Encouraging Influenza Vaccination Among Text4baby Pregnant Women and Mothers


      Pregnant women, postpartum women, and infants are at high risk for complications from influenza. From October to November 2012, Text4baby, a free national text service for pregnant women and mothers of infants aged <1 year, implemented a module of interactive messages encouraging maternal influenza vaccination. A program evaluation examined whether a text-based reminder or tailored education improved self-reported influenza vaccination or intent to be vaccinated later in the influenza season among Text4baby participants.


      Nearly one third (28,609/89,792) of enrollees responded to a text asking about their vaccination plans. Those planning to receive vaccination were randomly assigned to receive an encouragement message or an encouragement message plus the opportunity to schedule a reminder (n=3,021 at follow-up). Those not planning to be vaccinated were randomly assigned to receive general education or education tailored to their reason for non-vaccination (n=3,820 at follow-up). The effect of the enhanced messages was assessed using multinomial logistic regression in 2013–2014.


      A reminder increased the odds of vaccination at follow-up among mothers (AOR=2.0, 95% CI=1.4, 2.9) and of continued intent to be vaccinated later in the season (pregnant, AOR=2.1, 95% CI=1.4, 3.1; mother, AOR=1.7, 95% CI=1.1, 2.5). Among mothers not planning to be vaccinated because of cost, those who received a tailored message about low-cost vaccination had higher odds of vaccination at follow-up (AOR=1.9, 95% CI=1.1, 3.5). Other tailored messages were not effective.


      Text reminders and tailored education may encourage influenza vaccination among this vulnerable population; both have now been incorporated into Text4baby.
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        • Dodds L.
        • McNeil S.A.
        • Fell D.B.
        Impact of influenza exposure on rates of hospital admission and physician visits because of respiratory illness among pregnant women.
        CMAJ. 2007; 176: 463-468
        • Kennedy E.D.
        • Ahluwalia I.B.
        • Ding H.
        • Lu P.J.
        • Singleton J.A.
        • Bridges C.B.
        Monitoring seasonal influenza vaccination coverage among pregnant women in the United States.
        Am J Obstet Gynecol. 2012; 207(3): S9-S16
        • Neuzil K.M.
        • Reed G.W.
        • Mitchel E.F.
        • Simonsen L.
        • Griffin M.R.
        Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women.
        Am J Epidemiol. 1998; 148: 1094-1102
      1. CDC. Updated recommendations for obstetric health care providers related to use of antiviral medications in the treatment and prevention of influenza (current for the 2013-2014 season). 2014.

        • Beigi R.
        Prevention and management of influenza in pregnancy.
        Obstet Gynecol Clin N Am. 2014; 41: 535-546
      2. USDHHS. Pregnant women.

      3. CDC. Flu information for parents with young children. 2011.

        • Eick A.A.
        • Uyeki T.M.
        • Klimov A.
        • et al.
        Maternal influenza vaccination and effect on influenza virus infection in young infants.
        Arch Pediatr Adolesc Med. 2011; 165: 104-111
      4. American College of Obstetricians and Gynecologists. Influenza Vaccination During Pregnancy. Washington, DC: Committee Opinion; 2010. Report No.: 468.

      5. CDC. Influenza vaccination coverage among pregnant women—United States, 2012-13 Influenza Season.
        MMWR Morb Mortal Wkly Rep. 2013; 62: 787-792
      6. Pew Research Center. Mobile Technology Fact Sheet. Pew Internet: mobile. 2014.

