inFLUencing Vaccine Uptake

Seasonal influenza causes significant morbidity and mortality for high risk groups such as seniors, young children, individuals with underlying medical conditions, pregnant women and indigenous people (Government of Canada, 2018a).  It is estimated that each year in Canada, 12,200 hospitalizations and 3,500 deaths are caused by influenza; ranking it among the top 10 infection related deaths in Canada (Government of Canada, 2018b). The good news, influenza is preventable with annual vaccination.

The Canadian goal is to have at least 80% of high-risk groups vaccinated for influenza each year but in 2016/17, we fell short with vaccination rates at 37% for those with medical conditions and 69% for Seniors; these results are comparable to the previous year (Government of Canada, 2018c).  Moreover, only 37% of the remaining healthy 18-65 year olds received vaccination, which means we are far from achieving suggested herd immunity rates of 80% in the population (Government of Canada, 2018c; Plans-Rubio, 2012).

Using the Social Ecological Model (SEM) as a tool, let’s look at all the ways in which we can improve uptake of the vaccine and prevent unnecessary deaths and hospitalizations.

What is the SEM?

The SEM is a theory-based framework for understanding the multifaceted and interactive effects of 5 levels of influence shown in Figure 1.  It takes into consideration the social determinants of health which are the circumstances into which people are born, live, work and have access to healthcare but then explores forces that influence behavior at each levels.

How could the SEM help to improve influenza vaccine uptake?

Kumar et al. (2012) discuss that previous research on influenza vaccine uptake has focused largely on intrapersonal determinants and were the first to use the SEM to examine influenza vaccination uptake in the United States (US).  While some of their findings are applicable in Canada, there are fundamental differences in program administration that will be discussed.  Adjusting for this, the Canadian SEM for influenza vaccination is presented in Figure 2.  Drawing upon multiple studies and articles, each level of influence was populated with concepts that could help promote vaccination.

Figure 2:  Proposed Social Ecological Model for Influenza Vaccination

Policy/Enabling Environment:

In Canada, a free publicly funded universal influenza vaccine is provided in all provinces with the exclusion of British Columbia, Quebec and New Brunswick (Government of Canada, 2018d). Since its introduction in Ontario 2012, there has been an increase in uptake and a decrease in the annual burden of disease (Jeffery et al., 2008).  Kumar et al. (2012) cite lack of insurance and stringent medicare requirements as a possible impediment to vaccine uptake in the US. Remaining provinces should consider adopting this model.

As of 2012, Pharmacists in Ontario (and other provinces) were authorized to start providing influenza vaccination and this too has shown promising effects on uptake (Ubelacker, 2016; Finnegan, 2018).  Public Health, by mandate, also offers community based free flu clinics.  Increasing the ease and access to vaccine improves opportunities to get vaccinated.

Young children are at high-risk for developing complications or death from influenza.  Pebody et al. (2015) found that vaccinating pre-school and school-age children demonstrated a reduction in disease for those that received the vaccine and those that did not.  Extending yearly vaccination programs into schools would certainly increase accessibility and should be considered as a policy change moving forward.


As proposed by Kumar (2012), this category is largely driven by perceived community risk.  As such, concepts such as closures of emergency departments may play a motivating factor for getting vaccinated (Davis, 2018). However, at this point, we have done a disservice upstream and need to take lessons learned to improve prevention strategies for the future.

Schools should also partner closely with Public Health to promote vaccination.  Recent email communication from the Peel Board of Health (Ontario) to parents outlined personal hygiene strategies to prevent the spread of flu, but failed to recommend vaccination (Promoli, 2018).  Communication to parents should also include the promotion of vaccination through flu clinics, pharmacies and healthcare providers.

Engagement of influencers such as churches has also been demonstrated to improve vaccination (Frank, Kietzman & Wallace, 2014).  Using education sessions and on-site vaccination, one faith-based program servicing African-American and Latino populations was able to improve vaccination rates (Frank et al., 2014).  As such, these organizations can be a powerful ally in supporting the delivery of evidence based information and preventing disease transmission while reaching large audiences.


