Background
The consequences of annual influenza outbreaks are often underestimated by the general public. This circumstance may be due in part to a large proportion of healthy young adults experiencing only minor symptoms [
1], which has contributed to a lack of public awareness and complacency regarding the severity of its effects on vulnerable populations such as the elderly and individuals that are immunocompromised. Despite this misconception, influenza poses a serious public health threat around the world. The World Health Organization (WHO) estimates that annual influenza epidemics cause 3 to 5 million cases of severe illness worldwide, along with 250,000 to 500,000 annual deaths [
2]. These epidemics are also associated with overwhelmed clinics and hospitals, many of which need to account for increased staff absenteeism and productivity losses due to illness of health care workers (HCWs) [
2].
The impact of annual influenza epidemics on some of the most susceptible populations, such those living with chronic conditions, is even more striking. Global meta-analyses of risk factors for severe disease from pandemic influenza found that 31 % of patients hospitalized had at least one other chronic medical condition, as did 52 % of those admitted to intensive care units and 62 % of fatal cases [
3]. In the United States, individuals who were 65 or older consistently accounted for approximately 90 % of all influenza related deaths between 1976 and 2007 [
3].
Fortunately, vaccination can mitigate the negative effects of this common infectious disease. During the influenza seasons of 2010–2012, the Centers for Disease Control and Prevention found that influenza vaccination helped reduce children's risk of influenza-related intensive care unit admissions by 74 % [
4]. The use of vaccinations has also been associated with a 77 % reduction in influenza-related hospitalization among adults aged 50 or over [
5]. In addition, rates of influenza infections were found to be lower in vaccinated HCWs versus unvaccinated HCWs [
6] and other healthy adults [
7]. However, while vaccination may reduce the risk of influenza in HCWs, a recent systematic review reported the reduced risk to be less than 50 % as compared to HCWs who are not vaccinated; which suggests the need for additional solutions beyond HCW vaccinations [
6]. Furthermore, recent reviews highlight the lack of clear evidence to support the benefit of vaccinating HCWs [
8] to prevent the spread of influenza to elderly [
1].
Within high-income countries, influenza vaccination is readily accessible and many jurisdictions have implemented publicly funded programs to cover the cost [
9]. However, public vaccination uptake has been variable [
10,
11], and perhaps more importantly, some HCWs continue to resist participation in vaccination programs. For example, in Canada, voluntary uptake of the seasonal influenza vaccine by HCWs remains below the 90 % recommended level [
12] and varies substantially across health care organizations [
13]. Other studies have reported that in some locations more than 50 % of physicians also fail to take advantage of the annual influenza vaccination [
13]. Inadequate levels of HCW immunization can place the vulnerable populations they care for at greater risk of health complications [
14].
A potential solution to this problem is government-mandated inoculation for HCWs. However, in practice, there are substantial barriers to the adoption of such policies. For instance, the attitudes of HCWs in the United States toward whether to be vaccinated against influenza or not remains divided, prompting a backlash against suggestions of any mandatory policies [
15]. Surveys have revealed multiple reasons why HCWs disapprove of mandated vaccination. These include beliefs that the decision to be vaccinated is personal, fears of side effects, and concern that influenza vaccines are ineffective [
15]. There have also been legal obstacles to mandating vaccination as worker unions and professional associations have argued that such policies violate individual rights and freedoms [
16]. Specifically, in Canada, it has been argued that mandated immunization violates one's right to refuse unwanted medical treatment under section 7 of the Canadian Charter of Rights and Freedoms [
16].
New public policies are rarely adopted based solely on supportive evidence, public opinion, or interest group lobbying; rather, they typically require a confluence of events that is difficult to predict or orchestrate. Through the use of relevant frameworks, theories, or models, policy analysis can provide a greater understanding of the various processes involved and, in turn, enhance the likelihood of recognizing and seizing opportunities for new policies to be adopted [
17]. In this vein, Kingdon’s [
18] three process streams framework helps to explain how three elements or “streams”—
problems,
politics, and
policies—affect policy agenda setting dynamics. Kingdon argues that, while there is some interplay among the streams, they are largely independent of one another [
18]. This framework can be used to explain how issues may make their way onto the government’s decision agenda, which is a key step in the policy adoption process. The purpose of this paper is to identify the likelihood of adopting a policy for mandatory immunization of HCWs in Ontario based on a historical review of barriers to the agenda setting process.