      7. Pew Research Center. Americans and text messaging. Washington, DC: Pew Internet & American Life Project; 2011.

        • Fjeldsoe B.S.
        • Marshall A.L.
        • Miller Y.D.
        Behavior change interventions delivered by mobile telephone short-message service.
        Am J Prev Med. 2009; 36: 165-173
        • Cole-Lewis H.
        • Kershaw T.
        Text messaging as a tool for behavior change in disease prevention and management.
        Epidemiol Rev. 2010; 32: 56-59
        • Stockwell M.S.
        • Kharbanda E.O.
        • Martinez R.A.
        • Vargas C.Y.
        • Vawdrey D.K.
        • Camargo S.
        Effect of a text messaging intervention on influenza vaccination in an urban, low-income pediatric and adolescent population: a randomized controlled trial.
        JAMA. 2012; 307: 1702-1708
        • Stockwell M.S.
        • Westhoff C.
        • Kharbanda E.O.
        • et al.
        Influenza vaccine text message reminders for urban, low-income pregnant women: a randomized controlled trial.
        Am J Public Health. 2014; 104: e7-e12
        • Moniz M.H.
        • Hasley S.
        • Meyn L.A.
        • Beigi R.H.
        Improving influenza vaccination rates in pregnancy through text messaging: a randomized controlled trial.
        Obstet Gynecol. 2013; 121: 734-740
        • Whittaker R.
        • Matoff-Stepp S.
        • Meehan J.
        • et al.
        Text4baby: development and implementation of a national text messaging health information service.
        Am J Public Health. 2012; 102: 2207-2213
        • Evans W.D.
        • Abroms L.C.
        • Poropatrich R.
        • Nielsen P.E.
        • Wallace J.L.
        Mobile health evaluation methods: the Text4baby case study.
        J Health Commun. 2012; 17: 22-29
        • Jordan E.T.
        • Ray E.M.
        • Johnson P.
        • Evans W.D.
        Using text messaging to improve maternal and newborn health.
        Nurs Womens Health. 2011; 15: 206-212
        • Gazmararian J.A.
        • Elon L.
        • Yang B.
        • Graham M.
        • Parker R.
        Text4baby program: an opportunity to reach underserved pregnant and postpartum women?.
        Matern Child Health J. 2014; 18: 223-232
        • Martinez K.M.
        • Uekusa S.
        National Survey of Text4baby Participants. 2013;
        • Evans W.D.
        • Wallace J.L.
        • Snider J.
        Pilot evaluation of the Text4baby mobile health program.
        BMC Public Health. 2012; 12: 1031
      8. Text4baby. Text4baby Research and Evaluation. 2014.

      9. CDC. Influenza vaccination coverage among pregnant women—United States, 2011-12 Influenza Season.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 758-763
        • Lynch M.M.
        • Mitchell E.W.
        • Williams J.L.
        • et al.
        Pregnant and recently pregnant women’s perceptions about influenza A pandemic (H1N1) 2009: implications for public health and provider communication.
        Matern Child Health J. 2012; 16: 1657-1664
        • Eysenbach G.
        CONSORT-EHEALTH: improving and standardizing evaluation reports of web-based and mobile health interventions.
        J Med Internet Res. 2011; 13: e126
      10. Payne P. Do mHealth apps require randomized controlled trials—panel discusses at mHealth Summit. 2012.

        • Krishna S.
        • Boren S.
        • Balas E.
        Healthcare via cell phones: a systematic review.
        Telemed J E Health. 2009; 15: 231-240
        • Whittaker R.
        • McRobbie H.
        • Bullen C.
        • Borland R.
        • Rodgers A.
        • Gu Y.
        Mobile phone-based interventions for smoking cessation.
        Cochrane Database Syst Rev. 2012; 11: CD006611
        • Whittaker R.
        • Merry S.
        • Dorey E.
        • Maddison R.
        A development and evaluation process for mHealth interventions: examples from New Zealand.
        J Health Commun. 2012; 17: 11-21
        • Noar S.M.
        • Benac C.N.
        • Harris M.S.
        Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions.
        Psychol Bull. 2007; 133: 673-693
        • Kreuter M.W.
        • Farrell D.
        • Olevitch L.
        • Brennan L.
        Tailoring Health Messages: Customizing Communication With Computer Technology. Erlbaum, Mahwah, NJ2000
        • Doak C.C.
        • Doak L.G.
        • Root J.H.
        Teaching Patients With Low Literacy Skills. 2nd ed. J.B. Lippincott Company, Philadelphia, PA1996
        • Lewis M.A.
        • Uhring J.D.
        • Bann C.M.
        • et al.
        Tailored text messaging intervention for HIV adherence: a proof-of-concept study.
        Health Psychol. 2013; 32: 248-253
        • CDC
        Influenza vaccination coverage among pregnant women—United States, 2011-12 Influenza Season, United States.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 758-763