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. Author manuscript; available in PMC: 2026 Aug 13.
Published in final edited form as: Vaccine. 2025 Jul 1;61:127415. doi: 10.1016/j.vaccine.2025.127415

Parental reasons for non-receipt of influenza vaccination among children 6 months–17 years and changes over time, 2015–2024

Katherine E Kahn a,b, Tammy A Santibanez b, Anurag Jain a,b, Tianyi Zhou a,b, Carla L Black b
PMCID: PMC12908229  NIHMSID: NIHMS2141508  PMID: 40602343

Abstract

Background

Understanding parental reasons for not having their child receive an influenza vaccination and how reasons have changed over time can help immunization programs and providers tailor interventions to increase uptake of influenza vaccine among children. The objectives of this study were to estimate the percentage of children 6 months–17 years with a parent who reported selected reasons for non-receipt of influenza vaccination (or “non-vaccination”) during 2015–2024, assess whether there has been an increase or decrease in the reporting of each reason for non-vaccination, particularly pre versus post COVID-19 pandemic, and if reasons for non-vaccination differ by sociodemographic characteristics.

Methods

National Immunization Survey-Flu (NIS-Flu) parentally reported data for the 2015–16, 2016–17, 2019–20, 2022–23, and 2023–24 seasons were analyzed. Percentages of children not vaccinated against influenza whose parent reported each reason for non-vaccination, overall, by state, and by sociodemographic characteristics were calculated. Tests of association between sociodemographic characteristics and across seasons were conducted for each reason for non-vaccination using t-tests.

Results

The most commonly reported reasons for non-receipt of influenza vaccination across all seasons studied were: belief their child is unlikely to get very sick from influenza, concern about side effects/safety, and belief influenza vaccines do not work very well (48.2%, 43.3%, and 37.0%, respectively, in 2023–24). Parental reporting of thinking their child is unlikely to get very sick from influenza increased more than other reasons for non-vaccination since the COVID-19 pandemic. Across all seasons studied, very few reported access-related reasons. Reasons for non-vaccination varied by state and by demographic characteristics.

Conclusions

This study suggests that concern about influenza has decreased since the COVID-19 pandemic. A strong provider recommendation for influenza vaccination, including information about the safety of the vaccine and seriousness of influenza, could help increase influenza vaccination coverage among children.

Keywords: Influenza, Vaccination, Hesitancy, Children

Introduction

Children younger than 5 years, and especially those younger than 2 years, are at higher risk of serious influenza-related complications [1, 2]. Vaccination is an effective strategy in preventing influenza and, since 2008, has been recommended by the Advisory Committee on Immunization Practices (ACIP) for all children 6 months–18 years [3, 4]. Despite this well-established recommendation and a Healthy People 2030 target of 70% influenza vaccination coverage, an estimated 55.4% of children 6 months–17 years were vaccinated against influenza during the 2023–24 influenza season [5, 6]. Influenza vaccination coverage among children had been 63.7% during the 2019–20 season but declined during the COVID-19 pandemic and has continued to trend downward [7]. During the 2022–23 season, nearly one-third of children 6 months–17 years had a parent who indicated being hesitant about influenza vaccine for their child [8]. Understanding the reasons why parents choose not to get their children vaccinated against influenza can help immunization programs and providers tailor interventions and increase parental vaccine confidence and uptake of influenza vaccine among children. Reasons for non-receipt of influenza vaccination (or “non-vaccination”) can change over time and there may have been a shift in reasons from pre-COVID-19 pandemic to the current post-pandemic environment.

The objectives of this study were to: 1) estimate percentages of children 6 months–17 years not vaccinated against influenza whose parent reported selected reasons for not having the child get an influenza vaccination at the national level and at the state level, 2) assess whether there has been an increase or decrease in the parental reporting of each reason for non-vaccination over time, examining whether the proportions changed pre versus post pandemic, and 3) assess if parental reasons for non-vaccination differ by sociodemographic characteristics.

Methods

Data from the National Immunization Survey-Flu (NIS-Flu) from 2015−2024 were analyzed to assess parental reasons their child did not receive an influenza vaccination during the 2015–16, 2016–17, 2019–20, 2022–23, and 2023–24 influenza seasons [9, 10]. The NIS-Flu is an on-going, national random-digit-dialed cellular telephone survey of households with children; it was a dual landline and cellular telephone survey until January 2018 when it became a cellular only telephone survey [9–11]. The NIS-Flu includes three components: the NIS-Child for children 19–35 months, the NIS-Teen for adolescents 13–17 years, and the NIS Child Influenza Module for children 6–18 months and 3–12 years identified during the screening of households for the NIS-Child and NIS-Teen [9, 10]. Telephone interviews were conducted with adults ≥18 years knowledgeable about the child’s vaccinations (hereafter referred to as “parent”) during October through June for the five seasons from all 50 states and the District of Columbia. The Council of American Survey and Research Organizations (CASRO) response rates ranged from 53.5%–64.8% for landline (2015−16 and 2016−17 seasons only) and 19.6%–32.2% for cellular telephones [12].

