{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,2]],"date-time":"2026-05-02T11:10:59Z","timestamp":1777720259394,"version":"3.51.4"},"reference-count":46,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T00:00:00Z","timestamp":1777420800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Vaccines"],"abstract":"<jats:p>Background\/Objectives: Seasonal influenza vaccination is pivotal for protecting high-risk populations, including those with chronic health conditions (CHCs), from severe complications and outcomes. This study aims to describe the sociodemographic characteristics of unvaccinated children (6 months\u201317 years old) with CHCs, the reasons why vaccine hesitant parents chose not to vaccinate their children, and the factors associated with seasonal influenza non-vaccination among these children. Methods: This cross-sectional analysis used a sub-sample from the 2023 Childhood COVID-19 Immunization Coverage Survey, which captured data between April and July 2023. Parent and child characteristics were explored, using frequencies and proportions. Weighted unadjusted, partially adjusted (with child age and sex at birth), and fully adjusted multivariable quasi-Poisson models were designed to identify socio-demographic factors associated with seasonal influenza non-vaccination. Results: A total of 649\/1187 (55%) children with CHCs were unvaccinated against influenza during the 2022\u20132023 influenza season. Vaccine hesitant parents with unvaccinated children expressed concerns with vaccine effectiveness (39.1%) and safety (27.5%), as did parents who refused vaccination for their child (56.1% and 35.8%, respectively). Unvaccinated parents (RR: 4.549, 99% CI: 4.480, 4.619) and parents with low household income (RR: 1.428, 99% CI: 1.400, 1.456) were more likely to have unvaccinated children, whereas children who received an annual influenza vaccine (RR: 0.097, 99% CI: 0.094, 0.100) and did not have a disability (RR: 0.913, 99% CI: 0.904, 0.922) had a lower likelihood of non-vaccination. Conclusions: These findings highlight the need for renewed messaging and educational resources targeting vaccine hesitancy and misinformation prevalent among parents with vulnerable youth.<\/jats:p>","DOI":"10.3390\/vaccines14050396","type":"journal-article","created":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T09:46:11Z","timestamp":1777455971000},"page":"396","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Factors Associated with Seasonal Influenza Non-Vaccination Among Children with Chronic Health Conditions in Canada: A Cross-Sectional Study"],"prefix":"10.3390","volume":"14","author":[{"given":"Arlanna","family":"Pugh","sequence":"first","affiliation":[{"name":"Vaccine Coverage and Effectiveness Surveillance Division, Centre for Immunization surveillance and Programs, Infectious Diseases and Vaccination Programs Branch, Public Health Agency of Canada, Ottawa, ON K1A 0K9, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sailly","family":"Dave","sequence":"additional","affiliation":[{"name":"Vaccine Coverage and Effectiveness Surveillance Division, Centre for Immunization surveillance and Programs, Infectious Diseases and Vaccination Programs Branch, Public Health Agency of Canada, Ottawa, ON K1A 0K9, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-1351-5714","authenticated-orcid":false,"given":"Marwa","family":"Ebrahim","sequence":"additional","affiliation":[{"name":"Vaccine Coverage and Effectiveness Surveillance Division, Centre for Immunization surveillance and Programs, Infectious Diseases and Vaccination Programs Branch, Public Health Agency of Canada, Ottawa, ON K1A 0K9, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Julie A.","family":"Laroche","sequence":"additional","affiliation":[{"name":"Vaccine Coverage and Effectiveness Surveillance Division, Centre for Immunization surveillance and Programs, Infectious Diseases and Vaccination Programs Branch, Public Health Agency of Canada, Ottawa, ON K1A 0K9, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,29]]},"reference":[{"key":"ref_1","unstructured":"World Health Organization (2026, April 02). Vaccines Against Influenza: WHO Position Paper\u2014Weekly Epidemiological Record. Available online: https:\/\/www.who.int\/publications\/i\/item\/who-wer9719."},{"key":"ref_2","unstructured":"World Health Organization (2024, July 11). The Burden of Influenza. Available online: https:\/\/www.who.int\/news-room\/feature-stories\/detail\/the-burden-of-influenza."