Workplaces play a vital role in the promotion of influenza vaccination.  Healthcare facilities increase uptake by offering flu clinics, roving immunization carts and offering incentives.  Non-health care oriented businesses are also taking note that this may decrease sick time and improve the health of their staff.  As such, businesses hire companies to administer flu clinics on site (Richard, 2018).  With limited access to primary care physician, the addition of workplace clinics can improve uptake.

Physicians also play a significant role in educating patients and promoting influenza vaccination. One of the main factors that influence the intrapersonal level of the SEM is a physicians recommendation (Kumar, 2012).  A routine appointment presents an opportunity to offer vaccine.  It would be interesting to explore how often this is practiced and it may suggest an area for further research or policy development.

Some healthcare facilities routinely offer vaccine to admitted patients, residents or clients during influenza season and have policies to support this practice.  While an intuitive strategy, further work may be needed to understand reasons this is not adopted in all healthcare facilities.  Benefits of this approach would include uptake of vaccine as well as aid in the prevention of outbreaks in these settings.

During influenza outbreaks in healthcare facilities, policies that restrict unvaccinated staff from working also improve vaccination rates.  This practice has not been widely challenged and is incorporated into almost 90% of long-term care facilities in Ontario (Gruben, Siemieniuk & McGeer, 2014).  Application of this policy outside of healthcare settings would be challenging to implement as routine testing for influenza is not common in the community or other workplaces.

Several healthcare institutions in Ontario have enforced the “mask or vaccinate” policy during influenza season.  Legally, this has been a debatable practice (Gruben et al., 2014; Kim, 2016).  This policy requires individuals who have chosen not to vaccinate to wear a mask while working in patient care areas.  Recently, a decision was made in Ontario to overrule this policy by a labour arbitrator, requiring all hospitals whom participated to stop (Lupton, 2018).  While this can be seen as a setback, it reinforces that stronger messaging and education needs to continue.

Attempting to make the influenza vaccination a mandatory requirement for employment has not yet been directly challenged (Kim, 2016).  Gruben et al. (2014) cite multiple research studies that confirm vaccination rates for this group remain below 50% (Public Health Ontario n.d.; Alberta Health Services, 2013) and with evidence to support vaccination of healthcare workers is associated with improved patient outcomes, experts are now recommending that this be a condition of service (Bryce et al., 2012).  Unfortunately, this has not gained widespread adoption and should be considered for the future.


People are more likely to receive influenza vaccine if they have friends and family that ascribe to the same (Kumar, 2012). This can be a bit more challenging to study and Kumar (2012) admits that no studies to this effect have been done.  Social media has also become an easy tool used to share powerful stories that may compel followers to get vaccinated (Promoli, n.d.).

At Sunnybrook Health Sciences Centre (SHSC) in Ontario, staff working on patient care units are engaged in short dedicated weekly huddles to discuss quality improvement initiatives to improve patient safety.  Influenza vaccination is topical, and discussions can be facilitated in combination with an immunization cart.   Observing friends and colleagues roll up their sleeves may serve to promote uptake of the vaccine in this environment.


Campaigns promoting influenza vaccination are typically geared to influence a person’s decision to get vaccinated.  Addressing intrapersonal concerns such as the perceived risk of getting the flu, vaccine safety and options for vaccine administration may be important as these are cited as areas that affect personal decisions (Kumar, 2012).   In 2016, Buchan and Kwong, reviewed trends in influenza vaccine coverage and vaccine hesitancy in Canada from 2016/7 to 2013/14.  They found that 80% of individuals who did not receive the vaccine felt that it was “unnecessary”.  Further work is still needed to understand why influenza vaccination is unnecessary or address gaps in knowledge.  Future campaigns should consider these findings and use innovative ways to deliver messaging.

In conclusion, using the SEM, we are able to explore 5 different levels of influence for influenza vaccination.  Providing free universal vaccine and improved access to immunization appears to play a significant role in uptake but not enough to stand alone.  Focusing on all levels of influence is vital to bring vaccination rates to new heights.


