BACKGROUND AND OBJECTIVES:

The World Health Organization has designated vaccine hesitancy as 1 of the 10 leading threats to global health, yet there is limited current national data on prevalence of hesitancy among US parents. Among a nationally representative sample of US parents, we aimed to (1) assess and compare prevalence of hesitancy and factors driving hesitancy for routine childhood and influenza vaccination and (2) examine associations between sociodemographic characteristics and hesitancy for routine childhood or influenza vaccination.

METHODS:

In February 2019, we surveyed families with children using the largest online panel generating representative US samples. After weighting, we assessed hesitancy using a modified 5-point Vaccine Hesitancy Scale and labeled parents as hesitant if they scored >3.

RESULTS:

A total of 2176 of 4445 parents sampled completed the survey (response rate 49%). Hesitancy prevalence was 6.1% for routine childhood and 25.8% for influenza vaccines; 12% strongly and 27% somewhat agreed they had concerns about serious side effects of both routine childhood and influenza vaccines. A total of 70% strongly agreed that routine childhood vaccines are effective versus 26% for influenza vaccine (P < .001). In multivariable models, an educational level lower than a bachelor’s degree and household income <400% of the federal poverty level predicted hesitancy about both routine childhood and influenza vaccines.

CONCLUSIONS:

Almost 1 in 15 US parents are hesitant about routine childhood vaccines, whereas >1 in 4 are hesitant about influenza vaccine. Furthermore, 1 in 8 parents are concerned about vaccine safety for both routine childhood and influenza vaccines, and only 1 in 4 believe influenza vaccine is effective. Vaccine hesitancy, particularly for influenza vaccine, is prevalent in the United States.

What’s Known on This Subject:

The World Health Organization has designated vaccine hesitancy as 1 of the 10 leading threats to global health. However, there is limited current national data on prevalence of hesitancy among US parents about routine childhood and influenza vaccination.

In this study, we show that 6.1% of US parents are hesitant about routine childhood vaccines and 25.8% are hesitant about influenza vaccine. Although 1 in 8 parents are concerned about safety of both routine childhood and influenza vaccines, only 1 in 4 believe influenza vaccine is effective.

In 2019, the World Health Organization (WHO) designated vaccine hesitancy as 1 of the 10 leading threats to global health.1  In many countries, including the United States, hesitancy about childhood vaccines has contributed to lower rates of childhood vaccination, with associated outbreaks of vaccine-preventable diseases, including pertussis, mumps, and measles.216  Although researchers have assessed parental vaccine hesitancy in different localities, there are few recent US national data on the prevalence of hesitancy about routine childhood vaccines.1719

Even less is known about the national prevalence of parental hesitancy about influenza vaccination for children. Although yearly influenza vaccination is recommended for all children 6 months to 18 years,20  the influenza vaccination rate for US children in the 2018 to 2019 season was only 57.9%.21  It is unknown how much hesitancy contributes to this low rate. Understanding the role of hesitancy is critical given the substantial burden of seasonal influenza among children as reflected by influenza-related visits, hospitalizations, and deaths.2230  The fact that another of WHO’s top threats to global health is the possibility of a global influenza pandemic lends additional importance to understanding hesitancy about influenza vaccines.1

“Vaccine hesitancy” has been inconsistently defined, with some definitions focusing only on beliefs about perceived safety, effectiveness, or necessity of vaccines3133  and other definitions including issues of convenience or practical barriers to vaccination.34  Some experts have clearly differentiated between beliefs and behaviors, defining hesitancy as a continuum of attitudes and beliefs that do not always predict decisions to delay or refuse vaccination,17,31,3537  whereas others have used vaccination behaviors themselves to define hesitancy.31,35  This distinction matters because although hesitant parents may vaccinate under some circumstances, these parents may be vulnerable to antivaccine misinformation and require inoculation against misinformation.38  For the current study, we adopted a recent definition from the literature defining hesitancy as “a motivational state of being conflicted about or opposed to getting vaccinated”32  without reference to whether it leads to refusal or deferral of vaccination. No recent surveys have assessed the national prevalence of US parental vaccine hesitancy about either routine childhood or influenza vaccination. Although influenza vaccine could be included as a “routine” vaccine, in that it is recommended yearly, we hypothesized that parents view it differently from other childhood vaccines because each year it needs to be given again, its content and effectiveness vary, and it addresses a disease that is often perceived as minor compared with other childhood diseases.

Given the importance of understanding the prevalence of hesitancy and factors related to hesitancy, our study objectives were, among a nationally representative sample of US parents, to (1) assess and compare the levels of hesitancy about routine childhood and influenza vaccinations, (2) assess the relationship between parent-reported vaccination concerns and parent-reported refusal and deferral of routine childhood or influenza vaccinations, (3) assess parent demographic factors that are associated with hesitancy about routine childhood and influenza vaccines, and (4) assess the association between sociodemographic and health characteristics and hesitancy about childhood or influenza vaccination.

In February 2019, we surveyed families with children 6 months to <18 years of age using an online panel. The study was approved as exempt by the Colorado Multiple Institutional Review Board.

We used the Ipsos panel as the sampling frame (see Supplemental Information for additional details). The KnowledgePanel is constructed from a random sampling of addresses to create the largest Internet-based survey panel (N = 55 000) representative of the noninstitutionalized US population. Recruitment is achieved by using address-based sampling methods via the US Postal Service’s Delivery Sequence File (DSF). This method improves coverage compared with random-digit dialing and better represents the majority of households that no longer have landlines but rather only have mobile phones. Recruitment to the panel occurs through a series of mailings, including an initial invitation letter, a reminder postcard, and a subsequent follow-up letter. Panelists are offered a small incentive for completing questionnaires (eg, sweepstakes, small cash rewards). Ipsos routinely collects data regarding health status and sociodemographic variables predominately using the Current Population Survey (US Census Bureau) among other sources as needed. Data are weighted by using geodemographic benchmarks from the US Census Bureau’s Current Population Survey, including sex, age, race and ethnicity, education, census region, household income, home ownership, and geographic region. The KnowledgePanel has been used to collect the primary data for a large number of publications in peer-reviewed journals, with 10 PubMed publication listings in 2019 alone.3948

Inclusion criteria were (1) being a parent, stepparent, or foster parent of a child 6 months to <18 years and (2) being able to complete the online survey in English or Spanish. We did not include parents of children <6 months because the influenza vaccine is not recommended for this group, and we wanted parents to have had some experience with routine childhood vaccination. We randomly selected 1 child within each family to be the focus of the interview. Families were selected to reach a desired sample size of ∼2000 survey completions.

Vaccine Hesitancy

We modified the Vaccine Hesitancy Scale (VHS), an instrument developed by WHO’s Strategic Advisory Group of Experts on Immunization in 2015.49,50  The tool was developed on the basis of global pilot data of indicators for vaccine hesitancy and a literature review and incorporated elements of a tool developed in higher-income US populations.31,51,52  Although relatively new, the VHS has been used in numerous countries, either in part or as a complete scale, to assess hesitancy among parents for childhood or adolescent vaccines5356  and among adults for general vaccine hesitancy.57  The tool has been psychometrically validated and encompasses 10 items with Likert responses, including dimensions of vaccine confidence and vaccine risks.53,55,58  The tool has been validated in 2 studies on the basis of reported refusal of vaccination.53,54  Notably, it does not include issues of convenience or barriers to vaccination related to payment, transportation, or intercurrent illness. To increase the VHS’s relevance to a US population, we excluded this question: “All childhood vaccines offered by the government program in my community are beneficial.” To allow for comparisons between routine childhood and influenza vaccines, we also excluded a statement not relevant to influenza: “New vaccines carry more risks than older vaccines.” Thus, our scale for measuring both routine childhood and influenza hesitancy included 8 items. We also used a 4-point rather than a 5-point response scale (ie, we excluded the “neutral or not sure” response category) because of evidence that omitting the neutral option decreases the potential for socially desirable responding.59  We modified slightly the wording of the VHS to address influenza rather than childhood vaccines in general.

