Up the Uptake Final

Running Head: UP THE UPTAKE
Up the Uptake: Increasing Influenza Vaccination Rates
Among Pregnant Women in Whatcom County
Molly Carroll, Danika Troupe, Elin McWilliams, Paige Swift
Western Washington University
Community Health
March 2016

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TABLE OF CONTENTS
Program Summary……………………….………………………………………………………..2
Section I. Introduction………………………………………………………….…………………3
Health Problem: Influenza……………………………………………………….………3
Population: Pregnant Women and Infants……………………………….………………4
Influenza Vaccination……………………………………………………………………5
Section II. Literature Review: Contributing Factors……………..………………………………9
Intrapersonal Factors…………………………………………………………….……….9
Interpersonal Factors……………………………………………………………………..12
Institutional Factors…………………………………………………………………..….16
Community Factors……………………………………………………………………....18
Conclusion...……………………………………………………………………………..18
Section III. Evidence of Program Effectiveness…………………….…………………………...19
A Multilevel Approach……………………………………………………………..……19
Pamphlet……………………………………………………………………………...….20
Electronic Health Record Reminder………………………………………………..……23
Provider Education……………………………………………………………………….28
Section IV. Program Implementation……………...…………………………………………….30
Focus of Intervention………………………………………………………………..…...30
Program Mission, Goals, and Objectives………………………………………….…….30
Educational Plan………………………………………………..………………………..33
Section V. Program Evaluation……………………………………………………………..…...37
Educational Pamphlet…………………………………………………………………....37
Healthcare Provider Education…………………………………………………………..38
Reminder System………………………………………………………………...……....39
Program Outcome Evaluation……………………………………………………………40
Conclusion……………………………………………………………………………….41
References………………………………………………………………………………………..42

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Program Summary
Influenza is a viral respiratory infection that disproportionately infects and causes
complications in pregnant women, their fetuses, and infants. When the influenza vaccine is
administered to pregnant women, it is effective in reducing influenza infection and subsequent
complications in these populations. Grounded in evidenced-based interventions that include
education and tools for health clinics, the current program, “Up the Uptake,” is designed to
increase maternal influenza vaccination rates among pregnant women in Whatcom County,
Washington.

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Introduction
Health Problem: Influenza
Influenza, also known colloquially as “the flu,” is a common, contagious viral infection.
According to the Centers for Disease Control (CDC; n.d.a), influenza is a virus that causes
respiratory illness and is spread via droplets from infected individuals. Droplets are respiratory
particles that exit the body through coughing, sneezing, and exhaling. Individuals may contract
influenza if infected droplets land in their eyes or mouth, or if individuals interact with a surface
that has been contaminated by infected droplets, and then they touch their eyes, nose, or mouth.
The CDC (n.d.a) also states that individuals are contagious 24 hours before they begin showing
symptoms of influenza and remain contagious for five to seven days.
Influenza, although often mild, can lead to severe complications, and even death. These
complications have societal and financial consequences. Although the rates vary yearly and
geographically, Thompson and colleagues (2004) found influenza to be a major primary and
secondary cause of hospitalizations in the United States (approximately 226,054 and 294,128
each year, respectively). Furthermore, Molinari and colleagues (2007) estimated that nationally,
annual influenza epidemics account for an average 3.1 million days in the hospital, 31.4 million
outpatient visits, and over 9,000 deaths, which equate to 610,660 years of potential life lost.
Seasonal influenza’s prevalence and potential for significant morbidity and mortality creates a
tremendous economic burden in the United States. Medical payments and loss of income alone
cost the nation an estimated average of $26.8 billion a year (Molinari et al., 2007). In sum,
influenza’s high prevalence in the United States, as well as its potential to inflict serious harm,
adds a significant burden to American society and its economy.

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Population: Pregnant Women and Infants
Although all are at risk for influenza, some populations are disproportionately affected,
including young children and pregnant women (CDC, n.d.a). To relieve the unequal burden of
influenza on pregnant women and infants, the current program planners investigated the causes
and risks associated with influenza, as well as potential interventions to reduce this health
disparity.
In spite of the fact that pregnant women make up only 1% of the United States’
population at any given time, during the 2009-2010 influenza pandemic, pregnant women
represented 6.3% of all influenza-associated hospitalizations, and 5.7% of influenza-related
deaths (Mosby, Rasmussen, & Jamieson, 2011). Furthermore, a large study completed over ten
years examined discharge papers from over 8 million hospital stays and concluded that pregnant
women who have influenza are at an increased risk of death (Martin et al., 2013). These figures
demonstrate that pregnant women experience a disproportionate burden of influenza-related
morbidity and mortality.
The increased susceptibility and severity of influenza in pregnant women are due to the
physiological changes that occur to safely accommodate a growing fetus. Due to the fact that
influenza is a respiratory disease, changes in the lungs (e.g., decreased chest compliance and
elevated diaphragm) increase the risk of influenza complications in pregnancy (Mighty, 2010).
Pregnancy also causes immunologic changes that increase a pregnant woman’s susceptibility to
influenza (Jamieson, Theiler, & Rasmussen, 2016). These factors help to explain the increased
influenza-related morbidity and mortality experienced by pregnant women.
Influenza also poses an enhanced risk to the fetus. The CDC (n.d.b) states that influenza
in pregnant women increases the chance of premature labor. In addition, Yudin (2014) found that

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mothers who contracted influenza during pregnancy were four times more likely to give birth
prematurely. Further, the influenza virus can cross the placenta and pass to the fetus and may
result in fetal death (Lieberman, Bagdasarian, Thomas, & Van De Ven, 2011). Another
implication of trans-placental transfer is highlighted in studies that have suggested a link
between prenatal exposure to influenza and later cases of adult schizophrenia (Brown et al.,
2004) and bipolar disorder (Parboosing, Bao, Shen, Schaefer, & Brown, 2013). Lastly, women ill
with influenza during pregnancy are at risk for having a baby born with a lower than average
birth weight (Yudin, 2014). Thus, when a pregnant woman contracts influenza, the health of the
fetus may also be compromised.
Newborns also experience a heightened risk of influenza-related complications.
Thompson and colleagues (2004) found that, of all children, newborns experience the highest
risk for influenza-related death, especially those who were born prematurely or with a chronic
disease. One study by Bhat and colleagues (2005) found that during the 2003-2004 influenza
season, infants younger than six months experienced the highest influenza-related mortality rate
(0.9 per 100,000 for infants 0-6 months, 0.6 per 100,000 for infants 6-11 months, 0.2 per 100,000
for children 3 years old). Children under six months old are at increased risk of death, in part
because there is no influenza vaccination approved for children under six months old (Burke,
Nesmith, Ott, & Hedrick, 2010). Therefore, even though all children are at a heightened risk,
infants younger than six months are at an even higher risk of influenza-related morbidity and
mortality.
Influenza Vaccination
Fortunately, the influenza vaccine is a potential solution to alleviate the burden that
influenza poses on pregnant women and their infants. That is, when pregnant women receive the

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influenza vaccine, both the mother and the fetus experience protection from potential negative
health outcomes. For instance, when compared to pregnant women who have not received the
influenza vaccine, pregnant women who have received it experience fewer and shorter hospital
visits (Dodds et al., 2007). In addition, the use of an inactive influenza vaccine has been
associated with a decrease in the likelihood that an infant will be born prematurely (Omer et al.,
2011). Finally, when compared to pregnant women who have not received the influenza vaccine,
pregnant women who have are less likely to experience preterm birth and low birth-weight
infants (Legge, Dodds, MacDonald, Scott, & McNeil, 2014). Therefore, ensuring pregnant
women receive the influenza vaccine is imperative for reducing influenza-related morbidity and
mortality.
When a pregnant woman becomes vaccinated for influenza, the newborn also experiences
increased protection. For example, when given to pregnant mothers, the influenza vaccine is
effective at preventing hospitalization of newborns (Benowitz, 2010). Moreover, the influenza
vaccine has been shown to reduce illness from influenza by 63% in infants under six months of
age and prevent a third of all febrile respiratory illnesses in mothers and their newborn children
(Zaman et al., 2008). Hence, maternal influenza vaccination is an effective measure at protecting
infants who are too young to become vaccinated.
Although the CDC (n.d.b) emphasizes the importance of pregnant women receiving the
vaccine, vaccination rates remain low in the United States. Healthy People 2020 (U. S.
Department of Health and Human Services, 2016) reports that in 2008, only 27.6% of pregnant
women received the influenza vaccine, with the target set at 80% receiving the vaccine by the
year 2020. Although rates have improved since 2008, they are still low, with rates hovering
around 50% in the past two years (CDC, 2015a). Washington State’s rates are in line with the

