>> This means that Germany is far away from the WHO and EU vaccination target, according to which more than 90% girls should be fully vaccinated by 2030. In the individual age groups of 9 to 17-year-old boys, no more than 6% had completed the HPV vaccination in the same survey period (Rieck et al. 2021a). The Covid-19 pandemic has increased the existing vaccination gaps regarding the HPV vaccination. The number of HPV initial vaccinations billed beyond practice requirements fell by 13 percentage points among the 800,000 DAK insured people in 2020 alone (Witte et al. 2021).
The use of vaccines in adults also has potential to increase. The WHO's target of a vaccination rate of 75% for influenza vaccination among seniors was not achieved with a nationwide vaccination rate of 47.3% in the last survey period 2020/21 (Rieck et al. 2021b). This results in a discrepancy between the high acceptance of vaccinations and the actual vaccination rates among children, adolescents and adults. The phenomenon of “vaccine fatigue” or “vaccine hesitancy” describes the delay, omission or refusal of vaccinations despite available vaccines and offers (Heinemeier et al. 2021; MacDonald 2015). However, this term has a certain vagueness as it suggests psychological hesitation. However, vaccinations are not taken up due to insufficient information or poor accessibility of the target group (Betsch et al. 2019b).
How vaccination management could be improved was discussed at the 12th MSD Health Forum on September 14, 2022 on the topic of “Shaping innovative care together”. The forum offers an annual opportunity for dialogue to promote the progress of a future-proof healthcare system. Current health-related topics are discussed in various panel discussions and forums.
One of the forums addressed the question of the extent to which target groups could be better reached in everyday life in order to increase vaccination rates. The focus was particularly on how digital tools can support patients and doctors. Dr. Dr., among others, spoke on the topic of vaccination fatigue after two years of the corona pandemic.
Michael Hubmann, specialist in pediatric and adolescent medicine, medical director of the vaccination center in Fürth and member of the federal board of the professional association of pediatricians and adolescent doctors (BVKJ eV).
Evaluation of the
Corona vaccination campaign
In order to get an overview of the current mood, the participants in the MSD Health Forum were asked for their assessment of the success of the Corona campaign. A majority of the participants (37%) only gave this school grade “sufficient”. According to data from the vaccination dashboard published by the Federal Ministry of Health, 18.4 million people (22.2% of the population) in Germany have not yet been vaccinated (as of October 21, 2022). However, there is still no approved vaccine available for 4.0 million of these people (4.8%) aged 0 to 4 years. This results in 82.7% agreeing to the vaccination (Impfdashboard.de 2022). Compared to the vaccination rates for other vaccinations, this can be considered quite successful. Nevertheless, the lower proportion of vaccinated people with booster vaccinations shows that motivation in the population is increasingly decreasing (Fig. 1).
But what are the reasons for this increasing vaccination fatigue and the public's critical perception of the vaccination campaign? Dr. Hubmann sees the failed communication as the main cause. After the initial phase, it was no longer possible to reach the population with understandable and targeted messages. The ongoing high burden on healthcare workers also means that there is less capacity available for preventative measures and interventions to increase vaccination rates. Other reasons include the inadequate networking of the health system and the fragmentation of institutions and responsibilities. The many existing institutions should therefore be better networked in the future. Due to the lack of communication in the health system and the lack of simple and understandable messages to the population, sufficiently high vaccination rates could otherwise not be achieved.
Individual reasons for
the vaccination decision
In order to conduct target group-appropriate and -specific communication, it is important to better understand the individual reasons for the vaccination decision. These are complex and context-specific, meaning they vary across time, space and the vaccine in question. Psychological reasons for the vaccination decision can be explained in the so-called “5C model” according to Betsch et al. (2019b) can be summarized. In addition to trust, risk perception, weighing up risks and benefits and social willingness, this also includes barriers and structural hurdles. People who perceive higher practical barriers have been vaccinated less in recent years. Reducing these should therefore be the starting point for further interventions.
