COVID‐19 and Influenza Vaccine Uptake Among Nurses and Children Living in Their Households: A Cross‐Sectional Study

ABSTRACT

Background

Children are at lower risk from influenza and COVID‐19 than other age groups, but they can still be affected. Some adults, including healthcare workers, developed negative attitudes toward COVID‐19 vaccines during the COVID‐19 pandemic, which might lead to lowered pediatric vaccine uptake. We investigated COVID‐19 and seasonal flu vaccine uptake among nurses and children living in their households.

Methods

Using contact information from the state professional licensing body, we recruited 677 nurses from South Dakota with children living in their households to participate in an online survey. Data were collected in May 2024. The survey included questions regarding parental and pediatric vaccine uptake and social and political factors associated with vaccine hesitancy. We used logistic regression to analyze the data.

Results

We found that 64% were vaccinated for influenza and 18% of children were vaccinated for COVID‐19. The pediatric uptake of both vaccines was associated with parental COVID‐19 vaccination status and partially with influenza vaccination status. Nurses who identified with the Republican Party reported lowered vaccination rates for children living in their households.

Conclusions

Overall, we found low COVID‐19 and flu vaccination rates among children in our sample.

1. Introduction

While children are generally at lower risk from influenza and COVID‐19 than other age cohorts, they can still be affected. According to a report by the American Academy of Pediatrics, 234,000 children were hospitalized with COVID‐19 from fall 2020 to spring 2024 [1]. No fewer than 194 pediatric deaths due to COVID‐19 were reported during the 2023–2024 vaccination season, an increase from the previous season [2]. Vaccines can reliably protect children from influenza and COVID‐19, and the Centers for Disease Control and Prevention (CDC) has long recommended that children receive influenza vaccination annually. In 2024, the CDC advised that children 6 months and older receive the updated COVID‐19 vaccine [3].

Despite recommendations from federal healthcare authorities supporting it, vaccination was a controversial issue during the COVID‐19 pandemic in the United States. COVID‐19 vaccines were developed at an accelerated pace, leading to questions about vaccine safety. The spread of misinformation [4] and political attacks [5] undermined people's trust and confidence in COVID‐19 vaccines. Negative attitudes toward COVID‐19 vaccines might affect people's preferences toward receiving other vaccines. Research showed that adults who did not receive a COVID‐19 vaccine were less likely to receive the flu vaccine [6]. Some experts warned that society has entered a ‘vaccine hesitant moment’ [7].

One downstream consequence of increased COVID‐19 vaccine hesitancy among adults might be lower pediatric vaccine uptake, particularly for vaccines not required to attend school. According to one report, routine childhood vaccination rates decreased in the United States and other countries following the outbreak of COVID‐19 [8]. For example, adolescents aged 13 were less likely to receive the HPV vaccine in the post‐COVID‐19 pandemic period compared to a cohort before the pandemic [9]. At the same time, the number of reports about the adverse side effects of MMR vaccination increased dramatically [10].

This study investigated the personal pediatric flu and COVID‐19 vaccination decisions of healthcare workers (HCWs) in the post‐COVID‐19 pandemic period. We focused on one established vaccine and one new vaccine subjected to a high degree of controversy and politicization during the pandemic. Our study measured pediatric vaccine uptake, while most studies examining parental vaccine hesitancy were based on survey questions measuring parental vaccination attitudes. While vaccination intentions are a good predictor of vaccination behavior, it is not always the case [11]. We analyzed the data and explored the social and political correlates of children's vaccine uptake, which were identified by the extant literature [12, 13, 14].

We focused on vaccine uptake among children living in the households of nurses. Most parental vaccine hesitancy studies are based on general population samples, and studies based on surveys of HCWs are infrequent [15, 16], particularly U.S.‐based studies [17]. Nurses have advanced medical education and serve as advisors and consultants when parents make vaccination decisions for their children. Understanding nurses' pediatric vaccination decisions can help public health officials and administrators develop strategies and create resources that educate nurses and the public about the benefits of vaccination.

2. Data and Methods

2.1. Data Collection

The data came from a larger cross‐sectional survey of nurses in South Dakota fielded by the authors. The survey explored nurses' attitudes toward various issues, including health, which we reported in this study. We obtained the list of all registered nurses (RNs) and licensed practical nurses (LPNs) with contact information from the South Dakota Board of Nursing. Using the listed email addresses, on May 1, 2024, we emailed all RNs and LPNs an invitation to participate in an online survey. A total of 21,300 invitation emails were sent. Two reminders were emailed before the survey closed on May 13, 2024. The response rate was 9%. The survey was hosted on the QuestionPro platform, and each email included a personalized link to access the survey. Survey settings prevented participants from taking the survey multiple times and non‐invitees from accessing the survey. Participants provided consent to participate before starting the survey. Respondents did not receive compensation for completing the survey. The authors secured approval from South Dakota State University's institutional review board before fielding the survey.