The study sample included children in the NIS-Flu who had not received an influenza vaccination since July 1st during the influenza season of the interview and had information about reasons the parent did not have them vaccinated. Questions about reasons for non-vaccination were only included in interviews conducted during April–June of each influenza season. For children who did not receive an influenza vaccination, respondents were asked: “There are many reasons why parents don’t get flu vaccinations for their children. I am going to read a list of only a few of the many possible reasons why parents may not get a flu vaccination for their children. Please tell me if each statement is a reason why you did not get a flu vaccination for your child this flu season. Was one of the reasons that you did not get the flu vaccination for your child because…” The list of reasons included the following, and varied across seasons as noted in parentheses: your child is unlikely to get very sick from the flu (all seasons studied); you wanted to get the flu spray for your child but it was not available (2015–16, 2016–17, 2019–20); you were concerned about possible side effects or the safety of the flu vaccination (all seasons studied); the place where you usually get your child a flu vaccination did not give flu vaccination this season (2015–16, 2016–17); you believe that flu vaccines do not work very well (all seasons studied); you or your child don’t like needles or shots (2016–17, 2019–20, 2022–23, 2023–24); your child is unlikely to get the flu (2019–20, 2022–23, 2023–24); it costs too much to get the flu vaccination (2022–23, 2023–24); it was too hard to find a time or place to get the flu vaccination (2022–23, 2023–24). The respondent reported “yes” or “no” whether each reason was a reason of theirs for not having their child vaccinated. Children whose parent indicated they did not know about a particular reason or refused to answer were grouped with children whose parent answered “no” for that reason.

Information on child, maternal, and household sociodemographic characteristics was also collected during the interviews. The following sociodemographic variables were included in this study: child’s age at time of interview, child’s sex, child’s race and ethnicity, mother’s education level, household income/poverty level, number of children in the household, Metropolitan Statistical Area (MSA) status (urban, suburban, rural), respondent relation to the child, and influenza vaccination coverage in the child’s state of residence (<50%, 50% to <60%, ≥60%). The income/poverty level variable was defined based on total family income in the past calendar year and the U.S. Census poverty thresholds for that year specified for the applicable family size and number of children <18 years.

The proportion of children with a parent reporting each reason for not having their child get an influenza vaccination was calculated overall, by state, and by sociodemographic characteristics. Tests of association between sociodemographic characteristics and across seasons were conducted for each reason for non-vaccination using t-tests with significance set at p<0.05. Comparisons reported as being higher or lower were statistically significant, while comparisons that were not statistically significant are reported as not being different. Reported percentages of children and corresponding 95% confidence intervals (95% CI) are weighted, while reported sample sizes are unweighted. The unweighted sample sizes for each sociodemographic subgroup for the 2023–2024 season are included in Table 1. In addition. a sub-analysis was conducted to assess trends in the reporting of each reason among all children, regardless of influenza vaccination status (i.e., vaccinated children were included in the denominator, and for each reason we assessed the proportions of children who were vaccinated, were unvaccinated and their parent reported a particular reason, and were unvaccinated and their parent did not report that reason). The NCHS reliability criteria for proportions was implemented [13]. NIS-Flu survey weights were used to weight to population totals and adjust for non-response and households without cellular telephones. Analyses were conducted using SUDAAN release 11.0.4 (Research Triangle Institute, Research Triangle Park, NC) statistical software to account for the complex survey design. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.

Table 1.

Percentage of children 6 months–17 years who did not receive an influenza vaccination and parental reasons for non-vaccination, by selected demographic characteristics, United States, National Immunization Survey-Influenza (NIS-Flu), April–June interviews, 2023–24 influenza season

