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. Author manuscript; available in PMC: 2019 Jun 7.
Published in final edited form as: Vaccine. 2018 Jun 7;36(24):3486–3497. doi: 10.1016/j.vaccine.2018.04.077

Association between provider recommendation and influenza vaccination status among children

Katherine E Kahn a,b, Tammy A Santibanez b, Yusheng Zhai a,b, Carolyn B Bridges b
PMCID: PMC6432907  NIHMSID: NIHMS1010661  PMID: 29764679

Abstract

Background

Provider recommendation is associated with influenza vaccination receipt. The objectives of this study were to estimate the percentage of children 6 months–17 years for whom a provider recommendation for influenza vaccination was received, identify factors associated with receipt of provider recommendation, and evaluate the association between provider recommendation and influenza vaccination status among children.

Methods

National Immunization Survey-Flu (NIS-Flu) parentally reported data for the 2013–14, 2014–15, and 2015–16 seasons were analyzed. Tests of association between provider recommendation and demographic characteristics were conducted using Wald chi-square tests and pairwise comparison t-tests. Multivariable logistic regression was used to determine variables independently associated with receiving provider recommendation and the association between provider recommendation and influenza vaccination status.

Results

Approximately 70% of children had a parent report receiving a provider recommendation for influenza vaccination for their child. The strongest association between receipt of provider recommendation and demographic characteristics was with child’s age, with younger children (6–23 months, 2–4 years, and 5–12 years) being more likely to have a provider recommendation than older children (13–17 years). In addition, children living in a household above poverty with household income >$75,000 were more likely to have a parent report receipt of a provider recommendation than children living below poverty. Children with a provider recommendation were twice as likely to be vaccinated than those without.

Conclusions

This study affirms the importance of provider recommendation for influenza vaccination among children. Ensuring that parents of all children receive a provider recommendation may improve vaccination coverage.

Keywords: Child; Immunization; Influenza,human; Surveys and questionnaires; Vaccination; Vaccination coverage

Introduction

Influenza causes significant morbidity and mortality among children.[1;2] Vaccination is an effective strategy in preventing influenza and has been recommended by the Advisory Committee on Immunization Practices (ACIP) for all children 6 months and older since 2008.[3;4] Despite this well-established recommendation, only 59.3% of children 6 months–17 years were vaccinated during the 2015–16 influenza season, which is considerably lower than the Healthy People 2020 target of 70% influenza vaccination coverage.[5;6]

The ACIP has noted the critical role of a provider recommendation for influenza vaccination and has highlighted several studies that document the positive association between a provider recommendation and receipt of influenza vaccination in a variety of populations, including adults 50–64 years, high-risk adults, Medicare beneficiaries, young children 6–23 months, and children with asthma.[7–13] Numerous studies have shown that pregnant women who received a provider recommendation for influenza vaccination were much more likely to be vaccinated than those who did not.[14–23] Studies among hospitalized children and underserved adults also identified provider recommendation as an important factor associated with influenza vaccination.[24;25] A recent study on the general population of adults reported that adults who received a provider recommendation were 1.72 times more likely to be vaccinated than those who did not, but less than half of adults had received a provider recommendation.[26] To our knowledge, there are no published studies on provider recommendation of influenza vaccination that focus on all children 6 months–17 years, regardless of health conditions, using a national sample.

The objectives of this study were to: 1) quantify the proportion of children 6 months–17 years for whom a provider recommendation for influenza vaccination was received at the state and national levels by sociodemographic characteristics, 2) identify factors associated with parental receipt of a provider recommendation for their child’s influenza vaccination, and 3) determine whether parental receipt of a provider recommendation is independently associated with influenza vaccination status among children 6 months–17 years.

Methods

Data from the National Immunization Survey-Flu (NIS-Flu) from the 2013–14, 2014–15, and 2015–16 influenza seasons were analyzed to assess parental receipt of a provider recommendation for influenza vaccination for the child and influenza vaccination coverage by receipt of a provider recommendation during the three seasons.[27;28] The NIS-Flu is an ongoing, national list-assisted random-digit-dialed dual frame landline and cellular telephone survey of households with children. It includes three components: the NIS-Child for children 19–35 months, the NIS-Teen for adolescents 13–17 years, and the NIS Child Influenza Module for children 6–18 months and 3–12 years identified during the screening of households for the NIS-Child and NIS-Teen.[27–33] Telephone interviews were conducted with parents or guardians during October through June for the three seasons from all 50 states and the District of Columbia. The NIS-Flu survey questionnaire was available in English and Spanish, and Language Line Services was used for real-time translation into many other languages.[34] The Council of American Survey and Research Organizations (CASRO) response rates ranged from 53.5%–64.8% for landline and 29.9%–38.8% for cellular telephones.[5;35–37]

The study sample included children in the NIS-Flu who had at least one visit to a doctor or other health professional since July 1st during the influenza season of the interview and had information about whether a provider recommendation for influenza was received. Survey questions about provider recommendation were only asked during the April–June interview months. Survey respondents were asked, ‘Since July 1st, has [sample child] had a visit to a doctor or other health professional about his or her health?’; children were excluded if the respondent answered ‘No’, ‘Don’t Know’, or if they refused to answer (26.4%, 24.6%, and 24.3% for the 2013–14, 2014–15, and 2015–16 seasons, respectively). Respondents who answered ‘Yes’ were asked, ‘Since July 1st, did a doctor or other health professional tell you they recommend or say it was a good idea for [sample child] to get a flu vaccination?’; children were excluded if the respondent answered ‘Don’t Know’ or refused to answer (5.2%, 5.9%, and 5.9% for the 2013–14, 2014–15, and 2015–16 seasons, respectively). Respondents were also asked if their child had received an influenza vaccination since July 1st and, if so, during which month and year. Information on child, maternal, and household sociodemographic characteristics were also collected during the interviews.

State level and national influenza vaccination coverage estimates and methods were published previously for children 6 months and older and were calculated for this study using the same methodology for children who met the inclusion criteria described previously.[5;35;36] Tests of association between receipt of a provider recommendation for influenza vaccination and demographic variables were conducted using Wald chi-square tests followed by pair-wise comparison t-tests. Multivariable logistic regression was used to determine 1) variables independently associated with receipt of a provider recommendation, and 2) whether receipt of a provider recommendation was independently associated with receipt of an influenza vaccination. Independent variables in the models included the following: child’s age, sex, and race/ethnicity, language of the survey, mother’s education, poverty/annual household income, number of children in the household, urban/rural residence, and region of residence. Adjusted prevalence ratios (APR) and adjusted prevalences (AP) based on predicted marginals from the logistic regression models are reported. In addition, population attributable risk (PAR) was calculated using the prevalence of provider recommendation receipt and the prevalence ratio of influenza vaccination by provider recommendation receipt to assess the potential contribution of provider recommendation to the observed influenza vaccination level.

A two-sided significance level of 0.05 was adopted for all statistical tests. Reported percentages and corresponding 95% confidence intervals (95% CI) were weighted, while reported sample sizes were unweighted. All analyses were weighted to population totals and to adjust for households having multiple telephone lines, unit non-response, and non-coverage of non-telephone households. Analyses were conducted using SAS (version 9.3) and SUDAAN (version 11.0.0) statistical software to account for the complex design. Institutional review board (IRB) approval for conducting the NIS was obtained through the National Center for Health Statistics Research Ethics Review Board and the IRB of NORC at the University of Chicago.[38]

Results

There were 24,515, 26,825, and 25,261 children who had a provider visit and were included in the study for the 2013–14, 2014–15, and 2015–16 seasons, respectively. The characteristics of children included in the study sample are presented in Table 1. In addition, the characteristics of children who did not have a provider visit and were excluded from the study are also presented.

Table 1.

