World Health Organization · 1st edition, 2025 · 44 pages
Field-tested survey, priority indicators, and interview guides to measure and address barriers to influenza vaccination in health workers, pregnant persons, older adults, and adults with chronic conditions.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2025
- Audience
- Immunization programme managers, researchers, implementers, public health professionals
- Evidence
- Field-tested tools developed through rapid review, parallel translation, cognitive interviewing, and expert consensus; built on validated childhood and COVID-19 vaccination tools endorsed by WHO SAGE
- Reviewed
- 14 Oct 2026 · GMJ
What this guideline says
GMJ summary
This WHO guidance provides validated tools to assess the behavioural and social drivers of influenza vaccination among four priority populations: health workers, pregnant persons, older adults, and adults with chronic conditions. The tools are based on a four-domain framework covering thinking and feeling (perceived risk, vaccine confidence), social processes (norms, health worker recommendations), motivation (intention to vaccinate), and practical issues (access, affordability, service quality).
The core instrument is a 27-question survey with five priority indicators that can be used for brief assessments, supplemented by in-depth interview guides for target populations and programme stakeholders (vaccinators, community influencers, programme managers). The tools were developed through rapid review, parallel translation, cognitive interviewing in multiple countries, and field-testing, building on previously validated childhood and COVID-19 vaccination tools.
Countries are encouraged to use these standardized tools for routine tracking of trends, understanding reasons for low uptake, and monitoring intervention effectiveness. The guidance emphasizes verbal administration, retention of tested response options to ensure comparability, proper interviewer training, and integration of findings with other immunization programme data to continuously improve implementation.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Five priority indicators should be measured at minimum: confidence in vaccine benefits (% saying influenza vaccine is moderately/very important for health), family norms (% saying family/friends want them vaccinated), intention to vaccinate (% wanting to get vaccinated next season), knowing where to get vaccinated, and affordability (% finding vaccination moderately/very easy to pay for or free)
- Survey consists of 27 main questions covering all four domains of the behavioural and social drivers framework, with supplementary questions for health workers (7 questions) and pregnant persons (2 questions)
- Tools designed for WHO-recommended priority populations: health workers, pregnant persons, older adults (age 60 or 65+), and adults with chronic conditions including diabetes, obesity, heart disease, lung disease, or immunocompromised status
- Response options use standardized scales: no/yes for binary questions; not at all/a little/moderately/very for scaled questions; these should not be modified to maintain validity and comparability
- In-depth interview guides provided for three programme stakeholder groups: health workers as vaccinators, community influencers, and national/sub-national immunization programme managers
- Tools should be verbally administered in person or by phone; adaptation for self-administration (online, mail-in) requires removing interviewer instructions and adding simple respondent guidance
- Translation requires parallel translation by two independent experts, cognitive interviews with 8-10 people per priority population, and pilot testing with 5-10 people to check flow and skip logic
- Facility-based data collection reaches a biased sample of individuals already motivated toward vaccination and should be interpreted with caution
Priority indicators for the behavioural and social drivers of influenza vaccination
Table extracted from the guideline
| Domain | Construct | Priority question | Priority indicator |
|---|---|---|---|
| Thinking and feeling | Confidence in vaccine benefits | How important is the influenza vaccine for your health? Would you say… Not at all important, A little important, Moderately important, or Very important? | % of adults/health workers who say the influenza vaccine is 'moderately' or 'very' important for their health |
| Social processes | Family norms | Do you think most of your close family and friends want you to get the influenza vaccine? NO / YES | % of adults/health workers who say most of their family and friends want them to get the influenza vaccine |
| Motivation | Intention to get vaccinated | Do you want to get the influenza vaccine during the next flu season? Would you say… You do not want to, You are not sure, You want to, or You already got the influenza vaccine? | % of adults/health workers who say they want to get the influenza vaccine during the next flu season |
| Practical issues | Know where to get vaccinated | Do you know where to go to get the influenza vaccine for yourself? NO / YES | % of adults/health workers who say they know where to get the influenza vaccine for themselves |
| Practical issues | Affordability of vaccination | How easy is it for you to pay for the influenza vaccination? This includes any payment for the vaccine, the vaccination staff, or other administration fees. Would you say… Not at all easy, A little easy, Moderately easy, Very easy, or IT'S FREE | % of adults/health workers who say influenza vaccination is moderately or very easy to pay for or is free |
Source: World Health Organization, Behavioural and social drivers of influenza vaccination: tools and practical guidance for achieving high uptake. Reproduced in summary form.