Characteristics Number unvaccinated Percent among unvaccinated Percent unvaccinated among all children Reasons for non-vaccination* Percent among unvaccinated
Unlikely to get very sick from flu Concerned about side effects/ safety Flu vaccines do not work very well Do not like needles/ shots Unlikely to get the flu Costs too much Hard to find time or place
Unweighted n % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI)
Overall 15902 100.0 (± 0.0) 43.4 (± 0.8) 48.2 (± 1.3) 43.3 (± 1.3) 37.0 (± 1.2) 25.1 (± 1.1) 30.4 (± 1.2) 3.2 (± 0.4) 12.6 (± 0.9)
Child’s age
 6–23 months 1977 7.0 (± 0.6) 36.2 (± 2.4) 37.9 (± 3.9)† 56.2 (± 4.1)† 42.4 (± 4.0)† 20.9 (± 3.7) 30.3 (± 3.8) 3.1 (± 1.6) 11.9 (± 3.1)
 2–4 years 2080 11.0 (± 0.8) 36.0 (± 2.1) 47.5 (± 3.6) 49.6 (± 3.6)† 38.3 (± 3.5) 24.3 (± 3.1) 30.0 (± 3.3) 2.8 (± 1.1) 12.7 (± 2.4)
 5–12 years 6217 44.6 (± 1.2) 41.4 (± 1.2) 47.0 (± 1.9)† 43.8 (± 1.9)† 36.7 (± 1.9) 27.1 (± 1.7)† 29.0 (± 1.7)† 3.1 (± 0.6) 12.7 (± 1.3)
 13–17 years (Referent) 5628 37.5 (± 1.2) 51.6 (± 1.5) 51.6 (± 2.1) 38.5 (± 2.0) 36.0 (± 2.0) 23.6 (± 1.7) 32.2 (± 1.9) 3.4 (± 0.8) 12.5 (± 1.4)
Child’s sex
 Male 8290 51.5 (± 1.2) 43.8 (± 1.2) 48.3 (± 1.8) 41.7 (± 1.7)† 36.8 (± 1.7) 24.0 (± 1.5) 30.7 (± 1.6) 3.6 (± 0.7)† 12.6 (± 1.2)
 Female (Referent) 7612 48.5 (± 1.2) 43.0 (± 1.2) 48.0 (± 1.8) 45.1 (± 1.8) 37.3 (± 1.8) 26.1 (± 1.6) 30.1 (± 1.7) 2.7 (± 0.5) 12.5 (± 1.2)
Child’s race/ethnicity‡
 White, non-Hispanic (Referent) 8912 52.5 (± 1.3) 46.3 (± 1.2) 51.8 (± 1.7) 39.9 (± 1.7) 40.8 (± 1.7) 22.4 (± 1.4) 28.0 (± 1.5) 1.6 (± 0.4) 11.2 (± 1.1)
 Black, non-Hispanic 1497 14.8 (± 1.0) 46.5 (± 2.5) 38.9 (± 3.6)† 51.9 (± 3.7)† 32.3 (± 3.4)† 29.4 (± 3.4)† 33.3 (± 3.4)† 3.1 (± 1.2)† 9.9 (± 2.2)
 Hispanic 3578 22.9 (± 1.1) 38.5 (± 1.7) 46.8 (± 2.8)† 44.1 (± 2.8)† 31.9 (± 2.6)† 27.9 (± 2.5)† 35.4 (± 2.7)† 6.5 (± 1.3)† 15.8 (± 2.0)†
 Other, non-Hispanic 1915 9.9 (± 0.8) 38.4 (± 2.4) 45.6 (± 3.9)† 47.0 (± 4.0)† 36.2 (± 3.8)† 26.2 (± 3.5) 27.2 (± 3.4) 3.4 (± 1.5)† 16.4 (± 3.1)†
Mother’s education
 <High school 1057 7.4 (± 0.7) 36.6 (± 2.9) 47.2 (± 4.8) 44.2 (± 4.7)† 34.1 (± 4.4) 34.1 (± 4.5)† 36.0 (± 4.6)† 12.1 (± 3.2)† 18.2 (± 3.9)
 High school or equivalent 3317 21.7 (± 1.1) 51.3 (± 2.0) 46.6 (± 2.8) 47.9 (± 2.8)† 36.6 (± 2.7) 30.0 (± 2.6)† 34.3 (± 2.7)† 4.0 (± 1.1)† 11.4 (± 1.8)†
 Some college 4403 28.5 (± 1.2) 53.9 (± 1.8) 47.4 (± 2.5) 46.2 (± 2.5)† 39.7 (± 2.4)† 23.8 (± 2.1) 30.2 (± 2.3)† 1.9 (± 0.6) 8.8 (± 1.4)†
 ≥College degree (Referent) 6171 42.4 (± 1.3) 36.6 (± 1.2) 49.4 (± 2.1) 37.5 (± 2.0) 35.3 (± 2.0) 21.6 (± 1.7) 27.1 (± 1.8) 1.7 (± 0.5) 15.4 (± 1.5)
Poverty/annual household income§
 Above poverty (>$75,000) 7503 47.1 (± 1.3) 40.4 (± 1.2) 51.3 (± 1.9)† 38.3 (± 1.8)† 37.3 (± 1.8) 20.9 (± 1.5)† 26.9 (± 1.7)† 1.3 (± 0.4)† 13.1 (± 1.3)
 Above poverty (≤$75,000) 4225 26.2 (± 1.1) 50.7 (± 1.8) 45.1 (± 2.5) 44.5 (± 2.5)† 35.7 (± 2.4) 27.5 (± 2.2)† 32.7 (± 2.4) 2.9 (± 0.7)† 10.7 (± 1.5)†
 Below poverty (Referent) 2133 13.6 (± 0.9) 41.2 (± 2.3) 42.8 (± 3.4) 53.3 (± 3.4) 38.7 (± 3.4) 35.6 (± 3.4) 35.8 (± 3.2) 8.8 (± 2.1) 15.1 (± 2.6)
 Unknown 2041 13.1 (± 0.9) 45.1 (± 2.4) 48.5 (± 3.6)† 48.9 (± 3.6) 37.1 (± 3.5) 24.1 (± 3.1)† 32.7 (± 3.4) 4.4 (± 1.3)† 11.6 (± 2.4)†
Number of children in household
 1 (Referent) 5466 30.2 (± 1.2) 42.8 (± 1.4) 47.9 (± 2.2) 41.9 (± 2.2) 33.2 (± 2.1) 26.3 (± 2.0) 32.4 (± 2.1) 4.2 (± 0.9) 13.0 (± 1.6)
 2–3 8657 57.6 (± 1.3) 42.0 (± 1.1) 47.7 (± 1.7) 42.6 (± 1.7) 36.9 (± 1.7)† 24.7 (± 1.5) 29.5 (± 1.6)† 2.5 (± 0.5)† 13.0 (± 1.2)
 ≥4 1706 12.1 (± 0.9) 54.4 (± 2.9) 51.2 (± 4.0) 50.1 (± 4.0)† 47.2 (± 4.0)† 23.7 (± 3.4) 29.9 (± 3.6) 3.6 (± 1.7) 9.7 (± 2.4)†
Urban-rural residence
 Urban (MSA,|| principle city) 4605 28.7 (± 1.2) 38.4 (± 1.5) 46.1 (± 2.5)† 44.6 (± 2.5) 33.9 (± 2.3)† 26.9 (± 2.2) 32.8 (± 2.3) 4.0 (± 0.9) 13.2 (± 1.6)
 Suburban (MSA, not principle city) 7772 55.3 (± 1.3) 43.4 (± 1.1) 48.7 (± 1.8) 42.0 (± 1.7)† 38.0 (± 1.7) 24.3 (± 1.5) 29.1 (± 1.6) 2.8 (± 0.6) 12.4 (± 1.2)
 Rural (non-MSA) (Referent) 3525 16.0 (± 0.9) 57.2 (± 2.2) 50.1 (± 2.9) 45.7 (± 2.9) 39.4 (± 2.8) 24.3 (± 2.5) 30.6 (± 2.6) 2.8 (± 0.9) 12.0 (± 2.1)
Respondent relation to child
 Mother (Referent) 9690 59.7 (± 1.3) 43.5 (± 1.1) 45.4 (± 1.7) 43.7 (± 1.7) 37.6 (± 1.6) 26.3 (± 1.5) 27.9 (± 1.5) 2.9 (± 0.5) 13.7 (± 1.2)
 Father 4612 30.2 (± 1.2) 42.4 (± 1.5) 55.6 (± 2.3)† 41.5 (± 2.3) 38.5 (± 2.3) 21.7 (± 1.9)† 34.4 (± 2.2)† 2.9 (± 0.9) 10.7 (± 1.5)†
 Other 1600 10.0 (± 0.8) 46.3 (± 2.7) 42.1 (± 4.0) 46.5 (± 4.0) 29.4 (± 3.5)† 27.8 (± 3.7) 33.5 (± 3.8)† 5.2 (± 1.8)† 11.4 (± 2.6)
State of residence influenza vaccination coverage
 <50% coverage 5736 28.3 (± 1.1) 53.7 (± 1.7) 47.9 (± 2.3) 43.3 (± 2.3) 38.9 (± 2.3)† 24.2 (± 2.0) 31.0 (± 2.1) 3.2 (± 0.9) 11.9 (± 1.6)
 50% to <60% coverage 6767 47.7 (± 1.2) 44.5 (± 1.2) 48.9 (± 1.8) 43.0 (± 1.8) 37.6 (± 1.7)† 24.8 (± 1.5) 30.2 (± 1.6) 3.3 (± 0.6) 12.4 (± 1.2)
 ≥60% coverage (Referent) 3399 23.9 (± 1.2) 34.0 (± 1.6) 46.9 (± 3.0) 44.0 (± 3.0) 33.7 (± 2.8) 26.6 (± 2.7) 30.2 (± 2.7) 2.8 (± 0.9) 13.6 (± 2.1)
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Abbreviations: CI = confidence interval half-width; MSA = metropolitan statistical area.

