Published: 2021-02-25

Seasonal influenza vaccination: from hesitancy to social norm

Asif Parvez Malik, Sanjeewa Sumathipala


Seasonal influenza is of the most globally burdening vaccine-preventable diseases, infecting 3-5 billion people annually and according to the World Health Organisation (WHO) resulting in 250,000 to 500,000 deaths worldwide. Vaccination against influenza and all respiratory infections carries greater emphasis in the light of the COVID-19 pandemic. With added pressure on healthcare systems due to the coronavirus, Qatar is one country that is keen to emphasise the importance of influenza vaccination to prevent potential co-infection causing severe disease especially in high-risk groups. Currently seasonal influenza vaccines protect against 3 or 4 strains with revised data from the WHO twice yearly due to the changing natures of strains helping to maximise efficacy of the vaccines. It is recommended for specific high-risk groups to be prioritised for vaccination, including pregnant women, the elderly, children above 6 months of age, patients with chronic conditions as well as front line healthcare workers with risk of exposure. However, uptake of the vaccine remains low and contributes significantly to the burden of the disease. Barriers to vaccine uptake can be physical, such as unhealthy lifestyles, psychological, such as perception of disease as low-risk, contextual, such as lack of access to vaccinations, or sociodemographic, such as living alone. Vaccine coverage can be increased by knowledge of these barriers and how to address them. The physical barriers highlight the need to support behavioural change in lifestyle in order to increase vaccine uptake. Psychological barriers, usually due to misconceptions, can be addressed with education through public health campaigns and interactions between health professionals and patients. This education is not just a need for patients but also healthcare workers. It is up to healthcare providers and contractors to find ways of addressing contextual and sociodemographic barriers by increasing access to vaccination whether through transport, or home–care etc. A key barrier of those mentioned to vaccination is a lack of knowledge which needs to be addressed though positive discussions about the health benefits of immunisation as well as the traditional idea of disease-risk prevention. Addressing the above barriers will help to increase vaccine uptake, and produce health-conscientious societies where vaccination becomes a social norm.


Seasonal influenza, Vaccination, Social norm

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Vaccines and Immunization [Internet]. 2021. Available at: /health-topics/vaccines-and-immunization. Accessed on: 24 January 2021.

Needham J. Science and Civilisation in China. Biology and Biological Technology, Part VI: Medicine. Endeavour. 2000;24(6).

COVID-19 vaccine: First person receives Pfizer jab in UK [Internet]. BBC News. 2021. Available at: Accessed on: 24 January 2021.

Di Tondo E, Marigliano A, Pellegrini I, Di Stanislao F. Trend of emergency department presentations for influenza like illness: Differences between pandemic (2009-2010) and post-pandemic (2010-2011) season. World Health Organization (2009), (Fact sheet No 211, influenza (seasonal). Available at: Accessed on: 24 January 2021.

Timeline | History of Vaccines [Internet]. Available at: Accessed on: 24 January 2021.

Flu Vaccine (Flu Shot) Effectiveness 2020, Side Effects & COVID-19 [Internet]. eMedicineHealth. 2021. Available at: https://www.emedicinehealth. com/flu_vaccine/article_em.htm. Accessed on: 24 January 2021.

Crovari P, Alberti M, Alicino C. History and evolution of influenza vaccines. J Prev Med Hyg. 2011;3(53):91-4.

Krammer F, Palese P. Advances in the development of influenza virus vaccines. Nature Reviews Drug Discovery. 2015;14(3):167-82.

MOPH, HMC and PHCC launch Seasonal Influenza Campaign [Internet]. Available at: https://www. Accessed on: 24 January 2021.

Fight the flu. 2021. Available at: Accessed on: 24 January 2021.

5 Reasons why the 2020 Flu Shot is More Important Than Ever [Internet]. 2021. Available at: -why-the-2020-flu-shot-is-more-important-than-ever. Accessed on: 24 January 2021.