From the guideline
Verbatim
“SAGE recommended the systematic gathering and use of data on the behavioural and social drivers to assess the reasons for low uptake, for the routine tracking of trends, and for monitoring and evaluating interventions.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of Georgia's Public Health Institute and having supported our national immunization programme's expansion to include seasonal influenza vaccination for priority groups, I recognize these standardized tools address a critical gap in understanding uptake barriers. The five priority indicators—particularly confidence in vaccine benefits and knowledge of where to vaccinate—align precisely with challenges we observe among Georgian health workers and older adults, where coverage remains suboptimal despite vaccine availability. I would stress to Georgian colleagues the importance of measuring family norms and health worker recommendations, as our culture places high value on family consultation and trust in physicians. The practical caveat for Georgia is that meaningful implementation requires integration with our existing electronic immunization registry and sentinel influenza surveillance, sustained financing for annual surveys across regions including rural areas, and trained interviewers fluent in Georgian and minority languages—resources that must be planned now before the next influenza season.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 14 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia introduced seasonal influenza vaccination in the national immunization programme with WHO support, prioritizing health workers, older adults, pregnant women, and persons with chronic conditions. This guidance provides standardized tools that Georgian immunization programme managers can use to diagnose coverage gaps in these priority groups, track trends over successive seasons, and evaluate demand-generation interventions. The Republic of Georgia should consider adapting the survey to Georgian and minority languages (Azerbaijani, Armenian, Russian) following the parallel translation and cognitive interviewing protocol described, with particular attention to defining ‘older adults’ (age 60 or 65+) according to national policy. Integration of behavioural and social driver data with existing sentinel influenza surveillance and coverage monitoring systems would strengthen evidence-based programme improvement. Regional coordination across Armenia, Azerbaijan, and Georgia could enable comparative analysis and shared learning on addressing common barriers to influenza vaccination uptake in the South Caucasus.
Questions this guideline answers
Quick answers
What are the five priority indicators that must be measured at minimum?
The five priority indicators are: (1) confidence in vaccine benefits—percentage saying influenza vaccine is moderately or very important for their health; (2) family norms—percentage saying most family and friends want them vaccinated; (3) intention to vaccinate—percentage wanting to get vaccinated next flu season; (4) knowing where to get vaccinated—percentage who know where to go; and (5) affordability—percentage finding vaccination moderately or very easy to pay for or free. These can be measured using five specific questions from the full survey when time or resources are limited.
Can I modify the survey questions or response options to fit my local context?
No, modification of survey questions or response options is not recommended as this compromises validity and comparability. The tools have been carefully tested in multiple countries and languages. You may add supplementary questions for local context, but retain the existing questions and response options unchanged. You should adapt specific terms based on local programme context (e.g., 'health worker' vs 'provider', 'health facility' vs 'clinic') and reword the vaccination status question to match local programme policies and prioritized populations, but maintain the standardized scales: no/yes and not at all/a little/moderately/very.
How do I properly translate and adapt these tools to my local language?
Follow this five-step process: (1) select the survey or interview guides based on your research objectives and priority populations; (2) review and consider adding locally relevant questions without overburdening participants; (3) conduct parallel translation—have two experts independently translate the tool, then compare and reconcile the versions to ensure the original meaning is retained; (4) conduct cognitive interviews with 8-10 people from each prioritized population to verify that instructions, questions, and response options convey the intended meaning in the local language and cultural context; and (5) pilot test with 5-10 people to check flow, skip logic, and response options. Train interviewers adequately on survey design, skip patterns, and probing techniques before implementation.
What are the four domains of the behavioural and social drivers framework?
The four domains are: (1) Thinking and feeling—cognitive and emotional responses including perceived disease risk, vaccine confidence (perceived benefits, safety, trust in health workers); (2) Social processes—social experiences including social norms (support of family, religious leaders), health worker recommendation, and gender equity; (3) Motivation—readiness to vaccinate including vaccination intentions, willingness, and hesitancy (but not reasons for vaccination); and (4) Practical issues—experiences when trying to get vaccinated including availability, affordability, ease of access, service quality, and respect from health workers. All four domains are measurable and potentially modifiable to increase vaccine uptake.
Related on GMJ
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- ASF PHC — Standard 4 — Acute & Same-Day Care · Primary Health Clinic
- ASF PHC — Standard 7 — Governance & Staffing · Primary Health Clinic
- ASF Hospital — Standard 5 — Safety & Emergency Preparedness
- ASF Hospital — Standard 11 — Critical Care
- ASF Medical Transport — Standard 6 — Emergency Response During Transport
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 1st edition, 2025
- Status
- Current
- Published
- 2025-08-15
- Languages
- English
- Scope
- Global
- Audience
- Immunization programme managers, researchers, implementers, public health professionals
- Pages
- 44
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-010636-9
- Evidence
- Field-tested tools developed through rapid review, parallel translation, cognitive interviewing, and expert consensus; built on validated childhood and COVID-19 vaccination tools endorsed by WHO SAGE
- Record history
- Created 14 Oct 2026 · updated 14 Oct 2026 · next check Apr 2027
World Health Organization. Behavioural and social drivers of influenza vaccination: tools and practical guidance for achieving high uptake. Geneva: World Health Organization; 2025. 44 p. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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