Deferral and Refusal of Vaccines

We used a question similar to those used to validate the VHS49,50  to assess whether concerns about either routine childhood or influenza vaccines had led the respondent to defer or refuse these vaccines.

Randomly selected eligible panel members received an e-mail with a link to the survey. One automatic e-mail reminder was sent after 3 days if there was no response.

We examined demographics both without and with the poststratification weights provided by Ipsos to account for possible differential nonresponse. The poststratification weights were then used in all subsequent analyses. The score on the modified VHS was calculated by first reverse-coding negatively worded items and scoring responses for each item in the following manner: strongly agree = 1, agree = 2, disagree = 4, and strongly disagree = 5, such that higher values always indicated greater hesitancy. We scored responses in this manner to be able to map our results to previous literature using a 5-point response scale. We then calculated the average score of the 8 items included in our modified VHS. We defined “hesitant” as an average score >3 because this score would indicate a hesitancy level higher than the midpoint of the scale. We also did a sensitivity analysis to examine hesitancy using the cutoff of a score >4.

Separately for noninfluenza and influenza surveys, we calculated the proportion of respondents that reported deferral or refusal because of concerns about the vaccine for subjects with hesitant versus nonhesitant scores and calculated unadjusted risk ratios (URRs). We conducted multivariable Poisson regression models with robust error variance with the dependent variable being hesitant for routine childhood vaccination and, separately, being hesitant for influenza vaccination. Independent variables included the child’s reported general health, the number of children in the household, the age of the index child, and the respondent’s education, race and ethnicity, marital status, household income, region of residence, and metropolitan statistical area status, all factors shown to be related to vaccine hesitancy.60

Of the 4445 parents sampled, 2176 completed the survey (response rate 49%), with 2052 eligible respondents. In Table 1, we show characteristics of respondents and their child. The Cronbach α for our modified VHS was 0.89 for the childhood items and 0.95 for the influenza items, indicating that good internal consistency was maintained in our modified scales.

TABLE 1

Characteristics of Surveyed Population

Unweighted Sample (n = 2052), n (%)Weighted Sample (n = 2052), n (%)
Child’s health
Poor, fair, or good 217 (10.6) 230 (11.3)
Excellent or very good 1827 (89.4) 1812 (88.7)
Age of index child
1: 6 mo through 2 y 259 (12.6) 302 (14.7)
2: 3–5 y 323 (15.7) 326 (15.9)
3: 6–10 y 534 (26.0) 530 (25.8)
4: 11 y or older 936 (45.6) 893 (43.5)
No. children in household
1 820 (40.0) 831 (40.5)
2 791 (38.5) 769 (37.5)
3 or more 441 (21.5) 452 (22.0)
No. children in household (Ipsos data)
0 64 (3.1) 85 (4.1)
1 767 (37.4) 775 (37.8)
2 804 (39.2) 776 (37.8)
3 or more 417 (20.3) 416 (20.3)
No. adults in household (Ipsos data)
1 166 (8.1) 158 (7.7)
2 1462 (71.2) 1446 (70.5)
3 or more 424 (20.7) 448 (21.8)
Respondent employment
Working 1615 (78.7) 1582 (77.1)
Not working 437 (21.3) 470 (22.9)
Respondent marital status
Other (widowed, divorced, separated, never married, living with partner) 370 (18.0) 383 (18.7)
Married 1682 (82.0) 1669 (81.3)
Respondent age, y
18–24 20 (1.0) 33 (1.6)
25–34 463 (22.6) 551 (26.9)
35–44 909 (44.3) 852 (41.5)
45–54 534 (26.0) 501 (24.4)
55+ 126 (6.1) 115 (5.6)
Respondent education
HS or less 533 (26.0) 698 (34.0)
Some college 520 (25.3) 551 (26.8)
Bachelor’s degree or higher 999 (48.7) 804 (39.2)
Respondent race and ethnicity
White, non-Hispanic 1384 (67.4) 1178 (57.4)
African American, non-Hispanic 181 (8.8) 225 (11.0)
Hispanic 328 (16.0) 443 (21.6)
Other or multiracial, non-Hispanic 159 (7.7) 206 (10.1)
Household income
1: <$25 000 146 (7.1) 150 (7.3) 2:$25–49 000 363 (17.7) 405 (19.7)
3: $50–74 000 363 (17.7) 340 (16.6) 4:$75–99 000 312 (15.2) 300 (14.6)
5: ≥$100 000 868 (42.3) 857 (41.7) Percent of FPL <100% FPL 271 (13.2) 290 (14.1) 100%–400% FPL 1132 (55.2) 1089 (53.1) >400% FPL 649 (31.6) 673 (32.8) Region 4, based on state of residence Northeast 341 (16.6) 337 (16.4) Midwest 473 (23.1) 433 (21.1) South 715 (34.8) 773 (37.7) West 523 (25.5) 509 (24.8) MSA status Nonmetro 262 (12.8) 266 (12.9) Metro 1790 (87.2) 1786 (87.1) Unweighted Sample (n = 2052), n (%)Weighted Sample (n = 2052), n (%) Child’s health Poor, fair, or good 217 (10.6) 230 (11.3) Excellent or very good 1827 (89.4) 1812 (88.7) Age of index child 1: 6 mo through 2 y 259 (12.6) 302 (14.7) 2: 3–5 y 323 (15.7) 326 (15.9) 3: 6–10 y 534 (26.0) 530 (25.8) 4: 11 y or older 936 (45.6) 893 (43.5) No. children in household 1 820 (40.0) 831 (40.5) 2 791 (38.5) 769 (37.5) 3 or more 441 (21.5) 452 (22.0) No. children in household (Ipsos data) 0 64 (3.1) 85 (4.1) 1 767 (37.4) 775 (37.8) 2 804 (39.2) 776 (37.8) 3 or more 417 (20.3) 416 (20.3) No. adults in household (Ipsos data) 1 166 (8.1) 158 (7.7) 2 1462 (71.2) 1446 (70.5) 3 or more 424 (20.7) 448 (21.8) Respondent employment Working 1615 (78.7) 1582 (77.1) Not working 437 (21.3) 470 (22.9) Respondent marital status Other (widowed, divorced, separated, never married, living with partner) 370 (18.0) 383 (18.7) Married 1682 (82.0) 1669 (81.3) Respondent age, y 18–24 20 (1.0) 33 (1.6) 25–34 463 (22.6) 551 (26.9) 35–44 909 (44.3) 852 (41.5) 45–54 534 (26.0) 501 (24.4) 55+ 126 (6.1) 115 (5.6) Respondent education HS or less 533 (26.0) 698 (34.0) Some college 520 (25.3) 551 (26.8) Bachelor’s degree or higher 999 (48.7) 804 (39.2) Respondent race and ethnicity White, non-Hispanic 1384 (67.4) 1178 (57.4) African American, non-Hispanic 181 (8.8) 225 (11.0) Hispanic 328 (16.0) 443 (21.6) Other or multiracial, non-Hispanic 159 (7.7) 206 (10.1) Household income 1: <$25 000 146 (7.1) 150 (7.3)
2: $25–49 000 363 (17.7) 405 (19.7) 3:$50–74 000 363 (17.7) 340 (16.6)
4: $75–99 000 312 (15.2) 300 (14.6) 5: ≥$100 000 868 (42.3) 857 (41.7)
Percent of FPL
<100% FPL 271 (13.2) 290 (14.1)
100%–400% FPL 1132 (55.2) 1089 (53.1)
>400% FPL 649 (31.6) 673 (32.8)
Region 4, based on state of residence
Northeast 341 (16.6) 337 (16.4)
Midwest 473 (23.1) 433 (21.1)
South 715 (34.8) 773 (37.7)
West 523 (25.5) 509 (24.8)
MSA status
Nonmetro 262 (12.8) 266 (12.9)
Metro 1790 (87.2) 1786 (87.1)

FPL, federal poverty level; HS, high school; MSA, metropolitan statistical area.