*

Respondents could indicate more than one reason for non-vaccination against influenza; therefore, reasons were not mutually exclusive.

†

Estimate was statistically significantly different at p<0.05 from the referent group.

‡

Race and ethnicity were reported by parent/guardian respondent. Children of Hispanic ethnicity may be of any race. Children identified as multiple races had more than one race category selected. Other race included Asian, American Indian/Alaska Native, and Native Hawaiian/other Pacific Islander.

§

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

||

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

Results

The number of children with a parent who reported their child had not received an influenza vaccination and were included in the study ranged from 11,955 to 16,509 across the five influenza seasons during the 2015–2024 study period (Figure). The characteristics and percent of children unvaccinated against influenza for the 2023–24 influenza season are presented in Table 1. Overall, in the 2023–24 season, 44.3% of children were reported to have not received an influenza vaccination.

Figure.

Figure.

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Percentage of unvaccinated children 16 months–17 years who had a parent reporting each reason for non-vaccinationn against influenza, by influenza season, United States, National Immunization Survey-Flu (NIS-Flu), 2015–2024

* Statistically significant difference at p<0.05 compared with 2023–24.

Throughout the study, among unvaccinated children, the most common reasons parents reported for not having their child receive an influenza vaccination were: 1) belief that their child is unlikely to get very sick from the flu, 2) concern about possible side effects/safety of flu vaccination, and 3) belief that flu vaccines do not work very well (48.2%, 43.3%, and 37.0%, respectively, in the 2023–24 season) (Figure). Parents also frequently reported believing that their child is unlikely to get the flu and that they or their child doesn’t like needles/shots (30.4% and 25.1%, respectively, in 2023–24). Less commonly reported was difficulty finding a time/place to get flu vaccination, and that flu vaccination costs too much (12.6%, and 3.2%, respectively, in the 2023–24 season). Reasons also reported less frequently, and only asked about in the earlier seasons, were 1) usual place where child gets flu vaccination did not give flu vaccination this season, and 2) wanted flu spray for child but it was not available.

Parental reported reasons for their child not receiving an influenza vaccination were similar in the 2022–23 and 2023–24 seasons (Figure). However, differences were observed when comparing reasons in the 2023–24 season with the 2019–20 and earlier seasons (pre COVID-19 pandemic). From the 2019–20 season to the 2023–24 season, there was a decrease in concern about side effects/safety (45.3% to 43.3%) and belief that flu vaccines do not work very well (41.3% to 37.0%) as reported reasons for non-vaccination among unvaccinated children; whereas there was an increase in belief that their child is unlikely to get very sick from the flu (40.2% to 48.2%) and belief that their child is unlikely to get the flu (27.4% to 30.4%) (Figure). However, among all children, including those who were vaccinated, there were increases in the proportions of children who were unvaccinated with parents reporting concern about side effects/safety, belief that flu vaccines do not work very well, belief that their child is unlikely to get very sick from the flu, and belief that their child is unlikely to get the flu (Supplemental figure).