2.2. Measures

Participants provided information about their age, gender, ethnicity, education, and political self‐identification. They also answered questions about the presence of children in the household, and the flu and COVID‐19 vaccination status of these children. The survey also included questions measuring their own COVID‐19 vaccination status, flu vaccination status, the presence of COVID‐19 and flu vaccine mandates in the work setting, and an attention check question. Due to space limitations, we provide the full text of all questions used in this analysis in the appendix.

2.3. Analysis

The participants who reported having a child in their household and who passed the attention check were kept in the sample. We first described the data and then estimated two multivariate logistic regressions given the binary dependent variables. In the first model, the child's COVID‐19 vaccination status was the dependent variable, and the other variables were entered simultaneously as independent variables, except mandatory flu vaccination in the work setting. In the second model, the child's flu vaccination status was the dependent variable, and the other variables were entered simultaneously as independent variables, except the COVID‐19 vaccine mandate in the work setting. We created dummy variables for participants with Republican party affiliation, independents, and those who declined to answer, with Democrat party affiliation as the reference category. We reported adjusted odds ratios and 95% confidence intervals. Missing data were handled via case‐wise deletion. The analysis was not pre‐registered. We used STATA 18 for all analyses [18].

3. Results

Of the 1,908 responses in the survey, 677 participants indicated having children in their household. Of these, the 644 who passed the attention check question were kept in the final sample. Of these participants, the average age was 40 years, 93% identified as White, 88% identified as women, and 73% received at least a bachelor's degree. A majority (86%) received a flu vaccination during the 2023–2024 vaccination season; 12% did not receive a COVID‐19 vaccination, 5% received one dose, 34% completed the initial series, 30% received a booster dose, and 19% received multiple booster doses. Over 17% of participants identified with the Democratic Party, 44% with the Republican Party, 19% as independent, and 20% declined to provide their partisan self‐identification. Over 18% of children received a COVID‐19 vaccination, and 64% received a flu vaccination. We provided further details in Table S1.

As shown in Table 1, the child's uptake of COVID‐19 vaccine was strongly associated with the nurse's COVID‐19 vaccination status (aOR: 5.19, 95% CI: 3.58–7.52), and indicators for Republicans (aOR: 0.39, 95% CI: 0.21–0.72) and independents (aOR: 0.42, 95% CI: 0.19–0.92). The associations with other variables were not statistically significant. The McFadden's R‐squared value was 0.3149.

Table 1.

Correlates of pediatric flu and COVID‐19 vaccine uptake.

	COVID‐19 vaccine uptake			Flu vaccine uptake
	aOR	p	95% CI	aOR	p	95% CI
Parental COVID‐19 vaccination status	5.19	< 0.01	[3.58,7.52]	1.81	< 0.01	[1.49,2.19]
Parental flu vaccination status	2.95	0.17	[0.62,13.95]	8.85	< 0.01	[4.08,19.18]
Republican self‐identification	0.39	< 0.01	[0.21,0.72]	0.48	0.03	[0.25,0.93]
Independent	0.42	0.03	[0.19,0.92]	0.34	< 0.01	[0.16,0.69]
Decline to answer	1.14	0.74	[0.53,2.44]	0.45	0.03	[0.22,0.92]
Mandatory flu vaccination at work				0.81	0.4	[0.49,1.34]
Mandatory COVID‐19 vaccination at work	1.36	0.29	[0.78,2.37]
Parental age	0.99	0.69	[0.96,1.03]	0.96	< 0.01	[0.94,0.98]
White ethnicity	1.2	0.73	[0.43,3.35]	2.14	0.05	[1.00,4.60]
Male gender	1.86	0.09	[0.91,3.82]	1.56	0.19	[0.81,3.01]
Education	1.06	0.71	[0.79,1.42]	1.42	< 0.01	[1.13,1.79]
Pseudo R‐square	0.31			0.23
Observations	611			614

The child's uptake of flu vaccine was also related to the respondent's COVID‐19 vaccination status (aOR: 1.81, 95% CI: 1.49–2.19), parental flu vaccination status (aOR: 8.85, 95% CI: 4.08–19.18), indicators for Republican (aOR: 0.48, 95% CI: 0.25–0.93), independent (aOR: 0.34, 95% CI: 0.16–0.69), refusal to disclose partisan self‐identification (aOR: 0.45, 95% CI: 0.22–0.92), parental age (aOR: 0.96, 95% CI: 0.94–0.98), and education status (aOR: 1.42, 95% CI: 1.13–1.79). The McFadden's R‐squared value was 0.2280.

4. Discussion

The results make several contributions to the extant scholarship on vaccine hesitancy and will interest researchers and public health officials. First, we found lower vaccination rates for COVID‐19 than for flu among children living in respondents' households. The finding suggests that the respondents do not appear to be opposed to children in their households receiving vaccinations per se; rather, they might have lingering concerns about COVID‐19 vaccines and their safety for children. As scholars reported, COVID‐19 vaccines were the target of misinformation and partisan attacks during the COVID‐19 pandemic, undermining people's confidence in COVID‐19 vaccination [4, 5]. These concerns likely persist over time despite strong CDC recommendation from fall 2023 that children receive a COVID‐19 vaccination during the 2023–2024 vaccination season [19]. Flu vaccines for children, on the other hand, are more established and were not subjected to the same misinformation during the COVID‐19 pandemic, likely explaining the higher flu vaccination rate among children in our sample.

