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        Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail.

        Influenza Vaccination Coverage Among Pregnant Women — United States, 2012–13 Influenza Season

        Pregnant women and infants aged <6 months are at increased risk for influenza-related severe illness and hospitalization. Influenza vaccination of pregnant women has been shown to reduce the risk for illness in both mother and infant (1). To help protect pregnant women, the Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetricians and Gynecologists recommend influenza vaccination for all women who are or will be pregnant during the influenza season, regardless of trimester (1,2). To estimate influenza vaccination coverage among pregnant women during the 2012–13 influenza season, CDC analyzed data from an Internet panel survey conducted April 1–12, 2013. Among 1,702 self-selected survey respondents pregnant at any time during the 4-month period of October 2012–January 2013, 50.5% reported they received influenza vaccination before or during their pregnancy. Influenza vaccination coverage was higher among women reporting both a health-care provider recommendation and offer of influenza vaccination (70.5%) compared with women who received a recommendation but no offer of vaccination (46.3%) and women who received no recommendation (16.1%). Vaccination coverage of women who will be or are pregnant during an influenza season might be improved by implementing a combination of community-based interventions, including enhanced access to low-cost vaccination services, provider recommendation and offer of influenza vaccination, and education of pregnant women about influenza vaccination safety and efficacy during pregnancy to increase demand (3).

        To provide end-of-season estimates of influenza vaccination coverage, health-care provider recommendation and offer of vaccination, and information on knowledge, attitudes, and behaviors related to influenza vaccination among women pregnant during the 2012–13 influenza season, before the 2013–14 influenza season, CDC conducted an Internet panel survey during April 1–12, 2013.* Women aged 18–49 years who were pregnant at any time since August 2012 were recruited from a SurveySpot panel, a general population opt-in Internet panel operated by Survey Sampling International. Of 6,633 women who entered the survey, 2,198 were determined to be eligible, and 2,047 (93.1%) completed the survey.§ Data were weighted to reflect the age groups, race/ethnicity, and geographic distribution of the total U.S. population of pregnant women during 1990–2008.The methods and questions used in the April 2013 survey were similar to the April 2011 and April 2012 surveys (4,5). However, for this analysis, vaccination status was defined differently from the analyses of the 2010–11 and 2011–12 influenza seasons: 1) the vaccination time frame changed to July through April, compared with the previous timeframe of August through April; and 2) a woman was considered vaccinated only if she was vaccinated before or during pregnancy, whereas previously women vaccinated after pregnancy had also been counted (4,5). In this analysis, the study population was limited to women reporting being pregnant any time during the usual peak influenza vaccination period of October–January (n = 1,702).

        Survey respondents were asked questions about 1) their vaccination status before and during pregnancy, 2) whether their health-care provider recommended and offered influenza vaccination, 3) their attitudes regarding influenza and influenza vaccination, and 4) their reasons for receiving or not receiving influenza vaccination. To simplify the analysis, responses to five individual questions on attitudes were used to develop two composite scores defining attitudes toward influenza vaccination efficacy and the safety of influenza vaccination. A response to a sixth question was used as a measure of concern about influenza infection.** Because the study sample was based on pregnant women from an opt-in Internet panel rather than a probability sample, no statistical tests were performed. Differences were noted when there was a difference of ≥5 percentage points between any values being compared.