Sociodemographic and other characteristics of children 6 months–17 years who had a provider visit since July 1st during the influenza season, and children who did not have a provider visit, United States, National Immunization Survey-Flu (NIS-Flu), 2013–14 through 2015–16 influenza seasons

Characteristics 2013–14 influenza season 2014–15 influenza season 2015–16 influenza season
Visit since July 1st No visit since July 1st Visit since July 1st No visit since July 1st Visit since July 1st No visit since July 1st
unweighted
n		 weighted %
(± 95% CI*)		 unweighted
n		 weighted %
(± 95% CI)		 unweighted
n		 weighted %
(± 95% CI)		 unweighted
n		 weighted %
(± 95% CI)		 unweighted
n		 weighted %
(± 95% CI)		 unweighted
n		 weighted %
(± 95% CI)
Total 24,515 100 (± 0.0) 9,045 100 (± 0.0) 26,825 100 (± 0.0) 9,032 100 (± 0.0) 25,261 100 (± 0.0) 8,394 100 (± 0.0)
Influenza vaccination status
 ≥1 dose 15,560 60.7 (± 2.2) 5,284 59.2 (± 2.8) 17,179 61.2 (± 1.3) 5,183 55.8 (± 2.2) 15,996 60.4 (± 1.3) 4,916 59.2 (± 2.2)
 Not vaccinated 8,955 39.3 (± 2.2) 3,761 40.8 (± 2.8) 9,646 38.8 (± 1.3) 3,849 44.2 (± 2.2) 9,265 39.6 (± 1.3) 3,478 40.8 (± 2.2)
Provider recommendation
 Yes 17,294 69.1 (± 2.2) 19,135 71.0 (± 1.2) 17,784 70.3 (± 1.2)
 No 7,221 30.9 (± 2.2) 7,690 29.0 (± 1.2) 7,477 29.7 (± 1.2)
Child’s age
 6–23 months 3,303 10.0 (± 1.0) 502 5.2 (± 1.5) 4,049 10.3 (± 0.6) 583 4.2 (± 0.7) 3,748 10.0 (± 0.6) 581 5.0 (± 0.8)
 2–4 years 3,802 16.0 (± 2.2) 1,015 10.8 (± 1.6) 4,647 15.1 (± 0.9) 1,215 12.9 (± 1.4) 4,312 14.9 (± 0.9) 1,123 12.0 (± 1.3)
 5–12 years 11,693 42.5 (± 2.3) 5,269 54.6 (± 2.8) 11,324 44.7 (± 1.3) 4,619 50.8 (± 2.0) 10,264 45.3 (± 1.3) 4,109 50.8 (± 2.2)
 13–17 years 5,717 31.4 (± 2.2) 2,259 29.4 (± 2.5) 6,805 30.0 (± 1.2) 2,615 32.2 (± 2.0) 6,937 29.8 (± 1.2) 2,581 32.2 (± 2.1)
Child’s sex
 Male 12,583 50.7 (± 2.3) 4,692 51.7 (± 2.8) 13,797 51.3 (± 1.3) 4,680 50.5 (± 2.1) 13,088 50.3 (± 1.3) 4,452 53.4 (± 2.2)
 Female 11,932 49.3 (± 2.3) 4,353 48.3 (± 2.8) 13,028 48.7 (± 1.3) 4,352 49.5 (± 2.1) 12,173 49.7 (± 1.3) 3,942 46.6 (± 2.2)
Child’s race/ethnicity†
 White, non-Hispanic 15,006 54.1 (± 2.5) 5,258 51.6 (± 3.0) 15,357 54.5 (± 1.4) 4,720 49.4 (± 2.2) 14,934 53.9 (± 1.4) 4,486 47.2 (± 2.2)
 Black, non-Hispanic 2,510 14.3 (± 1.6) 928 13.2 (± 2.0) 2,840 13.8 (± 1.0) 1,012 13.5 (± 1.5) 2,744 13.2 (± 0.9) 975 16.0 (± 1.8)
 Hispanic 4,326 22.9 (± 2.6) 1,758 25.3 (± 2.8) 5,567 22.8 (± 1.3) 2,188 27.4 (± 2.1) 4,369 23.4 (± 1.3) 1,762 26.4 (± 2.2)
 Other, non-Hispanic 2,673 8.7 (± 1.5) 1,101 9.9 (± 1.7) 3,061 8.9 (± 0.7) 1,112 9.7 (± 1.2) 3,214 9.5 (± 0.8) 1,171 10.4 (± 1.3)
Language survey completed
 English 22,689 89.5 (± 1.4) 8,203 85.8 (± 2.3) 24,311 88.3 (± 1.1) 7,902 84.3 (± 1.8) 23,487 90.3 (± 0.9) 7,493 85.5 (± 1.8)
 Spanish 1,540 9.3 (± 1.3) 703 12.1 (± 2.2) 2,153 10.4 (± 1.1) 972 13.6 (± 1.8) 1,396 8.2 (± 0.8) 709 11.9 (± 1.7)
 Other language 286 1.2 (± 0.3) 139 2.1 (± 0.9) 361 1.3 (± 0.3) 158 2.1 (± 0.6) 378 1.6 (± 0.4) 192 2.6 (± 0.8)
Mother’s education
 <High school 2,127 13.3 (± 1.8) 1,055 16.1 (± 2.5) 2,420 11.9 (± 1.1) 1,179 17.8 (± 1.8) 2,175 11.7 (± 1.1) 1,035 16.1 (± 1.6)
 High school or equivalent 3,944 18.1 (± 1.8) 1,777 21.8 (± 2.6) 4,479 19.0 (± 1.2) 1,815 20.3 (± 1.8) 3,966 17.2 (± 1.0) 1,640 21.3 (± 2.1)
 Some college 6,223 25.5 (± 1.9) 2,353 27.0 (± 2.8) 6,643 25.9 (± 1.2) 2,230 24.0 (± 1.8) 6,200 25.7 (± 1.2) 1,979 22.6 (± 1.8)
 ≥College degree 11,309 43.1 (± 2.5) 3,409 35.1 (± 2.8) 12,128 43.2 (± 1.3) 3,313 38.0 (± 2.2) 11,817 45.4 (± 1.4) 3,279 40.0 (± 2.3)
Poverty/annual household income‡
 Above poverty (>$75,000) 9,993 35.5 (± 2.4) 3,222 31.4 (± 2.7) 10,817 36.0 (± 1.2) 3,144 32.8 (± 2.0) 10,648 38.6 (± 1.3) 3,079 33.2 (± 2.1)
 Above poverty (≤$75,000) 8,127 33.1 (± 2.2) 3,202 32.0 (± 2.7) 8,653 30.9 (± 1.2) 2,989 29.3 (± 1.9) 8,017 30.8 (± 1.3) 2,710 29.8 (± 2.0)
 Below poverty 3,909 21.8 (± 2.1) 1,532 24.2 (± 2.8) 4,562 21.3 (± 1.3) 1,686 23.6 (± 2.0) 3,833 19.0 (± 1.1) 1,469 22.2 (± 2.0)
 Unknown 2,486 9.6 (± 1.1) 1,089 12.4 (± 2.0) 2,793 11.8 (± 0.9) 1,213 14.4 (± 1.5) 2,763 11.6 (± 0.8) 1,136 14.8 (± 1.6)
Number of children in household
 1 7,952 25.6 (± 1.8) 2,684 22.1 (± 2.1) 9,363 26.7 (± 1.0) 2,861 23.4 (± 1.7) 8,941 26.7 (± 1.1) 2,692 24.2 (± 1.8)
 2–3 14,382 62.3 (± 2.2) 5,339 63.2 (± 2.8) 15,096 61.1 (± 1.3) 5,154 60.9 (± 2.2) 14,152 61.1 (± 1.3) 4,839 61.8 (± 2.2)
 ≥4 2,132 12.1 (± 1.6) 1,000 14.7 (± 2.3) 2,285 12.2 (± 1.1) 980 15.7 (± 1.9) 2,063 12.2 (± 1.0) 849 14.0 (± 1.6)
Urban-rural residence
 Urban (MSA,§ principal city) 6,505 25.7 (± 1.9) 2,240 24.8 (± 2.6) 7,566 26.6 (± 1.2) 2,395 25.2 (± 2.0) 6,764 25.9 (± 1.2) 2,277 25.2 (± 1.9)
 Suburban (MSA, not principal city) 13,097 60.5 (± 2.2) 4,696 58.3 (± 2.9) 14,615 59.7 (± 1.3) 4,815 59.8 (± 2.1) 13,945 59.8 (± 1.3) 4,513 59.8 (± 2.2)
 Rural (non-MSA) 4,913 13.8 (± 1.3) 2,109 16.9 (± 2.2) 4,644 13.7 (± 0.8) 1,822 15.0 (± 1.3) 4,552 14.3 (± 0.9) 1,604 15.1 (± 1.4)
Region of residence
 Northeast 5,325 17.8 (± 1.4) 1,427 12.5 (± 1.8) 5,432 17.2 (± 0.9) 1,374 14.0 (± 1.5) 5,854 17.6 (± 0.9) 1,529 13.0 (± 1.3)
 Midwest 5,013 21.5 (± 1.7) 2,056 20.7 (± 1.8) 5,170 21.5 (± 0.9) 1,874 21.8 (± 1.5) 4,652 21.4 (± 0.9) 1,627 21.9 (± 1.6)
 South 9,136 37.5 (± 2.2) 3,163 39.8 (± 2.9) 10,819 37.7 (± 1.2) 3,573 37.5 (± 2.0) 9,921 38.0 (± 1.2) 3,259 38.7 (± 2.1)
 West 5,041 23.2 (± 2.5) 2,399 27.0 (± 2.7) 5,404 23.5 (± 1.4) 2,211 26.7 (± 2.3) 4,834 23.0 (± 1.5) 1,979 26.5 (± 2.5)
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*

CI = confidence interval half-width.

