Barriers to and Enablers of Childhood Immunization Uptake in First Nations Communities in Canada: A Rapid Review of the Literature

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To support the broader project aimed at increasing immunization rates among First Nations children in northern Saskatchewan, we conducted a rapid review to examine the current evidence on barriers and enablers to childhood vaccine uptake within Canadian First Nations communities. Methods Following Cochrane Rapid Reviews Methods Group guidelines, we searched the Web of Science, PubMed, and Scopus for peer-reviewed studies published between 2003 and 2023. Eligible studies were limited to those published in English and focused on Canadian First Nations populations, reporting on factors influencing childhood immunization. We synthesized findings thematically, identifying patterns in barriers and enabling conditions. Results We included four studies in this review. We categorized the barriers to childhood immunization into three domains: parental or caregiver factors, healthcare provider factors, and health system factors. Parental barriers included fear of needles, misinformation, safety concerns, scheduling conflicts, transportation challenges, and child illness. Provider-related barriers involved scheduling challenges and perceived disrespect from healthcare staff. System-level barriers included rigid appointment policies, long wait times, and fragmented immunization records. We also identified key enablers such as trust in healthcare providers, culturally safe care, fear of disease outbreaks, on-reserve service delivery, data-sharing agreements, flexible service models, and community engagement. Conclusion To improve immunization rates in First Nations communities, public health interventions must address cultural, systemic, and logistical barriers. Strategies should prioritize culturally safe care, community engagement, enhanced communication, and flexible service delivery models supported by robust information-sharing systems. Figures Figure 1 Figure 2 Figure 3 1 Introduction Childhood immunization remains one of the most effective public health interventions for reducing morbidity and mortality from vaccine-preventable diseases [ 1 , 2 ]. In Canada, routine vaccination programs have achieved high national coverage; however, disparities persist among Indigenous populations, including the First Nations, Inuit, and Métis, owing to intersecting structural, geographic, and systemic barriers [ 3 – 5 ]. Despite all the benefits of increased childhood immunization rates, some northern Saskatchewan First Nations communities continue to report coverage levels below the recommended provincial target of 95% [ 6 ]. In 2021, immunization coverage was 84% for children under one year of age and 79% for children at their second birthday [ 7 ]. These persistent gaps present a significant public health concern, contributing to increased vulnerability to infectious disease outbreaks and preventable illness in early childhood. While national reports and several studies report immunization coverage among Indigenous peoples as a collective group, there remains a critical gap in synthesized evidence on childhood immunization that focuses specifically on First Nations communities. Given the distinct healthcare systems, governance structures, cultural traditions, and historical experiences that shape First Nations Peoples’ interactions with health services, dedicated and context-specific research is essential to support equitable and culturally informed public health strategies. To our knowledge, no rapid review has comprehensively assessed the barriers to and facilitators of childhood immunization within First Nations communities in Canada. A deeper understanding of these factors and their influence on immunization uptake is vital for developing targeted interventions aimed at improving vaccine equity and health outcomes among First Nations children. To address this gap, we conducted a rapid review of peer-reviewed literature to identify and synthesize the key barriers and enablers influencing childhood immunization uptake among First Nations communities across Canada. In collaboration with the Northern Inter-Tribal Health Authority (NITHA), we developed this review as part of a broader, community-guided research project. The overarching aim of the project is to identify culturally relevant, evidence-informed strategies to increase childhood immunization coverage among First Nations children aged 0–2 years in northern Saskatchewan. Our review offers critical foundational insights to inform locally tailored public health strategies and supports the next phases of our broader initiative to improve immunization equity and outcomes in the region. 3 Methods We carried out this rapid review in partnership with NITHA, which included a collaborative team of researchers, health professionals, family partners, knowledge users, and decision-makers. This team contributed meaningfully at every stage of the review process, including the development of research questions, the design and execution of the literature search, the analysis and interpretation of findings, the preparation of results, and the dissemination of the final report. Our review is embedded within a larger community-guided research initiative conducted within NITHA’s jurisdiction, focused on improving childhood immunization uptake in First Nations communities in northern Saskatchewan. We conducted the rapid review in five structured phases [ 8 ]: (a) developing the research question; (b) identifying and retrieving relevant literature; (c) screening and selecting studies for inclusion; (d) systematically charting the extracted data; and (e) synthesizing the findings through collation, summarization, and reporting. 3.1 Rapid Review Question Our rapid review aimed to answer the following question: What is known about the barriers to and enablers of childhood immunization uptake in Canadian First Nations communities? 3.2 Data Sources and Search Strategy Given that the PRISMA extension for Rapid Reviews (PRISMA-RR) has been under development since 2015 [ 9 , 10 ], we conducted our rapid review in accordance with the evidence-informed guidance provided by the Cochrane Rapid Reviews Methods Group [ 8 , 11 ]. We systematically searched Web of Science, PubMed, and Scopus for original peer-reviewed articles published between January 2003 and August 2023. We selected a 20-year time frame (2003–2023) to ensure a comprehensive and inclusive review of the literature. This extended period allowed us to capture both foundational and emerging evidence in a field where research specific to First Nations childhood immunization is limited. Moreover, this timeframe reflects a balance between historical context and contemporary relevance, enabling us to identify trends, persistent barriers, and evolving strategies within a changing policy and healthcare landscape. We focused on childhood immunization in Canadian First Nations communities as part of the broader NITHA’s First Nations childhood immunization project. Our search terms included combinations of 'children', 'immunization', 'barriers', 'enablers', 'First Nations', and 'Canada', as detailed in supplementary material 1. 