# Narrative Reminder Recall to Improve Pediatric Influenza Vaccination: A Pilot Randomized Clinical Trial

## TL;DR

A text message-based digital storytelling intervention for caregivers improved pediatric influenza vaccination rates, though few caregivers watched the stories.

## Contribution

This pilot trial demonstrates the feasibility and potential effectiveness of narrative-based digital stories in improving vaccination rates in underserved communities.

## Key findings

- 100% of text messages were successfully delivered to caregivers in the intervention group.
- Children of caregivers in the intervention group were 63% more likely to be vaccinated compared to those in usual care.
- Digital stories were viewed by only 7% of caregivers, indicating limited reach despite improved vaccination outcomes.

## Abstract

This pilot randomized clinical trial examines the reach of a text message–based digital story intervention for caregivers to encourage pediatric influenza vaccination.

Is a text message and digital storytelling intervention for caregivers to address influenza vaccination in children feasible?

In this pilot randomized clinical trial with 200 children and 198 caregivers in a safety-net health system during the 2024-2025 influenza season, 100% of texts reached intervention caregivers, and 7% of caregivers watched 1 or more digital stories. Children of intervention recipients were 63% more likely to be vaccinated compared with children of caregivers receiving usual care.

In this pilot randomized clinical trial, a cocreated, text message storytelling intervention was associated with improved pediatric influenza vaccination coverage, but digital stories had limited reach.

Seasonal influenza causes morbidity and mortality in vulnerable communities. Narrative reminder recall (ie, digital stories using multimodal narratives that uplift community voices) may be scalable as an equity-promoting intervention to increase vaccination rates.

To assess (1) the reach of texts with pediatric influenza vaccine digital stories among caregivers of young children and (2) associations of caregiver intervention assignment with time to child influenza vaccination.

This pilot randomized clinical trial included caregivers and their children (aged 6 months to 5 years) from 2 safety-net clinics in historically Black neighborhoods in Denver, Colorado between September 16, 2024, and March 31, 2025. Caregivers aged 18 years and older who preferred English and their children, provided they had 1 well visit in the past 18 months and would be aged 6 to 71 months during the influenza season, were included.

The digital storytelling intervention included texts with links to 5 stories (3 featuring caregivers who identified as Black or African American) sent in October 2024. Usual care included 1 message sent via an electronic health record messaging portal to caregivers of all children eligible for influenza vaccines.

The primary outcome was digital story reach (ie, the proportion of caregivers viewing 1 or more digital stories for any length of time). Time to first influenza vaccination was recorded for children. Adjusted Cox proportional hazards modeling (with 95% CI) fit time to vaccination by group and baseline covariates. Kaplan-Meier curves analyzed the proportions of children remaining unvaccinated by group over time.

Intention-to-treat analyses included 200 children (100 per group; mean [SD] age, 29.1 [16.1] months; 96 male [48%]; 77 Black or African American [39%]; 90 Hispanic or Latino/a [45%]; 54 White [27%]) and their 198 caregivers (100 usual care; 98 intervention; mean [SD] age, 30.5 [7.5] years; 176 mothers [89%]; 77 Black or African American [39%]; 87 Hispanic or Latino/a [44%]; 25 White [13%]). Overall, 686 of 686 texts (100%) were delivered; digital stories were viewed by 7 caregivers (7%). More children of intervention caregivers were vaccinated when influenza activity peaked on February 15, 2025, (percentage unvaccinated, 62% [95% CI, 53%-72%] in intervention vs 74% [95% CI, 66%-83%] in usual care; Z test, 1.82; P = .03). In adjusted analyses, children of intervention caregivers were 63% more likely to be vaccinated compared with children of caregivers receiving usual care (adjusted hazard ratio, 1.63; 95% CI, 1.01-2.64).

In this pilot randomized clinical trial of a text message digital storytelling intervention centering Black families, intervention receipt was associated with improved pediatric influenza vaccination, although intervention reach was low.

ClinicalTrials.gov Identifier: NCT06274359