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low national rates; during the 2010-2011 influenza season, only 54% of pregnant women
received the influenza vaccine (Washington State Department of Health [DOH], 2015).
Considering over 100,000 pregnancies occur in Washington each year (DOH, 2014), this leaves
an alarming number of women and their infants unprotected.
Due to a lack of specific data in Whatcom County, program planners extrapolated the
national and statewide data to residents of Whatcom County. Nationally, women aged 35-49
comprised the most vaccinated group at 61.9%, whereas those in the 18-24 year old age-group
had the lowest vaccination rates at 44.1% (CDC, 2015a). The Washington State Department of
Health (2014) found that in Whatcom County in 2014, 27.5% of pregnant women were 18-24
years old, making it the second largest age-group of pregnant women (the largest age-group was
made up of those aged 25-29, which accounted for 28% of all pregnancies in Whatcom County).
Knowing the high percentage of pregnant women in the 18-24 year old age-group in Whatcom
County, and assuming that the low national vaccination rates in this age-group are representative
of Whatcom County, efforts should be made to ensure that pregnant women in this group are
included in an intervention to increase vaccination rates. This program, however, addresses
pregnant women of every age.
Although there are differences in vaccination rates by ethnicity in the United States, all
ethnic groups are below the Healthy People 2020 goal of 80% (U.S. Department of Health and
Human Services, 2008). For instance, Hispanic1
women had the highest vaccination rates
(56.5%) during the 2014-2015 influenza season, and black, non-Hispanic women had the lowest
rates (38.9%) in that same season (CDC, 2015a). In Whatcom County in 2014, 8.9% of residents
identified as Hispanic, and only 1.2% identified as African American (The United States Census
1
Program planners used the term “Hispanic” to be in line with the CDC’s report, but recognize that Latino/Latina is
the more inclusive term.

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Bureau, 2014). In spite of the predominantly White population in Whatcom County (United
States Census Bureau, 2014), intervention efforts designed to increase maternal vaccination
rates, such as the current intervention, should reach all ethnicities given the low rates across
ethnic groups. For this reason, programs should appeal to the county’s demographics by being
inclusive of minority populations within Whatcom County.
Appealing to county demographics also entails involving those of varying income
brackets. Nearly half of all births in Whatcom County are to low-income mothers (those whose
income is 185% of the federal poverty line; Whatcom County Health Department, 2013). This is
significant because nationally, low-income mothers have been found to have lower influenza
vaccination rates than pregnant women at or above the federal poverty line (41.6% versus 53.8%,
respectively; Centers for Disease Control and Prevention, 2013a). Thus, interventions, such as
Up the Uptake, should include low-income mothers.
Due to the increased risk of influenza in pregnant women, their fetuses, and infants under
six months of age, maternal influenza vaccination is an important tool to protect these
populations from influenza-related morbidity and mortality. Up the Uptake is a program plan that
aims to increase uptake of maternal influenza vaccination in Whatcom County, in order to
decrease influenza-related morbidity and mortality in pregnant women, their fetuses, and infants.
This program addresses significant barriers to maternal influenza vaccination (described in
Section II), and adapts evidence-based interventions to fit the needs of Whatcom County
residents (existing interventions are described in Section III, and the current intervention is
described in Section IV). Although some ethnic groups and income brackets report lower
vaccination rates, Up the Uptake will include all ethnic groups and income brackets of those who
visit participating clinics in Whatcom County.

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Section II. Literature Review: Contributing Factors
In this section, the program planners use McLeroy and colleagues’ (1988) Social
Ecological Model (SEM; adapted from Urie Bronfenbrenner’s Ecological Systems Theory,
1979) to explore the multiple factors that contribute to vaccination rates among pregnant women.
The SEM considers multiple levels of influence on health behaviors: intrapersonal, interpersonal,
community, institutional, and public policy2
. By categorizing contributing factors into these
levels, the program planners explore the complex interaction of multiple levels of influence that
impact influenza vaccination-related behaviors, and thus vaccination rates, among pregnant
women. In addition, interventions that target multiple levels of the SEM may be necessary to
increase vaccination rates, because a multi-level approach is more likely to have successful
outcomes as it involves individual, social, and organizational contexts that influence health
behaviors.
Intrapersonal
Intrapersonal factors are defined as the knowledge, attitudes, beliefs, and intentions of an
individual that influence behavior (McLeroy, Bibeau, Steckler, & Glanz, 1988). These factors
can inhibit or facilitate positive health decisions. In the case of pregnant women receiving the
influenza vaccine, inhibiting factors include a low perceived risk and severity of influenza, and a
belief that the vaccine is harmful or not beneficial. In contrast, intrapersonal factors can also
promote receiving the influenza vaccine. The Health Belief Model theorizes that those who have
a high perceived susceptibility and severity of the illness, and high perceived benefit and low
perceived barriers to action are more likely to make positive health behavior decisions
(Hochbaum, Kegels, & Rosenstock, as explained by Champion & Skinner, 2008). These
2
There is little evidence on public policy factors, and have thus been omitted from this literature review.

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facilitating factors include pregnant women being knowledgeable about their susceptibility to
influenza, the severity of influenza to themselves and their infants, and being cognizant of all of
the benefits of the vaccine.
Perceived susceptibility and perceived severity. Some women may not feel at risk for
influenza, and consequently feel that they do not need the influenza vaccine. One study
(Meharry, Colson, Grizas, Stiller, & Vazquez, 2013) uncovered that some pregnant women have
a low perceived susceptibility to influenza because they believed themselves to be healthy and
had never previously contracted influenza. This belief may lead to the impression that they are
not at risk for influenza and thus they do not seek preventative care. In fact, in Washington State,
49% of pregnant women two to six months postpartum cited not being worried about getting sick
with influenza as a reason they did not get the influenza vaccine (Pregnancy Risk Assessment
Monitoring System [PRAMS] as cited in DOH, 2012). This low perceived susceptibility helps to
explain Washington’s low influenza vaccination rates among pregnant women (54%; DOH,
2015). Further, a systematic review of the literature (Yuen, & Tarrant, 2014) found that pregnant
women often underestimate the danger of influenza both to themselves and to their fetus. This
review concluded that low perceived severity of influenza during pregnancy is a significant
barrier to vaccination. Thus, when women are not aware of their susceptibility and the severity of
influenza, they may be less eager to become vaccinated.
Women are more likely to become vaccinated when they are aware of their susceptibility,
the susceptibility of their infant, and the severity of influenza (Meharry et al., 2013). Meharry
and colleagues (2013) found that one aspect of the benefits of the vaccine was particularly
convincing; when women were informed that the influenza vaccine transfers immunity to their
infants, they were much more likely to accept the vaccine. Further, one study (Tong, Biringer,