3.3 Eligibility criteria To ensure relevance to the research questions and objectives, we selected studies on the basis of the following inclusion criteria: Research has focused on childhood immunization service delivery within First Nations communities in Canada. Articles reporting on interventions, policies, or best practices designed to improve immunization uptake. Publications offering empirical data on outcomes, lessons learned, or actionable recommendations for improving immunization services. Studies that identify at least one barrier or one enabler related to childhood immunization uptake. Studies published in English. The exclusion criteria were as follows: (1) research conducted outside Canada or not specific to First Nations communities. (2) Articles that did not address childhood immunization service delivery or lacked relevant outcomes. Publications such as conference abstracts, editorials, letters, and any articles not published in English. 3.4 Screening and Selection Process We managed and organized the articles retrieved through the search strategy via Microsoft Excel to facilitate the removal of duplicates. After excluding duplicates, two reviewers, Emmanuel Dankwah (ED) and Carrie Gardipy (CG), independently screened the titles and abstracts of the remaining studies to assess their relevance on the basis of the established inclusion criteria. The reviewers resolved any discrepancies through discussion and consensus. When disagreements persisted, a third reviewer, Nnamdi Ndubuka (NN), intervened to help reach a final decision. We retrieved and assessed the full-text articles of potentially relevant studies for final eligibility. We documented the reasons for exclusion at each stage of the review process and used flow diagrams to visually represent the screening steps. 3.5 Data extraction We carried out the data extraction process via a standardized form designed to capture essential information from the selected studies. We assessed the methodological rigor and potential biases of both the quantitative and qualitative studies via the Joanna Briggs Institute (JBI) Critical Appraisal checklists [ 12 , 13 ]. These checklists helped us evaluate the quality of the studies in accordance with the established eligibility criteria, using parameters with responses classified as “yes,” “no,” “unclear,” or “not applicable.” A completed quality assessments for each included study are available on request. We classified studies that achieved scores ranging from 5–6 points as ‘high quality,’ whereas those scoring below this range were considered ‘low quality’ [ 14 ]. We systematically recorded key study details, including the author’s name, publication year, study design, geographical location (province and country), study population, target population, and quality rating, in a Microsoft Excel spreadsheet. 3.6 Data Synthesis and Analysis We adopted a narrative synthesis approach to analyze the data, incorporating methods such as tabulation and thematic analysis. We focused on thematically grouping the barriers and enablers identified across the included studies. We constructed a table for each study, capturing descriptive information and key findings, including themes, subthemes, barriers, and enablers. We categorized the barriers and enablers into three primary domains: factors related to parents or caregivers, issues within the health system, and challenges associated with healthcare providers. Thematic analysis was employed to identify and synthesize recurring themes from the included studies. We derived themes both deductively, on the basis of predefined categories related to immunization service delivery, and inductively, on the basis of emergent findings from the literature. We iteratively reviewed and refined these themes to ensure that they adequately captured the full range of relevant issues related to childhood immunization in First Nations communities. We then analyzed the synthesized findings to compare policies, practices, and outcomes related to childhood immunization service delivery across various jurisdictions in Canada. We interpreted the results to assess their implications for policy development, healthcare practices, and future research. On the basis of this evidence, we formulated recommendations to guide strategies aimed at improving immunization uptake and health outcomes among First Nations children. 3 Results 3.1 Search results Our database searches yielded 109 records. After removing duplicates, 56 unique abstracts remained for screening. Following title and abstract review, we excluded 33 studies that did not meet the inclusion criteria. We then assessed 23 full-text articles for eligibility, 19 of which were excluded on the basis of predefined criteria. Ultimately, four studies met the inclusion criteria and were retained for analysis. Figure 1 presents the flowchart of the rapid review process, including the reasons for study exclusion. 3.2 Descriptive analysis of the studies The four studies that met our inclusion criteria were geographically concentrated in only two Canadian provinces. Three studies (75%) were conducted in Alberta, and one (25%) was conducted in Ontario. The publication dates ranged from 2003–2023; only one study was published in 2003, while the remaining three (75%) were published within the last three years (2020–2023). In terms of methodology, one study (25%) employed a quantitative design (a retrospective cohort study), whereas the other three (75%) utilized qualitative approaches. Among the qualitative studies, one adopted an institutional ethnography framework, and two used interview-based methods. The full details of the included studies are presented in Table 1 . Table 1 Characteristics of the studies Author (year) Study design Study Area (Province and country) Study population Target population Study aim(s) Study quality Chiem et al., 2022[ 15 ] Qualitative study (Semi structured phone interviews) Northern Alberta, Canada 14 Parents with under immunized children Immunization for 2-year-old To identify reasons for under immunization in children in low socioeconomic status (SES) communities and propose suggestions to address issues/concerns identified by low SES parents for improving immunization coverage in their communities High MacDonald et al., 2022 [ 16 ] Qualitative study (Institutional Ethnography approach) Central Alberta, Canada 33 First Nations parents and 6 health center staff (nursing, clerical staff, and management) Immunization for preschool aged children To identify opportunities for innovation by exploring the work that nurses and parents must do to have children vaccinated. High MacDonald et al., 2023 [ 17 ] Quantitative study (Retrospective cohort study) Central Alberta, Canada First Nations children from a rural First Nations community in central Alberta Childhood immunization for 2- and 7-year-old To use linked data to accurately measure vaccine coverage by age 2 and 7 years for children living in a large First Nations community in Alberta, Canada. High Tarrant and Gregory, 2003 [ 18 ] Qualitative study (Interviews) North-Western Ontario, Canada 28 First Nations mothers Childhood Immunization for under 5 years To explore First Nations parents' beliefs about childhood immunizations and examined factors influencing immunization uptake. High 3.3 Barriers to Immunization Uptake Our rapid review revealed multiple barriers to childhood immunization within First Nations communities in Canada, which can be grouped into three main categories: parental and caregiver factors, health provider factors, and health system factors. 