†

Race/ethnicity is based on parental report. Children of Hispanic ethnicity may be of any race. Children categorized as white, black, or other were identified as non-Hispanic. The other race category included children of reported Asian, American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, other, or multiple (i.e. selected more than one race category) races.

‡

Poverty level was defined based on the reported number of people living in the household and annual household income, according to the U.S. Census poverty thresholds (https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html).

§

MSA = metropolitan statistical area. MSA was based on parent/guardian respondent-reported city, state, county, and zip code of residence using the (https://www.census.gov/programs-surveys/metro%20micro.html) MSA definitions file.

National and state level estimates for parental receipt of a provider recommendation for influenza vaccination among children are shown in Table 2 and Figure 1. During the 2015–16 season, 70.3% of children had a parent or guardian who reported receiving a provider recommendation for influenza vaccination of their child. Influenza vaccination coverage among children for whom a provider recommendation was received was 72.2%, compared with 32.1% among children for whom a provider recommendation was not received, resulting in a PAR estimate of 46.8%. At the state level during the 2015–16 season, the proportion of children for whom a provider recommendation was received ranged from 49.6% (Wyoming) to 83.7% (District of Columbia). In each state, vaccination coverage was higher among children with a provider recommendation compared with those without a provider recommendation. The PAR ranged from 16.7% (Maryland) to 70.7% (Montana). Overall, the proportion of children for whom a provider recommendation was received was similar during each season included in the study period. Comparing 2013–14 and 2015–16, the proportion of children with a provider recommendation increased in the District of Columbia and Texas and decreased in Kansas, Mississippi, and Wyoming (Table 2).

Table 2.

Weighted prevalence (%) of children 6 months–17 years for whom their parent received a provider recommendation for them to receive an influenza vaccination,* and who received influenza vaccination stratified by parental receipt of provider recommendation, nationally and by state of residence, United States, National Immunization Survey-Influenza (NIS-Flu), 2013–14 through 2015–16 influenza seasons