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Ofner-Agostini, Upshur, & McGeer, 2008) of postpartum women found that they were more
likely be vaccinated when they scored higher on knowledge tests about vaccines and pregnancy,
and had more positive attitudes of influenza vaccination. Therefore, efforts to increase
vaccination rates should include efforts to increase pregnant women’s knowledge about their
susceptibility to influenza, as well as the severity of influenza in pregnancy.
Perceived barriers. Although the side effects of the influenza vaccine are mild and
rarely serious (CDC, 2015c), the PRAMS (DOH, 2012) identified that in Washington State, 57%
of women were not vaccinated during their pregnancy because of concerns of adverse side
effects of the vaccine, and 47% cited concerns that the vaccine would harm the fetus. These
concerns about the vaccine’s safety are significant because other research (i.e., Meharry et al.,
2013; Henninger, Naleway, Crane, Donahue, & Irving, 2013) has demonstrated that when
women believe that the vaccine causes influenza or has serious negative side effects to
themselves or their fetus, they are less likely to become vaccinated. Therefore, to increase
vaccination rates, efforts need to be made to reassure women that the influenza vaccine is safe.
In addition to beliefs of negative side effects of the influenza vaccine, the PRAMS (DOH,
2012) discovered that 38% of unvaccinated, postpartum women in Washington State cited that
they did not believe in the vaccine’s effectiveness as a reason for declining the vaccine. If
pregnant women doubt a vaccine’s effectiveness, they may be less motivated to seek vaccination.
Many studies (Lynch et al., 2012; Meharry et al., 2013; Yudin, Salaripour, & Sgro, 2010)
have found that pregnant women are more likely to be vaccinated when they are given
information about vaccine safety and effectiveness, and the benefits to their infant are clearly
communicated to them. Conversely, when women do not feel like they have adequate
information to make a decision, they tend to prefer inaction over seeking out vaccination

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(Meharry et al., 2013). Education about the safety and efficacy of the influenza vaccine provided
by healthcare providers (HCPs) may help address this barrier, giving pregnant women the
confidence they need in making the decision to vaccinate.
Overall, a significant barrier to pregnant women receiving the influenza vaccine is the
concern for the well-being of their unborn and newborn children, and their concerns about the
safety of the influenza vaccine. Thus, medical and health education efforts need to be made to
inform pregnant women of their susceptibility to influenza, the susceptibility of their infants, the
severity of influenza, and reality that the risks of the vaccine are very low (CDC, 2015a). Finally,
intervention efforts need to be made to ensure that pregnant women are made fully aware of the
extent to which the influenza vaccine has protective effects.
Interpersonal
Interpersonal factors include the social environment and the people surrounding the
individual, including social networks and support systems (McLeroy et al., 1988). These factors
can serve as a “cue to action,” -- that is, a contributing factor that prompts health behavior
decisions (HBM; Champion and Skinner, 2008) -- and may facilitate pregnant women receiving
the vaccine. Conversely, interpersonal factors may also act as a barrier by applying social
pressure to not get vaccinated.
Healthcare provider offering. Multiple studies have found that a pregnant woman’s
HCP recommending and offering the influenza vaccine is a significant factor in whether or not a
woman is vaccinated (Meharry et al., 2013; Ahluwalia et al., 2010; Shavell, Moniz, Gonik, &
Beigi, 2012). In other words, pregnant women may have wanted, or at least may have been open
to the vaccine, but because it was not offered, they did not get vaccinated, in turn leaving them at
an unnecessarily higher risk for contracting influenza. The CDC (2015b) found that 64.9% of

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pregnant women participating in an online survey reported they were offered the vaccine by their
HCP, while 14.8% received a recommendation but no offer, and 20.3% received no
recommendation at all. Among these women, the highest rates of vaccination coverage was with
those who had a recommendation and an offer of the vaccine (67.9%). Those who only received
a recommendation had lower vaccination rates (33.5%), and the lowest vaccination rate occurred
among women whose HCP made no offer and no recommendation (8.5%). Rates were found to
be similar in Washington State where 64% of women who were vaccinated were both
recommended and offered the vaccine, whereas only 9% of women were vaccinated when there
was no HCP recommendation and no offer to vaccinate (DOH, 2012). This difference in
vaccination rates clearly demonstrates the critical role of HCPs in increasing influenza
vaccination rates. Specifically, when the HCP both recommends and offers the vaccine, a woman
is much more likely to be vaccinated.
The role of the HCP has been identified as a significant area for improvement in
increasing maternal vaccination rates. A report from the National Vaccination Advisory
Committee (2015) recognizes HCPs’ role in recommending and offering maternal immunizations
is a critical component to improving vaccination rates. Prenatal appointments are a prime
opportunity to discuss the influenza vaccine. In Washington State less than 1% of women are not
seeing a HCP during pregnancy (Washington State Department of Social and Health Services,
2014), thus the primary challenge is not in increasing access to care, but encouraging, discussing,
or offering the influenza vaccine. Interactions between mothers and HCPs creates an important
opportunity to discuss, and if available, provide the influenza vaccine.
In addition, the HCP's role of informing patients about the influenza vaccine involves
comprehensive education. This means patient education should go beyond that of just the

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benefits of receiving the vaccine, but should include the potential harm of remaining
unvaccinated. One study found that more than half of 200 HCPs surveyed reported they did not
always inform patients about the consequences of being unvaccinated, but the majority of
patients surveyed in this same study stated they were likely to get vaccinated if their HCP
recommended it (Johnson, Nichol, & Lipczynski, 2008). Johnson and colleagues’ work
highlights the importance of HCPs informing patients about the necessity of influenza
vaccination, which allows patients to make fully informed vaccination decisions, and may lead to
increased vaccination rates.
Healthcare provider relationship. The relationship of the HCP and the pregnant mother
also plays a role in vaccination decisions. Meharry and colleagues (2013) found that women who
stated they trusted their HCP and the vaccine-related information they provided, were more
likely to obtain the vaccine. In a study in Geneva, Switzerland, 35% of unvaccinated women
stated they would have considered getting the vaccine if they would have had a trusting
relationship with their HCP (Blanchard-Rohner et al., 2012). It is clear that HCPs play a critical
role in increasing vaccination rates among pregnant women, and pregnant patients are most
likely to respond to HCP recommendations when they trust their HCP.
Healthcare provider responsibility. There is evidence that HCPs are unsure about
whose responsibility it is to offer a pregnant woman the vaccine: the woman’s primary care
provider or her Obstetrician-Gynecologist (OB/GYN). OB/GYNs, who are often the only HCPs
women see during pregnancy (Kissen et al., 2011), were less likely than primary care physicians
to believe it was their responsibility to discuss, recommend, or provide influenza vaccines to
pregnant patients (Tong et al., 2008). In fact, uncertainty regarding who is responsible for
recommending the vaccine was confirmed as a primary reason HCPs did not offer the vaccine

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(Kissin et al., 2011). Confusion over whose responsibility it is to provide the vaccine contributes
to a missed opportunity for pregnant women to receive the protection of the vaccine.
Healthcare provider knowledge. Another barrier to maternal influenza vaccination is a
lack in HCPs’ knowledge about the safety and necessity of the influenza vaccine during
pregnancy. In a questionnaire given to 56 physicians providing prenatal care at a hospital in
Connecticut, 50% did not offer the vaccine as part of their services. Of the HCPs who did not
offer the vaccine, 25% stated that there were not enough data about influenza-related
complications during pregnancy, 10% stated insufficient evidence of the efficacy of the vaccine,
and 7% cited concerns about side effects of the vaccine as reasons why they did not offer the
influenza vaccine (Panda, Stiller, & Panda, 2011). These reasons for not offering the vaccine are
contrary to current maternal influenza vaccine recommendations put forward by the CDC (n.d.b).
Lack of compliance to the CDC’s recommendations is possibly due to the fact that about 40% of
HCPs believed their training surrounding vaccinations was insufficient in medical school and
residency (Power et al., 2009). HCP knowledge is a highly modifiable barrier that can be
addressed in order to help increase vaccination rates. Although the data are outdated, Schrag and
colleagues (2003) found that HCPs are open to education about vaccines. Offering training and
information on the influenza vaccine may help HCPs overcome their hesitation to recommend
the vaccine, which in turn can increase vaccination rates.
Family and peers. Family members and peers may also influence a woman's decision to
receive the influenza vaccine. Meharry and colleagues (2013) found that women who have
family members in the medical field or are around family members that are high-risk (such as
older adults or young children) are often more motivated to get the influenza vaccine. Family
members in the medical field may explain the value of the vaccine, thus increasing pregnant