3.3.1 Barriers to parents and caregivers In our analysis, we identified a range of parental and caregiver-related barriers that delay childhood immunization. These include emotional concerns such as fear and mistrust, gaps in culturally appropriate information, and logistical challenges such as transportation (Fig. 2 ). 3.3.1.1 Fear of needles Two qualitative studies indicated that the considerable anxiety caregivers experienced while watching their children receive injections discouraged many from returning for follow‑up doses [ 15 , 18 ]. 3.3.1.2 Misinformation Parents frequently encounter rumors in their communities and online that vaccines can cause severe illness or death [ 18 ]. Skepticism was strongest for newer products and for ingredients such as thimerosal, which weakened overall confidence in immunization programs [ 15 ]. 3.3.1.3 Safety concerns Caregivers commonly expressed anxiety about a perceived link between vaccination and autism, uncertainty regarding the cumulative toxicity of multiple injections, and fear that an intensive schedule could overwhelm a young child’s immune system [ 15 , 18 ]. These concerns prompted many parents to delay appointments or to accept only selected vaccines [ 15 , 18 ]. Parents also cited milder reactions such as fever after vaccination as additional reasons for hesitancy [ 15 , 18 ]. 3.3.1.4 Scheduling conflicts Caregivers struggle to attend weekday clinics because of competing work, household, and childcare responsibilities [ 15 , 18 ], and policies requiring separate appointments for each child further increase missed or postponed visits [ 16 ]. 3.3.1.5 Transportation difficulties Long travel distances, limited public transit, and unreliable access to community vans or fuel assistance make it difficult for families, particularly those in remote communities, to reach immunization services in time [ 15 , 16 ]. 3.3.1.6 Child Illness Frequent respiratory or ear infections result in routine deferral of scheduled vaccinations; parents and nurses alike prefer to postpone immunization when a child has fever or other acute symptoms, which contributes to cumulative delays in completing the schedule [ 18 ]. 3.3.2 Healthcare provider barriers In our review, we found that communication breakdowns and negative interactions with healthcare providers contributed to delays in or avoidance of childhood immunization in First Nations communities. 3.3.2.1 Scheduling conflicts Caregivers described repeated attempts to schedule appointments by telephone that went unanswered or were met with busy signals [ 15 ]. These communication breakdowns created frustration and often led parents to delay or abandon plans to vaccinate their children [ 15 ]. 3.3.2.2 Perceived disrespect and negative healthcare experience Some families felt dismissed or disrespected during clinic encounters [ 18 ], which led to mistrust of the health system and reduced adherence to recommended immunization schedules [ 15 , 16 ]. 3.3.3 Health system barriers In our study, we identified key health system barriers that hinder timely childhood immunization. These include rigid scheduling policies, long wait times, and fragmented record-keeping, all of which complicate access to services and reduce caregiver confidence in the healthcare system. 3.3.3.1 Scheduling policies Institutional rules often require parents to book separate appointments for each child [ 16 ]. This approach substantially increased the number of trips families had to make, creating additional childcare and transportation challenges [ 16 ]. 3.3.3.2 Long Wait Times Extended waiting periods discouraged attendance, as caregivers reported arriving on time yet sometimes waiting up to an hour before their children were seen, which led to frustration and ultimately missed or postponed immunization visits [ 18 ]. 3.3.3 Fragmented Records Immunization data are frequently divided into on‑reserve and off‑reserve health systems [ 17 ]. Incomplete access to a child’s full vaccination history results in missed doses or unnecessary repeat vaccinations, undermining both completion rates and caregiver confidence in the health system’s reliability [ 17 ]. 3.4 Enablers of Immunization Uptake In our study, we identified key enablers that support vaccine uptake, which span parental awareness, positive healthcare provider relationships, and supportive health system practices. These facilitators play crucial roles in overcoming barriers and enhancing immunization coverage. 3.4.1 Enabling of parents and caregivers Awareness of disease risk emerged as a crucial enabler of immunization at the caregiver and parental levels. One study reported that caregiver recognition of the dangers posed by vaccine-preventable diseases significantly influences vaccination uptake [ 18 ]. The evidence suggests that when caregivers understand the potential severity of these illnesses, especially during local outbreaks, they are more motivated to ensure that their children receive timely and complete immunizations (Fig. 3 ). 3.4.2 Healthcare provider enablers In our review, we identified healthcare provider-related enablers that supported childhood immunization uptake (Fig. 3 ). We found that building strong, trusting relationships with caregivers was consistently reported as a key factor. We also noted that clear communication about vaccine safety and benefits, consistent follow-up, and the delivery of care in respectful, culturally sensitive, and welcoming environments were important strategies used by providers to foster trust and encourage vaccine acceptance [ 15 , 18 ]. 3.4.3 Health System Enablers We identified several health system-level enablers that supported improved childhood immunization uptake. 3.4.3.1 Ongoing immunization services We found that offering immunization services within on-reserve communities reduced travel time and costs for families, contributing to higher vaccine completion rates [ 17 ]. 3.4.3.2 Flexible service delivery models We also noted that flexible service delivery models such as mobile clinics, extended hours, and proactive reminders via text or phone help accommodate caregivers managing work and household responsibilities [ 15 ]. 3.4.3.3 Data‑sharing agreements We observed that data-sharing agreements between on-reserve and off-reserve health systems, particularly through electronic record linkages, enhanced continuity of care by allowing providers access to complete vaccination histories, reducing both missed and duplicate doses [ 17 ]. 