Introduction: Seasonal influenza is associated with approximately 290,000–640,000 deaths worldwide each season, and impacts approximately 21 million people in the United States annually, resulting in significant public health and economic burdens. Preventing viral illnesses such as influenza is truly a global concern, given the potential for transmission in a modern, global culture, with this global risk and impact having been emphasized by the ongoing COVID-19 pandemic. People with diabetes (PWD), face increased risks from influenza, including poor glycemic control, pneumonia, premature death, acute cardiovascular complications, and hospitalizations which may result in a significant burden to the personal costs of healthcare for PWD. Vaccination remains the most effective primary prevention method against influenza, with effectiveness ranging from 29 to 48%. Vaccination for influenza in PWD is effective in reducing the risk of hospitalizations and mortality, as well as the overall cost of hospitalizations. Influenza vaccination has also been shown to be safe for PWD and does not impact an individual’s ability to engage in daily activities in the days following vaccination5,7,9. However, vaccination rates remain suboptimal, consistently falling under the 70% vaccination rate goal set by national guidelines for all individuals in the United States. In 2015 in the United States, 61.6% of adults with diabetes received an influenza vaccine. During 2016–17, national rates of influenza vaccination were approximately 40% in adults without any high risk conditions, and 59.7% for adults with a variety of high risk conditions (including diabetes).
Therefore there is a need for effective and scalable solutions to increase influenza vaccination rates in PWD. While a number of randomized controlled trials (RCTs) have assessed the effectiveness of interventions for increasing influenza vaccination rates, many have focused on other age groups or populations. One prospective digital interventional study demonstrated the potential effectiveness of general messaging and incentives via a health-related smartphone application (app) to increase vaccine uptake in a general Canadian population, suggesting this kind of intervention could be effective in PWD. A large RCT using digital messaging was also effective in increasing vaccination rates in the general population of adults in the United States. The use of health information technology (e.g., searching the internet for health information, emailing providers) and even simple electronic reminders delivered via digital patient portals have resulted in increased influenza vaccination rates, suggesting the potential of simple digital solutions. One of the primary reasons PWD report not getting vaccinated is a belief that they are not in a high-risk group, and providing education on the increased risk of negative health outcomes following influenza infection has shown promise in increasing vaccination rates in other populations. Additional reasons include fear of adverse reactions, difficulties with accessing the vaccine (e.g., time, health center access), or other beliefs surrounding the influenza vaccine (e.g., not effective, transmits the flu). Therefore, digital messaging that counters this lack of knowledge and barriers to vaccination could be effective for increasing uptake.
The aim of this study was to evaluate the effectiveness of a digitally administered intervention to increase influenza vaccine rates for PWD using a decentralized, blinded RCT. The primary endpoint was to examine the difference in self-reported influenza vaccination rates in 2 groups: PWD who received a digital intervention (PWD-I) and PWD who received no intervention (PWD-C). The following exploratory associations were also examined: (a) the impact of engagement with interventions on the influenza vaccination; (b) the impact of the timing of the intervention messages during influenza season on influenza vaccination status; (c) the reported level of influence on getting the influenza vaccine by each intervention message type within the PWD-I group; (d) the level of engagement with each intervention message within the PWD-I group; and (e) the impact of a healthcare worker’s recommendation on getting the influenza vaccine.
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