Since 2010, the Advisory Committee for Immunization Practices has recommended influenza vaccination for all people ≥6 months of age [1]. Yet, during the 2014–15 influenza season, only 43.6% of adults and 59.3% of children were vaccinated [2]. These rates remain below the national Healthy People 2020 target of 70% influenza vaccination coverage for adults and children [3]. Furthermore, racial/ethnic differences in influenza vaccination coverage have been persistent, with coverage being even lower for some racial/ethnic groups [4,5].

Many evidence-based strategies have been promoted for increasing influenza vaccination coverage, including but not limited to standing orders, provider reminders and recommendations, expanding access to vaccination services by reducing cost, and having vaccinations available at schools and pharmacies and other non-medical sites [6,7]. These strategies do not take into account specific patient attitudes; however, these strategies have been shown to work regardless of patient attitude [8]. Yet attitudes play a role in accepting vaccination as evidenced by a study of pregnant women which found the percentage vaccinated among women recommended and offered vaccine by their physician was 77.2% for those with a positive attitude about vaccine efficacy compared with 15.4% for those with a negative attitude; the percentages vaccinated were 79.2% for those with a positive and 26.1% for those with a negative attitude about vaccine safety [9]. An exploration of reasons for non-vaccination, by quantifying the most common reasons given for non-vaccination, could be useful to healthcare providers and immunization programs so that they are better prepared to address the concerns of patients. This could aid efforts to increase vaccination rates and decrease disparities in influenza vaccination. The objective of this study was to examine the reasons given for not receiving an influenza vaccination for adults and for children overall and by racial/ethnic group.

Table 1 shows the sample characteristics of the unvaccinated adults included in this study with regard to age, race/ethnicity, sex, poverty status, education, and MSA. Approximately one-fifth of respondents (17.2%) had only one reason for non-vaccination, with many respondents choosing two to four reasons for non-vaccination (Table 1).

The overall percentages of unvaccinated adults indicating each reason for not receiving an influenza vaccination during the 2011–12 season are included in Fig. 1. The most common were: “unlikely to get very sick from the flu” (52.3%); “never get the flu” (41.8%); “not in a high risk or priority group” (34.9%); and “concerned about side effects from the vaccination other than getting the flu from the vaccine” (30.9%). Seven of the reasons for non-vaccination differed by racial/ethnic group based upon the bivariate analyses; two are highlighted here (Table 2). Blacks (40.9%) were more likely than Hispanics (27.0%), whites (25.2%), and other/multiple race adults (21.2%) to report concerns about getting the flu from the vaccination. Blacks (39.8%) were more likely than whites (28.4%) and other/multiple race adults (29.3%) to report concerns about side effects from the vaccine. Additional differences are noted in Table 2.

The overall percentage of unvaccinated children whose parents indicated reasons for not getting their child the influenza vaccine are included in Fig. 1. The most common were: “unlikely to get very sick from the flu” (42.3%); “not in a high risk or priority group” (35.8%); “concerned about side effects from the vaccination other than getting the flu from the vaccine” (34.7%); and “never get the flu” (34.3%). Among parents, more blacks (44.4%) than whites (24.0%) and parents of other/multiple race children (19.0%) had concerns about their child getting the flu from the vaccination (Table 2). More Hispanics (16.9%) than whites (2.6%) and parents of other/multiple race children (1.1%) reported the child having an ongoing health condition as the reason for non-vaccination. More whites (39.4%) than blacks (22.1%) reported their child not being in a high risk group as a reason for non-vaccination. There were no other statistically significant racial/ethnic differences other than those described above (Table 2).

Based on the twelve multivariable logistic regression models for adults, many of the demographic variables were associated with reasons for non-vaccination (Table 3). Adults in the younger age groups were less likely to give the reasons of “allergic to the vaccine”, “have an ongoing health condition”, “never get the flu”, or “don’t trust government/doctors” compared to adults 65 years and older. Conversely these younger age groups were more likely than adults 65 years and older to give the reason “unlikely to get very sick from the flu”, “not in a high risk group”, and “the vaccine costs too much”. Adult females were more likely than males to give the reasons “concerns about getting the flu from the vaccination”, “concerns about side effects from the vaccine”, and “have an ongoing health condition”, but were less likely than males to give the reasons “never get the flu” and “unlikely to get very sick from the flu”. Black adults were more likely than white adults to give the reasons “concerns about getting the flu from the vaccination” and “concerns about side effects from the vaccine”, while blacks and Hispanic adults were less likely than whites to give the reason “not in a high risk group”. Adults with lower income were more likely than those in the highest income group to give the reasons: “don’t like needles shots”, “concerns about getting the flu from the vaccine”, concerns about side effects from the vaccine”, “have an ongoing health condition”, “don’t’ trust government/doctors”, and “the vaccine costs too much”. They were less likely than those in the highest income group to give the reason “not in a high risk group”. Adults living in an MSA were more likely than those in non-MSA areas to give the reason “have an ongoing health condition”.