For routine childhood vaccines (Table 2), the median score and interquartile range for the modified VHS scale was 1.4 (1.1–2.0); the mean was 1.7 (SD = 0.02). The percentage with scores >3 was 6.1% (95% confidence interval [CI]: 5.0%–7.3%). For influenza vaccine, the median score for the influenza modified VHS scale was 1.9 (interquartile range: 1.3–3.1), and the mean was 2.3 (SD = 0.03). The percentage of respondents with scores >3 was 25.8% (95% CI: 23.7%–28.0%). If cutoff levels of >4 were used, hesitancy levels (with 95% CIs) were 2.8% (range: 1.9%–3.6%) for routine childhood and 10.3% (range: 8.8%–11.8%) for influenza vaccines.

TABLE 2

Association Between Hesitancy on Modified VHS and Reporting Previous Vaccine Deferral or Refusal

n (%) in CategoryPercentage Who Had Refused Because of ConcernsaURR (95% CI)P
Hesitancy for childhood vaccines (>3)
Yes 126 (6.1) 67.5 7.8 (6.3–9.6) <.0001
No 1926 (93.9) 8.7 Reference —
Hesitancy for influenza vaccine (>3)
Yes 530 (25.8) 70.1 7.0 (5.8–8.5) <.0001
No 1522 (74.2) 10.0 Reference —
n (%) in CategoryPercentage Who Had Refused Because of ConcernsaURR (95% CI)P
Hesitancy for childhood vaccines (>3)
Yes 126 (6.1) 67.5 7.8 (6.3–9.6) <.0001
No 1926 (93.9) 8.7 Reference —
Hesitancy for influenza vaccine (>3)
Yes 530 (25.8) 70.1 7.0 (5.8–8.5) <.0001
No 1522 (74.2) 10.0 Reference —

—, not applicable.

a

Questions were as follows: “Did concerns about childhood vaccines ever keep you from getting your child any childhood vaccines?” “Did concerns about the flu vaccine ever keep you from getting your child the flu vaccine?”

Regarding routine childhood vaccines, among hesitant respondents, 67.5% had deferred or refused routine vaccination for their child because of concerns about that vaccine compared with 8.7% of nonhesitant parents; the URR for deferral and/or refusal among hesitant parents was 7.8 (95% CI: 6.3–9.6) (Table 2). Regarding influenza vaccine, among hesitant respondents, 70.1% had ever deferred or refused influenza vaccination for their child because of concerns about that vaccine compared with only 10.0% of nonhesitant respondents (URR: 7.0; 95% CI: 5.8–8.5). Among influenza vaccine–hesitant respondents, only 10.1% reported their child had received the vaccine or that they planned to have them vaccinated during the current season (8.6% had already been vaccinated) versus 84.1% of nonhesitant respondents (URR: 8.3; 95% CI: 6.1–11.4).

The item most associated with hesitancy about childhood vaccines was having concerns about serious side effects, with 12% strongly and 27% somewhat endorsing this concern (Fig 1). Thirteen percent either strongly or somewhat disagreed that “all childhood vaccines…are beneficial.” All other concerns were endorsed by <10%. The percentages of parents who were strongly or somewhat concerned about serious side effects of influenza vaccine were identical to those seen for routine childhood vaccines (Fig 1). However, only 26% strongly agreed that the influenza vaccine is effective, compared with 70% for childhood vaccines (P < .0001). Parents were also less likely to perceive influenza vaccines as important for their child’s health, to agree that influenza vaccines are beneficial and a good way to protect their child from disease, and to report doing what their child’s health care provider recommended regarding influenza vaccines.

FIGURE 1

Results of modified VHS for influenza vaccine (8 item) compared with modified VHS for childhood vaccines (8 items). a All questions are significant (P < .0001) except for “I am concerned about serious side effects of childhood vaccines” (P = .18).

FIGURE 1

Results of modified VHS for influenza vaccine (8 item) compared with modified VHS for childhood vaccines (8 items). a All questions are significant (P < .0001) except for “I am concerned about serious side effects of childhood vaccines” (P = .18).

Close modal

Lower respondent educational level and household income <400% of the federal poverty level were significantly associated with hesitancy for both routine childhood and influenza vaccines (Table 3). Poorer child health was associated with higher levels of hesitancy for routine childhood but not for influenza vaccines. Parents in the western United States and those with a referent child in the preschool years also were more hesitant about childhood vaccines. Race and ethnicity were not significantly associated with hesitancy about childhood vaccines, but Hispanic parents were less hesitant about influenza vaccines than white, non-Hispanic parents. Having more children in the household and being an unmarried respondent were also associated with hesitancy about influenza vaccines.

TABLE 3

Multivariable Models Predicting Childhood and Influenza Vaccine Hesitancy (Score >3)

