Barriers of Influenza Vaccination Intention and Behavior – A Systematic Review of Influenza Vaccine Hesitancy, 2005 – 2016

Abstract

BackgroundInfluenza vaccine hesitancy is a significant threat to global efforts to reduce the burden of seasonal and pandemic influenza. Potential barriers of influenza vaccination need to be identified to inform interventions to raise awareness, influenza vaccine acceptance and uptake.ObjectiveThis review aims to (1) identify relevant studies and extract individual barriers of seasonal and pandemic influenza vaccination for risk groups and the general public; and (2) map knowledge gaps in understanding influenza vaccine hesitancy to derive directions for further research and inform interventions in this area.MethodsThirteen databases covering the areas of Medicine, Bioscience, Psychology, Sociology and Public Health were searched for peer-reviewed articles published between the years 2005 and 2016. Following the PRISMA approach, 470 articles were selected and analyzed for significant barriers to influenza vaccine uptake or intention. The barriers for different risk groups and flu types were clustered according to a conceptual framework based on the Theory of Planned Behavior and discussed using the 4C model of reasons for non-vaccination.ResultsMost studies were conducted in the American and European region. Health care personnel (HCP) and the general public were the most studied populations, while parental decisions for children at high risk were under-represented. This study also identifies understudied concepts. A lack of confidence, inconvenience, calculation and complacency were identified to different extents as barriers to influenza vaccine uptake in risk groups.ConclusionMany different psychological, contextual, sociodemographic and physical barriers that are specific to certain risk groups were identified. While most sociodemographic and physical variables may be significantly related to influenza vaccine hesitancy, they cannot be used to explain its emergence or intensity. Psychological determinants were meaningfully related to uptake and should therefore be measured in a valid and comparable way. A compendium of measurements for future use is suggested as supporting information.

Factors associated with influenza vaccination among healthcare workers in acute care hospitals in Canada

“…34,35 Evaluations of programs targeting nurses suggest that multipronged approaches are necessary [36][37][38][39] to address the myriad reasons for vaccine hesitancy and refusal in this occupational group. 24,40 Lastly, in our study population, people identifying as Black had lower odds of being vaccinated against influenza compared with those with European heritage. Earlier findings of ethnicity's association with vaccine uptake have been contradictory.…”

“…It is likely necessary to tailor immunization programs differently to reach HCW at all levels of uptake, from refusers to those accepting influenza vaccine intermittently to those vaccinated annually. Reviews of the literature report that believing that influenza vaccine is effective, that influenza is highly contagious, and that prevention is important (including HCWs’ roles in transmission) are predictive of influenza vaccination . Further research is needed to determine how common concerns related to vaccine hesitancy in HCW (e.g vaccine safety and efficacy, perceived low risk of illness) are associated with the frequency of vaccine uptake in HCW working in settings with different vaccination policies and work cultures.…”

“…Although targeted educational strategies may be needed to resolve misconceptions, immunization programs focusing solely on education result in only minimal increases in coverage rates . Evaluations of programs targeting nurses suggest that multipronged approaches are necessary to address the myriad reasons for vaccine hesitancy and refusal in this occupational group …”

Can the Health Belief Model and moral responsibility explain influenza vaccination uptake among nurses?

“…Several reasons for receiving and not receiving vaccination have been identified in the literatures. For example, studies have shown that the common reasons for not receiving vaccination among nurses included low levels of risk perception, concerns about side effects, questions about vaccine's effectiveness/safety, inconvenience in accessing vaccination, fear of pain, or negative reports from media (Ajenjo et al, 2010;Clark, Cowan, & Wortley, 2009;Corace et al, 2013;Giannattasio et al, 2015;Hollmeyer, Hayden, Poland, & Buchholz, 2009;Maltezou et al, 2008;Schmid, Rauber, Betsch, Lidolt, & Denker, 2017;Wang, Lee, & Lee, 2015;Weingarten, Riedinger, Bolton, Miles, & Ault, 1989;Zhang, While, & Norman, 2011). On the other hand, the reasons for receiving vaccination among nurses included protecting oneself, patient, family members, friends and children, to avoid sick leave, recommendation/mandate by employer, perception of vaccine's effectiveness/ safety and accessibility of vaccination (Haviari et al, 2015;Hollmeyer et al, 2009;Maltezou et al, 2008;Tosh, Jacobson, & Poland, 2010;Zhang et al, 2011).…”

Factors influencing the uptake of influenza vaccine vary among different groups in the hard‐to‐reach population

“…Lastly, vaccine hesitancy among parents could contribute to this finding, although this was not explored in this outreach program. A systematic review on vaccine hesitancy identified that the lack of recommendations from medical personnel to parents for children to receive vaccine, the lack of perceived benefit of vaccine by the parents, and inconvenience to receive vaccine have contributed to vaccine hesitancy among parents 24 . In future outreach programs, the strategies that could be explored to optimise delivery to this population include targeting sites where children under five years of age frequently attend (such as the maternal child health clinics), and providing education to parents about the availability and benefit of the vaccines to children of this age group.…”