The Use of Technology to Promote Vaccination: A Social Ecological Model Based Framework

In light of the increased use of health information technology (IT) interventions for vaccinations, this article assesses the Social Ecological Model as a theoretical framework to map existing interventions and identify areas in which technology may be leveraged to combat undervaccination across the individual, interpersonal, organisational, community, and society levels. The authors argue that the model can be a useful analytical platform to address vaccine coverage across all populations, to examine specific barriers at each level, and to understand how interaction occurs between levels, which may help improve the impact of interventions.

The Social Ecological Model is a tool for addressing health behaviours by attributing health outcomes to factors existing on a number of levels beyond individual-level characteristics. It operates at these levels:

Individual: Text message vaccine reminders are starting to be used globally, including in low- and middle-income countries (LMICs); various studies, cited here, have demonstrated their effectiveness. Other technology-related interventions that can affect the individual domain are autodialer telephone reminders, email vaccine reminders, and mobile apps. For instance, the latter can be used by patients and families as part of personal health records (PHRs) documenting vaccinations given, including reminders for upcoming vaccinations, and/or serving as a place for trusted health information about both vaccines and the diseases they prevent. For an organisation or public health entity, such apps can also facilitate communication with patients and their communities or can be used by providers to track vaccination.

Interpersonal: Research has shown that the perceptions of families and friends regarding vaccine efficacy and safety are important. Among the conduits for exchange of vaccine information between parents and their family and friends are technological resources such as the internet (web content) and social media platforms (i.e. Web 2.0: Facebook, Twitter, Instagram, YouTube). As noted here: "A call for involvement by physicians, nurses, public health officials, and peer-reviewed research-driven organizations to provide accurate, easily and publicly accessible internet content focused on vaccine efficacy and safety may positively affect parents' conversations with their family and friends." Furthermore, "Given the influence of negative vaccine sentiments on parental vaccine perceptions, there is a need to engage healthcare professionals and organizations on social media with the goal of producing fact-based vaccine content and well-informed discussions among social network users on the interpersonal, organizational and community based-level." Several examples of such interventions are provided.

Organisational: Institutions can influence vaccination rates through the provision of clinical decision support tools, electronic health records (EHRs), and vaccine registries, as well as by fostering a workplace culture that emphasises the importance of vaccination. Other system-level interventions, such as bar coding, can also help with the documentation and tracking of vaccinations. However, more work is needed across the globe in both LMICs and high-income countries to further develop and promote the widespread use of these technologies so that can better track vaccinations given as well as supply. New technologies are continuing to emerge that can facilitate this effort, such as using blockchain as a secure way to monitor and share information.

Community: On this level, perceptions of risk of vaccine-preventable diseases (VPDs) in the community may play an important role. As reported here, the expanding use of technology for surveillance (e.g., crowd-source reporting like Flu Near You) can help provide insights into the actual burden of disease due to its capacity to capture reports of illnesses that were not treated at a medical centre. There is also new interest in using Google Trends to assess vaccination searches. Another form of vaccine-related surveillance is the use of text messages to capture vaccine adverse events (VAEs).

Society: Immunisation information systems (IIS) consolidate vaccination information across a population. While IIS are rare in LMICs, the World Health Organization (WHO) and Albania's Ministry of Health piloted and scaled up IIS that included a vaccine registry, VAE reporting, and vaccine stock management.

The authors explore the ways in which interventions can act across levels. For example, "when developing and testing a vaccine educational and interactive app, it would be important to consider the overlap of introducing push notifications between the user (individual) and their affiliated healthcare center's EHR and PHR (organizational). Will the push notifications be only for vaccine reminders or for educational purposes or both? If the app provides educational information, will the user have the ability to 'post' this information on their social media platforms to ask questions or share with friends (intrapersonal)? Once a user receives their vaccine it will be important for the app creators to map how this information will upload from the EHR to the local IIS to ensure maximally successful data exchange, usage and limit 'false positive' vaccine alerts (society)."

The authors suggest some next steps:

• Increase both the use and interactivity of text messages or email as part of a reminder-recall system across organisations.
• Ensure that medical and public health communities foster a coherent, effective social media presence that is characterised by clear and effective communication; this has the potential to positively change vaccination conversations online.
• Pursue novel forms of surveillance, including via text message, social media, and internet searches, which may extend the capacity to document the full disease burden in a community; this may have implications for educational counseling, focused anticipatory guidance, or campaigns regarding disease risk.
• Maximise the utility of EHRs and IIS through bidirectional data exchange with city and state run registries, which can minimise missed vaccination opportunities through clinical decision support tools.
• Create a national vaccine registry that includes data from all state registries, which could have a real public health impact for an increasingly mobile population.

In conclusion: "In the evaluation of technologic interventions for the improvement of vaccine coverage, education, communication, or data collection, researchers and practitioners may find that using this framework is helpful to better understand implications on each level and whether the approach is comprehensive."