We found COVID‐19 vaccine uptake was lower compared to results in a similar study of nurses from summer 2022 conducted in the same state that reported that more than half of the respondents' children received a COVID‐19 vaccine [17]. It is possible that children received a COVID‐19 vaccine during the pandemic, but then as the perceived threat posed by the virus subsided, children did not receive additional doses, an example of what public health authorities refer to as ‘vaccine fatigue’ [20].

Second, we found that respondents' own vaccination status was linked to child vaccination status, which is in line with existing studies [21, 22, 23], including studies that focused on flu vaccination among children [24, 25]. Studies conducted during the COVID‐19 pandemic showed that HCWs [26, 27] and nurses [17] who received a COVID‐19 vaccination were more likely to vaccinate the children in their households for COVID‐19. Overall, it seems respondents make vaccination decisions for family as a unit, so if they are vaccinated, they also vaccinate the children in their homes. There is likely an underlying parental attitude toward vaccines determining whether both the parent and the child will get vaccinated. Some have referred to this group as “vaccine enthusiasts” [28]. This finding suggests that any strategy to increase flu and COVID‐19 vaccination rates among children should focus on vaccinating the heads of households first. If the probability of parents getting vaccinated increases, the vaccination of their children will likely follow suit.

Third, the results showed that parental political partisanship in this group of nurses was associated with children's flu and COVID‐19 vaccination status. Compared to the nurses who identified with the Democratic Party, those who identified with the Republican Party or as independent, were less likely to vaccinate their children. Scholars showed that during the COVID‐19 pandemic, Republican parents [29, 30, 31], including those who are nurses [17], were less likely to vaccinate their children for COVID‐19. Other studies have shown a link between trust in political institutions and parental willingness to vaccinate children against COVID‐19 [29, 32, 33]. Our results show that political partisanship effects have persisted even after the end of the pandemic, a time when COVID‐19 vaccines are no longer subject to the same degree of attention in the media. We also found very similar results regarding flu vaccine uptake among children. Even though flu vaccination was not politicized as much as COVID‐19 vaccination during the pandemic and has been an established pediatric vaccination, the vaccination rates of children in our respondents' homes are structured by partisanship – almost as strongly as COVID‐19 vaccination. This finding suggests that when it comes to vaccination decisions for children, nurses are not immune from political influences, and partisanship plays a role just as in the general population. Public health authorities and vaccine advocates ought to recognize this fact as they craft outreach efforts to bolster vaccination rates.

5. Conclusion

We reported the findings of a survey on COVID‐19 and seasonal flu vaccine uptake among nurses and the children living in their households. Most studies exploring parental vaccine hesitancy are based on general population samples, and studies based on nurse sample are less common, as nurses who are parents can be a more challenging population to recruit. For this reason, the existing studies examining parental vaccine hesitancy among HCWs are often based on small samples [34, 35], which can raise questions regarding the findings. Although limited to a single state, our sample size is comparatively large. Our recruitment method and the fact that we did not provide financial incentives give us confidence results were not swayed by fraud or impersonation, which can be a problem in surveys of hard‐to‐reach populations [36, 37].

We report study limitations that can help guide further research on pediatric vaccine uptake. The findings were limited by a survey response rate of 9%, which while low, was consistent with similar studies using the same participant recruitment approach [17]. The design of our study did not allow us to ask follow‐up questions on why some respondents did not vaccinate their children. We encourage other investigators to do so in the context of an in‐depth interview and to focus on the parents who vaccinated their children for flu but not for COVID‐19. Such granular data would help develop strategies to boost pediatric COVID‐19 vaccine uptake. We also did not collect information about the child's health besides flu and COVID‐19 vaccine uptake. Researchers should consider exploring how the child's health and potential health conditions might affect parental decision‐making regarding the child's vaccination. We also caution against interpreting our estimates as causal effects. Further analysis is needed to explore the causal relationships that underlie the associations between parental vaccination status, presence of vaccination mandate at work, partisan self‐identification, and children's vaccination status explored in this study.

Author Contributions

Filip Viskupič: conceptualization, writing – original draft, writing – review and editing, formal analysis, investigation, methodology. David L. Wiltse: data curation, conceptualization, methodology, investigation, writing – review and editing. Thomas E. Stenvig: conceptualization, methodology, investigation, writing – review and editing.

Ethics Statement

Authors received approval from the Institutional Review Board at South Dakota State University before conducting the study.

Consent

Respondents provided implied consent before participating in the study.

Transparency statement

The lead author Filip Viskupič affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Supporting information

online appendix.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.