During the 2023–24 influenza season, among unvaccinated children, parental reasons for not having their child receive an influenza vaccination varied by sociodemographic characteristics (Table 1). Older children (13–17 years: 51.6%) were more likely to have a parent report that their child is unlikely to get very sick from the flu as a reason for non-vaccination than younger children (37.9%–47.0%), while younger children (43.8%–56.2%) were more likely to have a parent report concern about side effects/safety of the vaccine than older children (13–17 years: 38.5%). Non-Hispanic White (White) children (51.8%) were more likely to have a parent report that their child is unlikely to get very sick from the flu than children of other races and ethnicities (38.9%–46.8%), while Black (51.9%), Hispanic (44.1%), and children of other or multiple races (47.0%) were more likely to have a parent report concern about side effects/safety of the vaccine than White children (39.9%). White children (40.8%) were also more likely to have a parent report belief that flu vaccines do not work very well as a reason than Black children (32.3%), Hispanic children (31.9%), and non-Hispanic children of other or multiple races (36.2%). Other differences by sociodemographic characteristics are shown in Table 1.

During the 2023–24 influenza season, among unvaccinated children, parental reasons for not having their child receive an influenza vaccination also varied by state (Table 2). The percentage reporting their child is unlikely to get very sick from the flu ranged from 26.6% in Washington D.C. to 63.2% in Montana. The percentage reporting concern about side effects/safety of flu vaccination ranged from 24.8% in Nebraska to 51.4% in Massachusetts. The percentage reporting belief that flu vaccines do not work very well ranged from 17.8% in Washington D.C. to 50.4% in Alabama. All estimates by state for the 2023–24 influenza season are presented in Table 2.

Table 2.

Percentage of children 6 months–17 years who did not receive an influenza vaccination and parental reasons for non-vaccination, by state of residence, United States, National Immunization Survey-Influenza (NIS-Flu), April–June interviews, 2023–24 influenza season