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women’s motivation to vaccinate. Further, pregnant woman may feel a sense of responsibility to
receive the influenza vaccine to protect family members who are at a high-risk for getting
influenza. In contrast, this same study (Meharry et al., 2013) found that pregnant women have
also expressed being told by their family members to not get the influenza vaccine because they
did not get influenza when they were not pregnant. In conclusion, family members may influence
a pregnant woman’s decision to vaccinate by encouraging or dissuading vaccination.
Institutional
At the institutional level, an individual’s healthcare choices are impacted by informal
structures, rules, and regulations for actions (McLeroy, et al., 1988). The institutional level
includes, for instance, insurance coverage, and cost of the vaccine to the patients, as well as the
cost to HCPs to carry the vaccine.
Insurance coverage and vaccine affordability. An institutional barrier pregnant women
face related to receiving the influenza vaccine is not having health insurance or being
underinsured (National Vaccine Advisory Committee, 2012). A study by the CDC (2013a) found
that pregnant women who did not have insurance were less likely to be vaccinated. This was
confirmed by Panda and colleagues (2011) who found that 12.1% of postpartum women at a
Connecticut-based hospital, cited lack of insurance coverage as a reason for not getting the
vaccine. Further, even among those who have insurance, coverage may not extend to influenza
vaccines (National Vaccine Advisory Committee, 2015). For example, Medicaid, which covers
primarily those who are low-income, varies in its benefits state-to-state, and does not always
cover influenza vaccination (National Vaccine Advisory Committee, 2015). Fortunately, in
Washington, Medicaid coverage does expand to cover vaccines (Stewart, Lindley, Chang, &
Cox, 2014). Therefore, for those who have Medicaid in Washington, insurance coverage is not a

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barrier for obtaining the vaccine. However, for pregnant women who have to pay out-of-pocket
for the vaccine (Stewart et al., 2014), the cost may be an additional barrier.
According to the CDC (2016), prices range depending on the vaccine brand and
manufacturer, and on how much the HCP decides to charge for the vaccine. Although there is
variation in the cost, pregnant women, especially those who are low-income (those living in a
family of four, making less than $23,000 per year; CDC 2013a), may perceive the cost of the
vaccine to be too high. Low socioeconomic status, not working for wages, and living below the
poverty line (a family of four making less than $23,834 per year) are characteristics associated
with lower vaccination rates (CDC, 2013a). These characteristics may indicate that the cost of
the vaccine is a barrier, especially if this service is not covered by their insurance.
Costs to the healthcare provider. Another institutional barrier to pregnant women
receiving the influenza vaccine is that not all clinics offer the vaccine as part of their services.
Studies have found that a majority of HCPs cited a lack of adequate reimbursement from
insurance companies as the most common reason for not offering the vaccine (Schrag et al.,
2003; Panda et al., 2011). In addition, Kissin and colleagues (2011) found that providing the
vaccine is not a viable option for some clinics due to the high expenses of maintaining vaccines,
especially for small private practices. For example, Panda and colleagues (2011) found that some
HCPs do not have the proper equipment to store the vaccine. Further, the same study also found
that HCPs who did not offer the vaccine were unsure of the quantity or type (i.e. preservative-
free or thimerosal-containing vaccine) to order and stock. Panda, Schrag, and Kissin’s studies’
findings support some pregnant women’s reports that a reason for not becoming vaccinated is
that their HCP does not carry the vaccine (Meharry et al., 2013). Therefore, some HCPs may

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wish to provide the vaccine, but lack of adequate reimbursement, and the high cost to properly
maintain and supply the vaccine deter them.
Community Factors
Community factors are defined as the social networks that contribute to social identity
(McLeroy et al., 1988). Social networking often takes place via the Internet, which acts as a
virtual hub for interacting with others and communicating ideas and information. Lynch and
colleagues (2012) found that pregnant women use the Internet, especially pregnancy specific
websites, as a main source for trusted information. Among the pregnancy-related information
provided on the Internet, there is a vast amount of conflicting information about the safety of the
influenza vaccine. Thus, pregnant women who seek vaccine-related information on the Internet
are inundated with conflicting information about vaccines, and may lack the ability and
confidence to decipher what is and what is not empirically supported health information. Lynch’s
study (2012) also found that pregnant women who were more adverse to vaccines were actively
researching health topics on their own and weighing it against HCP recommendations. Lynch’s
findings suggest that perhaps women who are seeking information on their own, instead of
adhering to a HCP’s recommendations, are less likely to become vaccinated. Although the
Internet can be a source of credible information on influenza vaccination, it is also a source of
misleading information that may misguide pregnant women and their decisions to vaccinate.
More research is needed to better understand how the Internet affects influenza-vaccination
behaviors. Further, research is needed to develop strategies to increase health literacy and
combat false information that is readily accessed on the Internet.
Conclusion
Barriers to maternal influenza vaccination have been identified at all levels (excluding
public policy) of the SEM. However, the program planners of Up the Uptake have concluded

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that addressing intrapersonal determinants (i.e., lack of knowledge of influenza and influenza
vaccination), as well as interpersonal determinants (i.e., increasing HCP recommendations and
offering of the vaccine) are most significant and cost-effective to address. Therefore, the
program planners have developed an intervention specifically targeting these factors with the aim
of increasing maternal influenza vaccination in Whatcom County, and consequently decreasing
influenza-related morbidity and mortality in pregnant women and infants in the county.
Section III: Evidence of Program Effectiveness
A Multi-level Approach
As discussed in Section II, according to McLeroy and colleagues (1988), it is critical to
consider all levels of the Social Ecological Model (SEM) that support a behavior change. That is,
addressing one level of the model (e.g., intrapersonal) may be insufficient to achieve adequate
results of increasing maternal vaccination rates, because health behaviors are influenced by many
factors and multiple levels of the SEM. Thus, the Up the Uptake program planners have designed
an intervention that focuses on two levels: 1) intrapersonal barriers to knowledge and beliefs
about influenza and influenza vaccines, and, 2) interpersonal barriers, specifically, increasing
healthcare provider (HCP) offering of maternal influenza vaccinations. Although there are other
barriers at additional levels of the SEM, a thorough review of literature identified that
intrapersonal barriers and lack of HCP offering present the most significant barriers to maternal
influenza vaccination.
Further, to assure that programs are effective and use the best available peer-reviewed
evidence, the current program planners designed Up the Uptake based on four evidence-based
public health interventions. According to Brownson, Fielding, and Maylahn (2009), using

UP THE UPTAKE 20
evidence-based public health is critical to guiding program decision making, conducting sound
evaluation, and providing the best possible chance that the program will be successful. The
following section summarizes evidence-based interventions that are used as a framework for the
current program.
Pamphlet
To address the intrapersonal barriers (i.e., knowledge, attitudes, beliefs) of maternal
influenza vaccination, an educational pamphlet, designed using the constructs of the Health
Belief Model (HBM) was created by Meharry and colleagues (2014). The pamphlet had two
goals: first, to increase knowledge of influenza and influenza vaccination, and second, to
increase uptake of influenza vaccination in pregnancy.
Meharry and colleagues’ intervention targeted pregnant women at three different
locations in Connecticut. Women were eligible to participate in the study if they were currently
pregnant, at least 18 years old, and had not already received the influenza vaccine that season. Of
the women who disclosed their income (65.4%), those making less than $25,000 accounted for
the greatest proportion of participants (33.1%). Subjects were recruited between September 22,
2011 and February 2, 2012. The study’s participants were diverse in terms of ethnicity and
income. According to the United States Census Bureau (2015), the demographics in Whatcom
County closely resemble the demographics of Meharry’s intervention.
The brochure, titled Influenza and Pregnancy: One Flu Shot Protects You and Your
Baby, was designed based on the constructs of the HBM. Using the HBM’s constructs, the
pamphlet informed pregnant women on the following: their increased susceptibility to influenza,
the severity of influenza complications, the benefits of vaccination to the mother and infant, and
the safety of the vaccine. Concerns of vaccine safety (perceived barrier) has been identified as

