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Efficacy of codesigned COVID-19 booster vaccine promotion materials for long-term care staff: a cluster-randomized

Clarissa Hsu^1,2, Annalisa V Piccorelli³, Beverly B Green^3,4

¹Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1360, Seattle, WA, 98101, USA. Clarissa.W.Hsu@kp.org.

BMC Public Health

|June 25, 2026

Abstract

Background:

Among health care workers, long-term care center (LTCC) staff are among the most hesitant to obtain COVID-19 vaccines and boosters. Our objective was to compare the effectiveness of enhanced usual care (EUC) to codesigned materials (Codesign) in increasing COVID-19 booster vaccination rates and willingness to promote the booster among long term care center (LTCC) staff.

Methods:

We conducted a two-arm cluster-randomized trial in 40 LTCCs in Georgia (n = 21) and Washington (n = 19) from August 2021 to December 2023. EUC LTCCs distributed standard government COVID-19 booster promotion materials. LTCCs in the Codesign arm allowed staff to participate in virtual codesign teams. Over 10 weekly meetings, the teams developed tailored COVID-19 booster promotion materials. Materials were distributed to both arms in January 2023. Primary outcomes were LTCC-level COVID-19 booster vaccination and a Net Promoter Score (NPS) measuring booster promotion to coworkers. Secondary outcomes included staff-level vaccine hesitancy and confidence scores and booster promotion to friends and family.

Results:

We did not detect a significant difference between the EUC and Codesign arms in COVID-19 booster rates or primary NPS measure. Similarly, secondary and exploratory outcomes were not significantly different between either arm.

Conclusions:

The null findings of this trial are consistent with the challenges of other clinical trials of COVID-19 vaccine-promotion interventions in improving COVID-19 vaccine uptake among LTCC staff. Lessons for future research include identifying better ways to: (1) engage leaders and staff, (2) design more effective targeting messages, and (3) develop ways to target and customize dissemination.

Trial Registration:

This study is registered at www.

Clinicaltrials:

gov.

Clinicaltrials:

gov #NCT05449418. Date of registration: 6/22/2022.

Keywords:

COVID-19 Codesign Long-term care Vaccine hesitancy Vaccine uptake Vaccines

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