State of residence Number unvaccinated Percent unvaccinated among all children Reasons for non-vaccination* Percent among unvaccinated
Unlikely to get very sick from flu Concerned about side effects/safety Flu vaccines do not work very well Do not like needles/shots Unlikely to get the flu Costs too much Hard to find time or place
Unweighted n % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI) % (± 95% CI)
United States 15,902 43.4 (± 0.8) 48.2 (± 1.3) 43.3 (± 1.3) 37.0 (± 1.2) 25.1 (± 1.1) 30.4 (± 1.2) 3.2 (± 0.4) 12.6 (± 0.9)
Alabama 444 55.8 (± 4.7) 46.1 (± 6.6) 48.8 (± 6.3) 50.4 (± 6.7) 21.2 (± 5.7) 30.9 (± 5.8) 1.7 (± 1.4) 8.0 (± 3.8)
Alaska 159 53.6 (± 9.8) 55.6 (±13.2) 37.0 (±12.6) 38.7 (±13.4) 19.4 (± 9.0) 23.1 (± 8.8) 1.0 (± 1.1) —†
Arizona 318 48.4 (± 6.1) 55.1 (± 8.8) 40.2 (± 8.8) 37.2 (± 9.0) 25.0 (± 7.2) 32.5 (± 8.3) —† 15.2 (± 6.7)
Arkansas 315 46.1 (± 5.5) 45.6 (± 7.5) 47.9 (± 7.9) 41.2 (± 7.8) 30.9 (± 7.5) 34.6 (± 7.5) —† 12.8 (± 5.6)
California 439 36.4 (± 3.4) 46.3 (± 5.9) 43.6 (± 5.9) 33.7 (± 5.6) 28.9 (± 5.4) 29.7 (± 5.4) 3.0 (± 1.9) 14.9 (± 4.3)
Colorado 302 40.3 (± 4.3) 49.9 (± 6.8) 42.9 (± 6.7) 36.0 (± 6.5) 22.2 (± 5.6) 30.0 (± 6.4) —† 15.5 (± 4.9)
Connecticut 129 24.2 (± 5.1) 49.9 (±11.3) 40.2 (±11.5) 38.4 (±10.9) 23.3 (± 9.9) 29.2 (±10.6) —† 16.8 (± 9.7)
Delaware 196 35.4 (± 6.0) 48.6 (±10.0) 38.4 (± 9.5) 28.8 (± 9.3) 34.2 (±10.0) 27.3 (± 8.2) 1.0 (± 1.0) 6.8 (± 3.6)
District of Columbia 206 31.6 (± 8.0) 26.6 (±10.9) —† 17.8 (± 8.5) 16.9 (± 7.5) —† 1.1 (± 1.0) 9.5 (± 4.7)
Florida 454 56.8 (± 4.3) 47.7 (± 5.7) 42.5 (± 5.6) 36.5 (± 5.6) 24.7 (± 5.0) 34.0 (± 5.4) —† 12.3 (± 3.9)
Georgia 308 50.1 (± 5.1) 44.0 (± 7.0) 44.3 (± 7.1) 36.9 (± 7.0) 24.9 (± 6.1) 29.5 (± 6.6) —† 13.7 (± 5.1)
Hawaii 251 35.5 (± 5.5) 54.9 (± 9.1) 47.8 (± 9.3) 39.5 (± 9.2) 22.1 (± 6.8) 19.7 (± 6.4) 1.6 (± 1.6) 13.1 (± 5.7)
Idaho 222 57.2 (± 7.7) 52.7 (± 9.8) 35.0 (± 9.2) 35.7 (± 9.5) 28.4 (± 9.5) 24.9 (± 8.7) —† 15.4 (± 8.4)
Illinois 530 43.7 (± 3.9) 52.6 (± 6.0) 49.1 (± 6.1) 37.0 (± 6.0) 23.9 (± 5.2) 36.5 (± 6.0) 3.1 (± 2.1) 13.8 (± 4.1)
Indiana 332 51.5 (± 5.2) 49.1 (± 7.5) 47.7 (± 7.6) 41.2 (± 7.5) 25.1 (± 6.1) 27.6 (± 6.4) —† 10.2 (± 4.5)
Iowa 212 43.0 (± 6.2) 47.5 (± 9.8) 36.1 (± 8.7) 36.2 (± 9.2) 22.8 (± 8.0) 23.0 (± 7.9) —† 12.2 (± 6.9)
Kansas 341 52.8 (± 5.7) 48.5 (± 8.3) 34.5 (± 8.4) 35.9 (± 7.7) 23.2 (± 6.6) 23.4 (± 6.4) 2.5 (± 1.7) 16.3 (± 5.3)
Kentucky 438 49.1 (± 4.9) 44.9 (± 7.0) 45.3 (± 7.0) 37.3 (± 7.0) 26.7 (± 6.3) 26.4 (± 6.5) 2.1 (± 1.6) 16.7 (± 4.7)
Louisiana 428 51.4 (± 5.0) 43.8 (± 6.5) 40.6 (± 6.5) 32.3 (± 5.9) 24.3 (± 5.8) 31.4 (± 6.2) —† 10.7 (± 4.1)
Maine 231 42.7 (± 5.9) 43.1 (± 9.3) 46.1 (± 9.7) 42.7 (± 9.6) 23.8 (± 7.6) 21.3 (± 7.1) 1.0 (± 1.1) —†
Maryland 285 33.6 (± 4.7) 42.5 (± 8.4) 44.3 (± 8.8) 33.5 (± 8.7) 20.2 (± 6.7) 26.0 (± 7.2) —† 10.2 (± 4.3)
Massachusetts 148 22.2 (± 3.7) 48.1 (± 9.2) 51.4 (± 9.4) 39.0 (± 9.3) 28.5 (± 8.7) 25.2 (± 8.0) —† 15.5 (± 6.8)
Michigan 271 51.5 (± 5.6) 46.1 (± 8.0) 45.0 (± 7.9) 38.9 (± 7.7) 17.1 (± 6.3) 23.8 (± 6.6) 1.6 (± 1.9) 13.7 (± 5.8)
Minnesota 227 35.8 (± 4.9) 59.3 (± 8.1) 50.7 (± 8.4) 44.6 (± 8.3) 23.7 (± 7.3) 26.0 (± 7.0) 1.8 (± 1.7) 10.6 (± 4.4)
Mississippi 336 58.1 (± 7.0) 45.5 (± 8.2) 45.9 (± 8.1) 48.5 (± 8.2) 24.7 (± 6.8) 36.4 (± 8.1) —† 14.6 (± 7.0)
Missouri 240 45.8 (± 5.3) 50.7 (± 8.1) 47.9 (± 8.0) 41.9 (± 7.9) 21.0 (± 6.2) 28.3 (± 7.1) —† 11.8 (± 5.1)
Montana 328 56.8 (± 6.0) 63.2 (± 7.4) 43.1 (± 8.4) 45.8 (± 8.3) 25.6 (± 7.6) 34.9 (± 8.5) 2.2 (± 2.0) 8.1 (± 3.6)
Nebraska 176 48.8 (± 7.2) 59.3 (±10.1) 24.8 (± 8.3) 35.6 (± 9.8) 21.6 (± 8.3) 31.9 (±10.2) 1.1 (± 1.0) 15.0 (± 6.8)
Nevada 288 51.7 (± 7.5) 57.1 (±10.0) 44.9 (± 9.7) 39.0 (±10.3) 31.3 (±11.2) 40.3 (± 9.7) —† —†
New Hampshire 208 37.3 (± 5.9) 53.2 (± 9.6) 42.0 (± 9.4) 39.4 (± 9.8) 25.5 (± 9.5) 26.2 (± 9.3) —† 9.5 (± 4.7)
New Jersey 225 27.3 (± 4.3) 53.9 (± 9.2) 46.0 (± 9.1) 38.9 (± 9.1) 22.6 (± 7.9) 37.7 (± 9.1) 1.8 (± 1.6) 12.3 (± 6.7)
New Mexico 444 44.2 (± 5.0) 38.0 (± 6.9) 33.8 (± 6.9) 26.4 (± 6.2) 28.5 (± 6.7) 26.6 (± 6.2) —† 18.0 (± 6.2)
New York 417 34.6 (± 3.6) 45.5 (± 6.3) 44.9 (± 6.5) 27.6 (± 5.8) 26.2 (± 5.7) 31.2 (± 6.0) 1.8 (± 1.1) 13.8 (± 4.5)
North Carolina 323 41.8 (± 4.5) 46.1 (± 7.0) 49.6 (± 7.0) 42.4 (± 7.0) 26.3 (± 6.2) 37.4 (± 6.7) 1.6 (± 1.8) 9.1 (± 4.2)
North Dakota 239 43.5 (± 7.2) 58.6 (± 9.2) 46.9 (± 9.6) 47.7 (± 9.4) 18.1 (± 7.5) 32.1 (± 9.1) 0.4 (± 0.5) 10.6 (± 5.6)
Ohio 303 42.9 (± 4.9) 51.0 (± 7.4) 43.6 (± 7.3) 40.3 (± 7.3) 28.0 (± 6.8) 21.9 (± 5.9) 1.6 (± 1.5) 11.9 (± 5.3)
Oklahoma 361 54.2 (± 5.0) 44.1 (± 6.8) 40.2 (± 7.0) 33.5 (± 6.5) 28.9 (± 6.4) 32.8 (± 6.5) 2.0 (± 1.7) 13.0 (± 4.8)
Oregon 269 45.6 (± 5.4) 58.8 (± 7.8) 45.4 (± 8.0) 38.4 (± 7.7) 23.4 (± 6.2) 34.8 (± 7.5) —† 13.9 (± 6.1)
Pennsylvania 487 38.9 (± 3.5) 45.4 (± 5.8) 44.8 (± 5.8) 40.0 (± 5.7) 22.7 (± 4.7) 24.6 (± 4.9) 1.9 (± 1.5) 12.1 (± 3.8)
Rhode Island 109 29.7 (± 7.6) —† —† —† 21.1 (±12.7) 33.5 (±14.1) 0.5 (± 1.0) —†
South Carolina 420 51.8 (± 4.8) 50.1 (± 6.6) 40.7 (± 6.5) 35.8 (± 6.4) 24.6 (± 5.5) 32.4 (± 6.0) 2.5 (± 2.1) 9.7 (± 3.8)
South Dakota 198 41.5 (± 7.6) 51.5 (±11.3) 42.0 (±11.6) 44.7 (±11.2) 24.6 (± 9.6) 37.7 (±11.3) —† —†
Tennessee 245 49.1 (± 6.0) 45.2 (± 8.3) 46.0 (± 8.5) 41.7 (± 8.4) 22.7 (± 6.7) 30.1 (± 7.3) —† 13.0 (± 6.2)
Texas 1,197 47.6 (± 2.8) 46.8 (± 4.1) 40.9 (± 4.0) 34.9 (± 3.8) 25.3 (± 3.5) 32.4 (± 3.8) 4.5 (± 1.6) 10.8 (± 2.3)
Utah 181 42.5 (± 5.9) 54.8 (± 9.1) 31.8 (± 8.3) 42.2 (± 9.0) 27.4 (± 8.0) 34.7 (± 8.4) —† 16.5 (± 7.1)
Vermont 138 44.5 (± 9.6) —† 29.5 (±13.4) —† —† 27.6 (±13.9) 0.2 (± 0.4) —†
Virginia 346 37.0 (± 3.9) 44.9 (± 6.6) 42.2 (± 6.6) 35.8 (± 6.5) 28.9 (± 6.1) 32.7 (± 6.3) 3.6 (± 2.3) 10.2 (± 3.8)
Washington 287 39.6 (± 4.9) 46.2 (± 8.1) 36.0 (± 7.4) 33.3 (± 7.3) 23.1 (± 6.6) 22.6 (± 6.9) 1.4 (± 1.6) 13.5 (± 5.4)
West Virginia 375 52.9 (± 5.1) 41.1 (± 7.3) 45.4 (± 7.5) 42.0 (± 7.4) 26.8 (± 6.8) 28.2 (± 6.8) 2.5 (± 1.9) 9.7 (± 3.9)
Wisconsin 153 38.9 (± 6.6) 57.6 (±10.8) 39.5 (±10.6) 29.4 (± 9.3) 25.9 (±10.0) 31.8 (±10.2) —† —†
Wyoming 423 64.1 (± 6.7) 51.3 (± 8.6) 43.2 (± 8.8) 40.6 (± 8.2) 20.3 (± 6.4) 25.9 (± 8.1) 0.7 (± 0.6) 7.4 (± 3.3)
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Abbreviations: CI = confidence interval half-width.