3.4.3.4 Community engagement and leadership We found that engaging community leaders and elders in the planning and promotion of immunization efforts fostered a sense of shared responsibility and strengthened culturally grounded messaging that increased caregiver confidence in vaccines [ 16 ]. 4 Discussion Our rapid review explored the barriers to and enablers of childhood immunization within First Nations communities in Canada, with particular attention given to the experiences of parents, caregivers, healthcare providers, and health system factors influencing vaccine uptake. Our findings revealed a complex interplay of sociocultural, emotional, logistical, and institutional influences. Although several themes align with broader patterns of vaccine hesitancy documented across Canada, this review identified the unique, context-specific factors essential to understanding immunization dynamics within First Nations communities. 4.1 Barriers to Immunization Parents and caregivers face multiple challenges that hinder timely childhood immunization. A prominent barrier identified was the emotional distress experienced by parents and caregivers during the immunization process. Similar emotional barriers have been documented in the literature [ 19 , 20 ], where parental guilt and anxiety over their child's pain diminished trust in healthcare providers and vaccine programs. Evidence-based interventions aimed at minimizing procedural pain have been shown to improve vaccine acceptance [ 21 , 22 ]. Within the First Nations context, this emotional distress must be viewed through the lens of historical trauma and ongoing mistrust toward healthcare systems, which may amplify negative emotional responses to vaccination [ 5 , 23 ]. Thus, emotional reactions to immunization should be interpreted not only as individual experiences but also as reflections of broader historical and cultural realities that contribute to vaccine hesitancy. Misinformation, particularly regarding vaccine safety, has also emerged as a significant barrier. This challenge was intensified by the circulation of unverified information within communities, reinforcing skepticism about vaccine efficacy and safety. These findings are consistent with broader research on vaccine hesitancy, where misinformation is a critical factor in undermining vaccine confidence [ 24 ]. In First Nations contexts, historical marginalization and systemic inequities further exacerbate mistrust toward medical authorities, magnifying the impact of misinformation. Therefore, efforts to counter misinformation must go beyond scientific communication, integrating culturally sensitive approaches that acknowledge and address the sociopolitical conditions shaping these perceptions. Strategies such as narrative-based interventions have been proposed to mitigate vaccine-related misinformation among providers and parents [ 25 ]. Logistical challenges, including transportation barriers and limited access to healthcare infrastructure, were also identified as significant impediments to immunization. Similar issues have been reported in other rural and underserved populations, where difficulties in accessing healthcare services contribute to missed immunization opportunities and lower uptake rates [ 26 , 27 ]. In First Nations communities, these logistical obstacles are further compounded by longstanding disparities in access to healthcare resources, highlighting the urgent need for systemic solutions that address both immediate logistical barriers and their deeper structural roots. Healthcare providers play a crucial role in supporting immunization uptake; however, certain provider-related factors may act as barriers. Our review identified healthcare provider-related factors, particularly perceived disrespect and inadequate communication, as significant barriers to immunization uptake. This finding aligns with those of previous studies, which emphasized the critical role of provider attitudes and communication styles in influencing vaccine acceptance [ 27 ]. In First Nations communities, these barriers are further compounded by a legacy of systemic discrimination and colonial healthcare practices [ 5 , 23 ]. Numerous studies have argued that cultural safety, where healthcare professionals recognize and respect the distinct cultural and historical experiences of Indigenous peoples, is fundamental to rebuilding trust and improving immunization uptake [ 23 , 28 , 29 ]. Our findings strongly support the importance of integrating culturally safe practices into immunization services in First Nations communities. Moreover, at the health system level, several factors significantly impeded families’ access to immunization services. Rigid appointment scheduling practices, as identified in our review, have been reported in other healthcare settings, where inflexible scheduling structures contributed to missed immunization opportunities and reduced vaccine coverage [ 27 ]. Without adaptable appointment systems, First Nations families face compounded barriers that further widen immunization gaps. Fragmented immunization recording systems have also emerged as a major systemic challenge. Consistent with our findings, researchers emphasize that robust vaccine record tracking, high-quality data management, and seamless system integration are essential for improving routine childhood immunization rates and protecting against vaccine-preventable diseases [ 30 – 32 ]. 4.2 Enablers to Immunization Recognizing the risks associated with vaccine-preventable diseases strongly motivated parents and caregivers to pursue immunization. Our findings corroborate broader research showing that heightened awareness of disease consequences drives vaccine acceptance [ 27 , 32 , 33 ]. Studies have demonstrated that culturally sensitive educational campaigns tailored to community needs and experiences substantially improve vaccine uptake [ 28 , 29 ]. Community-based outreach efforts that emphasize the local impact of disease outbreaks appear particularly effective in First Nations contexts. Trust in healthcare providers has emerged as a crucial facilitator of vaccine acceptance. Our review aligns with evidence indicating that positive, respectful interactions between healthcare providers and parents significantly reduce vaccine hesitancy [ 27 , 33 ]. In First Nations communities, the delivery of culturally competent care proves essential. Our findings reinforce other studies, emphasizing that providers who engage respectfully and communicate effectively can strengthen parental vaccine confidence [ 32 , 33 ]. On-reserve healthcare services play a pivotal role in supporting immunization efforts. Our findings are consistent with research highlighting that proximity to culturally safe and community-based healthcare services improve health outcomes in rural and underserved populations [ 5 , 27 ]. On-reserve clinics offer accessible, trusted environments for vaccination and facilitate consistent follow-up care. Furthermore, flexible service delivery models such as mobile vaccination clinics and extended service hours have emerged as critical enablers. Similar to findings in other underserved settings [ 32 , 33 ], these adaptable models, when embedded into routine immunization programs, can substantially increase vaccine access and completion rates among First Nations populations. 