From the pediatrician's perspective, doctors and their vaccination recommendations also play a central role in the decision to get vaccinated. In the current representative survey by the BZgA, the most frequently cited reason for receiving a vaccination was the advice of doctors (Seefeld et al. 2022). According to Dr.'s experience, other influencing factors can Hubmann's previous knowledge and experience from his personal environment. The internet and social media also play a role. The spread of misinformation can strengthen negative attitudes towards vaccinations, as websites critical of vaccinations appear increasingly professional and thus suggest scientificity (Betsch et al. 2019b). The BZgA survey also surveyed the reasons for skipping vaccinations. One in five people said they had not taken advantage of vaccinations in recent years. Of these, 36% of those surveyed gave the reason that they did not consider the disease against which they were to be vaccinated to be particularly serious. Thanks to the success of vaccinations, infectious diseases occur less frequently, meaning that their dangers are regularly underestimated. In the survey, a further 32% stated that they had missed or forgotten the vaccination appointment (Seefeld et al. 2022).
Untapped potential of the
digitalization
While only a small percentage of the population is negative about vaccinations, a large proportion can be easily reached with targeted communication and education as well as low-threshold offers. Above all, the doctors who primarily vaccinate must be involved. However, in order to increase vaccination rates, sufficient capacity must be maintained or created in medical practices. The usual routines in everyday practice regarding vaccinations should therefore be reconsidered in order to create more efficient processes. At the same time, the barriers to participation in vaccinations for patients should be kept as low as possible and low-threshold access should be enabled. The digitalization of the healthcare system offers untapped potential for this. Systematic appointment reminders and digital appointment systems can relieve both the tension between families and employees in the healthcare system (Heiden et al. 2021; Betsch et al. 2019a).
Vaccination reminder systems are intended to prevent vaccinations from being forgotten and to achieve better vaccination rates. In a systematic review by Jacobson Vann et al. (2018), the effects of different reminder and recall systems on vaccination rates were examined. 75 studies from 10 different countries were included. A vaccination reminder increased the number of people vaccinated by an average of eight percentage points, depending on the age of the person, the type of vaccine and the reminder system.
In contrast to telephone or postal reminders, digital vaccination management systems offer a variety of advantages for practice employees. The time and organizational effort for the medical assistants (MFA) is significantly reduced by automatic sending, data protection-relevant procedures can be adhered to and the costs for the practices also fall. This means that existing and increasingly scarce resources can be better used by employees in the healthcare system and efficiency can be increased.
Digital vaccination reminder systems can, according to a meta-analysis by Atkinson et al. (2019) increase the chance of receiving a vaccination or completing a vaccination series relative to non-digital ones (OR= 1.18; 95 % CI1.11–1.25). This is especially true for parents who receive digital reminders for their children's vaccinations. In addition to improving vaccination rates as a quantitative target, the patient-related quality of care can also be improved. By sending patient information about vaccinations via digital applications, patients' health literacy can be strengthened (Dumit et al. 2018).
However, vaccination recall systems are currently not being used across the board by established practices. A qualitative study on the relevance of recall systems using the example of the HPV vaccination showed that use by practices and patients is currently still low. The study saw added value in linking recall systems with digital appointment allocation in order to increase efficiency and counteract reduced effectiveness due to a media disruption (Zettl et al. 2022).
The PraxisApp as an example
digital vaccination management
The professional association of pediatricians and adolescent doctors (BVKJ eV) introduced the practice app “My pediatrician and adolescent doctor” in 2014, which is now used by 1,771 pediatricians. Currently, 638,163 children are connected to their treating pediatricians and adolescents via the PraxisApp (as of October 21, 2022). In 2018, the BVKJ eV app was nominated for the MSD Health Prize for special innovations in healthcare. With the award, MSD honors particularly outstanding health solutions and promotes their implementation and further development. One goal of the joint cooperation between BVKJ-Service GmbH and MSD is to further scale and promote the app, to jointly develop the vaccination reminder system and to provide patient parents with vaccination profiles for all STIKO-recommended vaccinations created by the BVKJ Prevention Committee. The contribution of automated, digital vaccination reminders to vaccination willingness is part of a current evaluation by the BVKJ.