URR (95% CI) for Childhood Vaccine HesitancyAdjusted RR (95% CI) for Childhood Vaccine HesitancyURR (95% CI) for Influenza Vaccine HesitancyAdjusted RR (95% CI) for Influenza Vaccine Hesitancy
Child’s health
Good, fair, or poor 1.85 (1.16–2.93) 1.74 (1.08–2.83) 1.11 (0.86–1.43) 1.01 (0.79–1.30)
Excellent or very good Reference Reference Reference Reference
No. children in household
1 child Reference Reference Reference Reference
2 children 0.81 (0.50–1.29) 0.79 (0.49–1.27) 0.99 (0.81–1.20) 1.06 (0.87–1.28)
≥3 children 1.15 (0.72–1.82) 1.11 (0.70–1.76) 1.27 (1.03–1.56) 1.29 (1.04–1.60)
Age of index child
6 mo to 2 y vs 11+ y 1.28 (0.70–2.36) 1.66 (0.87–3.16) 0.88 (0.66–1.16) 0.88 (0.67–1.16)
3–5 y vs 11+ y 1.46 (0.87–2.45) 1.79 (1.04–3.06) 1.01 (0.79–1.27) 0.96 (0.76–1.22)
6–10 y vs 11+ y 1.04 (0.64–1.69) 1.11 (0.68–1.80) 0.89 (0.73–1.10) 0.83 (0.67–1.02)
11+ y Reference Reference Reference Reference
Respondent education
High school or less 2.88 (1.84–4.51) 2.42 (1.46–4.02) 1.76 (1.44–2.15) 1.57 (1.25–1.96)
Some college 2.14 (1.32–3.46) 1.79 (1.06–3.04) 1.71 (1.39–2.10) 1.52 (1.23–1.88)
Bachelor’s degree or higher Reference Reference Reference Reference
Respondent race and ethnicity
African American, non-Hispanic 1.61 (0.91–2.87) 1.79 (1.00–3.20) 1.26 (0.99–1.61) 1.14 (0.88–1.47)
Hispanic 1.27 (0.78–2.08) 0.90 (0.53–1.53) 0.83 (0.65–1.06) 0.68 (0.52–0.88)
Other or multiracial, non-Hispanic 0.64 (0.23–1.77) 0.83 (0.29–2.42) 0.76 (0.51–1.11) 0.91 (0.62–1.34)
White, non-Hispanic Reference Reference Reference Reference
Household income
<100% FPL 0.85 (0.47–1.53) 0.59 (0.30–1.19) 1.13 (0.91–1.41) 0.97 (0.76–1.25)
100%–400% FPL Reference Reference Reference Reference
>400% FPL 0.36 (0.22–0.60) 0.53 (0.32–0.87) 0.61 (0.49–0.75) 0.73 (0.58–0.92)
Region of residence
Midwest 1.14 (0.67–1.94) 1.26 (0.74–2.16) 1.01 (0.82–1.26) 0.97 (0.79–1.20)
Northeast 1.25 (0.68–2.31) 1.49 (0.79–2.83) 0.89 (0.69–1.15) 0.92 (0.71–1.18)
West 1.63 (1.00–2.65) 1.75 (1.09–2.82) 0.91 (0.73–1.13) 0.95 (0.76–1.19)
South Reference Reference Reference Reference
MSA status
Nonmetro 0.99 (0.58–1.67) 0.79 (0.45–1.37) 1.17 (0.94–1.46) 0.94 (0.75–1.18)
Metro Reference Reference Reference Reference
Marital status
Unmarried 1.33 (0.85–2.08) 1.00 (0.61–1.65) 1.43 (1.18–1.72) 1.25 (1.02–1.54)
Married Reference Reference Reference Reference
URR (95% CI) for Childhood Vaccine HesitancyAdjusted RR (95% CI) for Childhood Vaccine HesitancyURR (95% CI) for Influenza Vaccine HesitancyAdjusted RR (95% CI) for Influenza Vaccine Hesitancy
Child’s health
Good, fair, or poor 1.85 (1.16–2.93) 1.74 (1.08–2.83) 1.11 (0.86–1.43) 1.01 (0.79–1.30)
Excellent or very good Reference Reference Reference Reference
No. children in household
1 child Reference Reference Reference Reference
2 children 0.81 (0.50–1.29) 0.79 (0.49–1.27) 0.99 (0.81–1.20) 1.06 (0.87–1.28)
≥3 children 1.15 (0.72–1.82) 1.11 (0.70–1.76) 1.27 (1.03–1.56) 1.29 (1.04–1.60)
Age of index child
6 mo to 2 y vs 11+ y 1.28 (0.70–2.36) 1.66 (0.87–3.16) 0.88 (0.66–1.16) 0.88 (0.67–1.16)
3–5 y vs 11+ y 1.46 (0.87–2.45) 1.79 (1.04–3.06) 1.01 (0.79–1.27) 0.96 (0.76–1.22)
6–10 y vs 11+ y 1.04 (0.64–1.69) 1.11 (0.68–1.80) 0.89 (0.73–1.10) 0.83 (0.67–1.02)
11+ y Reference Reference Reference Reference
Respondent education
High school or less 2.88 (1.84–4.51) 2.42 (1.46–4.02) 1.76 (1.44–2.15) 1.57 (1.25–1.96)
Some college 2.14 (1.32–3.46) 1.79 (1.06–3.04) 1.71 (1.39–2.10) 1.52 (1.23–1.88)
Bachelor’s degree or higher Reference Reference Reference Reference
Respondent race and ethnicity
African American, non-Hispanic 1.61 (0.91–2.87) 1.79 (1.00–3.20) 1.26 (0.99–1.61) 1.14 (0.88–1.47)
Hispanic 1.27 (0.78–2.08) 0.90 (0.53–1.53) 0.83 (0.65–1.06) 0.68 (0.52–0.88)
Other or multiracial, non-Hispanic 0.64 (0.23–1.77) 0.83 (0.29–2.42) 0.76 (0.51–1.11) 0.91 (0.62–1.34)
White, non-Hispanic Reference Reference Reference Reference
Household income
<100% FPL 0.85 (0.47–1.53) 0.59 (0.30–1.19) 1.13 (0.91–1.41) 0.97 (0.76–1.25)
100%–400% FPL Reference Reference Reference Reference
>400% FPL 0.36 (0.22–0.60) 0.53 (0.32–0.87) 0.61 (0.49–0.75) 0.73 (0.58–0.92)
Region of residence
Midwest 1.14 (0.67–1.94) 1.26 (0.74–2.16) 1.01 (0.82–1.26) 0.97 (0.79–1.20)
Northeast 1.25 (0.68–2.31) 1.49 (0.79–2.83) 0.89 (0.69–1.15) 0.92 (0.71–1.18)
West 1.63 (1.00–2.65) 1.75 (1.09–2.82) 0.91 (0.73–1.13) 0.95 (0.76–1.19)
South Reference Reference Reference Reference
MSA status
Nonmetro 0.99 (0.58–1.67) 0.79 (0.45–1.37) 1.17 (0.94–1.46) 0.94 (0.75–1.18)
Metro Reference Reference Reference Reference
Marital status
Unmarried 1.33 (0.85–2.08) 1.00 (0.61–1.65) 1.43 (1.18–1.72) 1.25 (1.02–1.54)
Married Reference Reference Reference Reference

FPL, federal poverty level; MSA, metropolitan statistical area; RR, risk ratio.

In our study, we provide the first national estimates of hesitancy about routine childhood and influenza vaccination among representative samples of US parents of children across the age span, using a scale specifically developed and validated to assess vaccine hesitancy. In addition, because we used the same scale to assess hesitancy about both routine childhood and influenza vaccinations in the same parents, our data allow for direct comparisons of the levels of hesitancy for these different vaccine categories. In our data, it is demonstrated that (using a cutoff greater than the midpoint on the hesitancy scales), 6.1% of parents are hesitant about routine childhood vaccination, whereas >4 times that (25.8%) are hesitant about influenza vaccination. Whereas hesitancy about routine childhood vaccination is driven primarily by safety concerns, hesitancy about influenza vaccination is largely driven by concerns about low vaccine effectiveness. Concerns about the safety of routine childhood and influenza vaccinations were almost identical.

Previous data assessing childhood vaccine hesitancy rates in the United States have most often been measured by using the Parent Attitudes about Childhood Vaccines (PACV) scale,31,51,6165  which was developed and validated in primarily higher-income populations in Washington state. Estimates of the prevalence of hesitancy for childhood vaccines using a cutoff of >50 out of a possible score of 100 on the PACV have varied substantially depending on age and setting, from a high of 25% among parents of 19- to 35-month-old children within a closed-model health maintenance organization in Seattle31  to a low of 5.9% among parents of 24-month-olds in Washington state.61  By using a cutoff for the VHS indicating a hesitancy level higher than the midpoint of the scale (similar to >50 on the PACV scale), our rate of hesitancy about routine childhood vaccines is lower than some previous estimates using the PACV but is in line with others. Notably, previous estimates using the PACV were among parents of young children and were in a single state, whereas our data include parents of children across the age span and are weighted to be representative of regions and sociodemographic factors throughout the United States.

Researchers of another national study evaluated the effect of parent concerns on vaccination using questions from the 2009 National Immunization Surveys to examine the percentage of parents of 24- to 35-month-old children who had delayed or refused a vaccine dose on the basis of safety, concurrent illness, missed appointments, cost, or other issues.17  At that time, 25.8% of parents reported delaying, 8.2% had refused, and 5.8% had both delayed and refused ≥1 recommended vaccines. Many parents who delayed or refused a vaccine did so for reasons other than concerns about vaccines. For example, 45.9% of parents who both delayed and refused vaccines did so because of an illness in their child. These data are not an ideal comparison with the current study because they are >10 years old and were gathered from parents of children in a narrow age range.

We are not aware of researchers of any studies reporting nationally representative rates of parental hesitancy about influenza vaccination in any country. In 2 previous studies, both in Washington state, researchers used a modified PACV to measure hesitancy for influenza vaccine among parents with children seen in a pediatric emergency department and among a sample of hospitalized children. Levels of hesitancy in these 2 samples were 26%63  and 24%,62  respectively. Interestingly, these are much in line with national estimates we obtained for influenza hesitancy.