5 Implications for Research, Practice, and Policy Our review offers a comprehensive and timely synthesis of the barriers, enablers and effective initiatives to immunization among First Nations communities in Canada, an often-underrepresented population in vaccine research. By integrating both qualitative and quantitative evidence, we provide a nuanced understanding of immunization dynamics, reflecting diverse regional contexts across Canada. This structured approach captures the complex interplay among parents and caregivers, health providers, and health system factors influencing vaccine uptake, offering an up-to-date resource for healthcare providers and policymakers. Our findings have several implications for public health policy and practice. First, healthcare providers must receive cultural competence training to engage respectfully and effectively with First Nations families. Trust-building through culturally sensitive care can substantially enhance vaccine confidence. Involving elders and community leaders in vaccination initiatives is critical to overcoming hesitancy and strengthening trust in healthcare systems. Public health strategies should also prioritize minimizing emotional distress during vaccinations by adopting trauma-informed care practices and ensuring that vaccination appointments allow adequate time for supportive interactions. Addressing logistical barriers such as transportation challenges and rigid scheduling remains essential. Expanding access through mobile clinics, flexible service hours, and transportation support could significantly improve immunization rates. Furthermore, integrating immunization records across on- and off-reserve healthcare systems will enhance data quality and care continuity. Targeted public health campaigns must counter vaccine misinformation via trusted community voices and culturally tailored messaging that reflects the historical and social realities of First Nations communities. Our study identified a significant gap in the limited research examining the role of traditional Indigenous knowledge in informing immunization practices. Although some studies have highlighted the value of integrating cultural practices into healthcare, evidence remains scarce on how traditional healing systems could support immunization efforts [ 16 ]. Future research should investigate strategies to bridge Western medical practices with Indigenous knowledge systems to foster vaccine acceptance more holistically. 6 Limitations Some limitations warrant consideration. The relatively small number of included studies restricts the generalizability of our findings. While we aimed to incorporate a range of perspectives, the predominance of qualitative research may not fully represent the broader First Nations population. Additionally, the regional focus of many studies may limit the applicability of findings to all First Nations communities nationwide. Our exclusion of non-English studies and gray literature could also have omitted valuable insights not captured in mainstream academic sources. 7 Conclusion Our rapid review identified the multifaceted barriers and enablers influencing childhood immunization uptake in First Nations communities in Canada. Barriers included caregiver-related concerns such as fear of needles, misinformation, and logistical challenges; provider-related issues such as negative healthcare experiences; and systemic obstacles such as fragmented immunization records and restrictive scheduling policies. Conversely, enablers such as strong caregiver–provider relationships, accessible on-reserve services, flexible delivery models, and community engagement emerged as critical facilitators. Addressing these barriers while strengthening the enablers requires culturally sensitive, community-driven approaches that build trust, improve accessibility, and integrate Indigenous knowledge and leadership. Future public health initiatives must prioritize collaborative strategies that enhance system responsiveness and promote equitable immunization access for First Nations children, ultimately reducing vaccine-preventable diseases in these communities. Declarations Author Contribution N.N: Conceptualization, design of the review, final decisions about article inclusion, critically reviewed manuscript for important intellectual content; Supervision, accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved, Final approval of the version to be published.E.D: Design of the review, completed article screening and selection, data synthesis and analysis of results, prepared the original manuscript draft, reviewed manuscript for important intellectual content. S.W.: Conceptualization, design of the review, reviewed manuscripts drafts and contributed to refining the paper.C.G.: Completed article screening and selection. P.D.: Prepared the original manuscript draft, generated figures and tables, and contributed to refining the paper.G.A.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.J.N.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.A.A.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.A.F.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.G.M.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.I.K.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.G.G.: reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.All authors have read and approved the final manuscript prior to submission. 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Fullerton MM, Pateman M, Hasan H, Doucette EJ, Cantarutti S, Koyama A, et al. Barriers experienced by families new to Alberta, Canada when accessing routine-childhood vaccinations. BMC Public Health. 2023;23:1333. Ilesanmi MM, Abonyi S, Pahwa P, Gerdts V, Scwandt M, Neudorf C. Trends, barriers and enablers to measles immunization coverage in Saskatchewan, Canada: A mixed methods study. PLoS ONE. 2022;17:e0277876. Henderson RI, Shea-Budgell M, Healy C, Letendre A, Bill L, Healy B, et al. First nations people’s perspectives on barriers and supports for enhancing HPV vaccination: foundations for sustainable, community-driven strategies. Gynecol Oncol. 2018;149:93–100. Smylie J, Kirst M, McShane K, Firestone M, Wolfe S, O’Campo P. Understanding the role of Indigenous community participation in Indigenous prenatal and infant-toddler health promotion programs in Canada: A realist review. Soc Sci Med. 2016;150:128–43. Wilson SE, Wilton AS, Young J, Candido E, Bunko A, Buchan SA, et al. Assessing the completeness of infant and childhood immunizations within a provincial registry populated by parental reporting: a study using linked databases in Ontario, Canada. Vaccine. 