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"605","DOI":"10.1542\/pir.2023-005962","article-title":"Influenza in Children and Adolescents: Epidemiology, Management, and Prevention","volume":"44","author":"Wolf","year":"2023","journal-title":"Pediatr. Rev."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1111\/irv.12633","article-title":"Impact of Influenza on Hospitalization Rates in Children with a Range of Chronic Lung Diseases","volume":"13","author":"Homaira","year":"2019","journal-title":"Influenza Other Respir. Viruses"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"583","DOI":"10.1097\/INF.0000000000001083","article-title":"The Timeline of Influenza Virus Shedding in Children and Adults in a Household Transmission Study of Influenza in Managua, Nicaragua","volume":"35","author":"Ng","year":"2016","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1265","DOI":"10.3201\/eid1608.091918","article-title":"Correlation of Pandemic (H1N1) 2009 Viral Load with Disease Severity and Prolonged Viral Shedding in Children","volume":"16","author":"Li","year":"2010","journal-title":"Emerg. Infect. Dis."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"413","DOI":"10.14745\/ccdr.v49i10a02","article-title":"National Influenza Annual Report, Canada, 2022\u20132023: Canada\u2019s First Fall Epidemic since the 2019\u20132020 Season","volume":"49","author":"Schmidt","year":"2023","journal-title":"Can. Commun. Dis. Rep."},{"key":"ref_8","unstructured":"National Advisory Committee on Immunization (NACI) (2024, August 19). Influenza Vaccines: Canadian Immunization Guide. Available online: https:\/\/www.canada.ca\/en\/public-health\/services\/publications\/healthy-living\/canadian-immunization-guide-part-4-active-vaccines\/page-10-influenza-vaccine.html#a13."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1001\/jama.2010.250","article-title":"Effect of Influenza Vaccination of Children on Infection Rates in Hutterite Communities: A randomized trial","volume":"303","author":"Loeb","year":"2010","journal-title":"JAMA"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Wang, B., Russell, M.L., Moss, L., Fonseca, K., Earn, D.J.D., Aoki, F., Horsman, G., Van Caeseele, P., Chokani, K., and Vooght, M. (2016). Effect of Influenza Vaccination of Children on Infection Rate in Hutterite Communities: Follow-up Study of a Randomized Trial. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0167281"},{"key":"ref_11","unstructured":"Public Health Agency of Canada (2026, April 02). Childhood COVID-19 Immunization Coverage Survey (CCICS): 2022 Results, Available online: https:\/\/www.canada.ca\/en\/public-health\/services\/immunization-vaccines\/vaccination-coverage\/childhood-covid-19-immunization-coverage-survey-2022-results.html."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"874","DOI":"10.1007\/s11524-006-9084-z","article-title":"Beliefs and Attitudes about Influenza Immunization among Parents of Children with Chronic Medical Conditions over a Two-Year Period","volume":"83","author":"Lin","year":"2006","journal-title":"J. Urban Health"},{"key":"ref_13","first-page":"148","article-title":"Parental Perspectives on Influenza Vaccination of Children with Chronic Medical Conditions Background: Minorities and Those Living in the Inner City Have","volume":"98","author":"Lin","year":"2006","journal-title":"J. Natl. Med. Assoc."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e197","DOI":"10.1097\/INF.0000000000001550","article-title":"Factors Determining the Uptake of Influenza Vaccination among Children with Chronic Conditions","volume":"36","author":"Chau","year":"2017","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Schmid, P., Rauber, D., Betsch, C., Lidolt, G., and Denker, M.L. (2017). Barriers of Influenza Vaccination Intention and Behavior\u2014A Systematic Review of Influenza Vaccine Hesitancy, 2005\u20132016. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0170550"},{"key":"ref_16","unstructured":"Public Health Agency of Canada (2026, April 02). 2023 Childhood COVID-19 Immunization Coverage Survey Methodological Report, Available online: https:\/\/epe.lac-bac.gc.ca\/100\/200\/301\/pwgsc-tpsgc\/por-ef\/public_health_agency_canada\/2023\/130-22-e\/POR130-22-report.pdf."},{"key":"ref_17","unstructured":"Government of Canada (2023, September 24). Immunization of Persons with Chronic Diseases: Canadian Immunization Guide, Available online: https:\/\/www.canada.ca\/en\/public-health\/services\/publications\/healthy-living\/canadian-immunization-guide-part-3-vaccination-specific-populations\/page-7-immunization-persons-with-chronic-diseases.html."