Protecting The Herd Through Seasonal Influenza Vaccine. Presentation presented at PHCC. 2021.

WHO | Recommended composition of influenza virus vaccines for use in the 2015 southern hemisphere influenza season [Internet]. 2021 Available at: vaccines/virus/recommendations/2015_south/en/. Accessed on: 24 January 2021.

WHO. 2021. Available at: https://www.who. int/immunization/position_papers/PP_influenza_november2012_summary.pdf. Accessed on: 24 January 2021.

Influenza (Seasonal). 2021. Available at: detail/influenza-(seasonal). Accessed on: 24 January 2021.

Mertz D, Geraci J, Winkup J, Gessner B, Ortiz J, Loeb M. Pregnancy as a risk factor for severe outcomes from influenza virus infection: A systematic review and meta-analysis of observational studies. Vaccine. 2017;35(4):521-8.

El-Solh A, Grant B. A Comparison of Severity of Illness Scoring Systems for Critically III Obstetric Patients. Chest. 1996;110(5):1299-304.

Karlsson E, Marcelin G, Webby R, Schultz-Cherry S. Review on the impact of pregnancy and obesity on influenza virus infection. Influenza and Other Respiratory Viruses. 2012;6(6):449-60.

Michaan N, Amzallag S, Laskov I, Cohen Y, Fried M, Lessing J, et al. Maternal and neonatal outcome of pregnant women infected with H1N1 influenza virus (Swine Flu). J Maternal-Fetal Neonat Med. 2011;25(2):130-2.

Pierce M, Kurinczuk J, Spark P, Brocklehurst P, Knight M. Perinatal outcomes after maternal 2009/H1N1 infection: national cohort study. BMJ. 2011;342(2):3214.

Munoz F. The impact of influenza in children. Sem Pediatr Infect Dis. 2002;13(2):72-8.

WHO. 2021. Available at: influenza_vaccines_plan/advisory_group/members/Report_GAPAG_10th_SaoPaulo_FINAL.pdf. Accessed on: 24 January 2021.

Osterholm M, Kelley N, Sommer A, Belongia E. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12(1):36-44.

Larson H, Jarrett C, Eckersberger E, Smith D, 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):2150-9.

Betsch C, Böhm R, Chapman G. Using Behavioral Insights to Increase Vaccination Policy Effectiveness. Policy Insights from the Behavioral and Brain Sciences. 2015;2(1):61-73.

Li Z, Doan Q, Dobson S. Determinants of influenza immunization uptake in Canadian youths. Vaccine. 2010;28(19):3462-6.

Sammon C, McGrogan A, Snowball J, de Vries C. Factors associated with uptake of seasonal and pandemic influenza vaccine among clinical risk groups in the UK: An analysis using the General Practice Research Database. Vaccine. 2012;30(14):2483-9.

Kee S, Lee J, Cheong H, Chun B, Song J, Choi W, et al. Influenza vaccine coverage rates and perceptions on vaccination in South Korea. J Infect. 2007;55(3):273-81.

SteelFisher G, Blendon R, Kang M, Ward J, Kahn E, Maddox K, et al. Adoption of preventive behaviors in response to the 2009 H1N1 influenza pandemic: a multiethnic perspective. Influenza and Other Respiratory Viruses. 2015;9(3):131-42.

Villacorta R, Sood N. Determinants of healthcare provider recommendations for influenza vaccinations. Prev Med Rep. 2015;2:355-70.

Matsui D, Shigeta M, Ozasa K, Kuriyama N, Watanabe I, Watanabe Y. Factors associated with influenza vaccination status of residents of a rural community in Japan. BMC Public Health. 2011;11(1).

Lau J, Au D, Tsui H, Choi K. Prevalence and determinants of influenza vaccination in the Hong Kong Chinese adult population. Am J Infect Control. 2012;40(7):225-7.