UP THE UPTAKE 21
one of the most significant barriers to receiving the influenza vaccine. (Tong et al., 2008; Panda,
Stiller, & Panda, 2011; Meharry, Colson, Stiller, & Vasquez, 2013). The aim of using these
constructs was to decrease intrapersonal barriers to vaccination.
The content of the double-sided, tri-fold pamphlet used in this intervention covered
information on pregnancy and influenza, as well as information on the influenza vaccine. The
cover of the pamphlet consisted of the title, a photograph of a mother and her infant talking to a
HCP, and advertised the statement “A Two-For-One Benefit”. The inside panels gave an
overview of influenza (e.g., symptoms and transmission), the threat of influenza to pregnant
women and their infants, the transfer of immunity from mother to infant (the “two-for-one
benefit”), and the safety of the influenza vaccine during pregnancy. The back of the pamphlet
contained additional influenza prevention techniques, as well as resources for more information.
The brochure was developed in English and Spanish with culturally diverse photographs to help
assure cultural consciousness. In addition to receiving the pamphlet, some women (in a second
treatment group) were given a statement of benefits of the influenza vaccine to them and their
unborn children.
A randomized control trial was used to evaluate the pamphlet. Participants inclusion in
experimental and control groups were selected randomly at each location. Participants were
given a pretest and a posttest questionnaire. This questionnaire contained 25 items covering four
constructs of the HBM. All participants were given the posttest immediately after the
intervention. Information regarding vaccine uptake was obtained by an independent registered
nurse or prenatal instructor at the hospital-based clinic, and was self-reported by participants in
the private practice. To be counted in the experimental group in the study, the vaccine needed to
be administered within two months of the intervention. Thus, evaluations were made to

UP THE UPTAKE 22
determine if the pamphlet had an effect in two different areas: vaccine uptake, and perceptions of
health beliefs of maternal vaccination.
Both of the outcomes measured in the study were found to be positively and significantly
impacted by the intervention. For the primary outcome (vaccination acquisition), the treatment
group had a significantly higher vaccination rate than the control groups; 72.9% (p < .01) of the
pamphlet group became vaccinated, 86.1% (p < .001) of the pamphlet plus a benefit statement
group became vaccinated, and only 46.9% of the control group became vaccinated. There was no
significant difference between the two treatment groups (p = .145). The secondary outcome
demonstrated that perceptions of health benefits of vaccination increased with the intervention,
specifically, the perception of the benefits of maternal vaccination (p < .01), and the perception
of safety of the influenza vaccine (p < .001). These findings demonstrate that the intervention
was effective in both of the desired outcomes.
As to increase the effectiveness of the pamphlet, and based on the study’s results,
researchers suggested personalizing the pamphlet to fit the local population. They recommended
using photographs of local HCPs, especially prenatal HCPs. Researchers also emphasized that
including multicultural photos would increase the likelihood that a woman would read the
pamphlet when compared to the plain fact sheet currently used by the American College of
Obstetricians and Gynecologists.
Based on the success of the pamphlet in addressing the intrapersonal knowledge barriers
of maternal influenza vaccination, and the subsequent increase in maternal influenza vaccination
uptake, Up the Uptake program planners have included components of this pamphlet-based
intervention as core components of the current program.

UP THE UPTAKE 23
Electronic Health Record Reminder
The following studies have shown that vaccine reminder systems are effective in
addressing the interpersonal barrier of lack of HCPs offering (Wallis, Chin, Sur, & Yee, 2006;
Stockwell et al., 2015). One intervention by Wallis, Chin, Sur, & Yee (2006) increased the rate
of pregnant women receiving the vaccination for seasonal influenza by adding a reminder note
that read, “Think Flu Vaccine” to the charts of Obstetric-Gynecologic (OB/GYN) patients. This
intervention was nonexperimental and based off of the Theory of Reasoned Action which
examines how attitudes and subjective norms influence behavior (Ajzen & Madden, 1986).
Researchers also designed this intervention based on findings that women are more likely to
become vaccinated if it is recommended to them by a doctor (Meharry et al., 2013; Ahluwalia et
al., 2010; Shavell et al., 2012).
Wallis and colleagues (2006) contacted six separate physician practices that served
pregnant women. Practices ranged from small family medicine clinics to large OB/GYN
practices. To establish a baseline, researchers reviewed all the charts of pregnant patients from
the previous two years and noted any record of vaccination offering for pregnant women during
peak influenza season. Researchers established peak influenza season as spanning from
December to March.
To evaluate the effectiveness of this program, researchers reviewed the charts of all of the
pregnant patients of the participating practices post-intervention. Charts were not considered if
the patient had seen the doctor less than three times or if they had not visited the doctor after 14
weeks gestation. They also excluded charts of women who were not pregnant during peak
influenza season.

UP THE UPTAKE 24
Once researchers removed the disqualified charts, they reviewed the remaining charts for
documentation of a recommendation to receive the influenza vaccine. This was accomplished by
counting the charts that contained documentation of the administration of the vaccine, instruction
to obtain the vaccine from another physician, or patient refusal of the vaccine. The baseline data
collected before the intervention found that an average of only 1.5% of the doctors discussed the
influenza vaccine with pregnant women. After the intervention, discussions increased to 21.9%.
A further breakdown of these data demonstrated that the family practice clinics experienced a
more dramatic increase in influenza vaccination discussion (3.2% pre-intervention, 44.9% post-
intervention, p < .001). The results were less dramatic in Obstetric practices (1.2% pre-
intervention, 19.4% post-intervention, p < .001). Researchers also found the intervention was
more effective in smaller practices, which increased by 41.1%, whereas larger practices only
increased by 13.7%. Overall, the intervention was successful in increasing HCP offering of the
vaccine, even though there was variation in the success rates between differing clinics.
Wallis and colleagues’ goal was to design an intervention that was not time consuming or
costly, yet still increase the number of conversations that HCPs have with pregnant patients
about the influenza vaccine. By adding notes to the doctor’s charts, they were able to create an
effective program that was relatively simple to implement. The study is limited by the lack of a
control group, making it impossible to determine causation due to confounding variables that
may have had an influence on the rate of vaccination offering, rather than the program itself
(McKenzie, Neiger & Thackeray, 2013).
The intervention was overall successful in addressing one of the barriers to pregnant
women receiving the influenza vaccination and therefore, components of this study have been

UP THE UPTAKE 25
included in Up the Uptake as a core component to increase the rate of maternal influenza
vaccination.
In another, more recent study, Stockwell and colleagues (2015), tested the success of a
non-interruptive influenza vaccination reminder system. The intervention was implemented in
four different pediatric clinics in New York City during the 2010-2011 influenza season. The
demographics of the populations served by these clinics were largely low-income Latino families
and those relying on public insurance (e.g., Medicaid). The system itself securely accessed
vaccination information from New York City’s Immunization Information System (IIS), as well
as the local vaccine registry. The system integrated the immunization information and compiled
it on each clinics’ commercial Electronic Health Record (EHR) system.
The study itself was a cluster randomized crossover trial, in which participating clinics
were randomly assigned to a cluster with both an “on-period” (vaccination reminder system is
on, alerting providers of vaccination status) and an “off-period” (no reminders show up for
providers accessing EHR systems). Following the collection of data from each period, results
were compared between the on- and off-periods at each clinic, to determine whether or not the
intervention had made any difference in vaccination rates. Overall, the reminder system
demonstrated effectiveness in increasing vaccinations among children, as well as increasing
documentation for vaccination refusal.
When a patient’s electronic chart was accessed by the HCP, a non-interruptive color-
coded notification appeared in the corner of the screen, but did not impede use of the rest of the
EHR. Color-coding of the notification signified whether the patient was unvaccinated (orange),
vaccinated (green), needing additional doses (yellow), or allergic to egg protein (red). For
patients who were unvaccinated, the popup provided tips and talking points for HCPs to use