State of
residence		 2013–14 influenza season 2014–15 influenza season 2015–16 influenza season
Prevalence of provider
recommendation		 Influenza vaccination
coverage by
parental receipt of
provider recommendation
 PAR† Prevalence of provider
recommendation		 Influenza vaccination
coverage by
parental receipt of
provider recommendation
 PAR Prevalence of provider
recommendation		 Influenza vaccination
coverage by
parental receipt of
provider recommendation
 PAR
Recommenda
tion		 No
recommenda
tion		 Recommenda
tion		 No
recommenda
tion		 Recommenda
tion		 No
recommenda
tion
n % (± 95% CI‡) % (± 95% CI) % (± 95% CI) % n % (± 95% CI) % (± 95% CI) % (± 95% CI) % n % (± 95% CI) % (± 95% CI) % (± 95% CI) %
United States 24,515 69.1 (± 2.2) 71.1 (±2.4) 37.0 (±4.6) 38.9 26,826 71.0 (± 1.2) 72.4 (±1.4) 34.4 (±2.1) 44.0 25,261 70.3 (± 1.2) 72.2 (±1.5) 32.1 (±2.3) 46.8
Alabama 399 69.5 (± 6.2) 75.0 (±8.1) 37.1 (±10.8)§ 41.5 504 62.4 (± 7.3) 73.2 (±6.9) 35.7 (±11.5)§ 39.6 422 62.9 (± 6.5) 76.7 (±6.2) 47.9 (±11.7)§ 27.4
Alaska 380 62.9 (±10.0) 69.0 (±8.7) 29.9 (±13.7)§ 45.1 486 57.9 (± 7.3) 75.3 (±7.6) 39.6 (±11.1)§ 34.3 590 62.2 (± 6.4) 71.7 (±7.9) 19.8 (±6.8) 62.0
Arizona 369 66.1 (±11.0)§ 60.0 (±18.1)§ 21.9 (±11.8)§ 53.5 483 63.8 (± 6.8) 70.6 (±7.0) 27.0 (±9.7) 50.7 497 66.1 (± 6.8) 75.7 (±7.1) 33.2 (±10.3)§ 45.8
Arkansas 403 54.8 (±26.5)§ 81.6 (±9.9) 24.6 (±26.1)§ 55.9 391 65.5 (± 7.4) 71.0 (±10.1)§ 62.0 (±11.6)§ 8.7 340 63.6 (± 6.9) 82.4 (±6.8) 48.6 (±12.1)§ 30.7
California 457 77.7 (± 8.1) 76.3 (±8.9) 31.7 (±14.3)§ 52.2 607 74.5 (± 5.5) 71.1 (±6.6) 35.4 (±11.2)§ 42.9 519 70.2 (± 6.7) 67.2 (±8.5) 29.8 (±12.9)§ 46.8
Colorado 561 75.4 (± 7.1) 61.2 (±14.4)§ 43.6 (±13.0)§ 23.3 493 75.6 (± 5.2) 70.2 (±6.9) 28.4 (±10.4)§ 52.7 265 69.1 (± 8.2) 77.4 (±8.1) 33.0 (±15.2)§ 48.2
Connecticut 483 75.2 (± 6.5) 79.4 (±7.7) 31.2 (±11.1)§ 53.7 489 75.3 (± 5.5) 78.0 (±6.2) 33.2 (±11.3)§ 50.4 537 73.6 (± 6.1) 86.5 (±4.4) 37.4 (±10.6)§ 49.1
Delaware 518 75.2 (±11.6)§ 67.8 (±17.5)§ 27.9 (±16.6) § 51.8 419 77.4 (± 6.0) 80.8 (±6.2) 46.1 (±13.9)§ 36.8 431 78.0 (± 9.9) 80.9 (±9.5) 25.5 (±13.7)§ 62.9
District of Columbia 393 64.6 (±14.3)§ 85.3 (±5.6) 21.0 (±13.7) § 66.4 754 79.0 (± 5.2) 84.4 (±5.4) 43.0 (±12.2)§ 43.2 549 83.7 (± 4.9)|| 83.1 (±5.7) 52.3 (±13.7)§ 33.0
Florida 413 64.9 (± 8.6) 64.6 (±13.9)§ 30.2 (±11.2)§ 42.5 550 62.6 (± 6.1) 65.7 (±7.4) 22.8 (±7.6) 54.1 531 62.3 (± 5.9) 58.8 (±7.9) 26.9 (±8.7) 42.5
Georgia 391 64.8 (± 9.2) 66.9 (±10.1)§ 32.7 (±13.4)§ 40.4 511 70.2 (± 5.8) 70.9 (±7.1) 34.8 (±10.7)§ 42.1 528 68.7 (± 5.4) 66.5 (±7.7) 28.3 (±8.2) 48.1
Hawaii 310 80.5 (±10.0) 74.9 (±10.7)§ 42.7 (±26.9)§ 37.8 392 75.5 (± 7.6) 83.1 (±5.9) 57.0 (±16.5)§ 25.7 444 74.6 (± 6.5) 82.1 (±6.0) 43.9 (±12.7)§ 39.4
Idaho 276 59.2 (±10.7)§ 70.6 (±12.0)§ 29.7 (±18.9)§ 44.9 347 63.1 (± 7.4) 72.8 (±8.5) 28.5 (±12.6)§ 49.5 298 52.9 (±10.0) 71.3 (±9.6) 14.9 (±8.2) 66.7
Illinois 950 69.3 (±11.5)§ 60.8 (±12.3)§ 26.1 (±17.0)§ 48.0 1,003 71.4 (± 4.0) 67.0 (±5.4) 22.1 (±5.9) 59.2 773 68.7 (± 4.6) 69.5 (±5.3) 26.5 (±7.0) 52.7
Indiana 505 66.1 (± 7.9) 58.3 (±12.3)§ 28.6 (±11.4)§ 40.7 416 63.4 (± 6.2) 67.6 (±7.7) 34.8 (±10.7)§ 37.4 462 70.0 (± 6.0) 68.0 (±7.6) 19.2 (±7.5) 64.0
Iowa 388 65.9 (± 7.0) 70.3 (±11.0)§ 34.5 (±10.4)§ 40.6 396 71.3 (± 6.7) 69.5 (±7.8) 26.9 (±11.3)§ 53.0 392 68.2 (± 6.3) 68.5 (±7.9) 40.1 (±12.0)§ 32.6
Kansas 311 75.3 (± 7.8) 75.5 (±10.0) 35.8 (±12.2)§ 45.5 366 56.0 (±10.2)§,|| 70.4 (±9.3) 34.5 (±16.1)§ 36.8 304 63.3 (± 7.9) || 70.7 (±9.1) 23.5 (±11.5)§ 56.0
Kentucky 346 69.4 (± 8.1) 61.4 (±14.5)§ 25.3 (±9.7) 49.8 480 67.7 (± 5.8) 63.4 (±7.9) 30.3 (±9.3) 42.5 442 62.0 (± 6.1) 69.6 (±7.9) 25.4 (±8.5) 51.9
Louisiana 498 65.2 (± 8.9) 79.5 (±8.0) 24.4 (±8.9) 59.6 429 69.5 (± 5.8) 68.5 (±7.7) 38.1 (±10.8)§ 35.7 380 70.5 (± 6.1) 71.1 (±7.6) 19.6 (±8.7) 64.9
Maine 428 69.8 (±11.5)§ 71.7 (±7.2) 27.1 (±16.2)§ 53.5 452 77.5 (± 7.5) 79.1 (±6.1) 37.6 (±16.0)§ 46.1 575 69.0 (± 5.9) 75.6 (±6.7) 25.0 (±8.9) 58.3
Maryland 482 76.9 (± 8.4) 77.8 (±8.8) 34.0 (±15.8)§§ 49.8 718 78.9 (± 7.2) 79.7 (±8.2) 54.0 (±19.9)§ 27.3 699 71.1 (± 7.3) 81.3 (±7.4) 63.4 (±13.2)§ 16.7
Massachusetts 497 80.7 (± 7.5) 82.7 (±6.2) 40.5 (±17.9)§ 45.7 470 85.0 (± 4.6) 79.6 (±5.9) 52.2 (±16.3)§ 30.9 627 80.7 (± 4.5) 82.4 (±4.7) 51.2 (±13.0)§ 33.0
Michigan 389 66.1 (± 9.6) 69.6 (±13.3)§ 25.8 (±12.6)§ 52.9 408 73.3 (± 6.5) 66.3 (±7.4) 30.3 (±12.7)§ 46.5 342 73.8 (± 5.7) 64.2 (±8.1) 30.2 (±12.1)§ 45.4
Minnesota 318 61.1 (±24.2)§ 72.7 (±11.4)§ 18.6 (±19.5)§ 64.0 440 66.3 (± 7.3) 71.6 (±8.1) 48.8 (±14.3)§ 23.7 408 69.3 (± 6.1) 76.3 (±6.1) 49.0 (±12.1)§ 27.9
Mississippi 399 71.3 (±11.0)§ 59.1 (±26.5)§ 24.1 (±10.1)§ 50.9 453 64.8 (± 5.8) 60.5 (±7.9) 32.8 (±9.4) 35.4 386 54.9 (± 7.1)||, 75.4 (±7.5) 29.0 (±9.9) 46.8
Missouri 395 56.8 (±10.7)§ 66.7 (±10.5)§ 45.9 (±20.6)§ 20.5 398 71.9 (± 6.3)|| 70.4 (±8.1) 33.2 (±11.3)§ 44.6 356 68.1 (± 6.5) 80.2 (±6.5) 28.6 (±9.7) 55.1
Montana 352 60.9 (± 8.9) 76.1 (±8.3) 29.4 (±14.1)§ 49.2 303 58.0 (±10.4)§ 68.7 (±10.4)§ 18.9 (±12.4)§ 60.4 325 61.3 (±11.1)§ 67.7 (±12.3)§ 13.7 (±7.3) 70.7
Nebraska 327 47.7 (±30.0)|| 73.3 (±7.6) 14.5 (±17.9)§ 65.9 319 66.5 (± 8.2) 78.0 (±8.6) 50.2 (±15.6)§ 26.9 266 71.4 (± 8.0) 80.9 (±7.2) 24.1 (±11.7)§ 62.7
Nevada 452 70.7 (± 8.3) 71.0 (±11.3)§ 17.1 (±12.2)§ 69.0 374 61.5 (± 7.6) 62.4 (±10.2)§ 28.3 (±12.1)§ 42.6 321 67.3 (± 7.4) 66.6 (±10.4)§ 19.0 (±8.4) 62.8
New Hampshire 504 77.5 (± 8.8) 83.6 (±7.6) 44.2 (±14.5)§ 40.9 428 79.7 (± 5.1) 71.0 (±9.3) 33.0 (±12.2)§ 47.9 488 76.6 (± 5.4) 82.1 (±6.0) 47.5 (±12.8)§ 35.8
New Jersey 540 70.0 (± 8.2) 80.2 (±6.1) 37.7 (±16.1)§ 44.1 533 72.9 (± 5.3) 80.5 (±5.5) 37.9 (±10.9)§ 45.0 522 76.6 (± 4.6) 79.6 (±5.1) 38.2 (±11.0)§ 45.4
New Mexico 489 80.3 (± 9.4) 77.0 (±16.3)§ 41.5 (±10.7)§ 40.7 440 68.0 (± 6.1)|| 74.0 (±8.1) 53.0 (±11.6)§ 21.2 252 77.4 (± 7.1) 82.4 (±8.0) 32.5 (±13.9)§ 54.3
New York 862 69.3 (± 9.8) 69.7 (±8.8) 54.6 (±19.0)§ 16.1 1,020 75.7 (± 3.8) 74.8 (±5.0) 35.9 (±7.8) 45.1 950 76.0 (± 3.9) 72.8 (±4.6) 36.5 (±8.8) 43.0
North Carolina 502 76.9 (± 6.5) 68.6 (±14.8)§ 36.4 (±10.7)§ 40.5 384 68.5 (± 6.9) 74.9 (±7.4) 31.7 (±11.9)§ 48.3 537 77.6 (± 5.0) 69.6 (±7.1) 24.0 (±9.4) 59.6
North Dakota 373 63.8 (± 8.6) 68.3 (±10.6)§ 46.1 (±15.3)§ 23.5 334 74.4 (± 8.3) 79.6 (±7.7) 40.7 (±17.9)§ 41.6 243 66.8 (± 9.4) 75.7 (±12.2)§ 41.9 (±19.0)§ 35.0
Ohio 432 73.3 (± 8.7) 60.5 (±18.3)§ 22.4 (±8.8) 55.5 418 69.3 (± 6.2) 73.7 (±7.1) 23.7 (±9.7) 59.4 404 71.0 (± 6.2) 79.3 (±6.3) 21.2 (±10.3)§ 66.1
Oklahoma 417 68.1 (± 9.7) 83.1 (±7.9) 29.7 (±10.5)§ 55.0 367 69.9 (± 6.4) 75.4 (±8.3) 37.1 (±11.7)§ 41.9 325 60.4 (± 7.4) 81.9 (±6.7) 36.8 (±12.1)§ 42.5
Oregon 353 72.1 (± 8.2) 71.1 (±9.6) 25.6 (±13.4)§ 56.2 346 73.6 (± 7.0) 75.8 (±8.1) 31.1 (±14.8)§ 51.4 345 62.7 (± 7.9) 74.9 (±7.8) 25.0 (±9.4) 55.6
Pennsylvania 1,114 77.3 (± 5.1) 76.8 (±6.3) 24.0 (±8.3) 63.0 1,057 75.5 (± 8.3) 66.4 (±9.0) 30.5 (±15.6)§ 47.1 1,185 74.4 (± 5.8) 72.7 (±7.7) 25.5 (±9.4) 57.9
Rhode Island 442 83.6 (± 5.8) 86.5 (±5.4) 39.1 (±15.7)§ 50.3 506 85.0 (± 4.2) 87.0 (±4.5) 54.4 (±14.0)§ 33.7 550 79.7 (± 6.8) 82.2 (±5.4) 37.9 (±16.1)§ 48.2
South Carolina 463 68.3 (± 9.0) 75.0 (±10.4)§ 28.7 (±13.2)§ 52.4 487 63.1 (± 6.2) 66.5 (±7.7) 32.7 (±9.9) 39.5 661 65.1 (± 6.6) 72.1 (±7.9) 35.3 (±13.7)§ 40.4
South Dakota 291 66.8 (±10.1)§ 87.9 (±6.1) 50.9 (±17.9)§ 32.7 287 73.4 (± 8.2) 71.1 (±12.3)§ 46.5 (±16.7)§ 28.0 308 67.9 (± 8.0) 78.7 (±8.3) 54.2 (±15.4)§ 23.5
Tennessee 403 60.3 (±24.4)§ 75.0 (±7.9) 73.4 (±27.4)§ 1.3 425 65.8 (± 6.4) 76.5 (±6.8) 41.6 (±11.3)§ 35.6 400 70.6 (± 5.9) 79.2 (±5.9) 38.5 (±11.5)§ 42.7
Texas 2,109 60.4 (± 9.9) 74.6 (±8.2) 51.9 (±18.6)§ 20.9 2,955 72.5 (± 3.6)|| 78.5 (±4.2) 41.6 (±7.3) 39.1 2,113 71.1 (± 3.9)|| 70.5 (±5.4) 38.1 (±7.4) 37.7
Utah 297 58.6 (± 8.5) 64.9 (±9.5) 39.2 (±15.0)§ 27.8 277 58.1 (± 8.9) 76.7 (±8.7) 39.9 (±15.5)§ 34.9 282 64.9 (± 9.8) 75.3 (±9.0) 30.9 (±17.2)§ 48.3
Vermont 455 71.1 (± 9.5) 68.3 (±13.8)§ 18.1 (±10.4)§ 66.4 477 72.8 (± 5.3) 71.4 (±7.3) 26.1 (±9.1) 55.8 420 75.5 (± 6.9) 73.4 (±13.8)§ 31.0 (±13.0)§ 50.8
Virginia 492 63.5 (±16.1)§ 65.2 (±11.7)§ 62.9 (±25.6)§ 2.3 622 75.3 (± 6.8) 79.6 (±7.8) 38.0 (±15.4)§ 45.2 699 72.8 (± 5.9) 74.5 (±7.1) 34.7 (±11.6)§ 45.5
Washington 376 66.6 (± 9.3) 68.1 (±11.6)§ 47.4 (±18.7)§ 22.5 439 66.9 (± 6.9) 65.8 (±8.0) 34.1 (±12.4)§ 38.3 422 74.5 (± 6.4) 73.3 (±8.3) 37.7 (±14.2)§ 41.3
West Virginia 508 68.4 (± 8.2) 75.7 (±8.8) 19.4 (±8.3) 66.5 370 70.5 (± 6.6) 71.4 (±7.8) 4(±13.30.4 )§ 35.1 478 60.3 (± 8.9) 76.9 (±6.3) 21.6 (±10.1)§ 60.7
Wisconsin 334 73.5 (± 7.4) 70.1 (±8.8) 35.1 (±16.1)§ 42.3 385 76.8 (± 6.4) 65.9 (±8.9) 24.1 (±12.7)§ 57.1 394 80.2 (± 5.0) 67.7 (±7.5) 41.4 (±14.1)§ 33.8
Wyoming 369 75.2 (± 8.7) 51.8 (±19.2)§ 25.2 (±9.3) 44.3 418 57.8 (± 7.1)|| 64.9 (±8.6) 30.7 (±10.8)§ 39.2 274 49.6 (± 9.2)|| 63.1 (±11.3)§ 20.4 (±10.4)§ 50.9
Open in a new tab
*

