care, which included an automated telephone message sent at the beginning of November 2010 providing information on the seriousness of influenza, vaccine safety, and information on the Saturday vaccine clinics. Flyers advertising the Saturday vaccine clinics were also posted at the four clinic locations.
Randomized children who had received the influenza vaccine before October 2010 (the initiation of the study) were excluded from the analyses. In total, 9,213 children and their parents were included in the evaluation. There were 4,607 participants randomized to the intervention group and 4,606 participants randomized to the control group. Of these, 817 intervention group participants and 822 control group participants received the influenza vaccine prior to the start of the intervention, leaving 3,790 participants in the intervention group and 3,784 participants in the control group. There were no significant differences between intervention and control group participants on demographics (age, sex, race, insurance status, primary language, or clinic site) or prior influenza vaccination.
Key Evaluation Findings
Stockwell et al. (2012) found the following:
- Among children aged 6-23 months, significantly more intervention children were vaccinated for influenza by the end of the influenza season (March 31, 2011) compared with children in the control group (58.5 versus 52.3 percent).
- In addition, among this age group, significantly more children in the intervention group were vaccinated for influenza by the fall target date established by the Centers for Disease Control and Prevention's (CDC's) recommendations (November 30, 2010; 38.6 versus 32.0 percent).
- Among children aged two years to less than five years, significantly more children in the intervention group were vaccinated for influenza by the end of the influenza season compared with children in the control group (46.0 versus 42.2 percent) and by the fall target date established by the CDC's recommendations (December 15, 2010; 28.5 versus 23.9 percent).
- Within this age group, significantly more children in the intervention group were vaccinated for influenza by the fall target date (December 15, 2010; 28.5 percent versus 23.9 percent).
- Among children aged five to 18 years, there was no statistically difference in influenza vaccine uptake between intervention and control group participants by the end of the influenza season (27.8 versus 25.7 percent).
Health care providers, local public health agencies
The evaluation conducted at New York-Presbyterian Hospital and Columbia University was funded by a research grant from the Health Resources and Services Administration's Maternal and Child Health Bureau. Other potential funding sources include the National Institutes of Health (NIH) and the CDC, as well as foundation sources.
FluText is a text messaging intervention that involves sending a series of five weekly text messages to parents at the beginning of the influenza season. The text messages provide information regarding vaccine safety and the seriousness of influenza among children and adolescents, a recommendation for the target child to be vaccinated for influenza, and information on Saturday vaccine clinics at the child's health care provider.
Staff may be required to develop the content of the reminders to ensure that the messages are appropriate to the target community. For study purposes, these were developed with community input through focus groups and in-depth interviews. However, once developed, FluText messages are automated and thus additional staff are not required to send them. The configuration of the text messaging system does require a programmer to set up the automated messages and to monitor the system.
Issues to Consider
The evaluation (Stockwell et al., 2012) was conducted among families attending clinics at New York-Presbyterian Hospital and was a randomized evaluation in which children and their parents were assigned to receive FluText text messages or standard care. This study included children aged six months to 18 years. The intervention was found to effective in increasing influenza vaccine uptake among children at greatest risk for poor outcomes following infection with seasonal influenza: children aged six months to less than five years. However, the intervention was effective among children aged 5-18 years. This study was conducted in an urban setting with a predominantly low-income population. Ninety-five percent of the population treated was eligible for free vaccines through the Vaccines for Children program. FluText has not been evaluated in other settings.
It is important to note that this intervention was not accompanied by any apparent expansion of capacity for influenza vaccination at the four clinic sites. Therefore, to avoid overwhelming the clinic, not every family was made aware of every clinic date. This may have resulted in a lower observed effect of this intervention.
Finally, parents were notified about special Saturday flu clinics. However, these special clinics were not necessarily held at children's regular clinic site. Improved alignment in this area may have an impact on the effect of this intervention.
The evaluation of FluText described here was conducted by the same group of researchers who designed the Text4Health text messaging intervention.
New York-Presbyterian Hospital and Columbia University
Stockwell, Melissa S., Elyse Olshen Kharbanda, Raquel Andres Martinez, Celibell Y. Vargas, David K. Vawdrey, and Stewin Camargo, "Effect of a Text Messaging Intervention on Influenza Vaccination in an Urban Low-Income Pediatric and Adolescent Population,"
Journal of the American Medical Association,
Vol. 307, No. 16, 2012, pp. 1702-1708.