UP THE UPTAKE 26
when talking to the patient or their family about making vaccine-related decisions. In addition,
the popup window gave the HCP the convenience of immediately ordering vaccines for their
patient. If the HCP did not document vaccine status or reason for refusal of an unvaccinated
patient, the reminder system would further prompt the HCP with another reminder. Although the
reminder system did not require interaction from HCPs, response rates to the system’s prompts
were high, garnering a rate of approximately 83% and 85% in successive years during the study.
Ultimately, HCP responses to the reminder systems resulted in more knowledge
surrounding individual patients and their reasons for refusal, as well as an increase in the
successful delivery of vaccinations to those who had previously been unvaccinated. Children
seen by HCPs during the on-period had higher rates of vaccination delivery (73%), than those
who were seen during the off-periods (65.4%). Similarly, HCP documentation of reasons for
vaccine refusal occurred more frequently during the two on-periods of the study (68.1% and
73.2%) versus HCP documentation during the two off-periods (41.5% and 45.6%, p < .0001).
Overall, the intervention increased rates in vaccinations and HCP documentation. Due to the
success of this intervention in increasing HCP offering of the influenza vaccine, Up the Uptake
program planners have included its core components in efforts to increase provider offering and
subsequently, influenza vaccine uptake.
HCP reminder systems such as the one used in Stockwell’s (2015) study rely on
information gathered from Immunization Information Systems (IISs). IISs are confidential
computerized databases of vaccination information and records (CDC 2013b ). IISs have been
shown to positively increase vaccination rates and reduce vaccine-preventable deaths by
providing notifications to HCPs, informing them of their patients’ vaccine history and prompting
them when a patient was due for a new vaccine (Groom et al., 2015). In a 2015 systematic

UP THE UPTAKE 27
review (Groom et al., 2015), over 420 abstracts and articles were compiled and examined to
assess IISs’ usefulness in increasing immunization rates and thereby reducing vaccine-
preventable diseases.
Significant findings of the systematic review included the increase in rates of
vaccinations with the use of an IIS. An Australian study that was included in the review, reported
that rates of full immunizations among children 24 months old increased from 64% in 1997 to
92.7% in 2007 (Hull, Deeks, & McIntyre, 2009). Because IISs are variant in their specific
features, the reviewers grouped together IISs with similar features for comparison among groups.
For example, a specific feature of IISs examined in the systematic review was a built in alert that
would inform the HCP of patient immunization status (Groom et al., 2015). Of all the studies in
the review which tested this specific feature, the highest reported percent increase in vaccinations
was 14.2% (Chamberlain, 2010).
Groom and colleagues’ (2015) study, which included abstracts and articles from studies
conducted in high-income countries (e.g., US, Canada, Australia, the UK), concluded that the use
of IISs could potentially be useful in increasing vaccination rates and decreasing deaths from
vaccine preventable diseases. The authors noted that the drawbacks of IISs are that participation
in these programs is voluntary, thus creating gaps in knowledge of vaccination rates and
individual vaccination statuses. However, this may not present as great a challenge in the US,
where, according to the CDC, every state operates their own IIS, and about 86% of United
States’ children younger than six have vaccination data stored in an IIS (CDC, 2012). Thus,
implementing a reminder system in the already existing IIS is an efficient way to inform HCPs
on the vaccination status of their patients. Further, it serves as a reminder during the patient visit
to recommend and offer the vaccine. This intervention is intended to help address the lack of

UP THE UPTAKE 28
HCP offering identified as the most significant barrier to vaccination (DOH, 2012; Meharry et
al., 2013; Ahluwalia et al., 2010; Shavell et al., 2012).
Provider Education
The role of HCPs in providing accurate vaccination information, as well as offering the
influenza vaccine at patient visits, is vital in a pregnant patient’s vaccination decision-making.
However, Panda and colleagues (2011), using a non-experimental study design, found that HCPs
may be hesitant to offer the influenza vaccine because they are unsure of the safety, necessity, or
efficacy of the vaccine for pregnant patients. Because of the potential lack in HCP knowledge,
Panda and colleagues designed an intervention involving two components: an education
program, and reminder emails that emphasized the HCP’s role in maternal influenza
vaccinations.
The HCP education program component was implemented in the summer and fall of
2008 at Bridgeport Hospital, Connecticut. Following the program, emails were sent out to HCPs
during the 2008-2009 influenza season to remind them of the necessity of the influenza vaccine
during pregnancy.
Baseline data were obtained regarding HCP’s knowledge of maternal influenza
vaccination, and whether the HCP offered the vaccine. Surveys were distributed to all women on
the postpartum floor of the hospital and to all 56 physicians providing prenatal care. The results
of the baseline study found that only 19% of pregnant women were vaccinated. Of the women
who did not receive the vaccine, 67.9% did not get the vaccine because they believed it was not
safe during pregnancy, and 72% did not get the influenza vaccine because it was not offered to
them. A discrepancy in the data arose, as 85.7% of HCPs stated that they always offered the
vaccine. Beyond HCP offering, HCP knowledge was lacking, as only 39.3% of the HCPs

UP THE UPTAKE 29
correctly said that influenza severity is greater for pregnant women than for non-pregnant
women. Further, 41% of HCPs believed that more information about vaccine safety and efficacy
is necessary in order to improve maternal influenza vaccination rates.
After the intervention, posttests were administered to postpartum patients during the
following influenza season. Results indicated that the education program for HCPs may have
been effective; vaccination rates in pregnant women increased by 12% (19% pre-intervention,
31% post-intervention). Further, there was a 13% increase in women reporting that their HCP
offered the influenza vaccine (28% pre-intervention, 51% post-intervention). Moreover,
vaccination rates in the hospital improved from 60% (pre-intervention) to 80% (post-
intervention). However, no improvements of HCP knowledge are reported due to the fact that a
post-intervention questionnaire was not provided to the physicians.
Although the components of the HCP education were not described, and the evidence
regarding the effectiveness of the intervention on HCP education is limited, but the study did
indicate that there are gaps in knowledge about maternal influenza vaccination. Because of these
gaps in knowledge, and the low cost to provide education to HCPs through emails, Up the
Uptake program planners use a HCP education component of physician education in their
program including maternal vaccination information and a reminder about HCP’s role in
recommending the vaccine. Because of the low cost of providing this educational email, and the
potential benefits of having well informed HCPs, the current program planners believe this
component is justified. Program planners will evaluate the effects of HCP education through
both a pretest and posttest assessing HCP knowledge of the maternal influenza vaccinations.

UP THE UPTAKE 30
Section IV: Program Implementation
Focus of Intervention
Up the Uptake is a preventative program focused on increasing the rates of maternal
influenza vaccination in Whatcom County, Washington. This program aims to decrease the
incidence of influenza-related morbidity and mortality among pregnant women and infants by
working with Obstetrician-Gynecologist (OB/GYN) and Family Practice Clinics in Whatcom
County that offer the influenza vaccine. (For the sake of brevity, OB/GYN and Family Practice
Clinics in Whatcom County that offer the influenza vaccine will hereafter be referred to as
eligible clinics [ECs]). By distributing an educational pamphlet at ECs, one focus of the program
is to increase pregnant women’s knowledge of influenza, as well as increase knowledge of the
safety and importance of the influenza vaccine. In conjunction, this program aims to increase
healthcare provider (HCP) offering of influenza vaccines during appointments with pregnant
women. This will be accomplished by educating HCPs on the importance of maternal influenza
vaccination. Finally, this program involves implementing vaccine reminder notifications in the
Electronic Health Record (EHR) systems of ECs, which will serve as a cue to action for the
HCPs to offer the influenza vaccine.
Program Mission, Goals, and Objectives
Mission statement. The purpose of Up the Uptake is to increase maternal influenza
vaccinations by providing influenza education and vaccine information to pregnant women, and
by providing education and reminder tools for HCPs in order to reduce influenza-related
morbidity and mortality of pregnant women and infants.
Goal: Partner with OB/GYN and Family Practice Clinics in Whatcom County who offer
the influenza vaccine (ECs).
Objectives:

UP THE UPTAKE 31
Process:
I. By August 15, 2016, a list will be compiled of all ECs.
II. By August 22, 2016, participation of 75% of all ECs will be obtained.
Goal: Increase knowledge of influenza and influenza vaccination among pregnant
women who visit ECs in Whatcom County.
Objectives:
Process:
I. By March 1, 2017, knowledge pretest for patients will be administered to
all clinics (participating and non).
II. By August 1, 2017, educational pamphlets designed based on the HBM
about influenza facts relevant to pregnancy will be completed in English
and Spanish.
III. By August 1, 2017, instructions for receptionists at participating ECs
about the distribution of pamphlets will be designed and printed.
IV. By September 1, 2017, informational pamphlets will be distributed to all
participating ECs.
V. By October 15, 2017, participating ECs will be called to inquire about
their pamphlet inventory.
VI. By January 2, 2018, participating ECs will be called a final time to
inquire about their pamphlet inventory.
Impact:
Learning:
By March 31, 2018, pregnant women at all participating ECs will
experience:
I. Reduced beliefs about negative side effects due to the influenza vaccine
by 50%.
II. Reduced beliefs that influenza vaccine harms fetuses by 50%.
III. Increased awareness of belief of vaccine’s effectiveness by 25%.
IV. Increased awareness of the potential severity of influenza on themselves
and their infants by 25%.
V. Increased awareness of their susceptibility to influenza by 25%.
VI. Increased awareness of the “Two-for-One Benefit” of maternal
Influenza vaccinations by 50%.
Behavioral:
I. By March 31, 2018, 80% increase number of pregnant women within
ECs who receive the influenza vaccination to 80%.
Environmental:

UP THE UPTAKE 32
I. By September 1, 2017, all personnel responsible for patient check-ins at
participating ECs will offer informational pamphlets to pregnant women
at intake.
Goal: Improve HCP’s knowledge of influenza vaccine at ECs.
Objectives:
Process:
I. By March 1, 2017, pretest for HCPs will be administered to all clinics
(participating and non).
II. By August 1, 2017, a template email to HCPs will be completed. This
will include a reminder of the importance of influenza vaccination for
pregnant women, and vaccination information such as safety and
efficacy.
III. By August 30, 2017, email addresses will be gathered from all HCP’s
who see pregnant women at participating ECs.
IV. By September 1, 2017, a reminder informational email will be sent to all
HCPs.
V. By January 15, 2018, a second reminder informational email will be sent
out a final time to all HCPs.
Impact:
Learning:
By September 1, 2018, 100% of HCPs at participating ECs:
I. Can state the CDC recommendations for maternal influenza
vaccinations.
II. Can explain the importance (e.g., the “two-for-one” benefit) of maternal
influenza vaccinations.
Behavioral:
I. By September 1, 2018, 100% of HCPs will offer influenza vaccines to
all eligible pregnant women within Whatcom County who are patients at
participating ECs.
Goal: Improve influenza vaccination reminder tools for HCPs in participating ECs.
Objectives:
Process:
I. By August 1, 2017, a program staff member will be trained in creating
color-coded influenza vaccine reminder system in EHRs.
II. By August 31, 2017, the EHR reminder system will be implemented
within participating ECs.

UP THE UPTAKE 33
Impact:
Behavioral:
I. By March 31, 2018, 100% of HCPs in participating ECs will interact
with 85% of the EHR reminders for pregnant women who have not been
vaccinated.
II. By September 1, 2018, 100% of HCPs will offer influenza vaccines to
all eligible pregnant patients within participating ECs.
Environmental:
I. By September 1, 2017, 100% of the participating ECs will adopt non-
interruptive influenza vaccination reminder systems.
Goal: Reduce influenza-related morbidity and mortality in pregnant women and infants.
Objectives:
Process:
I. By August 31, 2017, baseline information on numbers of pregnant
women vaccinated during the previous influenza season will be gathered
from each EC (participating and non).
II. By March 1, 2017, charts will be reviewed from participating ECs to
establish a baseline of how often HCPs offer the influenza vaccine and
the number of vaccines given.
III. On March 1, 2018, a chart review will be conducted to establish how
often HCPs in participating ECs offered the influenza vaccine and the
number of vaccines given during that flu season.
Outcome:
By March 1, 20183
, reduce:
I. Incidence rates of influenza among pregnant women by 50%.
II. The average annual influenza-attributable hospital admissions among
pregnant women by 20%.
III. Influenza-related infant mortality to 0.8 per 100,000.
IV. Influenza-related illness in infants 0-6 months of age by 50%.
V. Influenza attributed preterm births by 10%.
Educational Plan
Up the Uptake is designed for implementation in participating ECs for the 2017-2018
influenza season; the purpose is to increase seasonal influenza vaccination rates among pregnant
women, and therefore decrease influenza-related morbidity and mortality among pregnant
3
The success of these outcomes is dependent on the effectiveness of the 2017-2018 influenza vaccine, as well as the
severity of the influenza strain. These figures are based upon the 2015-2016 influenza vaccine’s effectiveness.

UP THE UPTAKE 34
women and infants. Increasing maternal influenza vaccination rates will be accomplished by: (a)
disseminating an educational pamphlet to all pregnant women visiting participating ECs, (b)
increasing HCP’s awareness of the necessity of the influenza vaccine through an informational
email, and (c) implementing vaccination reminders in EHR systems in order to prompt HCPs to
offer the vaccine. The design of this program is based on constructs of the Health Belief Model
(HBM), as well as evidence-based interventions (EBIs). By combining components of patient
education, as well as providing HCPs with education and reminder tools, this program addresses
significant barriers to maternal influenza vaccination rates.
Based on evidence that information provided in the form of pamphlets has been effective
at impacting related knowledge (Meharry et. al, 2014), a team of health education specialists will
design an educational pamphlet that includes information about the safety, necessity, and
efficacy of the influenza vaccine. The pamphlet will be delivered to the participating ECs and
disseminated to all pregnant patients when they check in for their appointments. The health
educator team will also design and distribute an email to all HCPs who work at the participating
ECs. This email will include information from the CDC about safety, efficacy, and necessity of
the influenza vaccine during pregnancy, along with a reminder for all HCPs about their role in
recommending and offering the vaccine. Further, a reminder system will be implemented into the
EHR systems of the ECs. This reminder system will inform the HCPs on the influenza
vaccination status of the patient and will serve as a reminder to offer the vaccine.
Key features. These features of the program are vital to the success of the intervention
and outline the timeline and steps of the program.
I. In August of 2017, before the beginning of influenza season, the informational
email will be sent to all HCPs at participating ECs. This email will include

UP THE UPTAKE 35
information from the CDC regarding safety, efficacy, and necessity of the
influenza vaccine during pregnancy. In addition, this email will remind HCPs of
their role in recommending and offering the vaccine. Follow-up emails will be
sent in mid-September of 2017, and again in January of 2018.
II. In September of 2017, educational pamphlets in English and Spanish will be
distributed to participating ECs. Personnel responsible for checking in patients for
their appointments will be given both verbal and written instructions to give a
pamphlet to every pregnant patient. Pamphlets will also be placed in waiting
rooms or exam rooms.
III. In October of 2017 and January of 2018, health educators will contact
participating ECs to inquire about pamphlets inventory.
IV. In September of 2017, a color-coded influenza reminder system will be
implemented into the EHR systems of participating ECs. This reminder system
will appear in a nonobtrusive manner every time the chart is opened, and will
indicate the vaccination status of each pregnant patient.
Program support components. Before the intervention is implemented, program
planners will contact each EC in Whatcom County to discuss participation in the program. Once
participating ECs are identified, health educators will collaborate with technology support
individuals at these ECs in order to set up the vaccine reminder system on all electronic charts of
pregnant patients.
An essential component of the program is the design and content of the pamphlet for
pregnant mothers. This pamphlet, based off of the constructs of the HBM, provides information
on pregnant women’s increased susceptibility to influenza, the severity of influenza
complications, the benefits of vaccination to the mother and infant, and the safety of the vaccine.

