title: Reasons for low influenza vaccination coverage among adults in Puerto Rico, influenza season 2013-2014.
abstract: BACKGROUND
  Influenza vaccination is recommended annually for all persons 6 months and older. Reports of increased influenza-related morbidity and mortality during the 2013-2014 influenza season raised concerns about low adult influenza immunization rates in Puerto Rico. In order to inform public health actions to increase vaccination rates, we surveyed adults in Puerto Rico regarding influenza vaccination-related attitudes and barriers.
  
  
  METHODS
  A random-digit-dialing telephone survey (50% landline: 50% cellphone) regarding influenza vaccination, attitudes, practices and barriers was conducted November 19-25, 2013 among adults in Puerto Rico. Survey results were weighted to reflect sampling design and adjustments for non-response.
  
  
  RESULTS
  Among 439 surveyed, 229 completed the survey with a 52% response rate. Respondents' median age was 55 years; 18% reported receiving 2013-2014 influenza vaccination. Among 180 unvaccinated respondents, 38% reported barriers associated with limited access to vaccination, 24% reported they did not want or need influenza vaccination, and 20% reported safety concerns. Vaccinated respondents were more likely to know if they were recommended for influenza vaccination, to report greater perceived risk of influenza illness, and to report being less concerned about influenza vaccine safety (p-value<0.05). Of the 175 respondents who saw a healthcare provider (HCP) since July 1, 2013, 38% reported their HCP recommended influenza vaccination and 17% were offered vaccination. Vaccination rates were higher among adults who received a recommendation and/or offer of influenza vaccination (43% vs. 14%; p-value<0.01).
  
  
  CONCLUSIONS
  Failure of HCP to recommend and/or offer influenza vaccination and patient attitudes (low perceived risk of influenza virus infection) may have contributed to low vaccination rates during the 2013-2014 season. HCP and public health practitioners should strongly recommend influenza vaccination and provide vaccinations during clinical encounters or refer patients for vaccination.
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA; Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA. Electronic address: wus3@cdc.gov.
authors.forename: Carmen S
authors.initials: CS
authors.lastname: Arriola
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA; Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Melissa C
authors.initials: MC
authors.lastname: Mercado-Crespo
authors.affiliation: Puerto Rico Department of Health, San Juan, Puerto Rico, USA.
authors.forename: Brenda
authors.initials: B
authors.lastname: Rivera
authors.affiliation: Puerto Rico Department of Health, San Juan, Puerto Rico, USA.
authors.forename: Ruby
authors.initials: R
authors.lastname: Serrano-Rodriguez
authors.affiliation: Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Nora
authors.initials: N
authors.lastname: Macklin
authors.affiliation: Puerto Rico Department of Health, San Juan, Puerto Rico, USA.
authors.forename: Angel
authors.initials: A
authors.lastname: Rivera
authors.affiliation: Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Samuel
authors.initials: S
authors.lastname: Graitcer
authors.affiliation: Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Mayra
authors.initials: M
authors.lastname: Lacen
authors.affiliation: Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Carolyn B
authors.initials: CB
authors.lastname: Bridges
authors.affiliation: Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Erin D
authors.initials: ED
authors.lastname: Kennedy
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004363:Drug Utilization; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007252:Influenza Vaccines / Q000008:administration & dosage*; D007251:Influenza, Human / Q000517:prevention & control*; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D011647:Puerto Rico; D014611:Vaccination / Q000523:psychology*; D055815:Young Adult
chemical_list: D007252:Influenza Vaccines
keywords: Attitudes; Barriers; Influenza vaccination