*

Respondents could indicate more than one reason for non-vaccination against influenza; therefore, reasons were not mutually exclusive.

†

Does not meet NCHS reliability criteria (https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf).

Discussion

We found that, across all seasons studied, the most common reasons parents indicated for not having their child receive an influenza vaccination were belief that their child is not at risk to get very sick from influenza, concern about side effects or safety of influenza vaccination, and belief that influenza vaccines are not very effective; these reasons were reported by nearly 40–50% of parents of unvaccinated children during the 2023–24 influenza season, while only 3% reported the cost of vaccination as a barrier to vaccination and 13% reported difficulty in finding a time or place for vaccination. This is the first study, to our knowledge, that uses a national sample to assess current reasons why parents do not have their child vaccinated against influenza, as well as to compare reasons for non-vaccination reported pre and post COVID-19 pandemic. Prior to this study, findings from the 2011–12 National Flu Survey on parental reasons for not having their child receive an influenza vaccination were similar to our study findings, with believing their child was unlikely to get very sick from the flu (42%) and concern about side effects from vaccination (35%) being among the most common reasons [14]. Also similar are parental reasons for not having their child vaccinated against COVID-19, with the top 3 reasons for non-vaccination of children with the 2023–24 COVID-19 vaccine being concern about side effects or safety of the vaccine, belief that COVID is not a serious disease for their child, and not believing the vaccines work well [15]. In addition, access-related reasons, such as cost or difficulty finding time or a place, were reported less frequently by parents in other studies as well [14, 15]. Being aware of the reasons for non-vaccination against influenza identified in this study may help pediatric vaccination providers and programs to inform interventions and conversations to help improve influenza vaccination uptake among children.