In our data, it is shown that hesitancy for influenza vaccination was >4 times higher than for routine childhood vaccination, and, importantly, the factors driving hesitancy differed. Concerns about serious side effects were similar, but concerns about many of the other factors were much higher for influenza vaccination, especially concerns about effectiveness. Concerns about low effectiveness may have led to other concerns. For example, parents convinced that the influenza vaccine is ineffective might also deny that it is “important for the health of others,” “important for their child’s health,” or “a good way to protect my child from disease” and might be less likely to do “what my child’s health care provider recommends about flu vaccine.” Confidence in influenza vaccine effectiveness may have been eroded during well-publicized influenza seasons during which there was a significant mismatch between circulating and vaccine strains of influenza.6671  Poor live attenuated influenza vaccine effectiveness, with removal of the vaccine from Advisory Committee on Immunization Practices recommendations during 2 seasons, also may have eroded confidence in influenza vaccine’s effectiveness.66

Previous US-based studies have revealed inconsistent relationships between parental vaccine hesitancy or deferrals and/or refusals and vaccine assessed, age of child, parent demographics, and whether data were national or regional. Although researchers of most national surveys have found lower income to be associated with higher levels of concern about the safety or necessity of vaccines,36,72,73  researchers of at least one study, on the basis of the 2009 National Immunization Surveys, showed the opposite.17  Similarly, although researchers of most past studies have found lower educational level to be associated with more concerns about vaccine safety or efficacy,36,72,73  others have shown that parents with higher educational levels are more likely to forego immunizations17,37  or to have safety concerns.31  National data have generally revealed that, although Hispanic and African American parents have expressed high levels of concern about childhood vaccines,18,72  they have demonstrated a lower likelihood of refusal of childhood vaccinations.18,35  It is important to note that all of these surveys were conducted 6 to 16 years ago, and no national data are available on parental influenza vaccine hesitancy with which to directly compare our data.

We found higher rates of hesitancy for both childhood and influenza vaccines among parents with less than a bachelor’s degree and with household incomes <400% of the federal poverty level, consistent with the findings of most previous national studies. Although we did not find racial or ethnic differences in degree of hesitancy for routine childhood vaccines, we did see lower hesitancy about influenza vaccine among parents of Hispanic children. This is consistent with data from the Centers for Disease Control and Prevention about influenza vaccine coverage for the 2018 to 2019 influenza season, which revealed higher levels of receipt among Hispanic children,74  although beliefs were not examined.

Our data have some notable strengths and weaknesses. To our knowledge, we are the first to assess and compare hesitancy about routine childhood and influenza vaccines in a nationally representative sample of parents. We used a modification of the WHO internationally validated scale to assess hesitancy, which should allow for international comparisons. However, survey data have inherent potential weaknesses, including reporting bias based on social desirability. In addition, there has been insufficient discussion of the cutoff that should be used for defining hesitancy using the VHS. To make comparisons and model associations, we created a midscale cutoff for hesitancy, comparable to what has been done for the PACV. However, different cutoffs could be used with different results, as demonstrated in our sensitivity analyses. Our response rate was ∼50%, although weighting helps to mitigate any bias introduced by differential nonresponse. Our exclusion of infants <6 months of age, which was done because flu vaccination is recommended only for those >6 months of age, may bias our assessment of hesitancy for routine childhood vaccinations. There are 2 studies whose authors examine hesitancy longitudinally in infancy, both using the PACV; 1 revealed a hesitancy rate of 9.7% at birth and 8% at 6 months and another revealed similar levels of hesitancy at ∼2 and 4 months of age, with both scores61  predictive of childhood immunization status at 19 months of age.52  Therefore, the exclusion of infants <6 months of age in our study may have no effect or may result in a slight underestimate of hesitancy. Finally, we could internally validate our data only by comparing to parent report of receipt of vaccines rather than actual vaccination data.

In our data, we demonstrate the extent of parental concerns about vaccine safety for both routine childhood and influenza vaccines and identify substantial additional concerns about the effectiveness of influenza vaccines that are contributing to hesitancy for these vaccines. In view of our findings, what methods can be used to increase decisions to vaccinate among parents who are hesitant? There have been multiple recent reviews discussing interventions,32,7577  but a surprising lack of evidence exists to support the effectiveness of most of them in countering hesitancy or increasing vaccination.32  Evidence is strongest for methods that build on whatever favorable intentions to vaccinate exist or those that focus on changing behavior directly rather than trying to change beliefs or attitudes. Such interventions would include strong and presumptive (rather than open-ended) recommendations by a trusted provider,7881  the use of standing orders,82  methods to facilitate ease of vaccine delivery (eg, influenza vaccination clinics or school-based vaccination delivery), reminder and recall,83  and, at the state level, preschool and school vaccination requirements8493  as well as the minimization of philosophic exemptions to such requirements.2,94,95  There is evidence that communication techniques such as motivational interviewing can be helpful in convincing some hesitant parents to vaccinate in the primary care setting.96,97  The use of social media interventions,98,99  some of which involving trained parents as advocates for vaccination within their own communities,100  have shown some effectiveness in overcoming hesitancy. However, more work needs to be done to develop methods that are practical and effective for convincing vaccine-hesitant parents to vaccinate. With respect to influenza vaccination, with our data, we underscore the importance of better communicating to providers and parents the effectiveness of influenza vaccines in reducing severity and morbidity from influenza, even in years when the vaccine has relatively low effectiveness.101  Quantifying the level of hesitancy nationally on a longitudinal basis by using a consistent measure is a critical first step in guiding and measuring the effectiveness of future interventions to counter vaccine hesitancy.

Drs Kempe and Szilagyi conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Zimet conceptualized and designed the study and reviewed and revised the manuscript; Ms Saville, Ms Albertin, and Ms Breck participated in the conceptualization and design of the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content; Dr Dickinson, Ms Helmkamp, and Mr Vangala contributed to the design of the survey instrument, conducted the initial analyses, and reviewed and revised the manuscript; Drs Humiston and Rand contributed to the study design and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under award number R01AI114903. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funding organization was not involved in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. Funded by the National Institutes of Health (NIH).