        Of the 1,702 women pregnant at any time during October 2012–January 2013, 50.5% reported influenza vaccination since July 1, 2012; 14.6% were vaccinated before pregnancy and 35.9% during pregnancy (15.7% first trimester, 10.6% second trimester, 8.1% third trimester, and 1.5% unknown trimester) (Table 1). Among the 1,620 women with at least one health-care provider visit since July 2012 who provided information on a provider recommendation and offer, 54.6% reported receiving a provider recommendation and offer of vaccination, 16.7% reported receiving a provider recommendation but no offer of vaccination, and 28.7% reported receiving no recommendation. Women who reported receiving both a provider recommendation and offer of influenza vaccination had higher vaccination coverage (70.5%) compared with women who reported receiving a provider recommendation but no offer (46.3%) and women who reported receiving no recommendation (16.1%) (Table 1, Figure). Women with the following reported characteristics had lower influenza vaccination coverage than other women within each comparison stratum: aged 18–24 years, non-Hispanic black, having an education less than a college degree, not married, reporting no health insurance, not working for wages, living below the poverty level, having no high-risk conditions associated with increased complications for influenza, and having fewer than six health-care provider visits since July 2012 (Table 1). Vaccination coverage among women with a negative attitude toward the efficacy of influenza vaccination was 9.8%, compared with 64.2% among those with a positive attitude. Women with a negative attitude towards the safety of vaccination had lower coverage than those with a positive attitude (13.0% versus 65.6%), and those with no concern about influenza infection had lower coverage than those with concern about influenza infection (47.1% versus 52.8%) (Table 1). The outcomes regarding attitudes were similar whether using responses to the composite scores or the individual questions.

        Overall, 72.3% of women reported receiving a health-care provider recommendation for vaccination, with or without reporting an offer of vaccination (Table 2). Women with both a provider recommendation and offer of influenza vaccination had higher vaccination coverage compared with women who received only a recommendation or who received no recommendation across all socio-demographic subgroups and attitude categories (Table 2). Among women who received a provider recommendation and offer of vaccination, coverage was 19.4% for those who reported a negative attitude toward influenza vaccination efficacy, 19.4% for those who reported a negative attitude towards the safety of influenza vaccination, and 68.8% for those who reported no concern about influenza infection; vaccination coverage was lower among women who did not receive a provider recommendation and also reported a negative attitude toward vaccination efficacy (2.5%) or the safety of influenza vaccination (7.7%) or no concern about influenza infection (15.6%).

        The top three reasons women reported for vaccination were to protect their infant from influenza (33.2%), to protect themselves from influenza (20.0%), and because their health-care provider recommended vaccination (15.7%). The top three reasons reported for nonvaccination were concern about safety risk to the infant (20.5%), that the vaccination would give pregnant women influenza (13.6%), and that vaccination was not effective in preventing influenza (10.6%).

        Reported by

        Sarah Ball, ScD, Sara Donahue, DrPH, David Izrael, MS, Deborah K. Walker, EdD, Abt Associates, Inc., Cambridge, Massachusetts. Rachel Martonik, Charles DiSogra, DrPH, Abt SRBI, New York, New York. Helen Ding, MD, Stacie M. Greby, DVM, Katherine Kahn, MPH, Peng-Jun Lu, MD, PhD, Walter W. Williams, MD, James A. Singleton, PhD, Erin D. Kennedy, DVM, Carolyn B. Bridges, MD, Immunization Svcs Div, Lisa A. Grohskopf, MD, Influenza Div, National Center for Immunization and Respiratory Diseases; Denise J. Jamieson, MD, Indu Ahluwalia PhD, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Helen Ding, hding@cdc.gov, 404-639-8513.

        Editorial Note

        Overall influenza vaccination coverage among pregnant women during the 2012–13 influenza season was 50.5%. Vaccination coverage among pregnant women was 47.0%–49.0% for the 2010–11 and 2011–12 influenza seasons (4,5); however, these estimates are not directly comparable because the change in the definition of vaccination status for this most recent season (including changing the measurement of influenza vaccination for pregnant women to July through April and restricting vaccination to receipt before or during pregnancy). Women reporting no health insurance, not working for wages, having fewer than six health-care provider visits since July 2012, or lower socioeconomic status indicators (less education and living below the poverty level) had lower vaccination coverage than other women in the survey. Negative attitudes toward the efficacy or safety of influenza vaccination and having no concern about influenza infection were also associated with lower vaccination coverage. Provider recommendation and offer of influenza vaccination was associated with higher levels of vaccination coverage, even when women reported no health insurance, not working for wages, lower socioeconomic status indicators, a negative attitude toward the efficacy or safety of influenza vaccination, or a lack of concern about influenza infection.