As noted previously, influenza vaccination coverage among children decreased significantly during the COVID-19 pandemic and continues to decline, with coverage getting further away from the Healthy People 2030 target [5, 6]. Although the top parental reasons for non-vaccination against influenza have continued to be the same during our period of analysis, as influenza vaccination coverage among children has decreased there has been an increase in the percentage of parents of unvaccinated children who believe their child is not at risk of getting influenza or getting very sick from influenza, whereas the percentages of parents of unvaccinated children reporting concerns about side effects or safety and doubts about the effectiveness of influenza vaccines have decreased. The changes in reasons observed over time demonstrate the need to continue to monitor parental reasons for non-vaccination, and that as changes in influenza vaccination coverage occur there may also be changes in the reasons for non-vaccination among the unvaccinated. A separate report from the 2022–23 influenza season focusing on vaccine hesitancy found that nearly one-third of children had a parent report being hesitant about influenza vaccine; the authors noted that influenza-specific vaccine hesitancy did not increase from 2020 to 2023, although influenza vaccination coverage declined during this time period [8]. Results of the current study suggest that lack of concern about influenza disease might have been a larger contributor to the decrease in vaccination coverage than hesitancy about the vaccine.

The increase in parents having a low perceived risk regarding the severity of influenza that was observed in this study could be related to unusually low influenza activity during the COVID-19 pandemic. CDC’s Influenza Hospitalization Surveillance Network (FluSurv-NET) reported an overall cumulative hospitalization rate of only 0.8 per 100,000 population for the 2020–2021 season, compared with 66.2 per 100,000 population for the previous season; the rate increased but remained significantly lower for the 2021–22 season (17.5 per 100,000 population) [16]. In addition, only 1 pediatric death was reported to CDC during the 2020–21 season; more pediatric deaths were reported during the 2021–22 season (49 deaths), but still significantly fewer than during the 8 seasons prior to the COVID-19 pandemic (95–199 deaths) [17]. This notable decrease in influenza virus activity during the COVID-19 pandemic was likely due to public health measures used to control the spread of COVID-19, such as mask-wearing, social distancing, school closures, increased teleworking, and reduced travel, which also prevented the spread of influenza. Hospitalizations and deaths due to influenza have since increased to pre-COVID-19 pandemic levels [16, 17], but the temporary lower influenza circulation may have weakened parental perceptions of influenza severity and the need for vaccination, and influenced their reasoning for non-vaccination in the post-COVID-19 pandemic period.

A provider recommendation for influenza vaccination is known to be a strong predictor of influenza vaccination among children as well as other populations [18–20]. The American Academy of Pediatrics (AAP) encourages providers to strongly recommend influenza vaccination for their eligible patients [21, 22]. CDC offers guidance to assist healthcare providers in how to give a strong recommendation for influenza vaccination and provide important information to help their patients make informed decisions about vaccinations, such as sharing specific reasons why recommended vaccines are right for the patient [23]. With the decreasing concern among parents about influenza, it may be especially important to share with parents the risk of hospitalization and death for children from influenza and the protection that vaccination provides from serious complications, particularly for parents of children younger than 5 years, those with certain underlying medical conditions, and those in certain race and ethnicity groups such as Black and Hispanic children [24]. However, prior research has shown that communications that emphasize the dangers of vaccine-preventable diseases may not be effective, particularly among those with negative attitudes about vaccines, and can sometimes increase misperceptions and reduce vaccination intention among certain groups of hesitant parents. Therefore, tailoring vaccine communications about vaccination to align with parents’ preexisting beliefs and levels of hesitancy is critical [25]. CDC and AAP recommend strategies that providers can use to effectively communicate with parents about getting their children vaccinated, including use of a presumptive approach which is associated with increased vaccine uptake in children, even among parents with negative vaccine attitudes [26–28]. Addressing parent questions and concerns about influenza vaccines, including those related to side effects and safety, and vaccine effectiveness, is also important and a key piece of a strong provider recommendation; discussing these topics may be especially relevant since they are top reasons parents are not getting their child an influenza vaccination.

The findings of this study are subject to several limitations. First, the NIS-Flu excludes households with no telephones or with only landline telephones, and weighting adjustments may not eliminate all possible bias from an incomplete sample frame. Second, response rates were low, and influenza vaccination coverage may differ between the children of survey respondents and non-respondents; survey weighting adjustments may not adequately control these differences. Third, influenza vaccination status of the child was based on parental report and subject to respondent recall bias; studies have shown that parent report of influenza vaccination has been higher than provider report [29–31]. Fourth, the question about reasons for non-vaccination against influenza were only asked during April–June, months after the peak influenza vaccination period and after a decision about vaccinating their child might have occurred. Fifth, there could have been other important reasons for non-vaccination that were not assessed in the survey.

Conclusions

The results of this study highlight a decrease in concern about influenza since the COVID-19 pandemic and identify groups of children who might be at higher risk for not getting vaccinated against influenza because parents do not think they will get very sick from influenza, such as older children and White children. A strong provider recommendation for influenza vaccination, including information about the safety of the vaccine and seriousness of influenza, might help increase vaccination coverage among children.

Supplementary Material

1

Funding:

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

Abbreviations:

ACIP

Advisory Committee on Immunization Practices

NIS-Flu

National Immunization Survey-Flu

NIS-Child

National Immunization Survey-Child

NIS-Teen

National Immunization Survey-Teen

CASRO

Council of American Survey and Research Organizations

CI

Confidence Interval

MSA

Metropolitan Statistical Area

AAP

American Academy of Pediatrics

Footnotes

Disclosure

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

Declarations of interest: none

All authors attest they meet the ICMJE criteria for authorship.

References

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS2141508-supplement-1.pdf (118.9KB, pdf)

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