2020;38:5223–30. Vest JR, Kirk HM, Issel LM. Quality and integration of public health information systems: A systematic review focused on immunization and vital records systems. Online J Public Health Inf. 2012;4. Wong King Yuen SM, Doucette EJ, Ford C, Fullerton MM, Vetro G, Koyama A, et al. Addressing Barriers Newcomer Families Face When Obtaining Routine Childhood Vaccines in Alberta, Canada. Vaccines (Basel). 2024;12:1380. Carlson SJ, Tomkinson S, Hannah A, Attwell K. What happens at two? Immunization stakeholders’ perspectives on factors influencing suboptimal childhood vaccine uptake for toddlers in regional and remote Western Australia. BMC Health Serv Res. 2024;24:968. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial1Ndubukaetal.docx Cite Share Download PDF Status: Published Journal Publication published 31 Jan, 2026 Read the published version in Discover Public Health → Version 1 posted Editorial decision: Revision requested 05 Dec, 2025 Reviews received at journal 28 Oct, 2025 Reviews received at journal 26 Oct, 2025 Reviews received at journal 21 Oct, 2025 Reviewers agreed at journal 14 Oct, 2025 Reviewers agreed at journal 13 Oct, 2025 Reviewers agreed at journal 11 Oct, 2025 Reviews received at journal 10 Sep, 2025 Reviewers agreed at journal 03 Sep, 2025 Reviewers agreed at journal 29 Aug, 2025 Reviewers invited by journal 27 Aug, 2025 Editor invited by journal 01 Aug, 2025 Editor assigned by journal 14 Jul, 2025 Submission checks completed at journal 14 Jul, 2025 First submitted to journal 11 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7097815","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":509645944,"identity":"25ce69a2-07d4-44ee-bbd3-58e00d07bb55","order_by":0,"name":"Nnamdi Ndubuka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYHACA2YGhgQGfgbGBmbStEg2MDY2k6bF4AADI3FazKWbt0kXtqXJG99ubn9cUMMgzy92AL8WyznHyqRntuUYbrtzsLF5xjEGw5mzEwi46kaOmTRvWwXjthuJjc08bAwJBreJ1GK/eQZIyz/iteQkbpAAauFtI0pLWrH1jHNpyTOADpvN2ydBjF+SN94uKEu27Z+R/uAzzzcbeX5pAlrQgQRpykfBKBgFo2AUYAcAqypDQN/rJ0EAAAAASUVORK5CYII=","orcid":"","institution":"Northern Inter-Tribal Health Authority","correspondingAuthor":true,"prefix":"","firstName":"Nnamdi","middleName":"","lastName":"Ndubuka","suffix":""},{"id":509645948,"identity":"d6209ded-7ec7-4a8a-8483-cf5b7d628b8f","order_by":1,"name":"Emmanuel Dankwah","email":"","orcid":"","institution":"Northern Inter-Tribal Health Authority","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Dankwah","suffix":""},{"id":509645950,"identity":"90882833-be21-4d29-a134-9ee52eed5750","order_by":2,"name":"Shirley Woods","email":"","orcid":"","institution":"Prince Albert Grand Council","correspondingAuthor":false,"prefix":"","firstName":"Shirley","middleName":"","lastName":"Woods","suffix":""},{"id":509645951,"identity":"ca67d6c6-0a98-463e-9053-be4671361964","order_by":3,"name":"Carrie Gardipy-Mckenzie","email":"","orcid":"","institution":"Northern Inter-Tribal Health Authority","correspondingAuthor":false,"prefix":"","firstName":"Carrie","middleName":"","lastName":"Gardipy-Mckenzie","suffix":""},{"id":509645954,"identity":"0674244f-bd7d-48cd-adc3-cdb875d581d7","order_by":4,"name":"Priscilla Dankwah","email":"","orcid":"","institution":"Brock University","correspondingAuthor":false,"prefix":"","firstName":"Priscilla","middleName":"","lastName":"Dankwah","suffix":""},{"id":509645955,"identity":"18a99dc3-375b-4153-bf94-3d394af77a50","order_by":5,"name":"Grace Akinjobi","email":"","orcid":"","institution":"Northern Inter-Tribal Health Authority","correspondingAuthor":false,"prefix":"","firstName":"Grace","middleName":"","lastName":"Akinjobi","suffix":""},{"id":509645957,"identity":"d8e4a8f1-d2fb-49a0-8433-2ac0e648adcf","order_by":6,"name":"Justina Ndubuka","email":"","orcid":"","institution":"Northern Inter-Tribal Health Authority","correspondingAuthor":false,"prefix":"","firstName":"Justina","middleName":"","lastName":"Ndubuka","suffix":""},{"id":509645959,"identity":"bb82c87e-2c0c-4fb0-ba43-da80d9040333","order_by":7,"name":"Adeshola Abati","email":"","orcid":"","institution":"Northern Inter-Tribal Health Authority","correspondingAuthor":false,"prefix":"","firstName":"Adeshola","middleName":"","lastName":"Abati","suffix":""},{"id":509645960,"identity":"733b38ac-8f01-4106-8462-a529b792f896","order_by":8,"name":"Ibrahim Khan","email":"","orcid":"","institution":"Indigenous Services Canada","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Khan","suffix":""},{"id":509645962,"identity":"32dbf145-9382-48ed-acda-1f6db82b8b1e","order_by":9,"name":"Amanda Froehlich-Chow","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Froehlich-Chow","suffix":""},{"id":509645964,"identity":"f8d93eef-f1a7-4083-b070-849df5bbf502","order_by":10,"name":"Geoffrey Maina","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Geoffrey","middleName":"","lastName":"Maina","suffix":""},{"id":509645965,"identity":"09d78d98-4cae-40c1-ace8-11a8659e6163","order_by":11,"name":"Gary Groot","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Gary","middleName":"","lastName":"Groot","suffix":""}],"badges":[],"createdAt":"2025-07-11 05:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7097815/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7097815/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12982-026-01455-7","type":"published","date":"2026-01-31T15:58:29+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90791148,"identity":"1758abe6-ebfb-4f8c-afa9-0c9bd2d8a8b4","added_by":"auto","created_at":"2025-09-08 08:20:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64297,"visible":true,"origin":"","legend":"\u003cp\u003eRapid review flow diagram of the search and selection of articles\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7097815/v1/12a548f3901737f1030daf50.jpg"},{"id":90792363,"identity":"3cb48036-15e7-4aad-bcc6-46bf47d0eeaf","added_by":"auto","created_at":"2025-09-08 08:28:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":139056,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe key themes of the barriers identified through our review\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7097815/v1/13ef74504e5e1231f93d1a6b.jpg"},{"id":90791154,"identity":"442120a1-69f5-467a-95b7-949467751c0c","added_by":"auto","created_at":"2025-09-08 08:20:00","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1290165,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThe key themes of enablers identified through our review\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7097815/v1/8bbb8679cf23d71ee0457fc2.jpg"},{"id":101692338,"identity":"d8c83672-3f7e-49b4-9e2a-a04e0c6ba78b","added_by":"auto","created_at":"2026-02-02 16:17:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2594454,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7097815/v1/df6fdf88-b257-4c98-af9f-9d0f93cffa36.pdf"},{"id":90791164,"identity":"c7b53f04-e4b2-4dc5-8b5e-4af0254f2e13","added_by":"auto","created_at":"2025-09-08 08:20:02","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16995,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial1Ndubukaetal.docx","url":"https://assets-eu.researchsquare.com/files/rs-7097815/v1/300de35ac7226a2ecc0b6988.