        Among women with at least one health-care provider visit, 54.6% reported receiving a provider recommendation and offer of vaccination. In any practice, barriers to providers recommending and offering vaccination might include physician's concern about time spent discussing the vaccination; administrative and financial issues, such as concern about the up-front cost of ordering vaccines; high costs of storing and maintaining vaccines; not having electronic health records; and organizational challenges of vaccine administration (6–8). Systems supporting provider recommendation and offer, such as standing orders and provider reminder systems, can reduce missed opportunities for vaccination and improve vaccination coverage when implemented with strategies to improve access to vaccination services, such as strategies that reduce patient cost and increase demand (e.g., patient education) (3). Full implementation of the Affordable Care Act might allow access to ACIP-recommended vaccinations, such as influenza vaccination, for pregnant women with no cost sharing when provided by an in-network provider, and thus minimize concerns about vaccination cost. Providers who do not provide vaccinations in their office can recommend vaccination and refer pregnant women to another in-network provider that administers influenza vaccinations.

        Pregnant women who were not vaccinated reported concern about the safety risk to their infants and the misconceptions that the vaccination would give them influenza or that vaccination was ineffective as the top reasons for nonvaccination. However, health-care provider recommendation and offer was associated with increased vaccination coverage in all demographic groups. Education messages for pregnant women need to emphasize that vaccination during pregnancy can protect not only pregnant women themselves but also their infants during the first 6 months of life (9). Such messages can be delivered through multiple means, including routine provider education, prenatal consultation, social media, and text messaging (e.g., https://text4baby.org). These efforts might help providers address negative attitudes and misconceptions about vaccination.

        The findings in this report are subject to at least five limitations. First, estimates might be biased if the selection processes for entry into the Internet panel and a woman's decision to participate in this particular survey were related to receipt of vaccination. Comparing 2010–11 influenza season vaccination estimates from 18 states in both the Internet panel survey and the Pregnancy Risk Assessment Monitoring System (PRAMS), a probability sampling survey, the Internet panel survey estimate for women pregnant at any time during October 2010–January 2011 (50.2%) was similar to the estimate from PRAMS for women who were pregnant in the same period (49.2%) (10). Additional comparisons with PRAMS and other available data sources over multiple seasons are needed to determine whether the more timely Internet panel survey estimates, despite sampling differences, provide valid assessments of trends. Second, the survey was self-administered and not validated by medical record review. Third, the results were weighted to the distribution of pregnant women in the U.S. population, but the study sample did not include women without Internet access. Therefore, it might not be a representative sample of pregnant women, and findings might not be generalizable to all pregnant women in the United States. Fourth, this was a cross-sectional survey. Self-reported vaccination status, attitudes, and provider recommendation and offer were measured at the time of the survey. Interactions that happened before the survey (e.g., choosing a provider with similar attitudes or a change in attitudes because of a provider recommendation or offer) could not be captured by this survey. Finally, the 2012–13 influenza season coverage estimates are not directly comparable with estimates from the 2011–12 and 2010–11 seasons reported previously (4,5) because of the change in measuring vaccination coverage in this season.

        Health-care provider recommendation and offer of influenza vaccination were associated with higher vaccination levels among pregnant women. Vaccination programs that include reducing patient cost of vaccination, reducing missed opportunities for vaccination by ensuring vaccination recommendations are provided at each visit, and increasing demand are needed (3). Tailored educational messages should emphasize that vaccination during pregnancy will not only decrease the risk for influenza-related illness and complications in pregnant women themselves, but can also decrease the risk for illness in infants for up to 6 months, while they are too young to be vaccinated (9).

