title: Barriers of Influenza Vaccination Intention and Behavior - A Systematic Review of Influenza Vaccine Hesitancy, 2005 - 2016.
abstract: BACKGROUND
  Influenza 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.
  
  
  OBJECTIVE
  This 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.
  
  
  METHODS
  Thirteen 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.
  
  
  RESULTS
  Most 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.
  
  
  CONCLUSIONS
  Many 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.
authors.affiliation: Center for Empirical Research in Economics and Behavioral Sciences, University of Erfurt, Erfurt, Germany.|Department of Media and Communication Sciences, University of Erfurt, Erfurt, Germany.
authors.forename: Philipp
authors.initials: P
authors.lastname: Schmid
authors.affiliation: Center for Empirical Research in Economics and Behavioral Sciences, University of Erfurt, Erfurt, Germany.|Department of Media and Communication Sciences, University of Erfurt, Erfurt, Germany.
authors.forename: Dorothee
authors.initials: D
authors.lastname: Rauber
authors.affiliation: Center for Empirical Research in Economics and Behavioral Sciences, University of Erfurt, Erfurt, Germany.|Department of Media and Communication Sciences, University of Erfurt, Erfurt, Germany.
authors.forename: Cornelia
authors.initials: C
authors.lastname: Betsch
authors.affiliation: Department of Media and Communication Sciences, University of Erfurt, Erfurt, Germany.
authors.forename: Gianni
authors.initials: G
authors.lastname: Lidolt
authors.affiliation: Department of Media and Communication Sciences, University of Erfurt, Erfurt, Germany.
authors.forename: Marie-Luisa
authors.initials: ML
authors.lastname: Denker
mesh_terms: D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000523:psychology; D006801:Humans; D007252:Influenza Vaccines / Q000627:therapeutic use*; D007251:Influenza, Human / Q000453:epidemiology* / Q000517:prevention & control* / Q000821:virology; D058873:Pandemics; D010342:Patient Acceptance of Health Care / Q000523:psychology; D014611:Vaccination / Q000523:psychology
chemical_list: D007252:Influenza Vaccines