Can Text Messages to Patients’ Parents Boost Influenza Immunization Rates?

Jessica Tomaszewski, MD

Stockwell MS, Hofstetter AM, DuRivage N, et al. Text message reminders for second dose of influenza vaccine: a randomized controlled trial. Pediatrics. 2015;135(1):e83-e91.

As pediatric health care providers, we work to find novel ways to improve influenza vaccination rates every year. Children younger than 9 are especially vulnerable to the flu, and they are at particular risk for undervaccination since they may require 2 doses in a given season. Nationally, 56.6% of children aged 6 months to 17 years receive at least one dose during the flu season. Still, only 40% to 60% of these children receive the second dose needed to prevent undervaccination.

With this in mind, Stockwell and colleagues attempted to determine whether text messages improved the reminder recall system for patients’ second dose of the influenza vaccine.1 Traditional contact methods (eg, mail, phone) have very little proven efficacy in low-income, minority patients, but text messaging seems more effective among this population.2 Texts are being used increasingly as a means of communicating with patients, and this study looked at the potential benefits of educational texts to help with influenza vaccine coverage.

The researchers conducted a randomized, controlled trial during the 2012–2013 influenza season at 3 community-based pediatric clinics. These sites primarily serve a Latino population, and the majority of the clinics’ patients are eligible for free vaccines through the CDC. Eligible participants were families of children between 6 months and 8 years at vaccination who received the first dose of the flu vaccine at a study site. Participating families had to have a cell phone that could receive texts, and their health literacy was assessed before initiation.

The authors randomly assigned 660 participants into 3 arms: those receiving a written reminder only, those receiving a “conventional” text plus a written reminder, and those receiving an “educational” text plus written reminder. The educational texts included information about the second dose, such as its timing and the time needed to reach full protection against influenza. Parents could choose to receive more information if desired.

Children in the educational text reminder group were significantly more likely (72.7%) to receive a second dose of the influenza vaccine within the period specified by the study than were children in the conventional text reminder group (66.7%) or the written reminder only group (57.1%). Moreover, children in the educational text group were more likely to receive the vaccine within 2 weeks of its due date.

Parents were surveyed afterwards, and the vast majority (98%) said they were satisfied or very satisfied with the text reminders. More than half (60.8%) said that the text was either the main reason or part of the reason they brought their child for a second dose, and 70.1% said it prompted them to bring their child sooner. Of the 220 families in the educational arm, 34 (15.7%) responded to the text to ask for more educational material.

We strive to empower our patients’ families with education to help them make healthy decisions for their children, and the most effective means might involve interactive technology such as text messaging. Worth noting is that parents who were most likely to return for their child’s second dose of the vaccine (and in the most timely manner) received more educational information. While the effectiveness of text message reminders for patients needs more exploration, it is a promising way to ensure adherence and continuity of care.

Jessica Tomaszewski, MD, is an assistant clinical professor of pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania, and a hospitalist pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Charles A. Pohl, MD—Series Editor, is a professor of pediatrics, senior associate dean of student affairs and career counseling, and associate provost for student affairs at the Sidney Kimmel Medical College at Thomas Jefferson University.


1. Stockwell MS, Hofstetter AM, DuRivage N, et al. Text message reminders for second dose of influenza vaccine: a randomized controlled trial. Pediatrics. 2015;135(1):e83-e91.

2. Stockwell MS, Kharbanda EO, Martinez RA, Vargas CY, Vawdrey DK, Camargo S. Effect of a text messaging intervention on influenza vaccination in an urban, low-income pediatric and adolescent population: a randomized controlled trial. JAMA. 2012;307(16):1702-1708.