Text4baby Influenza Messaging and Influenza Vaccination Among Pregnant Women

Pregnant women are at risk for severe influenza-related complications; however, only 52% reported receiving an influenza vaccination during the 2013-2014 influenza season in the United States (US). Reminder/recall systems have been shown to improve vaccination coverage; texting has been used to deliver reminders and education because of its prevalent use and popularity among minorities and people with lower income and education levels. Text4baby, a free national (US) mobile health (mHealth) service (described in more detail at Related Summaries, below), provides influenza vaccination education and reminders to pregnant women. This study examined reported influenza vaccination during pregnancy among Text4baby participants who reported receiving influenza messages and women who reported never participating in Text4baby.

The primary outcome of this study was self-reported influenza vaccination coverage, defined as vaccination received before and during pregnancy since July (July 2012 for the April 2013 survey and July 2013 for the April 2014 survey). Opt-in internet panel surveys (April 2013 and 2014) of pregnant women collected the following: demographic and other characteristics; influenza vaccination knowledge, attitudes, and behaviours; and Text4baby participation. Women aged 18-49 years, pregnant anytime from October to January (N=3,321) were included. Text4baby influenza message recallers were those who reported receiving Text4baby influenza messages during their current/most recent pregnancy (n=377). Text4baby non-participants reported never receiving Text4baby messages (n=2,824). Multivariable logistic regression was performed (2014-2016) controlling for demographic and other characteristics, high-risk conditions, and provider recommendation and offer to vaccinate. Adjusted prevalence ratios (APRs) were calculated. Random sampling was assumed for this non-probability sample.

Text4baby recallers were more likely than non-participants to report influenza vaccination regardless of receipt of provider recommendation and/or offer to vaccinate (provider recommendation/offer APR=1.29, 95% confidence interval (CI)=1.21, 1.37, provider recommendation/no offer APR=1.52, 95% CI=1.07, 2.17). Among women receiving neither a provider recommendation nor offer to vaccinate, Text4baby recallers were more than 3 times as likely to report influenza vaccination compared with non-participants (APR=3.39, 95% CI=2.03, 5.67). More than three quarters (77.0%) of Text4baby recallers reported Text4baby influenza messages helped them make a decision about the vaccination, and 88.6% reported that the influenza messages helped them remember to get vaccinated.

The findings viewed another way: Rates of vaccination were lowest for those who received neither a recommendation nor an offer (13.5%), higher for those who received a recommendation but no offer (39.5%; crude prevalence ratio (CPR)=2.92, 95% CI=2.33, 3.66), and highest for those who received a provider recommendation and offer (70.5%; CPR=5.21, 95% CI=4.28, 6.35). Influenza vaccination coverage for Text4baby recallers was 81.3% compared with 47.1% for non-participants (CPR=1.73, 95% CI=1.61, 1.85).

In short, these findings support the potential of Text4baby to improve influenza vaccination coverage among a group with historically low vaccination coverage. Text4baby and Text4baby partners, numbering more than 1,400 nationwide, implement national and community-based campaigns to reach and enroll women who may not be connected to the healthcare system. The fact that more than three-quarters of Text4baby influenza message recallers reported that Text4baby influenza messages helped them make a decision about vaccination and reminded them to be vaccinated suggests that the positive association between Text4baby status and vaccination may be attributed specifically to Text4baby influenza modules. Findings from this study are consistent with other studies, such as qualitative research that suggests multi-component approaches, including positively framed, tailored messages that highlight vaccination benefits for pregnant women and their children - all of which were incorporated as part of the Text4baby influenza modules - may lead to increased vaccination.

In conclusion: "Study findings support the need for continued efforts not only to encourage busy providers to recommend and offer vaccination, but also to reinforce a recommendation and offer with other approaches, like Text4baby, that can maximize opportunities to provide preventive care to protect mothers and infants."