Children who did not have a provider visit between July 1 and the date of the interview during an influenza season were excluded

†

PAR = population attributable risk. Population attributable risk is a measure to assess the potential contribution of provider recommendation to the observed vaccination level and was calculated using the formula: P (PR-1) / [P (PR-1)+1], where P was the prevalence of receiving a provider recommendation for influenza vaccination and PR was the prevalence ratio of vaccination by provider recommendation.

‡

CI = confidence interval half-width.

§

Estimates might not be reliable because confidence interval half-width is >10.

||

Statistically significant difference compared with the estimate for prevalence of provider recommendation from the 2013–14 influenza season.

Statistically significant difference compared with the estimate for prevalence of provider recommendation from the 2014–15 influenza season.

Figure 1.

Figure 1.

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Prevalence of children 6 months–17 years for whom their parent received a provider recommendation for them to receive an influenza vaccination, United States, National Immunization Survey-Flu (NIS-Flu), 2015–16 influenza season

In bivariate analysis, child’s age, number of children in the household, and region of residence were all found to be associated with parental receipt of a provider recommendation across all three seasons studied, whereas child’s gender and race/ethnicity were not associated with receipt of a provider recommendation (Table 3). Compared with younger children, those 13–17 years were less likely to have a parent report receiving a provider recommendation. During the 2015–16 season, the proportion of children with a provider recommendation decreased with increasing age of the child (80.0%, 75.8%, 72.2%, and 61.6% among children 6–23 months, 2–4 years, 5–12 years and 13–17 years, respectively). Children living in a household with 2–3 children compared with those with only 1 child and children living in the Northeast compared with those living in the Midwest and the South were consistently more likely to have a parent report receiving a provider recommendation. Comparing 2013–14 and 2015–16, only one difference was noted: an increase in the proportion of children living in urban areas whose parent reported receiving a provider recommendation (68.4% versus 73.9%). Across all seasons and groups studied, vaccination coverage was higher among children for whom a provider recommendation was received. During the 2015–16 season, the PAR among all groups ranged from 23.7% for children whose parent completed the survey in Spanish to 61.1% for children who lived in households with 4 or more children. Additional estimates of parental receipt of a provider recommendation by sociodemographic characteristics are presented in Table 3.

Table 3.

Weighted prevalence (%) of children 6 months–17 years for whom their parent received a provider recommendation for them to receive an influenza vaccination,* and who received influenza vaccination stratified by parental receipt of provider recommendation, by selected sociodemographic characteristics, United States, National Immunization Survey-Influenza (NIS-Flu), 2013–14 through 2015–16 influenza seasons