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1016\/j.acap.2010.01.005","article-title":"Techniques for Handling Missing Data in Secondary Analyses of Large Surveys","volume":"10","author":"Langkamp","year":"2010","journal-title":"Acad. Pediatr."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1186\/2193-1801-2-222","article-title":"Principled Missing Data Methods for Researchers","volume":"2","author":"Dong","year":"2013","journal-title":"Springerplus"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2308","DOI":"10.1016\/j.sapharm.2021.03.009","article-title":"Missing Data in Surveys: Key Concepts, Approaches, and Applications","volume":"18","author":"Mirzaei","year":"2022","journal-title":"Res. Soc. Adm. Pharm."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Veerapandian, R., Snyder, J.D., and Samarasinghe, A.E. (2018). Influenza in Asthmatics: For Better or for Worse?. Front. Immunol., 9.","DOI":"10.3389\/fimmu.2018.01843"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"458","DOI":"10.1111\/j.1398-9995.2010.02505.x","article-title":"Viruses and Bacteria in Acute Asthma Exacerbations\u2014A GA 2LEN-DARE* Systematic Review","volume":"66","author":"Papadopoulos","year":"2011","journal-title":"Allergy"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1199","DOI":"10.1016\/j.jaci.2006.08.032","article-title":"Asthma, Influenza, and Vaccination","volume":"118","author":"Glezen","year":"2006","journal-title":"J. Allergy Clin. Immunol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"702","DOI":"10.1093\/aje\/kwh090","article-title":"A Modified Poisson Regression Approach to Prospective Studies with Binary Data","volume":"159","author":"Zou","year":"2004","journal-title":"Am. J. Epidemiol."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Barros, A.J., and Hirakata, V.N. (2003). Alternatives for Logistic Regression in Cross-Sectional Studies: An Empirical Comparison of Models That Directly Estimate the Prevalence Ratio. BMC Med. Res. Methodol., 3.","DOI":"10.1186\/1471-2288-3-21"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Fonseca Martinez, B.A., Leotti, V.B., de Silva, G.S.e., Nunes, L.N., Machado, G., and Corbellini, L.G. (2017). Odds Ratio or Prevalence Ratio? An Overview of Reported Statistical Methods and Appropriateness of Interpretations in Cross-Sectional Studies with Dichotomous Outcomes in Veterinary Medicine. Front. Vet. Sci., 4.","DOI":"10.3389\/fvets.2017.00193"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1055\/s-0038-1633907","article-title":"Different Methods to Calculate Effect Estimates in Cross-Sectional Studies","volume":"43","author":"Behrens","year":"2004","journal-title":"Methods Inf. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1","DOI":"10.18637\/jss.v009.i08","article-title":"Analysis of Complex Survey Samples","volume":"9","author":"Lumley","year":"2004","journal-title":"J. Stat. Softw."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1351","DOI":"10.1038\/s41416-020-1019-z","article-title":"Let the Question Determine the Methods: Descriptive Epidemiology Done Right","volume":"123","author":"Conroy","year":"2020","journal-title":"Br. J. Cancer"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"6364","DOI":"10.1016\/j.vaccine.2014.06.044","article-title":"Prevalence and Determinants of Influenza Vaccine Coverage at Tertiary Pediatric Hospitals","volume":"32","author":"Newcombe","year":"2014","journal-title":"Vaccine"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"6545","DOI":"10.1016\/j.vaccine.2020.08.008","article-title":"Influenza Vaccination Coverage among Adults with Diabetes, United States, 2007\u201308 through 2017\u201318 Seasons","volume":"38","author":"Hung","year":"2020","journal-title":"Vaccine"},{"key":"ref_32","unstructured":"Public Health Agency of Canada (2026, April 02). Childhood COVID-19 Immunization Coverage Survey (CCICS): 2023 Results, Available online: https:\/\/www.canada.ca\/en\/public-health\/services\/immunization-vaccines\/vaccination-coverage\/childhood-covid-19-immunization-coverage-survey-2023-results.html."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e268","DOI":"10.1097\/INF.0000000000001579","article-title":"Influenza Vaccination Rate and Reasons for Nonvaccination in Children with Cardiac Disease","volume":"36","author":"Livni","year":"2017","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"8138","DOI":"10.1016\/j.vaccine.2018.09.039","article-title":"Influenza Vaccination: Uptake and Associations in a Cross-Sectional Study of Children with Special Risk Medical Conditions","volume":"36","author":"Tuckerman","year":"2018","journal-title":"Vaccine"},{"key":"ref_35","unstructured":"World Health Organization (2024, August 20). Influenza Vaccines. Available online: https:\/\/www.emro.who.int\/health-topics\/influenza\/influenza-vaccines.html."