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers to and Enablers of Childhood Immunization Uptake in First Nations Communities in Canada: A Rapid Review of the Literature","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eChildhood immunization remains one of the most effective public health interventions for reducing morbidity and mortality from vaccine-preventable diseases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Canada, routine vaccination programs have achieved high national coverage; however, disparities persist among Indigenous populations, including the First Nations, Inuit, and M\u0026eacute;tis, owing to intersecting structural, geographic, and systemic barriers [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite all the benefits of increased childhood immunization rates, some northern Saskatchewan First Nations communities continue to report coverage levels below the recommended provincial target of 95% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In 2021, immunization coverage was 84% for children under one year of age and 79% for children at their second birthday [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These persistent gaps present a significant public health concern, contributing to increased vulnerability to infectious disease outbreaks and preventable illness in early childhood.\u003c/p\u003e\u003cp\u003eWhile national reports and several studies report immunization coverage among Indigenous peoples as a collective group, there remains a critical gap in synthesized evidence on childhood immunization that focuses specifically on First Nations communities. Given the distinct healthcare systems, governance structures, cultural traditions, and historical experiences that shape First Nations Peoples\u0026rsquo; interactions with health services, dedicated and context-specific research is essential to support equitable and culturally informed public health strategies. To our knowledge, no rapid review has comprehensively assessed the barriers to and facilitators of childhood immunization within First Nations communities in Canada. A deeper understanding of these factors and their influence on immunization uptake is vital for developing targeted interventions aimed at improving vaccine equity and health outcomes among First Nations children.\u003c/p\u003e\u003cp\u003eTo address this gap, we conducted a rapid review of peer-reviewed literature to identify and synthesize the key barriers and enablers influencing childhood immunization uptake among First Nations communities across Canada. In collaboration with the Northern Inter-Tribal Health Authority (NITHA), we developed this review as part of a broader, community-guided research project. The overarching aim of the project is to identify culturally relevant, evidence-informed strategies to increase childhood immunization coverage among First Nations children aged 0\u0026ndash;2 years in northern Saskatchewan. Our review offers critical foundational insights to inform locally tailored public health strategies and supports the next phases of our broader initiative to improve immunization equity and outcomes in the region.\u003c/p\u003e"},{"header":"3 Methods","content":"\u003cp\u003eWe carried out this rapid review in partnership with NITHA, which included a collaborative team of researchers, health professionals, family partners, knowledge users, and decision-makers. This team contributed meaningfully at every stage of the review process, including the development of research questions, the design and execution of the literature search, the analysis and interpretation of findings, the preparation of results, and the dissemination of the final report. Our review is embedded within a larger community-guided research initiative conducted within NITHA\u0026rsquo;s jurisdiction, focused on improving childhood immunization uptake in First Nations communities in northern Saskatchewan.\u003c/p\u003e\u003cp\u003eWe conducted the rapid review in five structured phases [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]: (a) developing the research question; (b) identifying and retrieving relevant literature; (c) screening and selecting studies for inclusion; (d) systematically charting the extracted data; and (e) synthesizing the findings through collation, summarization, and reporting.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Rapid Review Question\u003c/h2\u003e\u003cp\u003eOur rapid review aimed to answer the following question: What is known about the barriers to and enablers of childhood immunization uptake in Canadian First Nations communities?\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Data Sources and Search Strategy\u003c/h2\u003e\u003cp\u003eGiven that the PRISMA extension for Rapid Reviews (PRISMA-RR) has been under development since 2015 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], we conducted our rapid review in accordance with the evidence-informed guidance provided by the Cochrane Rapid Reviews Methods Group [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. We systematically searched Web of Science, PubMed, and Scopus for original peer-reviewed articles published between January 2003 and August 2023. We selected a 20-year time frame (2003\u0026ndash;2023) to ensure a comprehensive and inclusive review of the literature. This extended period allowed us to capture both foundational and emerging evidence in a field where research specific to First Nations childhood immunization is limited. Moreover, this timeframe reflects a balance between historical context and contemporary relevance, enabling us to identify trends, persistent barriers, and evolving strategies within a changing policy and healthcare landscape.\u003c/p\u003e\u003cp\u003eWe focused on childhood immunization in Canadian First Nations communities as part of the broader NITHA\u0026rsquo;s First Nations childhood immunization project. Our search terms included combinations of 'children', 'immunization', 'barriers', 'enablers', 'First Nations', and 'Canada', as detailed in supplementary material 1.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Eligibility criteria\u003c/h2\u003e\u003cp\u003eTo ensure relevance to the research questions and objectives, we selected studies on the basis of the following inclusion criteria:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eResearch has focused on childhood immunization service delivery within First Nations communities in Canada.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eArticles reporting on interventions, policies, or best practices designed to improve immunization uptake.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePublications offering empirical data on outcomes, lessons learned, or actionable recommendations for improving immunization services.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies that identify at least one barrier or one enabler related to childhood immunization uptake.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies published in English.