        Acknowledgments

        Faith Lewis, MA, John Sokolowski, MA, Daniel Duplantier, MA, Abt SRBI, New York, New York. Megan C. Lindley, MPH, Immunization Svcs Div, National Center for Immunization and Respiratory Diseases; David P. Hopkins, MD, Div of Epidemiology, Analysis, and Library Svcs (proposed), Center for Surveillance, Epidemiology and Laboratory Svcs (proposed), Office of Public Health Scientific Svcs, CDC.

        References

        1. CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices—United States, 2013–2014. MMWR 2013;62(No. RR-7).
        2. American Congress of Obstetricians and Gynecologists Committee on Obstetric Practice. ACOG committee opinion no. 468: influenza vaccination during pregnancy. Obstet Gynecol 2010;116:1006–7.
        3. Community Preventive Services Task Force. In: Guide to Community Preventive Services. Increasing appropriate vaccination: community-based interventions implemented in combination (abbreviated). Atlanta, GA: Community Preventive Services Task Force; 2013. Available at http://www.thecommunityguide.org/vaccines/communityinterventions.html.
        4. CDC. Influenza vaccination coverage among pregnant women—United States, 2010–11 influenza season. MMWR 2011;60:1078–82.
        5. CDC. Influenza vaccination coverage among pregnant women—2011–12 influenza season, United States. MMWR 2012;61:758–63.
        6. Johnson DR, Nichol KL, Lipczynski K. Barriers to adult immunization. Am J Med 2008;121(7B):S28–35.
        7. American Medical Association. Report 4 of the Council on Science and Public Health (I-08). Financing of adult vaccines: recommendations for action. Chicago, Illinois: American Medical Association; 2008. Available at http://www.ama-assn.org/resources/doc/csaph/csaph4i08-summary.pdf.
        8. Panda B, Stiller R, Panda A. Influenza vaccination during pregnancy and factors for lacking compliance with current CDC guidelines. J Matern Fetal Neonatal Med 2011;24:402–6.
        9. Meharry PM, Colson ER, Grizas AP, Stiller R, Vázquez M. Reasons why women accept or reject the trivalent inactivated influenza vaccine (TIV) during pregnancy. Matern Child Health J 2013;17:156–64.
        10. Ding H, Ahluwalia I, Euler G, Boyle J, Singleton J, Greby S. A comparison of a mailed-in probability sample survey and a non-probability Internet Panel Survey for assessing self-reported influenza vaccination levels among pregnant women. 68th annual conference of the American Association for Public Opinion Research; Boston, Massachusetts; May 16–19, 2013.

        * Comparable National Health Interview Survey data for this population will not be available until July 2014.

        Additional information available at http://www.surveysampling.com. The SurveySpot panelists were recruited from Internet sites that host a large number of frequent visitors and diverse Internet traffic. Multiple methods of recruitment were used, including banner ads, direct invitations, pop-ups, and web intercepts. The panel represents approximately 1 million households, and new panelists are continually being recruited; existing panelists are removed from the panel if they have opted-out or have not responded to an invitation within a specified period. A minimal incentive is routinely used to maintain the panel but not for an inducement to participate in a particular survey. Pregnant women panelists in this report were recruited from the SurveySpot panel using two methods: 1) an email invitation from SurveySpot sent to panel members aged 18–49 years, female, and living in the United States; and 2) a pop-up message inviting panel members visiting the SurveySpot website (http://www.surveyspot.com) to answer a series of screening questions and, if eligible, to take the survey.

        § A survey response rate requires specification of the denominator at each stage of sampling. During recruitment of an online opt-in survey sample, such as the Internet panel described in this report, these numbers are not available; therefore, the response rate cannot be calculated. Instead, the survey completion rate is provided.