CI

confidence interval

DSF

Delivery Sequence File

PACV

URR

VHS

Vaccine Hesitancy Scale

WHO

World Health Organization

1
World Health Organization
.
Ten threats to global health in 2019
.
2
Omer
SB
,
Pan
WK
,
Halsey
NA
, et al
.
Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence
.
JAMA
.
2006
;
296
(
14
):
1757
1763
3
A
,
Tserenpuntsag
B
,
Blog
DS
,
Halsey
NA
,
Easton
DE
,
Shaw
J
.
Religious exemptions for immunization and risk of pertussis in New York State, 2000–2011
.
Pediatrics
.
2013
;
132
(
1
):
37
43
4
Feikin
DR
,
Lezotte
DC
,
Hamman
RF
,
Salmon
DA
,
Chen
RT
,
Hoffman
RE
.
Individual and community risks of measles and pertussis associated with personal exemptions to immunization
.
JAMA
.
2000
;
284
(
24
):
3145
3150
5
Centers for Disease Control and Prevention
.
Measles cases and outbreaks. 2019
.
Available at: https://www.cdc.gov/measles/cases-outbreaks.html. Accessed November 26, 2019
6
Smith
PJ
,
Humiston
SG
,
Parnell
T
,
Vannice
KS
,
Salmon
DA
.
The association between intentional delay of vaccine administration and timely childhood vaccination coverage
.
Public Health Rep
.
2010
;
125
(
4
):
534
541
7
Omer
SB
,
Salmon
DA
,
Orenstein
WA
,
deHart
MP
,
Halsey
N
.
Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases
.
N Engl J Med
.
2009
;
360
(
19
):
1981
1988
8
Ahmed
A
,
Lee
KS
,
Bukhsh
A
, et al
.
Outbreak of vaccine-preventable diseases in Muslim majority countries
.
J Infect Public Health
.
2018
;
11
(
2
):
153
155
9
Ruderfer
D
,
Krilov
LR
.
Vaccine-preventable outbreaks: still with us after all these years
.
Pediatr Ann
.
2015
;
44
(
4
):
e76
e81
10
VK
,
Bednarczyk
RA
,
Salmon
DA
,
Omer
SB
.
Association between vaccine refusal and vaccine-preventable diseases in the United States: a review of measles and pertussis
.
JAMA
.
2016
;
315
(
11
):
1149
1158
11
World Health Organization
.
2017 Assessment Report of the Global Vaccine Action Plan Strategic Advisory Group of Experts on Immunization.
Geneva, Switzerland
:
World Health Organization
;
2017
12
Ward
JK
,
Colgrove
J
,
Verger
P
.
Why France is making eight new vaccines mandatory
.
Vaccine
.
2018
;
36
(
14
):
1801
1803
13
Sherrard
L
,
Hiebert
J
,
Cunliffe
J
,
Mendoza
L
,
Cutler
J
.
.
Can Commun Dis Rep
.
2016
;
42
(
7
):
139
145
14
Guidelines for the prevention and control of measles outbreaks in Canada: an Advisory Committee Statement (ACS) Measles and Rubella Elimination Working Group (MREWG)
.
Can Commun Dis Rep
.
2013
;
39
(
ACS-3
):
1
52
15
Centers for Disease Control and Prevention (CDC)
.
Mumps outbreak on a university campus–California, 2011
.
MMWR Morb Mortal Wkly Rep
.
2012
;
61
(
48
):
986
989
16
Barskey
AE
,
Schulte
C
,
Rosen
JB
, et al
.
Mumps outbreak in orthodox jewish communities in the United States
.
N Engl J Med
.
2012
;
367
(
18
):
1704
1713
17
Smith
PJ
,
Humiston
SG
,
Marcuse
EK
, et al
.
Parental delay or refusal of vaccine doses, childhood vaccination coverage at 24 months of age, and the Health Belief Model
.
Public Health Rep
.
2011
;
126
(
suppl 2
):
135
146
18
Freed
GL
,
Clark
SJ
,
Butchart
AT
,
Singer
DC
,
Davis
MM
.
Parental vaccine safety concerns in 2009
.
Pediatrics
.
2010
;
125
(
4
):
654
659
19
Kennedy
A
,
M
,
Sheedy
K
.
Vaccine attitudes, concerns, and information sources reported by parents of young children: results from the 2009 HealthStyles survey
.
Pediatrics
.
2011
;
127
(
suppl 1
):
S92
S99
20
Grohskopf
LA
,
Alyanak
E
,
Broder
KR
,
Walter
EB
,
Fry
AM
,
Jernigan
DB
.
Prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices - United States, 2019–20 influenza season
.
MMWR Recomm Rep
.
2019
;
68
(
3
):
1
21
21
Centers for Disease Control and Prevention
. 2016–17 influenza season vaccination coverage estimates for local areas and territories.
2017
. Available at: https://www.cdc.gov/flu/fluvaxview/local-areas-estimates-2016-17.htm. Accessed May 23, 2018
22
Flannery
B
,
Clippard
J
,
Zimmerman
RK
, et al;
Centers for Disease Control and Prevention
.
Early estimates of seasonal influenza vaccine effectiveness - United States, January 2015
.
MMWR Morb Mortal Wkly Rep
.
2015
;
64
(
1
):
10
15
23
Poehling
KA
,
Edwards
KM
,
Weinberg
GA
, et al;
New Vaccine Surveillance Network
.
The underrecognized burden of influenza in young children
.
N Engl J Med
.
2006
;
355
(
1
):
31
40
24
Neuzil
KM
,
Zhu
Y
,
Griffin
MR
, et al
.
Burden of interpandemic influenza in children younger than 5 years: a 25-year prospective study
.
J Infect Dis
.
2002
;
185
(
2
):
147
152
25
Zhou
H
,
Thompson
WW
,
Viboud
CG
, et al
.
Hospitalizations associated with influenza and respiratory syncytial virus in the United States, 1993–2008
.
Clin Infect Dis
.
2012
;
54
(
10
):
1427
1436
26
Committee on Infectious Diseases
.
Recommendations for prevention and control of influenza in children, 2017–2018
.
Pediatrics
.
2017
;
140
(
4
):
e20172550
27
Lafond
KE
,
Nair
H
,
Rasooly
MH
, et al;
Global Respiratory Hospitalizations—Influenza Proportion Positive (GRIPP) Working Group
.
Global role and burden of influenza in pediatric respiratory hospitalizations, 1982–2012: a systematic analysis
.
PLoS Med
.
2016
;
13
(
3
):
e1001977
28
O’Brien
MA
,
Uyeki
TM
,
Shay
DK
, et al
.
Incidence of outpatient visits and hospitalizations related to influenza in infants and young children
.
Pediatrics
.
2004
;
113
(
3, pt 1
):
585
593
29
Thompson
WW
,
Shay
DK
,
Weintraub
E
, et al
.
Mortality associated with influenza and respiratory syncytial virus in the United States
.
JAMA
.
2003
;
289
(
2
):
179
186
30
Thompson
WW
,
Shay
DK
,
Weintraub
E
, et al
.
Influenza-associated hospitalizations in the United States
.
JAMA
.
2004
;
292
(
11
):
1333
1340
31
Opel
DJ
,
Taylor
JA
,
Mangione-Smith
R
, et al
.
Validity and reliability of a survey to identify vaccine-hesitant parents
.
Vaccine
.
2011
;
29
(
38
):
6598
6605
32
Brewer
NT
,
Chapman
GB
,
Rothman
AJ
,
J
,
Kempe
A
.
Increasing vaccination: putting psychological science into action
.
Psychol Sci Public Interest
.
2017
;
18
(
3
):
149
207
33
Hendrix
KS
,
Sturm
LA
,
Zimet
GD
,
Meslin
EM
.
Ethics and childhood vaccination policy in the United States
.
Am J Public Health
.
2016
;
106
(
2
):
273
278
34
MacDonald
NE
;
SAGE Working Group on Vaccine Hesitancy
.
Vaccine hesitancy: definition, scope and determinants
.
Vaccine
.
2015
;
33
(
34
):
4161
4164
35
Gust
DA
,
Darling
N
,
Kennedy
A
,
Schwartz
B
.
Parents with doubts about vaccines: which vaccines and reasons why
.
Pediatrics
.
2008
;
122
(
4
):
718
725
36
Smith
PJ
,
Chu
SY
,
Barker
LE
.
Children who have received no vaccines: who are they and where do they live?
Pediatrics