Characteristics		 2013–14 influenza season 2014–15 influenza season 2015–16 influenza season
Prevalence of
provider
recommendati
on		 Influenza vaccination coverage†
by parental receipt of
provider recommendation
 PAR‡ Prevalence of
provider
recommendati
on		 Influenza vaccination coverage
by parental receipt of
provider recommendation
 PAR Prevalence of
provider
recommendati
on		 Influenza vaccination coverage
by parental receipt of
provider recommendation
 PAR
Recommendati
on		 No
recommendati
on		 Recommendati
on		 No
recommendat
ion		 Recommendati
on		 No
recommendati
on
% (± 95% CI§) % (± 95% CI) % (± 95% CI) % % (± 95% CI) % (± 95% CI) % (± 95% CI) % % (± 95% CI) % (± 95% CI) % (± 95% CI) %
Overall 69.1 (± 2.2) 71.1 (±2.4) 37.0 (±4.6) 38.9 71.0 (± 1.2) 72.4 (±1.4) 34.4 (±2.1) 44.0 70.3 (± 1.2) 72.2 (±1.5) 32.1 (±2.3) 46.8
Child’s age
 a. 6–23 months 77.3 (± 4.9)||,d 79.2 (±5.7)c,d 34.8 (±10.5) 49.7 80.7 (± 2.5)c,d 80.8 (±2.6)c,d 42.5 (±7.2)d 42.1 80.0 (± 2.5)b,c,d 80.7 (±3.2)c,d 37.3 (±6.6)d 48.2
 b. 2–4 years 78.9 (± 4.3)c,d 79.8 (±4.9)c,d 43.1 (±8.7)d 40.2 77.5 (± 2.5)c,d 77.9 (±2.6)c,d 43.1 (±6.1)d 38.5 75.8 (± 2.9)a,c,d 76.5 (±3.2)d 40.0 (±6.7)d 40.9
 c. 5–12 years 71.6 (± 3.1)b,d 71.7 (±3.2)a,b,d 43.0 (±7.4)d 32.3 72.3 (± 1.7)a,b,d 73.6 (±2.1)a,b,d 37.4 (±3.4)d 41.2 72.2 (± 1.8)a,b,d 73.5 (±2.3)a,d 33.5 (±3.5)d 46.3
 d. 13–17 years 58.2 (± 4.4)a,b,c 60.6 (±5.2)a,b,c 30.3 (±7.5)b,c 36.8 62.5 (± 2.4)a,b,c 63.2 (±3.2)a,b,c 27.0 (±3.3)a,b,c 45.6 61.6 (± 2.3)a,b,c 63.6 (±3.2)a,b,c 27.3 (±3.7)a,b,c 45.0
Child’s sex
 a. Male 69.4 (± 3.2) 74.0 (±3.2)b 38.4 (±6.2) 39.2 71.1 (± 1.6) 74.2 (±1.8)b 35.4 (±2.9) 43.8 69.2 (± 1.7) 72.2 (±1.9) 33.4 (±3.3) 44.6
 b. Female 68.9 (± 3.1) 68.1 (±3.5)a 35.5 (±6.9) 38.8 70.9 (± 1.7) 70.4 (±2.1)a 33.3 (±3.1) 44.1 71.5 (± 1.7) 72.2 (±2.3) 30.7 (±3.0) 49.1
Child’s race/ethnicity**
 a. White, non-Hispanic 68.7 (± 2.4) 68.6 (±3.0)c,d 33.5 (±5.1) 41.9 70.2 (± 1.5) 71.2 (±1.8)d 31.6 (±2.8)c,d 46.8 69.2 (± 1.5) 71.4 (±1.9)d 27.9 (±2.4)c,d 51.9
 b. Black, non-Hispanic 69.0 (± 5.3) 65.0 (±7.4)c,d 33.6 (±10.0) 39.2 71.0 (± 3.1) 70.0 (±4.1)d 33.4 (±5.6)d 43.8 70.5 (± 3.0) 69.8 (±3.8)d 32.3 (±5.4)d 45.0
 c. Hispanic 70.9 (± 6.3) 76.8 (±4.9)a,b 45.9 (±13.2) 32.3 72.5 (± 2.7) 74.1 (±3.5) 38.5 (±5.1)a 40.1 72.9 (± 3.0) 73.6 (±4.1) 38.0 (±5.9)a 40.6
 d. Other, non-Hispanic 67.7 (± 8.7) 81.1 (±5.1)a,b 42.5 (±16.7) 38.1 72.3 (± 3.4) 78.7 (±3.7)a,b 43.6 (±7.0)a,b 36.8 70.6 (± 4.4) 76.6 (±4.4)a,b 43.7 (±10.0)a,b 34.7
Language survey completed
 a. English 68.4 (± 2.4)b 70.0 (±2.7)b,c 36.7 (±4.9) 38.3 70.3 (± 1.2)b 71.5 (±1.4)b 32.6 (±2.2)b,c 45.6 70.0 (± 1.3) 71.2 (±1.6)b,c 29.8 (±2.3)b,c 49.3
 b. Spanish 77.2 (± 7.5)a,c 79.0 (±5.7)a 38.2 (±15.7) 45.2 77.4 (± 3.8)a,c 79.5 (±5.4)a 49.7 (±8.5)a 31.7 75.1 (± 4.6) 80.7 (±5.0)a 57.1 (±10.2),a 23.7
 c. Other language 63.3 (±11.2)b 84.5 (±10.4),a 52.4 (±17.4) 27.9 67.6 (± 8.9)b 72.5 (±14.6) 60.4 (±14.1),a 11.9 64.2 (±10.0) 87.4 (±9.5)a 53.2 (±14.7),a 29.2
Mother’s education
 a. <High school 68.2 (± 7.3) 75.5 (±6.5)b,c 49.2 (±15.0),c 26.7 71.2 (± 3.8)d 75.1 (±4.9)b,c 41.8 (±7.6)c 36.2 71.0 (± 4.2) 78.0 (±4.3)b,c 45.1 (±8.2)b,c,d 34.1
 b. High school or equivalent 63.7 (± 5.9) 63.3 (±6.2)a,d 33.1 (±12.8) 36.8 67.6 (± 3.1)d 68.1 (±4.2)a,d 35.2 (±5.0) 38.7 66.9 (± 3.0)d 71.3 (±4.0)a,c 30.7 (±4.7)a 46.9
 c. Some college 68.7 (± 3.5) 66.2 (±4.6)a,d 28.5 (±4.9)a,d 47.6 67.7 (± 2.4)d 66.4 (±2.9)a,d 30.8 (±4.0)a 43.9 66.3 (± 2.6)d 65.7 (±3.4)a,b,d 27.2 (±3.8)a 48.4
 d. ≥College degree 72.3 (± 3.4) 76.3 (±3.0)b,c 40.4 (±7.4)c 39.1 75.7 (± 1.6)a,b,c 76.4 (±1.8)b,c 35.2 (±3.4) 47.0 73.9 (± 1.7)b,c 74.5 (±2.2)c 31.6 (±3.8)a 50.1
Poverty/annual household income††
 a. Above poverty (>$75,000) 73.7 (± 3.2)b,c,d 77.2 (±3.2)b 38.8 (±6.7) 42.2 76.0 (± 1.7)b,c,d 75.4 (±2.0)b 34.4 (±3.7) 47.5 72.5 (± 1.9)‡‡ 74.3 (±2.1)b 31.8 (±4.1) 49.2
 b. Above poverty (≤$75,000) 68.2 (± 3.6)a 64.1 (±4.5)a,c 31.2 (±6.9) 41.8 68.5 (± 2.1)a 68.4 (±2.6)a,d 32.7 (±3.5)c 42.8 69.3 (± 2.2) 67.2 (±3.2)a,c 28.3 (±3.3)c,d 48.8
 c. Below poverty 65.4 (± 5.9)a 71.3 (±5.4)b 45.3 (±12.3) 27.3 69.6 (± 2.8)a,d 71.4 (±3.6) 40.0 (±5.3)b,d 35.3 68.4 (± 3.0) 76.6 (±3.2)b 37.1 (±5.7)b 42.1
 d. Unknown 64.5 (± 6.2)a 70.5 (±5.9) 31.8 (±8.9) 44.0 64.7 (± 3.7)a,c 74.4 (±4.5)b 29.4 (±5.3)c 49.8 69.2 (± 3.4) 71.4 (±4.4) 34.9 (±5.6)b 42.0
Number of children in household
 a. 1 62.2 (± 3.9)b,c 71.4 (±4.2) 32.2 (±6.5) 43.1 67.9 (± 1.9)b,§§ 72.0 (±2.4) 35.1 (±3.1) 41.7 66.2 (± 2.2)b,c 72.8 (±3.0) 31.0 (±3.9)c 47.2
 b. 2–3 71.5 (± 3.0)a 71.7 (±3.2) 39.1 (±6.8) 37.3 73.0 (± 1.6)a,c 72.2 (±1.9) 34.2 (±3.0) 44.8 71.5 (± 1.6)a 72.9 (±1.8) 34.7 (±3.1)c 44.0
 c. ≥4 71.4 (± 5.5)a 67.4 (±7.0) 39.5 (±10.2) 33.5 67.4 (± 4.0)b 73.7 (±4.4) 33.4 (±7.2) 44.9 73.7 (± 3.6)a,‡‡ 67.6 (±5.5) 21.6 (±5.2)a,b 61.1
Urban-rural residence
 a. Urban (MSA,|||| principal city) 68.4 (± 4.0) 73.3 (±4.0) 34.3 (±7.4) 43.7 73.1 (± 2.3)c,§§ 75.6 (±2.7)b,c 35.4 (±4.2) 45.4 73.9 (± 2.2)b,c,§§ 77.5 (±2.5)b,c 38.0 (±4.7)b,c 43.4
 b. Suburban (MSA, not principal city) 70.7 (± 3.1) 70.1 (±3.5) 41.4 (±6.6)c 32.9 72.0 (± 1.5)c 71.9 (±1.9)a,c 35.3 (±2.8) 42.7 70.4 (± 1.7)a,c 70.4 (±2.1)a 30.9 (±3.1)a 47.4
 c. Rural (non-MSA) 63.8 (± 4.9) 71.8 (±4.3) 25.7 (±5.9)b 53.4 62.3 (± 3.3)a,b 67.8 (±3.3)a,b 30.0 (±5.2) 44.0 63.7 (± 2.9)a,b 69.8 (±3.8)a 28.7 (±4.2)a 47.7
Region of residence
 a. Northeast 73.3 (± 4.2)b,c 75.9 (±3.8)b 41.8 (±10.7),b 37.4 76.6 (± 2.5)b,c,d 75.1 (±2.9)b 36.3 (±5.4) 45.0 76.0 (± 2.2)b,c,d 76.5 (±2.7)b,c,d 35.3 (±4.6)b 47.0
 b. Midwest 67.3 (± 4.3)a 65.4 (±5.4)a 28.4 (±6.1)a,c 46.7 69.8 (± 2.1)a 69.4 (±2.5)a,c 30.6 (±3.8)c 47.0 70.7 (± 2.0)a 72.1 (±2.4)a 29.0 (±3.6)a,c 51.2
 c. South 65.6 (± 3.8)a,d 71.3 (±3.7) 41.8 (±8.3)b 31.6 69.2 (± 1.7)a 73.6 (±2.0)b 36.0 (±3.1)b 42.0 68.4 (± 1.7)a 71.0 (±2.3)a 34.2 (±3.0)b 42.4
 d. West 73.5 (± 4.8)c 72.0 (±6.0) 32.9 (±7.3) 46.6 70.9 (± 3.2)a 71.0 (±3.9) 34.1 (±5.7) 43.4 69.0 (± 3.7)a 70.8 (±4.8)a 29.6 (±6.8) 49.0
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*

Children who did not have a provider visit between July 1and the date of the interview during an influenza season were excluded.

†

Influenza vaccination coverage was calculated by the Kaplan Meier method.

‡

PAR = population attributable risk. Population attributable risk is a measure to assess the potential contribution of provider recommendation to the observed vaccination level and was calculated using the formula: P (PR-1) / [P (PR-1)+1], where P was the prevalence of receiving a provider recommendation for influenza vaccination and PR was the prevalence ratio of vaccination by provider recommendation.

§

CI = confidence interval half-width.

||

The presence or absence of superscripted letters denotes whether that estimate was statistically significantly different at P < 0.05 from another row, and denotes which row it differed from (a, b, c, or d), based on pair-wise comparison t-test. For example, in 2013–14, the percentage of children 6–23 months (a) who received a provider recommendation (77.3%) was statistically significantly different from the percentage of children 13–17 years (d) who received a provider recommendation (58.2%).

Estimates might not be reliable because confidence interval half-width is >10.

**

Race/ethnicity is based on parental report. Children of Hispanic ethnicity may be of any race. Children categorized as white, black, or other were identified as non-Hispanic. The other race category included children of reported Asian, American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, other, or multiple (i.e. selected more than one race category) races.

††

Poverty level was defined based on the reported number of people living in the household and annual household income, according to the U.S. Census poverty thresholds (https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html).