Based on the twelve multivariable logistic regression models for parents of children, various demographic variables were associated with each reason for non-vaccination of children (Table 4). Compared to parents of children in younger age groups, parents of children in older age groups were less likely to give the reason “concern about side effects from the vaccine” and more likely to give the reasons of “never get the flu” and “unlikely to get very sick from the flu”. Compared to parents of white children, parents of Hispanic children were less likely to give the reason “don’t like needles/shots” while more likely to give the reason “have an ongoing health condition.” Parents of black children were more likely than those of white children to give the reason “concerns about getting the flu from the vaccination” but less likely to give the reasons “not in a high risk group”. Parents of children with lower income were more likely than those in the highest income group to give the reasons: “don’t like needles/shots”, “concerns about side effects from the vaccine”, “have an ongoing health condition”, and “the vaccine costs too much”. Sex and MSA were not associated with any of the reasons based on the multivariable models.

In the analyses of the subset of unvaccinated parent-child pairs, the observed proportion of agreement between the reasons parents gave for not being vaccinated themselves and for not having their child vaccinated was >75% for ten of the twelve reasons (Table 5). When examining the kappa statistic however there was fair to good agreement for only half of the reasons.

This study found that the most common reasons given for not receiving an influenza vaccination during the 2011–12 influenza season were related to not perceiving themselves or their child at risk for influenza or not being at risk for getting very ill if they do get the disease. Concerns about side effects of the influenza vaccine were generally the next most common reasons given. Some previous studies examined reasons for non-vaccination but focused only on older adults and did not test for racial/ethnic group differences. In these studies the most common reasons were related to not perceiving themselves at risk for influenza and concerns about side effects of the influenza vaccine, similar to what our study found for all adults and parents [15–17]. Health professionals should take what opportunities they have available in their interactions with patients to provide objective information about the risks of influenza, the benefits of influenza vaccination, and address concerns that parents have. One resource includes the educational patient brochures, posters, and flyers available at http://www.cdc.gov/flu/freeresources/print-general.htm

This study found some similarities and differences between the racial/ethnic groups in reported reasons for not receiving an influenza vaccination. For example, there were no racial/ethnic differences in the overall most frequently given reason for non-vaccination: “unlikely to get very sick from the flu”. Among the more striking differences was that “concerns about getting the flu from the vaccination” was much more commonly reported as a reason for non-vaccination by black adults (41%) and by parents of black children (44%) compared to the other racial/ethnic groups (30% or less). This was the most frequently reported reason for non-vaccination given by parents of black children, while for all other racial/ethnic groups “unlikely to get very sick from the flu” was the most frequently given reason. This on-going misconception appears to be more prevalent in black communities than other communities and may be a contributing factor to the persistent racial/ethnic differences in influenza vaccination coverage. Research has shown that the mere presentation of facts and statistics in an attempt to persuade people to change their belief may cause them to become more entrenched in the belief [18]. Creative approaches will be needed to dispel this misconception among blacks, as well as among other racial/ethnic groups. Because of the finding that reasons for non-vaccination given by parents for themselves do not highly correspond to reasons they give for not having their child vaccinated, providers should not assume the reasons are the same when talking to parents about their vaccination concerns.

The study is subject to at least four limitations. First, vaccination status was based upon self or parent report and was not verified with medical records [19–21]. Second, the response rate was low however some survey methodologist report that response rates lack validity as a measure for survey bias [22]. Third, the accurate measure of reasons for non-vaccination is complicated because the reasons can vary over time for the same person and by the way the question is asked during a survey; the questions are asked at the time of the interview which is months after the decision was made. Fourth, the profile of reasons for non-vaccination for the 2011–12 season may not apply to the current or future seasons due to variability in the unique circumstances of each influenza season such as reports of early influenza deaths among children or a mismatch of the strains in the vaccine and the circulating virus.

In conclusion, the most common reasons for non-vaccination were related to not perceiving the risks of influenza and concerns about side effects of the influenza vaccine and there were racial/ethnic differences in reasons. Knowledge of these findings can guide the choice of interventions to decrease racial/ethnic differences in influenza vaccination rates. Healthcare providers, as well as immunization programs and their partners, should be made aware of the many reasons for non-vaccination and utilize strategies to help address these barriers.