Methods
Background information regarding the effectiveness and uptake of influenza vaccinations was gathered via narrative review, which included academic and newspaper articles, as well as government reports. Subsequently, these materials were analysed using Kingdon’s agenda setting framework of three converging streams leading to windows of opportunity for possible policy adoption. No permissions to analyse the data used in this study were necessary or granted.
The authors independently categorized historical events as falling primarily into the problems, politics, or policies stream (see Table
1). Categories are based on Kingdon’s description as noted below. Any discrepancies in classification were resolved through discussion.
Table 1
Windows of opportunity for policy change (mandatory vaccination of health care workers)
Problems (perception there is a problem that needs to be acted addressed) | ▪ ER overcrowding due to heavy flu season resulting in reduced access to care | ▪ SARS (severe acute respiratory syndrome) outbreak ▪ H1N1 outbreak/pandemic | ▪ Growing calls from experts for mandatory HCW immunization |
Politics (events promoting or inhibiting political action) | ▪ Heightened media attention pressures government to act ▪ Court challenges in opposition to mandatory HCW vaccination | ▪ Production delays, low vaccine supplies and rationing ▪ H1N1 outbreak turns out to be mild (loss of public interest) | ▪ Evidence of cost-effectiveness of flu vaccination ▪ Other jurisdictions adopting mandatory policies for HCWs |
Policies (availability and feasibility of options) | ▪ Wide availability of public vaccination programs | ▪ Favorable arbitrator ruling on mandatory HCW vaccinations | ▪ Favorable court rulings on mandatory HCW vaccinations |
In Kingdon’s framework, the problems stream involves the identification of a particular social problem that has gained public or decision-maker attention and cannot be easily ignored. These problems may come to light through awareness of a change in an indicator, such as an increased infection rate, or a focusing event/crisis, such as the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. In the politics stream, the governmental agenda is formulated and the list of issues or problems to be given attention is prioritized. This stream is impacted by political events (such as changes in public opinion/national mood), and organized forces (such as a change in government due to elections). In the policies stream, experts analyse the various problems, and suggest technically feasible and politically acceptable solutions to them.
Generally, the three streams flow independently of one another; however, a time-limited window of opportunity may open when these streams converge (as politically acceptable solutions to prioritized problems are identified). At this point of convergence, issues are most likely to reach the government’s decision agenda—where policy problems and their proposed solutions are under active discussion by government decision-makers—and thus, most likely to result in the adoption of a new policy. Policy windows can also close rapidly. This tends to occur when: problems, politics, and policies are not adequately linked together; initiatives that are implemented lead to either failure or success; indicators of severity lessen; other critical items push the issue off the agenda; there has been movement through an “issue attention cycle” (i.e., a gradual decline of interest in the condition).
Using Kingdon’s agenda setting framework (three process streams that lead to windows of opportunity when they converge) the objective of this paper is to analyse the likelihood of government adopting a mandatory vaccination policy for HCWs in Ontario.
Conclusions
By analysing the progress of mandatory HCW immunization through the lens of Kingdon’s framework, the separate streams of problems, politics, and policies can be seen to converge and diverge repeatedly over an extended period (policy windows have opened and closed several times). Since the implementation of UIIP in Ontario, there have been several potential opportunities to pursue a mandatory HCW vaccination policy. In each instance a technically feasible solution was available (policies stream). However, despite the policy's importance—protecting the public—the problem’s prominence (problems stream) and the political environment (politics stream) only aligned with the policies stream for a very short period of time. During these periods there was inadequate support for the issue to remain on the government’s decision agenda long enough to result in the adoption of a new policy. In part, this seems to have been due to other problems gaining prominence and displacing the issue of mandatory vaccination of HCWs from a priority position. In addition, each time this issue gained prominence, opposition lobby groups reacted, making the proposed solution less politically acceptable.
Although the call for mandatory HCW vaccination has withstood some legal challenges—including to the Charter of Rights and Freedoms, The Freedom of Information and Privacy Act, and the Human Rights Code—there remains small but committed groups who continue to oppose such a policy. As a result, it seems highly unlikely that a mandatory HCW vaccination policy will be adopted by the Ontario government until perception of the problem’s importance is sufficient to overcome the political opposition to implementing a solution.