‡‡

Statistically significant difference compared with the estimate for prevalence of provider recommendation from the 2014–15 influenza season.

§§

Statistically significant difference compared with the estimate for prevalence of provider recommendation from the 2013–14 influenza season.

||||

MSA = metropolitan statistical area. MSA was based on parent/guardian respondent-reported city, state, county, and zip code of residence using the (https://www.census.gov/programs-surveys/metro-micro.html) MSA definitions file.

The results of the multivariable analysis to determine factors associated with parental receipt of a provider recommendation for influenza vaccination for the child were generally consistent with the bivariate analysis (Table 4). The strongest association observed across the 2013–14, 2014–15, and 2015–16 seasons was between parental receipt of a provider recommendation and child’s age, with children 6–23 months (APR 1.37, 1.28, and 1.31, respectively), 2–4 years (APR 1.37, 1.22, and 1.23, respectively), and 5–12 years (APR 1.24, 1.13, and 1.17, respectively) being more likely to have a parent report receipt of a provider recommendation than children 13–17 years. In addition, throughout the study, children living above poverty and with an annual household income greater than $75,000 were more likely to have a parent report receipt of a provider recommendation than children living below poverty (APR 1.19, 1.09, and 1.06, respectively). All results from the model are presented in Table 4, including APRs and APs.

Table 4.

Association of parental receipt of a provider recommendation for their child to receive influenza vaccination with sociodemographic characteristics among children 6 months–17 years who had a provider visit since July 1st during the influenza season, United States, National Immunization Survey-Influenza (NIS-Flu), 2013–14 through 2015–16 influenza seasons


Characteristics		 2013–14 influenza season 2014–15 influenza season 2015–16 influenza season
APR* ± 95% CI† AP‡ % APR ± 95% CI AP % APR ± 95% CI AP %
Child’s age
 6–23 months 1.37 (1.25–1.51) 79.3 (74.6–83.3) 1.28 (1.22–1.34) 81.3 (78.7–83.6) 1.31 (1.25–1.37) 80.8 (78.3–83.1)
 2–4 years 1.37 (1.25–1.49) 78.9 (74.9–82.5) 1.22 (1.17–1.29) 78.0 (75.4–80.4) 1.23 (1.16–1.29) 75.7 (72.6–78.6)
 5–12 years 1.24 (1.14–1.34) 71.5 (68.5–74.2) 1.13 (1.08–1.18) 72.2 (70.5–73.9) 1.17 (1.11–1.22) 72.0 (70.2–73.8)
 13–17 years Referent 57.8 (53.3–62.2) Referent 63.7 (61.3–66.1) Referent 61.8 (59.4–64.2)
Child’s sex
 Male 1.01 (0.95–1.07) 69.5 (66.5–72.4) 1.00 (0.97–1.03) 71.5 (69.9–73.1) 0.97 (0.94–1.00) 69.3 (67.5–71.0)
 Female Referent 69.0 (65.9–71.9) Referent 71.6 (69.8–73.2) Referent 71.5 (69.8–73.2)
Child’s race/ethnicity§
 White, non-Hispanic Referent 69.1 (66.6–71.5) Referent 71.1 (69.4–72.7) Referent 69.1 (67.4–70.8)
 Black, non-Hispanic 1.07 (0.99–1.15) 73.9 (68.7–78.5) 1.04 (0.99–1.09) 73.9 (70.8–76.8) 1.05 (1.00–1.10) 72.3 (69.2–75.3)
 Hispanic 0.96 (0.86–1.08) 66.7 (59.4–73.3) 0.99 (0.94–1.05) 70.5 (67.0–73.8) 1.05 (0.99–1.11) 72.3 (68.6–75.7)
 Other, non-Hispanic 0.99 (0.89–1.10) 68.2 (60.7–74.8) 1.03 (0.98–1.09) 73.2 (69.5–76.7) 1.02 (0.95–1.09) 70.5 (65.8–74.9)
Language survey completed
 English Referent 67.6 (64.7–70.4) Referent 70.2 (68.7–71.5) Referent 69.9 (68.5–71.4)
 Spanish 1.23 (1.11–1.36) 83.0 (75.2–88.6) 1.17 (1.11–1.24) 82.4 (78.0–86.0) 1.09 (1.00–1.18) 75.9 (69.8–81.1)
 Other language 0.96 (0.79–1.17) 64.7 (51.5–76.0) 0.97 (0.83–1.13) 68.0 (56.6–77.5) 0.97 (0.81–1.15) 67.8 (55.2–78.2)
Mother’s education
 <High school Referent 66.9 (59.3–73.7) Referent 70.6 (66.2–74.6) Referent 70.1 (65.6–74.4)
 High school or equivalent 0.99 (0.86–1.13) 66.1 (60.8–71.0) 0.97 (0.90–1.04) 68.5 (65.4–71.4) 0.97 (0.90–1.04) 67.7 (64.6–70.7)
 Some college 1.05 (0.93–1.18) 70.0 (66.7–73.0) 0.99 (0.92–1.06) 69.8 (67.4–72.0) 0.96 (0.89–1.03) 67.3 (64.8–69.8)
 ≥College degree 1.06 (0.94–1.20) 71.0 (67.3–74.3) 1.05 (0.98–1.13) 74.4 (72.5–76.2) 1.04 (0.97–1.12) 73.3 (71.4–75.1)
Poverty/annual household income||
 Above poverty (>$75,000) 1.19 (1.07–1.32) 73.9 (70.8–76.7) 1.09 (1.03–1.15) 75.5 (73.6–77.4) 1.06 (1.00–1.13) 72.0 (69.9–73.9)
 Above poverty (≤$75,000) 1.12 (1.01–1.24) 69.4 (65.9–72.7) 1.00 (0.95–1.06) 69.7 (67.5–71.7) 1.04 (0.98–1.10) 70.4 (68.2–72.6)
 Below poverty Referent 62.1 (55.9–67.9) Referent 69.4 (66.1–72.5) Referent 67.6 (64.2–70.8)
 Unknown 1.06 (0.93–1.21) 66.0 (59.7–71.7) 0.97 (0.89–1.04) 67.0 (62.7–71.0) 1.03 (0.95–1.10) 69.4 (65.4–73.1)
Number of children in household
 1 Referent 62.5 (58.9–66.0) Referent 69.0 (67.2–70.8) Referent 66.8 (64.5–69.0)
 2–3 1.14 (1.07–1.21) 71.3 (68.3–74.0) 1.06 (1.02–1.10) 73.1 (71.5–74.7) 1.06 (1.02–1.11) 71.1 (69.4–72.7)
 ≥4 1.17 (1.07–1.27) 72.9 (67.8–77.5) 1.00 (0.94–1.07) 69.2 (65.1–73.0) 1.12 (1.06–1.19) 74.8 (71.0–78.2)
Urban-rural residence
 Urban (MSA, principal city) 1.00 (0.91–1.08) 67.7 (63.7–71.4) 1.11 (1.05–1.18) 73.3 (70.9–75.5) 1.12 (1.06–1.18) 73.3 (71.0–75.5)
 Suburban (MSA, not principal city) 1.03 (0.96–1.11) 70.2 (67.2–73.1) 1.10 (1.04–1.16) 72.2 (70.6–73.7) 1.07 (1.02–1.13) 70.3 (68.6–72.0)
 Rural (non-MSA) Referent 68.0 (63.4–72.3) Referent 65.8 (62.4–69.0) Referent 65.6 (62.5–68.6)
Region of residence
 Northeast 1.10 (1.02–1.18) 73.1 (68.8–77.0) 1.09 (1.05–1.14) 76.7 (74.1–79.1) 1.11 (1.07–1.16) 75.9 (73.6–78.1)
 Midwest 1.02 (0.95–1.10) 68.0 (64.2–71.7) 1.02 (0.98–1.06) 71.4 (69.2–73.4) 1.05 (1.01–1.09) 71.8 (69.7–73.8)
 South Referent 66.5 (62.9–70.0) Referent 70.1 (68.3–71.9) Referent 68.1 (66.3–69.9)
 West 1.08 (1.00–1.17) 72.0 (67.7–75.9) 1.00 (0.95–1.05) 70.3 (67.1–73.3) 1.01 (0.95–1.07) 68.7 (64.9–72.2)
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*

APR = adjusted prevalence ratio. Estimates in bold are statistically significantly different from the referent (P < 0.05). All variables listed in the table were included in the model.

†

CI = confidence interval.

‡

AP = adjusted prevalence.

§

Race/ethnicity is based on parental report. Children of Hispanic ethnicity may be of any race. Children categorized as white, black, or other were identified as non-Hispanic. The other race category included children of reported Asian, American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, other, or multiple (i.e. selected more than one race category) races.

||

Poverty level was defined based on the reported number of people living in the household and annual household income, according to the U.S. Census poverty thresholds (https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html).