In addition to vaccination management and online appointment management, the app offers many other functions. For example, potentially harmless symptoms can be quickly clarified through the KBV-certified video consultation, which can also be billed according to EBM. A chat function offers employees in practices the advantage over the telephone in that they can process inquiries according to their own time management. Digital diaries for monitoring patients are also part of the app.
Since November 2021, patients and their parents have been able to receive automatic reminders for all STIKO-recommended vaccinations via the app. At the same time, information about the respective vaccination is sent with each reminder. This takes the form of a vaccination profile that is based on the STIKO recommendations. This is intended to provide early information and prevent misinformation. If STIKO recommendations change, the information flyers will be adjusted promptly so that the information is always up to date. Using the online appointment booking system, parents can make low-threshold appointments for a vaccination, regardless of the practice opening hours. This also has the advantage for the MFA that telephone appointment requests are significantly reduced and this creates relief. Parents are informed about data protection-relevant processes when registering the app and must actively consent to these, so that an external data comparison between existing patients and new patients is no longer necessary.
With each vaccination reminder, parents are also sent a query to enable the creation of a vaccination record. The data will be used to evaluate automated vaccination reminders for vaccination rates and timely vaccinations. In the further course, an evaluation of the data on the HPV vaccination is planned together with the KV.
The role of the GKV
According to Section 132e SGB V, the health insurance companies conclude contracts with, among other things, the statutory health insurance associations and doctors regarding the implementation of protective vaccinations. According to paragraph 4, the aim is to increase the vaccination rates “for the vaccinations recommended by the Standing Vaccination Commission at the Robert Koch Institute in accordance with Section 20 Paragraph 2 of the Infection Protection Act”. Accordingly, in addition to doctors, health insurance companies in particular are called upon to counteract vaccination fatigue through selective contracts and new offers. In a resolution of the Conference of Health Ministers (GMK) on June 16, 2021 regarding the HPV vaccination, the health insurance companies were asked to establish or further develop vaccination reminder systems for their insured persons. In addition to the BMG, the National Association of Statutory Health Insurance Physicians (KBV) and as part of the continuing education offers of the medical associations, these are intended to "work towards supporting standardized vaccination management in doctors' practices as well as the establishment of an electronic vaccination certificate with an evidence-based vaccination reminder function" (GMK 2021) .
As part of the MSD Health Forum, the BKK Bavarian regional association's experiences with digital applications were explained. 57 BKKs have concluded the selective contract “BKK STARKE KIDS” with BVKJ Service GmbH. To this end, BVKJ eV's PraxisApp was included in its health program and selective contract in order to promote a hybrid care model. The vaccination schedule for the HPV vaccination could be steered from the triple vaccination to the earlier and therefore more efficient double vaccination schedule through the greater advisory involvement of pediatricians. A greater focus by health insurance companies on hybrid care models could further increase the use of digital applications in medical practices.
Successful digitalization
drive solutions forward
But how can the successes of digital campaigns and applications in the field of pediatric and adolescent medicine be transferred to other target groups and vaccinations? The implementation of vaccination reminder systems for vaccinations in adults is quite promising. Because these vaccinations are no longer performed routinely, as are vaccinations during childhood checkups, it is more difficult to remind adults about vaccinations during doctor's visits. Although checking the vaccination status is in theory part of the preventative check-ups
is, the vaccination rates as well as the BZgA survey show that there is still considerable potential for improvement (Neufeind et al. 2020). In order to prevent vaccinations from being forgotten or delayed, these
digital vaccination reminder systems are helpful
rich tool.