        The sample of pregnant women was weighted to reflect the age group, race/ethnicity, and geographic region of all pregnant women in the United States during 1990–2008. The total population of pregnant women in the United States in 2012 and the distribution of pregnant women by age and race/ethnicity groups was determined based on data for the number of pregnant women in the United States during 1990–2008 (available at http://www.cy118119.com/nchs/data/nvsr/nvsr60/nvsr60_07.pdf). The distribution of U.S. pregnant women age 18–44 years by census region in 2008 was determined based on estimates provided for each state in the Guttmacher Institute's state data center (available at http://www.guttmacher.org/datacenter).

        ** Three composite variables were created. First, the influenza vaccination efficacy attitude composite variable was created based on responses to two questions regarding attitudes toward influenza vaccination: 1) "Flu vaccine is somewhat/very effective in preventing flu" and 2) "Agree/Strongly agree that if a pregnant woman receives the flu vaccination, it will protect the baby from getting the flu after it is born." One point was given for each "yes" answer for either of the two questions. Respondents who had a summary score of 1 or 2 were defined as having a "positive" attitude, and those with a summary score of 0 were defined as having a "negative" attitude. Second, the safety of influenza vaccination attitude composite variable was created based on responses to three questions regarding attitudes toward influenza vaccination: 1) "Flu vaccination is somewhat/very/completely safe for most adult women," 2) "Flu vaccination is somewhat/very/completely safe for pregnant women," and 3) Flu vaccination that a pregnant women receives is somewhat/very/completely safe for her baby." One point was given for each "yes" answer to any of the three questions. Respondents who had a summary score of 2 or 3 were defined as having a "positive" attitude, and those with a summary score of 1 or 0 were defined as having a "negative" attitude. Third, the influenza infection variable was created based on response to a question regarding attitude toward influenza infection: "If a pregnant woman gets the flu, it is somewhat/very likely to harm the baby." Respondents with a "yes" answer were defined as "concerned," and respondents with a "no" answer were defined as "not concerned."


        What is already known on this topic?

        Influenza vaccination coverage among pregnant women increased substantially to approximately 50% during the 2009–10 influenza season, and the increased coverage was sustained during the 2010–11 and 2011–12 influenza seasons.

        What is added by this report?

        Based on the responses of 1,702 self-selected participants in an Internet panel survey, for the 2012–13 influenza season, 50.5% of pregnant women were vaccinated against influenza, and 72.3% of pregnant women reported receiving a health-care provider recommendation of vaccination. Women who received a provider recommendation and offer of vaccination had higher vaccination coverage than women who received a provider recommendation alone or received no recommendation, even when they had a negative attitude toward vaccination efficacy or the safety of vaccination.

        What are the implications for public health practice?

        Continued efforts are needed to increase knowledge among pregnant women about the risk for influenza and the safety and efficacy of influenza vaccination for themselves and their infants. Efforts are also needed to increase opportunities for providers to recommend and offer influenza vaccination to pregnant women to protect both them and their infants.


        TABLE 1. Influenza vaccination coverage among women who were pregnant at any time during October 2012–January 2013, by selected characteristics — Internet panel survey, United States, 2012–13 influenza season

        Characteristic

        Unweighted
        no.

        Weighted
        %

        Weighted
        % vaccinated
        *

        Total

        1,702

        100.0

        50.5

        Vaccinated before pregnancy

        239

        14.6

        Vaccinated during pregnancy

        638

        35.9

        1st trimester

        273

        15.7

        2nd trimester

        200

        10.6

        3rd trimester

        138

        8.1

        Unvaccinated

        776

        49.5

        Age group (yrs)