.
2004
;
114
(
1
):
187
195
37
Gilkey
MB
,
McRee
AL
,
Brewer
NT
.
Forgone vaccination during childhood and adolescence: findings of a statewide survey of parents
.
Prev Med
.
2013
;
56
(
3–4
):
202
206
38
Wong
NC
.
“Vaccinations are safe and effective”: inoculating positive HPV vaccine attitudes against antivaccination attack messages
.
Commun Rep
.
2016
;
29
(
3
):
127
138
39
Samsky
MD
,
Lin
L
,
Greene
SJ
, et al
.
Patient perceptions and familiarity with medical therapy for heart failure [published online ahead of print November 17, 2019]
.
JAMA Cardiol
.
doi: 10.1001/jamacardio.2019.4987
40
Ishida
JH
,
Wong
PO
,
Cohen
BE
,
Vali
M
,
Steigerwald
S
,
Keyhani
S
.
Substitution of marijuana for opioids in a national survey of US adults
.
PLoS One
.
2019
;
14
(
10
):
e0222577
41
Schoenborn
NL
,
Crossnohere
NL
,
Bridges
JFP
,
Pollack
CE
,
Pilla
SJ
,
Boyd
CM
.
Patient perceptions of diabetes guideline frameworks for individualizing glycemic targets [published online ahead of print September 16, 2019]
.
JAMA Intern Med
.
doi: 10.1001/jamainternmed.2019.3806
42
Herbenick
D
,
Eastman-Mueller
H
,
Fu
TC
,
Dodge
B
,
Ponander
K
,
Sanders
SA
.
Women’s sexual satisfaction, communication, and reasons for (No longer) faking orgasm: findings from a U.S. Probability sample
.
Arch Sex Behav
.
2019
;
48
(
8
):
2461
2472
43
Flynn
KE
,
Whicker
D
,
Lin
L
,
Cusatis
R
,
Nyitray
A
,
Weinfurt
KP
.
Sexual orientation and patient-provider communication about sexual problems or concerns among US adults
.
J Gen Intern Med
.
2019
;
34
(
11
):
2505
2511
44
Schoenborn
NL
,
Crossnohere
NL
,
Janssen
EM
, et al
.
Examining generalizability of older adults’ preferences for discussing cessation of screening colonoscopies in older adults with low health literacy
.
J Gen Intern Med
.
2019
;
34
(
11
):
2512
2519
45
Karras
E
,
Stokes
CM
,
Warfield
SC
,
Barth
SK
,
Bossarte
RM
.
A randomized controlled trial of public messaging to promote safe firearm storage among U.S. military veterans
.
Soc Sci Med
.
2019
;
241
:
112205
46
Fu
TC
,
Hensel
DJ
,
Beckmeyer
JJ
,
Dodge
B
,
Herbenick
D
.
Considerations in the measurement and reporting of withdrawal: findings from the 2018 national survey of sexual health and behavior
.
J Sex Med
.
2019
;
16
(
8
):
1170
1177
47
Herbenick
D
,
Bartelt
E
,
Fu
TJ
, et al
.
Feeling scared during sex: findings from a US probability sample of women and men ages 14 to 60
.
J Sex Marital Ther
.
2019
;
45
(
5
):
424
439
48
Fernandez Lynch
H
,
Joffe
S
,
Thirumurthy
H
,
Xie
D
,
Largent
EA
.
Association between financial incentives and participant deception about study eligibility
.
JAMA Netw Open
.
2019
;
2
(
1
):
e187355
49
Larson
HJ
,
Jarrett
C
,
Schulz
WS
, et al;
SAGE Working Group on Vaccine Hesitancy
.
Measuring vaccine hesitancy: the development of a survey tool
.
Vaccine
.
2015
;
33
(
34
):
4165
4175
50
Report of the SAGE working group on vaccine hesitancy
.
2014
.
51
Opel
DJ
,
Mangione-Smith
R
,
Taylor
JA
, et al
.
Development of a survey to identify vaccine-hesitant parents: the Parent Attitudes about Childhood Vaccines survey
.
Hum Vaccin
.
2011
;
7
(
4
):
419
425
52
Opel
DJ
,
Taylor
JA
,
Zhou
C
,
Catz
S
,
Myaing
M
,
Mangione-Smith
R
.
The relationship between Parent Attitudes about Childhood Vaccines survey scores and future child immunization status: a validation study
.
JAMA Pediatr
.
2013
;
167
(
11
):
1065
1071
53
Shapiro
GK
,
Tatar
O
,
Dube
E
, et al
.
The Vaccine Hesitancy Scale: psychometric properties and validation
.
Vaccine
.
2018
;
36
(
5
):
660
667
54
Shapiro
GK
,
Tatar
O
,
Amsel
R
, et al
.
Using an integrated conceptual framework to investigate parents’ HPV vaccine decision for their daughters and sons
.
Prev Med
.
2018
;
116
:
203
210
55
Domek
GJ
,
O’Leary
ST
,
Bull
S
, et al
.
Measuring vaccine hesitancy: field testing the WHO SAGE working group on vaccine hesitancy survey tool in Guatemala
.
Vaccine
.
2018
;
36
(
35
):
5273
5281
56
Miko
D
,
Costache
C
,
Colosi
HA
,
Neculicioiu
V
,
Colosi
IA
.
Qualitative assessment of vaccine hesitancy in Romania
.
Medicina (Kaunas)
.
2019
;
55
(
6
):
E282
57
Larson
HJ
,
de Figueiredo
A
,
Xiahong
Z
, et al
.
The state of vaccine confidence 2016: global insights through a 67-country survey
.
EBioMedicine
.
2016
;
12
:
295
301
58
Luyten
J
,
Bruyneel
L
,
van Hoek
AJ
.
Assessing vaccine hesitancy in the UK population using a generalized vaccine hesitancy survey instrument
.
Vaccine
.
2019
;
37
(
18
):
2494
2501
59
Chyung
SY
,
Roberts
K
,
Swanson
I
,
Hankinson
A
.
Evidence‐based survey design: the use of a midpoint on the Likert scale
.
Perform Improv
.
2017
;
56
(
10
):
15
23
60
Larson
HJ
,
Jarrett
C
,
Eckersberger
E
,
Smith
DM
,
Paterson
P
.
Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007-2012
.
Vaccine
.
2014
;
32
(
19
):
2150
2159
61
Henrikson
NB
,
Anderson
ML
,
Opel
DJ
,
Dunn
J
,
Marcuse
EK
,
Grossman
DC
.
Longitudinal trends in vaccine hesitancy in a cohort of mothers surveyed in Washington state, 2013–2015
.
Public Health Rep
.
2017
;
132
(
4
):
451
454
62
Hofstetter
AM
,
Simon
TD
,
Lepere
K
, et al
.
Parental vaccine hesitancy and declination of influenza vaccination among hospitalized children
.
Hosp Pediatr
.
2018
;
8
(
10
):
628
635
63
Strelitz
B
,
Gritton
J
,
Klein
EJ
, et al
.
Parental vaccine hesitancy and acceptance of seasonal influenza vaccine in the pediatric emergency department
.
Vaccine
.
2015
;
33
(
15
):
1802
1807
64
Williams
SE
,
Morgan
A
,
Opel
D
,
Edwards
K
,
Weinberg
S
,
Rothman
R
.
Screening tool predicts future underimmunization among a pediatric practice in Tennessee
.
Clin Pediatr (Phila)
.
2016
;
55
(
6
):
537
542
65
Cunningham
RM
,
Minard
CG
,
Guffey
D
,
Swaim
LS
,
Opel
DJ
,
Boom
JA
.
Prevalence of vaccine hesitancy among expectant mothers in Houston, Texas
.
.
2018
;
18
(
2
):
154
160
66
Grohskopf
LA
,
Sokolow
LZ
,
Broder
KR
, et al
.
Prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices - United States, 2016–17 influenza season
.
MMWR Recomm Rep
.
2016
;
65
(
5
):
1
54
67
Zimmerman
RK
,
Nowalk
MP
,
Chung
J
, et al
.
2014–2015 influenza vaccine effectiveness in the United States by vaccine type
.
Clin Infect Dis
.
2016
;
63
(
12
):
1564
1573
68
Belongia
EA
,
Kieke
BA
,
Donahue
JG
, et al;
Marshfield Influenza Study Group
.
Effectiveness of inactivated influenza vaccines varied substantially with antigenic match from the 2004-2005 season to the 2006–2007 season
.
J Infect Dis
.
2009
;
199
(
2
):
159
167
69
Welch
A
.
This year’s flu vaccine may only be 10% effective, experts warn. CBS News. December 5, 2017
.
70
Scutti
S
.