According to Dr. Hubmann various reasons. For a successful transformation of the healthcare system, the benefits and security of digitalization in particular must be recognizable. “Digitalization is successful when it brings benefits for patients and those working in the healthcare system,” concluded Dr. Hubman. There are currently still numerous hurdles in the digitalization of the healthcare system. Unreadable health insurance cards or a lack of integration options for digital applications into everyday practice and the practice software often prevented things from running smoothly. Without clear digital patient allocation, data could not be integrated and compiled. Therefore, no change can be achieved with the existing systems. Instead, the courage must be found to rebuild it from scratch, demanded Dr. Hubman.
The WHO has already announced the “European Vaccine
Action Plan” for 2015 to 2020
an electronic vaccination register is recommended (WHO 2014). In terms of implementation, the German healthcare system lags far behind the existing technical possibilities. International experience shows how digital applications can be more closely integrated into the healthcare system. In countries such as Finland or Sweden, where an electronic patient record and a national vaccination register already exist, data can be linked more easily and evaluated and verified nationally. This opens up further opportunities to promote and better monitor vaccination rates. In Denmark, a national reminder system for child vaccinations has existed since 2014, which sends reminders to parents (Heiden et al. 2021).
Conclusion
In summary, from the following
The MSD Health Forum noted that the corona pandemic has certainly led to greater public awareness of vaccinations. One way to continue to counteract vaccination fatigue and better reach target groups is to use digital vaccination reminder systems. The digitalization solution presented and consistently developed to meet the needs of practices and patients, in conjunction with well-planned networked communication, could help to demonstrably improve the vaccination rates in Germany, which are still too low. The benefits of vaccination reminder systems for increasing vaccination rates and improving health literacy have already been confirmed in numerous studies. In addition, digital applications can be used to relieve the increasingly scarce resources of healthcare workers. Digitalization in vaccination management is therefore one of the cornerstones for greater efficiency in the healthcare system and a way to provide better care for the population. <<
from:
Nora Wisniowski, MPH 1,
Prof. Dr. Clarissa Kurscheid 1,
Andreas Suck 2,
Dr. Michael Hubmann 3

¹ figus GmbH Priv. Research Institute for Health and System Design, Cologne
² MSD Sharp & Dohme GmbH, Munich
³ Specialist in pediatric and adolescent medicine, neuropediatrics, pediatrician Zirndorf

Correspondence address:
Prof. Dr. Clarissa Kurscheid
figus GmbH Priv. Research Institute for Health and Systems Design
Domstrasse 55-73 / 50668 Cologne
Email: [email protected]

Atkinson, KM/Wilson, K./Murphy, MSQ/El-Halabi, S./Kahale, LA/Laflamme, LL/El-Khatib, Z. (2019): Effectiveness of digital technologies at improving vaccine uptake and series completion - A systematic review and meta-analysis of randomized controlled trials. In: Vaccine 2019, 37, 23: 3050–3060
Betsch, C./Breuer, C./Hacker, J./Happe, K./Hecker, M. (2019a): Building protection together. Behavioral science options for increasing vaccination uptake. Ed. National Academy of Sciences Leopoldina and Academy of Sciences in Hamburg. In: https://www.leopoldina.org/uploads/tx_leopublication/2019_Diskussionspapier_Schutzimpfungen_Web.pdf (accessed on October 21, 2022)