        18–24

        477

        33.1

        48.7

        25–34

        970

        50.5

        50.5

        35–49

        255

        16.3

        54.1

        Race/Ethnicity

        White, non-Hispanic

        1,093

        50.3

        52.2

        Black, non-Hispanic

        175

        18.8

        45.4

        Hispanic

        278

        23.8

        50.1

        Other, non-Hispanic

        156

        7.2

        53.1

        Education

        Less than college degree

        844

        51.8

        43.9

        College degree

        656

        36.8

        57.3

        More than college degree

        202

        11.4

        58.5

        Married

        Yes

        1,120

        62.2

        54.8

        No

        582

        37.8

        43.5

        Health insurance coverage

        Any public

        659

        41.8

        50.0

        Private/Military only

        939

        51.7

        53.0

        No insurance

        104

        6.5

        33.7

        Working status

        No

        860

        50.4

        44.7

        Yes

        842

        49.6

        56.4

        Poverty status§

        Below poverty level

        404

        26.0

        41.6

        At or above poverty level

        1,289

        74.0

        53.8

        High-risk conditions

        Yes

        613

        36.3

        57.8

        No

        1,089

        63.7

        46.4

        No. of provider visits since July 2012

        0

        27

        1.5

        —**

        1–5

        682

        41.6

        48.0

        6–10

        598

        34.9

        53.1

        >10

        395

        21.9

        53.1

        Reported provider recommendation and/or offer††

        Recommendation and offer

        895

        54.6

        70.5

        Recommendation but no offer

        270

        16.7

        46.3

        No recommendation

        455

        28.7

        16.1

        Attitude toward efficacy of influenza vaccination§§

        Negative

        430

        25.2

        9.8

        Positive

        1,272

        74.8

        64.2

        Attitude toward safety of influenza vaccination¶¶

        Negative

        475

        28.7

        13.0

        Positive

        1,227

        71.3

        65.6

        Attitude toward influenza infection***

        Not concerned

        686

        39.5

        47.1

        Concerned

        1,016

        60.5

        52.8


        TABLE 1. (Continued) Influenza vaccination coverage among women who were pregnant at any time during October 2012–January 2013, by selected characteristics — Internet panel survey, United States, 2012–13 influenza season

        * Women who reported being vaccinated since July 2012 and being vaccinated either before or during pregnancy were defined as vaccinated. Overall, 2.9% of women reported vaccination after pregnancy and were categorized as unvaccinated during pregnancy. The revised estimates for the 2010–11 and 2011–12 influenza seasons using the 2012–13 definition were 44.0% and 47.6%, respectively (CDC, unpublished data, 2013).

        Those who were employed for wages or self-employed were categorized as working. Those who were out of work, homemakers, students, retired, or unable to work were grouped as not working.

        § Below poverty were defined as a total of annual family income of <$23,283 for a family of four with two minors as of 2012, as determined by the U.S. Census Bureau (information available at http://www.census.gov/hhes/www/poverty/data/threshld).

        Conditions associated with increased risk for serious medical complication from influenza, including chronic asthma, a lung condition other than asthma, a heart condition, diabetes, a kidney condition, a liver condition, obesity, or a weakened immune system caused by a chronic illness or by medications taken for a chronic illness.

        ** Sample size was <30; vaccination coverage estimates were not reliable.

        †† Excluded women who did not visit a provider since July 2012 (n = 27) and women who did not respond or did not know whether they received a provider offer (n = 55).

        §§ Composite variable created based on responses to two questions regarding attitudes toward influenza vaccination: 1) "Flu vaccine is somewhat/very effective in preventing flu" and 2) "Agree/Strongly agree that if a pregnant woman receives the flu vaccination, it will protect the baby from getting the flu after it is born." One point was given for each "yes" answer for either of the two questions. Respondents who had a summary score of 1 or 2 were defined as having a "positive" attitude, and those with a summary score of 0 were defined as having a "negative" attitude.

        ¶¶ Composite variable created based on responses to three questions regarding attitudes toward influenza vaccination: 1) "Flu vaccination is somewhat/very/completely safe for most adult women," 2) "Flu vaccination is somewhat/very/completely safe for pregnant women," and 3) "Flu vaccination that a pregnant women receives is somewhat/very/completely safe for her baby." One point was given for each "yes" answer to any of the three questions. Respondents who had a summary score of 2 or 3 were defined as having a "positive" attitude, and those with a summary score of 0 or 1 were defined as having a "negative" attitude.