UP THE UPTAKE 36
In addition, the pamphlet includes images of women, infants, and local HCPs. These aspects of
the pamphlet are essential to increasing maternal influenza vaccination.
Moreover, education for HCPs on the importance of influenza vaccination in pregnant
women, as well as HCPs’ role in increasing vaccination rates will be provided by email
throughout the influenza season. Including vaccination status updates and reminders on the
charts of pregnant women also serves as a cue to action for the HCP to help ensure that the
vaccine is being offered to all eligible pregnant women.
Feedback from HCP’s and the receptionists at the participating clinics will be obtained
throughout the program to ensure that core components of the program are being administered.
This will also serve as an opportunity to adjust any necessary details to ensure the program’s
success. At the end of the influenza season, an evaluation to determine increases in maternal
influenza vaccination rates will be performed, which will provide information about the overall
success of the program.
Other programmatic needs. Other resources needed for the program include:
● Space
○ OB/GYN and Family Practice Clinics who offer the influenza vaccine
● Time
○ Designing pamphlet
○ Designing and compiling information for the HCP email
○ Contacting all healthcare facilities (initial contact as well as follow up for
pamphlet refill)
○ Setting up EHR reminder systems
○ Disseminating pamphlets
○ Writing and sending emails to HCPs
● Equipment
○ Computer design software (e.g., Adobe InDesign) for pamphlet
○ Color and ink printer for pamphlet
○ Computer with Internet access to send emails to HCPs
● Personnel
○ Six health educators for team who will:

UP THE UPTAKE 37
■ Design pamphlet
■ Distribute pamphlet to participating ECs
■ Educate receptionists at participating ECs on pamphlet
dissemination
■ Send e-mails
■ Set up reminder system in clinics
○ Information Technology participation at participating ECs
○ Personnel responsible for checking in patients at participating ECs who
disseminate pamphlet
○ HCPs who offer and provide influenza vaccine
Section V. Program Evaluation
Evaluations of this program will be made for each core component: the educational
pamphlet, the healthcare provider (HCP) education emails, and the Electronic Health Record
(EHR) reminder system. The formative evaluation assesses the quality of the components, the
process evaluation assesses whether components are being delivered completely and on
schedule, and the impact evaluation assesses the effectiveness of each component. The outcome
evaluation assesses the changes in health outcomes as a result of all of the aspects of the
program.
Educational Pamphlet
Process Evaluation. Evaluations throughout the program will be conducted to ensure
that pamphlets are created in two languages (English and Spanish) and printed and distributed to
the eligible clinics (ECs)4
by the beginning of the 1st of September, 2017. Further, calls will be
made throughout the influenza season (October 15th, 2017, and January 2, 2018) to ensure that
pamphlets are stocked at ECs.
4
Eligible Clinics have been previously defined as Obstetric-Gynecologic and Family Practice Clinics in Whatcom
County that offer the influenza vaccine.

UP THE UPTAKE 38
Formative evaluation. The educational pamphlet will be pre-tested in a focus group with
pregnant women in Whatcom County in the 2016-2017 influenza season (prior to program
implementation). This focus group will provide feedback about the pamphlets’ content,
readability, and likelihood of reading the pamphlet. After necessary changes are made,
interviews with personnel distributing the pamphlets will be conducted to obtain qualitative
feedback as to how the pamphlet is being received by patients.
Impact evaluation. A quasi-experimental design will be used to evaluate the impact of
the pamphlet on pregnant women’s knowledge about influenza and the influenza vaccine. First, a
knowledge pretest will be conducted at the end of the 2016-2017 influenza season using a
sample of pregnant women at ECs. The results from this pretest will be used to establish baseline
knowledge about influenza, and influenza vaccination (see Section IV for more details). After
program implementation (at the end of March, 2018), a posttest will be given to a sample of
pregnant women at the clinics who received the pamphlet (experimental group), and to a sample
of pregnant women at clinics who are not participating in the intervention (comparison group)5
.
The posttest data will be compared to pretest data in order to evaluate whether or not the
pamphlet was associated with a significant increase in pregnant patients’ knowledge of influenza
and the influenza vaccine.
Healthcare Provider Education
Process. Evaluations will be made to ensure that the pretests and posttests for HCPs are
distributed and collected. Further, evaluations will be made throughout the course of the program
to ensure that the educational email is completed, and that emails have been sent to HCPs on
specified dates (August, 2017, mid-September, 2017, and January, 2018).
5
If 100% of eligible clinics in Whatcom County participate in the program, the comparison group will be clinics in
a nearby county with similar demographics (e.g., Skagit County).

UP THE UPTAKE 39
Formative. Program planners will pilot test the educational email by sending it to seven
HCPs who offer the vaccine. The HCPs will be asked to review the email for clarity and content
and to reply with feedback and potential changes.
Impact. HCP knowledge will be evaluated using a quasi-experimental design. A pretest
and posttest will be given to all HCPs in participating (experimental group) and nonparticipating
(comparison group) clinics1
in Whatcom County. These tests will examine HCPs’ awareness of
the CDC’s recommendations for maternal influenza vaccines, and HCPs’ ability to explain the
importance, safety, and efficacy of maternal influenza vaccines. Further, the rates of HCPs
offering the influenza vaccine to pregnant patients will be evaluated using a quasi-experimental
design. Documented offers of the vaccine to pregnant patients at the end of the 2016-2017
influenza season will be recorded as a baseline in participating and nonparticipating clinics. The
data will be collected again at the end of the 2017-2018 influenza season in both participating
and non-participating clinics. The rates of offering will be compared and tested for significance.
Reminder System
Process Evaluation. Evaluators will ensure that a staff member has been trained in
creating the color-coded vaccination reminder systems. Evaluations will be conducted
throughout the program to ensure that the EHR system was implemented in ECs on time and that
the pop-up notification is showing for each chart.
Formative Evaluation. Evaluators will also determine whether or not the EHR
vaccination reminder system was helpful to HCPs by holding a focus group with HCPs from a
smaller subset of the total participating ECs. A trained facilitator will moderate the focus group,
posing questions to gauge the overall usefulness of the vaccine reminder system. The facilitator
will ask questions about the ease of using the reminder system, such as, “Was the vaccine

UP THE UPTAKE 40
reminder system easy to use?”, “Did the reminder system cause problems with the fluidity of
patient interactions?”, “Did you encounter any technical problems with the reminder system?”
Facilitators will also ask about any benefits HCPs may have experienced as a result of using the
system (e.g., “Did you find that the vaccine reminder system’s tips for talking to patients about
vaccines were helpful when counseling a patient on vaccine decision-making?”)
Impact Evaluation. A quasi-experimental design will be used to evaluate the
effectiveness of the EHR reminder system. A systematic review of the charts from all
participating and non-participating EC’s for the 2016-2017 influenza season will be conducted in
order to investigate how often the influenza vaccine is being offered to pregnant patients. This
will create a baseline for comparison post-intervention. After the intervention, charts will be
reviewed again in order to identify if the offering of the influenza vaccine significantly increased
compared to the pretest results. Further, a non-experimental study will examine rates of HCP
interaction with the EHR reminder system. Data will be collected to identify how often HCPs
interacted with the reminder system, as opposed to ignoring the notification.
Program Outcome Evaluation
Baseline data will be collected from hospitals and clinics in Whatcom County during the
2016-2017 influenza season and will be compared to data in the 2017-2018 influenza season.
Data will be collected about the following: influenza diagnoses and hospitalizations in pregnant
women, infant mortality rates, infant influenza diagnoses, and influenza-related preterm births.
These data will be collected again in the 2017-2018 season and compared. It is important to note
that the success of the outcomes will also be dependent on the efficacy of the 2017-2018
influenza vaccine, as well as the severity of the circulating influenza strain.

UP THE UPTAKE 41
Conclusion
By performing process, formative, and impact evaluations of each core component,
program planners will be able to ensure that Up the Uptake’s core components are well designed,
implemented as designed, and have made sufficient contribution to the success of the program.
Further, by performing an outcome evaluation of the entire program as a whole, program
planners will be able to identify the program’s effectiveness in reducing influenza illness and
influenza-related complications in pregnant women and their infants in Whatcom County,
Washington.

UP THE UPTAKE 42
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