Betsch, C./Schmid, P./Korn, L./Steinmeyer, L./Heinemeier, D./Eitze, S. et al. (2019b): Explaining, measuring and changing vaccination behavior psychologically. In: Federal Health Gazette, Health Research, Health Protection 2019, 62, 4: 400–409
Dumit, EM/Novillo-Ortiz, D./Contreras, M./Velandia, M./Danovaro-Holliday, MC (2018): The use of eHealth with immunizations: An overview of systematic reviews. In: Vaccine 2018, 36, 52: 7923–7928
GMK (2021): Resolutions of the GMK June 16, 2021. TOP: 8.1 Vaccination against human papilloma viruses (HPV). In: https://www.gmkonline.de/Beschluesse.html?id=1134&jahr=2021 (accessed on October 21, 2022)
Heiden, I. ad/Weber, V./Bock, H./Gothe, H. (2021): Systematic inventory analysis in the funding priority area of development, testing and evaluation of digital media for the promotion of vaccination using the example of HPV “digiMed-HPV”. Final report for the Federal Ministry of Health. Ed. IGES Institute GmbH. Berlin. In: https://www.bundesgesundheitsministerium.de/fileadmin/Files/5_Publikationen/Praevention/finalreport/IGES_digiMed_Finalreport_bf.pdf (accessed on October 21, 2022)
Heinemeier, D./Terhardt, M./Betsch, C. (2021): Explaining and changing vaccination behavior psychologically using the example of the HPV vaccination. In: Gynecologist 2021, 54, 9: 665–672
Vaccinationdashboard.de (2022): Current vaccination status. Ed. Federal Ministry of Health (BMG). In: https://impfdashboard.de/, last updated on October 21, 2022 (accessed on October 21, 2022)
Jacobson Vann, JC/Jacobson, RM/Coyne-Beasley, T./Asafu-Adjei, JK/Szilagyi, PG (2018): Patient reminder and recall interventions to improve immunization rates. In: The Cochrane database of systematic reviews 1, CD003941
MacDonald, NE (2015): Vaccine hesitancy: Definition, scope and determinants. In: Vaccine 2015, 33,34: 4161–4164
Neufeind, J./Betsch, C./Habersaat, KB/Eckardt, M./Schmid, P./Wichmann, O. (2020): Barriers and drivers to adult vaccination among family physicians - Insights for tailoring the immunization program in Germany . In: Vaccine 2020, 38, 27: 4252–4262
Rieck, T./Feig, M./Siedler, A. (2021a): Vaccination rates for child vaccinations in Germany - current results from the RKI vaccination surveillance. Epidemiological Bulletin 2021, 49: 6-29
Rieck, T./Steffen, A./Feig, M./Siedler, A. (2021b): Vaccination rates among adults in Germany - Latest news from the KV vaccination surveillance. Epidemiological Bulletin 2021, 50: 3-22
Seefeld, L./Horstkötter, N./Ommen, O./Reckendrees, B./Stander, V./Goecke, M. et al. (2022): Attitudes, knowledge and behavior of adults and parents towards vaccinations - results of the 2021 representative survey on infection protection. BZgA research report. Ed. Federal Center for Health Education. Cologne. In: https://www.bzga.de/fileadmin/user_upload/PDF/studien/kritiksschutzstudie_2016--f4f414f596989cf814a77a03d45df8a1.pdf (accessed on October 21, 2022)
WHO (2014): European Vaccine Action Plan 2015-2020. Ed. World Health Organization. Copenhagen, Denmark. In: https://www.euro.who.int/__data/assets/pdf_file/0007/255679/WHO_EVAP_UK_v30_WEBx.pdf (accessed on October 21, 2022)
Witte, J./Batram, M./Hasemann, L./Dankhoff, M./Greiner, W. (2021): Children and Youth Report 2021 Health care for children and adolescents in Germany Focus: Addictions. In: https://www.dak.de/dak/download/report-2519092.pdf (accessed on October 25, 2022)
Zettl, A./Schwartz, S./Seewald, B./Bauer, K./Trübswetter, A. (2022): Responsibilities, cost-benefit considerations and digitalization stress. Results of a qualitative study on the relevance of recall systems using the example of HPV vaccination. Ed. Robert Koch Institute and YOUSE GmbH. Berlin. In: https://www.rki.de/DE/Content/Infekt/Impfen/forschungsprojekte/HPV-Impfung-Recallsysteme/ Results.pdf?__blob=publicationFile (accessed on October 21, 2022).