        *** Variable created based on response to a question regarding attitude toward influenza infection: "If a pregnant woman gets the flu, it is somewhat/very likely to harm the baby." Respondents with a "yes" answer were defined as "concerned," and respondents with a "no" answer were defined as "not concerned."


        FIGURE. Influenza vaccination before and during pregnancy, overall and by health-care provider recommendation and offer* of influenza vaccination, among women pregnant at any time during October 2012–January 2013 — Internet panel survey, United States, 2012–13 influenza season

        The figure shows influenza vaccination before and during pregnancy, overall and by health-care provider recommendation and offer of influenza vaccination, among women pregnant any time during October 2012-January 2013 in the United States during the 2012-13 influenza season. Women who reported receiving both a provider recommendation and offer of influenza vaccination had higher vaccination coverage (70.5%) compared with women who reported receiving a provider recommendation but no offer (46.3%) and women who reported receiving no recommen?dation (16.1%).

        * Excluded women who did not visit a health-care provider since July 2012 (n = 27) and/or did not respond or did not know whether they received an offer of vaccination (n = 55).

        Alternate Text: The figure above shows influenza vaccination before and during pregnancy, overall and by health-care provider recommendation and offer of influenza vaccination, among women pregnant any time during October 2012-January 2013 in the United States during the 2012-13 influenza season. Women who reported receiving both a provider recommendation and offer of influenza vaccination had higher vaccination coverage (70.5%) compared with women who reported receiving a provider recommendation but no offer (46.3%) and women who reported receiving no recommen?dation (16.1%).


        TABLE 2. Percentage of pregnant women receiving a health-care provider recommendation for influenza vaccination and influenza vaccination coverage, by provider recommendation and offer and selected characteristics, among women who visited a provider at least once since July 2012 and were pregnant at any time during October 2012–January 2013 — Internet panel survey, United States, 2012–13 influenza season

        Characteristic

        Reported a provider recommendation

        Vaccination recommendation or offer

        Recommendation
        and offer

        Recommendation
        but no offer

        No
        recommendation

        No.

        Weighted
        %

        No.

        Weighted
        %

        No.

        Weighted
        %

        No.

        Weighted
        %

        Total

        1,675

        72.3

        895*

        70.5

        270*

        46.3

        455*

        16.1

        Age group (yrs)