Flu Season is here, and experts are already concerned. CNN. November 9, 2017
.
71
Sun
L
.
This season’s flu vaccine is only 36 percent effective, but experts say you should still get it. The Washington Post. February 15, 2018
.
72
Shui
IM
,
Weintraub
ES
,
Gust
DA
.
Parents concerned about vaccine safety: differences in race/ethnicity and attitudes
.
Am J Prev Med
.
2006
;
31
(
3
):
244
251
73
Gust
DA
,
Woodruff
R
,
Kennedy
A
,
Brown
C
,
Sheedy
K
,
Hibbs
B
.
Parental perceptions surrounding risks and benefits of immunization
.
Semin Pediatr Infect Dis
.
2003
;
14
(
3
):
207
212
74
Centers for Disease Control and Prevention
. Influenza vaccination coverage: FluVaxView.
2018
. Available at: https://www.cdc.gov/flu/fluvaxview/index.htm. Accessed November 26, 2019
75
Edwards
KM
,
Hackell
JM
;
Committee on Infectious Diseases, The Committee on Practice and Ambulatory Medicine
.
Countering vaccine hesitancy
.
Pediatrics
.
2016
;
138
(
3
):
e20162146
76
Salmon
DA
,
Dudley
MZ
,
Glanz
JM
,
Omer
SB
.
Vaccine hesitancy: causes, consequences, and a call to action
.
Am J Prev Med
.
2015
;
49
(
6,
suppl 4
):
S391
S398
77
Cataldi
JR
,
Kerns
ME
,
O’Leary
ST
.
Evidence-based strategies to increase vaccination uptake: a review
.
Curr Opin Pediatr
.
2020
;
32
(
1
):
151
159
78
Opel
DJ
,
Heritage
J
,
Taylor
JA
, et al
.
The architecture of provider-parent vaccine discussions at health supervision visits
.
Pediatrics
.
2013
;
132
(
6
):
1037
1046
79
Brewer
NT
,
Hall
ME
,
Malo
TL
,
Gilkey
MB
,
Quinn
B
,
Lathren
C
.
Announcements versus conversations to improve HPV vaccination coverage: a randomized trial
.
Pediatrics
.
2017
;
139
(
1
):
e20161764
80
Opel
DJ
,
Mangione-Smith
R
,
Robinson
JD
, et al
.
The influence of provider communication behaviors on parental vaccine acceptance and visit experience
.
Am J Public Health
.
2015
;
105
(
10
):
1998
2004
81
Opel
DJ
,
Zhou
C
,
Robinson
JD
, et al
.
Impact of childhood vaccine discussion format over time on immunization status
.
.
2018
;
18
(
4
):
430
436
82
The Community Guide
.
Vaccination programs: standing orders
.
83
The Community Guide
.
Vaccination programs: client reminder and recall systems
.
2015
.
84
Fogarty
KJ
,
Massoudi
MS
,
Gallo
W
,
Averhoff
FM
,
Yusuf
H
,
Fishbein
D
.
Vaccine coverage levels after implementation of a middle school vaccination requirement, Florida, 1997–2000
.
Public Health Rep
.
2004
;
119
(
2
):
163
169
85
Bugenske
E
,
Stokley
S
,
Kennedy
A
,
Dorell
C
.
Middle school vaccination requirements and adolescent vaccination coverage
.
Pediatrics
.
2012
;
129
(
6
):
1056
1063
86
Davis
MM
,
Gaglia
MA
.
Associations of daycare and school entry vaccination requirements with varicella immunization rates
.
Vaccine
.
2005
;
23
(
23
):
3053
3060
87
Lopez
AS
,
Kolasa
MS
,
Seward
JF
.
Status of school entry requirements for varicella vaccination and vaccination coverage 11 years after implementation of the varicella vaccination program
.
J Infect Dis
.
2008
;
197
(
suppl 2
):
S76
S81
88
Morita
JY
,
Ramirez
E
,
Trick
WE
.
Effect of a school-entry vaccination requirement on racial and ethnic disparities in hepatitis B immunization coverage levels among public school students
.
Pediatrics
.
2008
;
121
(
3
).
89
Simpson
JE
,
Hills
RA
,
Allwes
D
,
Rasmussen
L
.
Uptake of meningococcal vaccine in Arizona schoolchildren after implementation of school-entry immunization requirements
.
Public Health Rep
.
2013
;
128
(
1
):
37
45
90
Thompson
EL
,
Livingston
MD
III
,
Daley
EM
,
Zimet
GD
.
Human papillomavirus vaccine initiation for adolescents following Rhode Island’s school-entry requirement, 2010–2016
.
Am J Public Health
.
2018
;
108
(
10
):
1421
1423
91
Baughman
AL
,
Williams
WW
,
Atkinson
WL
,
Cook
LG
,
Collins
M
.
The impact of college prematriculation immunization requirements on risk for measles outbreaks
.
JAMA
.
1994
;
272
(
14
):
1127
1132
92
Duggirala
HJ
,
Hassig
SE
,
Santana
S
,
Rice
J
.
Evaluation of a hepatitis A immunization program
.
Pediatr Infect Dis J
.
2005
;
24
(
11
):
974
978
93
Robbins
KB
,
Brandling-Bennett
D
,
Hinman
AR
.
Low measles incidence: association with enforcement of school immunization laws
.
Am J Public Health
.
1981
;
71
(
3
):
270
274
94
Delamater
PL
,
Pingali
SC
,
Buttenheim
AM
,
Salmon
DA
,
Klein
NP
,
Omer
SB
.
Elimination of nonmedical immunization exemptions in California and school-entry vaccine status
.
Pediatrics
.
2019
;
143
(
6
):
e20183301
95
Omer
SB
,
Porter
RM
,
Allen
K
,
Salmon
DA
,
Bednarczyk
RA
.
Trends in kindergarten rates of vaccine exemption and state-level policy, 2011–2016
.
Open Forum Infect Dis
.
2017
;
5
(
2
):
ofx244
96
Dempsey
AF
,
Pyrznawoski
J
,
Lockhart
S
, et al
.
Effect of a health care professional communication training intervention on adolescent human papillomavirus vaccination: a cluster randomized clinical trial
.
JAMA Pediatr
.
2018
;
172
(
5
):
e180016
97
Perkins
RB
,
Zisblatt
L
,
Legler
A
,
Trucks
E
,
Hanchate
A
,
Gorin
SS
.
Effectiveness of a provider-focused intervention to improve HPV vaccination rates in boys and girls
.
Vaccine
.
2015
;
33
(
9
):
1223
1229
98
Daley
MF
,
Narwaney
KJ
,
Shoup
JA
,
Wagner
NM
,
Glanz
JM
.
Addressing parents’ vaccine concerns: a randomized trial of a social media intervention
.
Am J Prev Med
.
2018
;
55
(
1
):
44
54
99
Glanz
JM
,
Wagner
NM
,
Narwaney
KJ
, et al
.
Web-based social media intervention to increase vaccine acceptance: a randomized controlled trial
.
Pediatrics
.
2017
;
140
(
6
):
e20171117
100
Schoeppe
J
,
A
,
Melton
M
, et al
.
The Immunity Community: a community engagement strategy for reducing vaccine hesitancy
.
Health Promot Pract
.
2017
;
18
(
5
):
654
661
101
Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases
.
Estimated influenza illness, medical visits, and hospitalizations averted by vaccination
.
Available at: https://www.cdc.gov/flu/vaccines-work/burden-averted.htm. Accessed November 26, 2019

Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Zimet received an honorarium from Sanofi Pasteur for work on the Adolescent Immunization Initiative and consulting fees and travel support from Merck related to human papillomavirus vaccination; Dr Humiston received an honorarium from Sanofi Pasteur for work on the Clinical Immunization Collaborative Virtual Advisory Board; the other authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Dr Zimet received an honorarium from Sanofi Pasteur and consulting fees and travel support from Merck. Dr Humiston received an honorarium from Sanofi Pasteur; the other authors have indicated they have no financial relationships relevant to this article to disclose.