Alberta Health Services.  (2013).  Alberta respiratory virus surveillance report: update for flu weeks 31-34: (Jul. 28-Aug.24, 2013).  Retrieved from       surv-resp-virus-2013-08-29.pdf

Bryce, E., Embree, J., Evans, G., Johnston, L., Katz, K., McGeer, A., Moore, D., Roth, V., Simor, A., Suh, K,Vearncombe, M. (2012). AMMI canada position paper: 2012 mandatory influenza immunization of health care workers. Canadian Journal of Infectious Diseases and Medical Microbiology , Vol 23, Iss 4, Pp e93-e95 (2012), (4), e93. doi:10.1155/2012/756824

Buchan, S. A., & Kwong, J. C. (2016). Trends in influenza vaccine coverage and vaccine hesitancy in canada, 2006/07 to 2013/14: Results from cross-sectional survey data. CMAJ Open,4(3), E455-E462. doi:10.9778/cmajo.20160050

Davis, G. (2018, March 20).  Influenza outbreak declared at Campbellford Memorial hospital.  Global News.  Retrieved from

Finnegan, G. (2018, May 22).  Does pharmacy vaccination increase overall uptake? [blog post]. Retrieved from

Frank, J. C., Kietzman, K. G., Wallace, S. P. (2014).  Bringing it to the community: Successful programs that increase the use of clinical preventative services by vulnerable older populations.  Retrieved from UCLA

Government of Canada.  (May 1, 2018a).  Canadian immunization guide chapter on influenza and statement on seasonal influenza vaccine for 2018–2019.  Retrieved from

Government of Canada. (October 19, 2018b).  Flu (influenza): For health professionals.  Retrieved from

Government of Canada.  (February 19, 2018c). 2016/2017 Seasonal influenza (flu) vaccine coverage survey results.  Retrieved from

Government of Canada.  (September 12, 2018d).  Public funding for influenza vaccination by province/territory (as of September 2018).  Retrieved from

Gruben, V., Siemieniuk, R. A., & McGeer, A. (2014). Health care workers, mandatory influenza vaccination policies and the law. Canadian Medical Association Journal, (14), 1076. doi:10.1503/cmaj.140035

Jeffrey, C. K., Thérèse, A. S., Lim, J., Allison, J. M., Ross, E. G. U., Johansen, H., Douglas, G. M. (2008). The effect of universal influenza immunization on mortality and health care use. PLoS Medicine, Vol 5, Iss 10, p e211 (2008), (10), e211. doi:10.1371/journal.pmed.0050211

Kim, J. S. (2016). Masking your rights: Facemask requirements under mandatory influenza-vaccination policies violate privacy rights of health care workers [comments]. San Diego Law Review, 427. Retrieved from

Kumar, S., Quinn, S. C., Kim, K. H., Musa, D., Hilyard, K. M., & Freimuth, V. S. (2012). The social ecological model as a framework for determinants of 2009 H1N1 influenza vaccine uptake in the united states. Health Education & Behavior, 39(2), 229-243. doi:10.1177/1090198111415105

Lupton, A. (2018, September 12). “Vaccinate or mask” policy ruling prompts London hospitals to review practices.  CBC news.  Retrieved from

Plans-Rubió, P. (2012). The vaccination coverage required to establish herd immunity against influenza viruses. Preventive Medicine, 55, 72-77. doi:10.1016/j.ypmed.2012.02.015

Pebody, R. G., Green, H. K., Andrews, N., Boddington, N. L., Zhao, H., Yonova, I., Zambon, M. (2015). Uptake and impact of vaccinating school age children against influenza during a season with circulation of drifted influenza A and B strains, england, 2014/15. Euro Surveillance : Bulletin Europeen Sur Les Maladies Transmissibles = European Communicable Disease Bulletin, (39) doi:10.2807/1560-7917.ES.2015.20.39.30029

Promoli, J.  (2018, October 27).  For jude for everyone [Twitter moment].  Retrieved from

Promoli, J. (n.d.).  For jude for everyone [blog post].  Retrieved from

Public Health Ontario.  (n.d.).  Ontario Respiratory Virus Bulletin 2013-2014.  Retrieved from

Richard, J. (2018).  Should companies enforce flu shot in canada?  Monster.  Retrieved from

Kim, J. S. (2016). Masking your rights: Facemask requirements under mandatory influenza-vaccination policies violate privacy rights of health care workers [comments]. San Diego Law Review, 427. Retrieved from

Ubelacker, S. (2016, August 8).  Flu shot uptake high in provinces that allow vaccination by pharmacists: study.  CTVnews.  Retrieved from


Leave a Reply

Your email address will not be published. Required fields are marked *