        18–24

        466

        72.2

        236

        67.5

        76

        45.3

        129

        21.0

        25–34

        956

        72.2

        519

        70.6

        154

        46.2

        261

        12.8

        35–49

        253

        72.9

        140

        75.6

        40

        49.0

        65

        16.8

        Race/Ethnicity

        White, non-Hispanic

        1,075

        73.3

        583

        70.8

        178

        49.5

        286

        16.6

        Black, non-Hispanic

        171

        69.5

        87

        66.5

        52

        20.0

        Hispanic

        276

        71.9

        146

        72.3

        42

        39.9

        76

        12.6

        Other, non-Hispanic

        153

        73.9

        79

        72.8

        41

        14.2

        Education

        Less than college degree

        824

        69.0

        406

        65.5

        129

        41.1

        255

        13.9

        College degree

        650

        76.9

        370

        75.9

        106

        47.2

        157

        19.9

        More than college degree

        201

        76.9

        119

        72.2

        35

        65.2

        43

        16.9

        Married

        Yes

        1,109

        75.4

        639

        73.5

        175

        47.0

        270

        15.7

        No

        566

        67.1

        256

        64.0

        95

        45.3

        185

        16.7

        Health insurance coverage

        Any public

        645

        72.1

        335

        71.7

        104

        43.3

        179

        17.4

        Private/Military only

        930

        74.1

        522

        71.6

        151

        49.8

        236

        15.5

        No insurance

        100

        58.9

        38

        46.4

        40

        14.2

        Working status§

        No

        840

        70.2

        420

        65.9

        142

        41.3

        245

        13.7

        Yes

        835

        74.4

        475

        74.5

        128

        51.8

        210

        18.9

        Poverty status

        Below poverty level

        398

        68.7

        196

        63.1

        62

        37.7

        121

        13.2

        At or above poverty level

        1,268

        73.7

        696

        72.9

        206

        49.1

        330

        17.4

        High-risk conditions**

        Yes

        607

        78.8

        358

        73.9

        96

        54.4

        130

        19.6

        No

        1,068

        68.5

        537

        68.1

        174

        41.5

        325

        14.8

        No. of provider visits since July 2012

        1–5

        682

        67.8

        323

        69.0

        110

        49.1

        221

        16.2

        6–10

        598

        74.2

        327

        72.6

        99

        43.8

        152

        18.1

        >10

        395

        77.7

        45

        69.7

        61

        45.1

        82

        12.3

        Attitude toward efficacy of influenza vaccination††

        Negative

        422

        51.7

        147

        19.4

        57

        8.6

        206

        2.5

        Positive

        1,253

        79.2

        748

        80.6

        213

        57.5

        249

        26.8

        Attitude toward safety of influenza vaccination§§

        Negative

        462

        50.6

        137

        19.4

        76

        13.7

        234

        7.7

        Positive

        1,213

        80.9

        758

        80.1

        194

        61.2

        221

        24.8

        Attitude toward influenza infection¶¶

        Not concerned

        678

        70.8

        331

        68.8

        125

        44.3

        202

        15.6

        Concerned

        997

        73.3

        564

        71.5

        145

        47.9

        253

        16.5


        TABLE 2. (Continued) Percentage of pregnant women receiving a health-care provider recommendation for influenza vaccination and influenza vaccination coverage, by provider recommendation and offer and selected characteristics, among women who visited a provider at least once since July 2012 and were pregnant at any time during October 2012–January 2013 — Internet panel survey, United States, 2012–13 influenza season

        * Excluded women who did not respond or did not know whether they received a provider offer of vaccination (n = 55).

        Sample size was <30; vaccination coverage estimates were not reliable.

        § Those who were employed for wages or self-employed were categorized as working. Those who were out of work, homemakers, students, retired, or unable to work were grouped as not working.

        Below poverty were defined as a total of annual family income of <$23,283 for a family of four with two minors as of 2012, as determined by the U.S. Census Bureau (information available at http://www.census.gov/hhes/www/poverty/data/threshld).

        ** Conditions associated with increased risk for serious medical complication from influenza, including chronic asthma, a lung condition other than asthma, a heart condition, diabetes, a kidney condition, a liver condition, obesity, or a weakened immune system caused by a chronic illness or by medications taken for a chronic illness.

        †† Composite variable created based on responses to two questions regarding attitudes toward influenza vaccination: 1) "Flu vaccine is somewhat/very effective in preventing flu"; 2) "Agree/Strongly agree that if a pregnant woman receives the flu vaccination, it will protect the baby from getting the flu after it is born." One point was given for each "yes" answer for either of the two questions. Respondents who had a summary score of 1 or 2 were defined as having a "positive" attitude, and those with a summary score of 0 were defined as having a "negative" attitude.

        §§ Composite variable created based on responses to three questions regarding attitudes toward influenza vaccination: 1) "Flu vaccination is somewhat/very/completely safe for most adult women," and 2) "Flu vaccination is somewhat/very/completely safe for pregnant women," and 3) "Flu vaccination that a pregnant women receives is somewhat/very/completely safe for her baby." One point was given for each "yes" answer to any of the three questions. Respondents who had a summary score of 2 or 3 were defined as having a "positive" attitude, and those with a summary score of 0 or 1 were defined as having a "negative" attitude.

        ¶¶ Variable created based on response to a question regarding attitude toward influenza infection: "If a pregnant woman gets the flu, it is somewhat/very likely to harm the baby." Respondents with a "yes" answer were defined as "concerned," and respondents with a "no" answer were defined as "not concerned."



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