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Tuckerman, J., Crawford, N.W., and Marshall, H.S. (2020). Disparities in Parental Awareness of Children\u2019s Seasonal Influenza Vaccination Recommendations and Influencers of Vaccination. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0230425"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"3303","DOI":"10.1016\/j.vaccine.2019.04.083","article-title":"Knowledge, Attitudes and Practices Related to Influenza Illness and Vaccination in Children: Role of Awareness Campaigns in Changing Parents\u2019 Attitudes toward Influenza Vaccination in Jordan","volume":"37","author":"Awad","year":"2019","journal-title":"Vaccine"},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Pandolfi, E., Marino, M.G., Carloni, E., Romano, M., Gesualdo, F., Borgia, P., Carloni, R., Guarino, A., Giannattasio, A., and Tozzi, A.E. (2012). The Effect of Physician\u2019s Recommendation on Seasonal Influenza Immunization in Children with Chronic Diseases. BMC Public Health, 12, Available online: https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC3585468\/.","DOI":"10.1186\/1471-2458-12-984"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1007\/s00431-020-03751-z","article-title":"Key Role of Pediatricians and Disease for Influenza Vaccination in Children with High-Risk Chronic Diseases","volume":"180","author":"Alauzet","year":"2021","journal-title":"Eur. J. Pediatr."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Fadl, N., Al Awaidy, S.T., Elshabrawy, A., Makhlouf, M.S.A.H., Ibrahim, S.A., Abdel-Rahman, S., Tookhy, N.A., Alsalmani, A., Al-Saeedi, M., and Al-Sawalha, I. (2023). Determinants of Parental Seasonal Influenza Vaccine Hesitancy in the Eastern Mediterranean Region: A Cross-Sectional Study. Front. Public Health, 11, Available online: https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC10086336\/.","DOI":"10.3389\/fpubh.2023.1132798"},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Al-Qerem, W., Jarab, A., Hammad, A., Alasmari, F., Ling, J., Al-Zayadneh, E., Al-Iede, M., Alazab, B., and Hajeer, L. (2023). Knowledge, Attitudes, and Practices of Influenza Vaccination among Parents of Children with Asthma: A Cross-Sectional Study. Vaccines, 11, Available online: https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC10301876\/.","DOI":"10.3390\/vaccines11061074"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"4161","DOI":"10.1016\/j.vaccine.2015.04.036","article-title":"Vaccine Hesitancy: Definition, Scope and Determinants","volume":"33","author":"MacDonald","year":"2015","journal-title":"Vaccine"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1001\/archpedi.159.10.986","article-title":"Missed Opportunities for Influenza Vaccination in Children with Chronic Medical Conditions","volume":"159","author":"Daley","year":"2005","journal-title":"Arch. Pediatr. Adolesc. Med."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Lind, C., Russell, M.L., Collins, R., MacDonald, J., Frank, C.J., and Davis, A.E. (2015). How Rural and Urban Parents Describe Convenience in the Context of School-Based Influenza Vaccination: A Qualitative Study. BMC Health Serv. Res., 15, Available online: https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC4307148\/.","DOI":"10.1186\/s12913-014-0663-5"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1080\/00380253.2025.2539348","article-title":"It\u2019s a Matter of Institutional Trust: Seasonal Childhood Vaccine Uptake During a Time of Mixed Messages in Alberta, Canada","volume":"67","author":"DeKeseredy","year":"2026","journal-title":"Sociol. Q."},{"key":"ref_46","unstructured":"Public Health Agency of Canada (2026, April 02). Childhood Seasonal Immunization Coverage Survey (CSICS): 2024 Results, Available online: https:\/\/www.canada.ca\/en\/public-health\/services\/immunization-vaccines\/vaccination-coverage\/childhood-seasonal-immunization-coverage-survey-2024-results.html."}],"container-title":["Vaccines"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-393X\/14\/5\/396\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T10:29:20Z","timestamp":1777458560000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-393X\/14\/5\/396"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,29]]},"references-count":46,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["vaccines14050396"],"URL":"https:\/\/doi.org\/10.3390\/vaccines14050396","relation":{},"ISSN":["2076-393X"],"issn-type":[{"value":"2076-393X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,29]]}}}