MSA = metropolitan statistical area. MSA was based on parent/guardian respondent-reported city, state, county, and zip code of residence using the (https://www.census.gov/programs-surveys/metro-micro.html) MSA definitions file.

The results of the multivariable analysis to determine whether parental receipt of a provider recommendation for influenza vaccination for the child was independently associated with the child’s influenza vaccination status are presented in Table 5. Across all three seasons studied, children for whom a parent reported receipt of a provider recommendation were approximately twice as likely to be vaccinated compared with children whose parent did not report receiving a provider recommendation, even after controlling for the other demographic characteristics in the model (APR 1.80, 1.91, and 2.12 for the 2013–14, 2014–15, and 2015–16 seasons, respectively).

Table 5.

Association of receiving influenza vaccination with parental receipt of a provider recommendation for their child to receive influenza vaccination, controlling for sociodemographic characteristics,* among children 6 months–17 years who had a provider visit since July 1st during the influenza season, United States, National Immunization Survey-Influenza (NIS-Flu), 2013–14 through 2015–16 influenza seasons

Characteristics 2013–14 2014–15 2015–16
APR† ± 95% CI‡ AP§ % APR ± 95% CI AP % APR ± 95% CI AP %
Provider recommendation
 Yes 1.80 (1.61–2.01) 70.7 (68.4–73.0) 1.91 (1.79–2.04) 71.2 (69.8–72.7) 2.12 (1.98–2.28) 71.5 (70.0–73.1)
 No Referent 39.3 (35.0–43.8) Referent 37.3 (35.0–39.6) Referent 33.7 (31.4–36.0)
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*

The model included the following sociodemographic variables: child’s age, child’s sex, child’s race/ethnicity, language survey completed, mother’s education, poverty/annual household income, number of children in household, urban/rural residence, and region of residence.

†

APR = adjusted prevalence ratio. Estimates in bold are statistically significantly different from the referent (P < 0.05).

‡

CI = confidence interval.

§

AP = adjusted prevalence.

Discussion

We found that, across all seasons studied, approximately 70% of children 6 months–17 years had a parent report receipt of a provider recommendation for influenza vaccination for their child. While this proportion may seem relatively high, it still indicates a significant number of children for whom a provider recommendation was not received, or if it was, the recommendation may not have been strong enough or adequately understood by the child’s parent. This is the first study, to our knowledge, that uses a national sample to estimate the proportion of all children, regardless of age or health conditions, for whom a provider recommendation for influenza vaccination was received and to estimate influenza vaccination coverage among this population by receipt of a provider recommendation. Studies conducted among other populations varied. For example, Gnanasekaran et al. reported that only 55% of parents of children 5–18 years with asthma in Massachusetts reported that their child’s doctor had recommended the influenza vaccine during the 2003–04 season, but this was before the ACIP recommended annual influenza vaccination for all children in 2008.[3;9] Benedict et al. found that only 43.5% of adults in the general U.S. population received a provider recommendation for influenza vaccination during the 2011–12 season, although this study took place fairly soon after the ACIP established a universal recommendation that included all adults regardless of age or health conditions.[8;26] According to reports by the CDC, based on Internet panel surveys, receipt of a provider recommendation among pregnant women increased from 62.9% during the 2011–12 season to 80.1% during the 2015–16 season.[15;17;20–22]

For all three seasons, influenza vaccination coverage was significantly higher among children for whom a provider recommendation was received than among children for whom a provider recommendation was not received. Our estimate that approximately 47% of vaccination coverage among children could be attributed to parental receipt of a provider recommendation during the 2015–16 season, highlights the critical importance of a provider recommendation for children. Our findings are consistent with several studies among pregnant women.[14–17;23] For example, CDC reported that pregnant women who received a provider recommendation or offer of seasonal influenza vaccination were much more likely to be vaccinated (62.1%) than those who did not (14.3%) during the 2009–10 season and the proportion of seasonal vaccination coverage estimated to be attributed to provider offer or recommendation was even higher (74%).[16] In addition, Gnanasekaran et al. reported 70% vaccination coverage among children with asthma whose physician recommended influenza vaccination versus 38% among those without a recommendation, and Winston et al. reported 83.7% vaccination coverage among Medicare beneficiaries who reported receiving a provider recommendation compared with 55.8% who did not.[9;13] Likewise, a study on children 6–23 months, following the 2002–03 season, reported that 90.6% of parents who had a vaccinated child believed that their child’s doctor thought the child should have a flu shot compared with 31.6% of parents who had an unvaccinated child.[11]

In our study, child’s age had the strongest association with parental receipt of a provider recommendation for influenza vaccination of the child across all three seasons. It is possible that providers are more likely to strongly recommend influenza vaccination for children younger than 5 years, and especially those younger than 2 years, because they are at higher risk of serious adverse complications from influenza infection.[39–42] Children less than 2 years are also receiving a number of routine vaccinations, and it would presumably be convenient for providers to recommend and administer influenza vaccine at the same time as other vaccines are given. In fact, a study in Seattle found that parents of young children were more likely to accept the influenza vaccine when recommended along with other routine vaccines.[43] Young children tend to have more encounters with their provider and, thus, have more opportunities to receive a provider recommendation for influenza vaccination. Pediatricians and family physicians have reported the following as primary barriers to adolescent immunization: adolescents rarely make preventive health visits, adolescents are not aware of the need for immunizations, and adolescents and/or parents underestimate the risk of vaccine-preventable diseases.[44] All of the adolescents included in our study had visited a provider, but the type of visit was not assessed. If the visit was not a preventive health visit (e.g., sick visit or sports physical) it is possible that a provider might not routinely recommend an influenza vaccination at such a visit. It is important for providers to take advantage of every patient encounter to recommend and, if possible, offer influenza vaccination. Providers should refer to The Guide to Community Preventive Services, which provides guidance on effective interventions for increasing vaccination rates.[45]

We also found that children living in households with higher incomes (>$75,000) were more likely to have a parent report receipt of a provider recommendation for influenza vaccination for their child than those living at or below poverty. It is possible that parents of low income children struggle to get their child to a preventive care visit and may be more likely to bring their child to the doctor when the child is sick, at which time the parent may not receive a recommendation for influenza vaccination. It also is possible that providers who serve a higher proportion of low income children may be less likely to recommend or offer influenza vaccination. This could be due to a variety of reasons that may disproportionately affect the practices of these providers such as the anticipated cost or burden of offering influenza vaccination, storage capacity, provider beliefs about influenza vaccination, and anticipated patient beliefs about influenza vaccination. However, the Vaccines for Children (VFC) program, which provides vaccines at no cost to children who are uninsured, underinsured, Medicaid-eligible, or American Indian or Alaska Native, should reduce financial barriers to vaccination.[46] Further studies are needed to address socioeconomic differences in receipt of a provider recommendation for influenza vaccination and identify strategies to ensure all children have access to influenza vaccination services.

We found that a provider recommendation for influenza vaccination was strongly associated with vaccination status among children. Across all seasons studied, children who had a parent report receipt of a provider recommendation were approximately two times more likely to be vaccinated than children without a recommendation, even when controlling for demographic characteristics.. This reinforces the importance of a provider recommendation for influenza vaccination among children. Other studies involving different groups of children reported that a provider recommendation was the most important factor related to vaccination status.[9;11]

The findings of this study are subject to several limitations. First, receipt of a provider recommendation for influenza vaccination for the child and influenza vaccination status of the child were based on parental report and subject to whether parents recognized statements by providers as a recommendation. In addition, we did not know about the type of provider visit the child had, which may not have been a preventive care visit, or whether the child had multiple visits and, therefore, more opportunities to receive a provider recommendation. Furthermore, the timing of the visit was unknown and the questions about provider recommendation were only asked during April–June, potentially several months after a provider recommendation or vaccination might have occurred. Therefore, the results are subject to respondent recall bias. In addition, the NIS-Flu is a telephone survey that excludes households with no telephone service. Finally, the CASRO response rate was low, especially for the cellular telephone sample. Non-coverage and non-response bias may remain even after weighting adjustments designed to reduce these types of bias.

Conclusions

The results of this study highlight the strong relationship between a provider recommendation and influenza vaccination among children and identify groups of children for whom improvements in provider recommendations are needed, notably older children and children living below poverty. Policy makers and healthcare providers and healthcare systems should consider potential access barriers and mitigation strategies to improve the proportion of children whose parents receive an influenza vaccination recommendation from their child’s provider.

Acknowledgments

Funding:This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Abbreviations:

ACIP

Advisory Committee on Immunization Practices

NIS-Flu

National Immunization Survey-Flu

NIS-Child

National Immunization Survey-Child

NIS-Teen

National Immunization Survey-Teen

CASRO

Council of American Survey and Research Organizations

APR

Adjusted Prevalence Ratio

AP

Adjusted Prevalence

PAR

Population Attributable Risk

CI

Confidence Interval

MSA

Metropolitan Statistical Area

Footnotes

Disclosure

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Declarations of interest: none

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