Hothersall E, de Bellis-Ayres S, Jordan R. Factors associated with uptake of pandemic influenza vaccine among general practitioners and practice nurses in Shropshire, UK. Prim Care Resp J. 2012;21(3):302-7.

Taksdal S, Mak D, Joyce S, Tomlin S, Carcione D, Armstrong P. Predictors of uptake of influenza vaccination—a survey of pregnant women in Western Australia. Aust Fam Physician. 2013.

Gallagher S, Povey R. Determinants of older adults’ intentions to vaccinate against influenza: a theoretical application. J Public Health. 2006;28(2):139-44.

Frew P, Painter J, Hixson B, Kulb C, Moore K, del Rio C, et al. Factors mediating seasonal and influenza A (H1N1) vaccine acceptance among ethnically diverse populations in the urban south. Vaccine. 2012;30(28):4200-8.

Looijmans-van den Akker I, van Delden J, Verheij T, van Essen G, van der Sande M, Hulscher M et al. Which determinants should be targeted to increase influenza vaccination uptake among health care workers in nursing homes? Vaccine. 2009;27(34):4724-30.

Santibanez T. Behavior and Beliefs About Influenza Vaccine Among Adults Aged 5064 Years. Am J Health Behavior. 2010;34(1).

Dlugacz Y, Fleischer A, Carney M, Copperman N, Ahmed I, Ross Z, et al. 2009 H1N1 Vaccination by Pregnant Women During the 2009–10 H1N1 Influenza Pandemic. Obstet Gynecol Survey. 2012;67(8):466-7.

Quach S, Hamid J, Pereira J, Heidebrecht C, Deeks S, Crowcroft N, et al. Influenza vaccination coverage across ethnic groups in Canada. Canad Med Assoc J. 2012;184(15):1673-81.

Caballero P, Tuells J, Duro-Torrijos J, Nolasco A. Acceptability of pandemic A(H1N1) influenza vaccination by Essential Community Workers in 2010 Alicante (Spain), perceived seriousness and sources of information. Prev Med. 2013;57(5):725-8.

Sintes X, Nebot M, Izquierdo C, Ruiz L, Domínguez A, Bayas J, et al. Factors associated with pneumococcal and influenza vaccination in hospitalized people aged ⩾65 years. Epidemiol Infect. 2010;139(5):666-73.

Cramm J, Twisk J, Nieboer A. Self-management abilities and frailty are important for healthy aging among community-dwelling older people; a cross-sectional study. BMC Geriatr. 2014.

Ford E, Bergmann M, Boeing H. Healthy lifestyle behaviors and all-cause mortality among adults in the United States. Prev Med. 2015.

Telford R, Rogers A. What influences elderly peoples' decisions about whether to accept the influenza vaccination? A qualitative study. Health Educ Res. 2003;18:743-53.

French D, Cameron E, Benton J, Deaton C, Harvie M. Can Communicating Personalised Disease Risk Promote Healthy Behaviour Change? A Systematic Review of Systematic Reviews. Ann Behav Med. 2017;51(5):718-29.

Nyhan B, Reifler J, Richey S, Freed G. Effective Messages in Vaccine Promotion: A Randomized Trial. Pediatrics. 2014;133(4):835-42.

Vietri J, Li M, Galvani A, Chapman G. Vaccinating to Help Ourselves and Others. Medical Decision Making. 2011;32(3):447-58.

Korn L, Betsch C, Böhm R, Meier N. Social nudging: The effect of social feedback interventions on vaccine uptake. Health Psychology. 2018;37(11):1045-54.

Nan X, Xie B, Madden K. Acceptability of the H1N1 Vaccine Among Older Adults: The Interplay of Message Framing and Perceived Vaccine Safety and Efficacy. Health Communic. 2012;27(6):559-68.

Johnson D, Mosley J, Smith L. Patient Barriers to Receiving the Influenza Vaccine Looking beyond access, cost, and misconceptions. Inside Influenza Readiness. 2015;3(11).