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe exclusion criteria were as follows: (1) research conducted outside Canada or not specific to First Nations communities. (2) Articles that did not address childhood immunization service delivery or lacked relevant outcomes. Publications such as conference abstracts, editorials, letters, and any articles not published in English.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Screening and Selection Process\u003c/h2\u003e\u003cp\u003eWe managed and organized the articles retrieved through the search strategy via Microsoft Excel to facilitate the removal of duplicates. After excluding duplicates, two reviewers, Emmanuel Dankwah (ED) and Carrie Gardipy (CG), independently screened the titles and abstracts of the remaining studies to assess their relevance on the basis of the established inclusion criteria. The reviewers resolved any discrepancies through discussion and consensus. When disagreements persisted, a third reviewer, Nnamdi Ndubuka (NN), intervened to help reach a final decision. We retrieved and assessed the full-text articles of potentially relevant studies for final eligibility. We documented the reasons for exclusion at each stage of the review process and used flow diagrams to visually represent the screening steps.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Data extraction\u003c/h2\u003e\u003cp\u003eWe carried out the data extraction process via a standardized form designed to capture essential information from the selected studies. We assessed the methodological rigor and potential biases of both the quantitative and qualitative studies via the Joanna Briggs Institute (JBI) Critical Appraisal checklists [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These checklists helped us evaluate the quality of the studies in accordance with the established eligibility criteria, using parameters with responses classified as \u0026ldquo;yes,\u0026rdquo; \u0026ldquo;no,\u0026rdquo; \u0026ldquo;unclear,\u0026rdquo; or \u0026ldquo;not applicable.\u0026rdquo; A completed quality assessments for each included study are available on request.\u003c/p\u003e\u003cp\u003eWe classified studies that achieved scores ranging from 5\u0026ndash;6 points as \u0026lsquo;high quality,\u0026rsquo; whereas those scoring below this range were considered \u0026lsquo;low quality\u0026rsquo; [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. We systematically recorded key study details, including the author\u0026rsquo;s name, publication year, study design, geographical location (province and country), study population, target population, and quality rating, in a Microsoft Excel spreadsheet.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.6 Data Synthesis and Analysis\u003c/h2\u003e\u003cp\u003eWe adopted a narrative synthesis approach to analyze the data, incorporating methods such as tabulation and thematic analysis. We focused on thematically grouping the barriers and enablers identified across the included studies. We constructed a table for each study, capturing descriptive information and key findings, including themes, subthemes, barriers, and enablers. We categorized the barriers and enablers into three primary domains: factors related to parents or caregivers, issues within the health system, and challenges associated with healthcare providers.\u003c/p\u003e\u003cp\u003eThematic analysis was employed to identify and synthesize recurring themes from the included studies. We derived themes both deductively, on the basis of predefined categories related to immunization service delivery, and inductively, on the basis of emergent findings from the literature. We iteratively reviewed and refined these themes to ensure that they adequately captured the full range of relevant issues related to childhood immunization in First Nations communities.\u003c/p\u003e\u003cp\u003eWe then analyzed the synthesized findings to compare policies, practices, and outcomes related to childhood immunization service delivery across various jurisdictions in Canada. We interpreted the results to assess their implications for policy development, healthcare practices, and future research. On the basis of this evidence, we formulated recommendations to guide strategies aimed at improving immunization uptake and health outcomes among First Nations children.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Search results\u003c/h2\u003e\u003cp\u003eOur database searches yielded 109 records. After removing duplicates, 56 unique abstracts remained for screening. Following title and abstract review, we excluded 33 studies that did not meet the inclusion criteria. We then assessed 23 full-text articles for eligibility, 19 of which were excluded on the basis of predefined criteria. Ultimately, four studies met the inclusion criteria and were retained for analysis. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the flowchart of the rapid review process, including the reasons for study exclusion.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Descriptive analysis of the studies\u003c/h2\u003e\u003cp\u003eThe four studies that met our inclusion criteria were geographically concentrated in only two Canadian provinces. Three studies (75%) were conducted in Alberta, and one (25%) was conducted in Ontario. The publication dates ranged from 2003\u0026ndash;2023; only one study was published in 2003, while the remaining three (75%) were published within the last three years (2020\u0026ndash;2023). In terms of methodology, one study (25%) employed a quantitative design (a retrospective cohort study), whereas the other three (75%) utilized qualitative approaches. Among the qualitative studies, one adopted an institutional ethnography framework, and two used interview-based methods. The full details of the included studies are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of the studies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor (year)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudy design\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudy Area (Province and country)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStudy population\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTarget population\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStudy aim(s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eStudy quality\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChiem et al., 2022[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQualitative study (Semi structured phone interviews)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNorthern Alberta, Canada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 Parents with under immunized children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eImmunization for 2-year-old\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo identify reasons for under immunization in children in low socioeconomic status (SES) communities and propose suggestions to address issues/concerns identified by low SES parents for improving immunization coverage in their communities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMacDonald et al., 2022 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQualitative study (Institutional Ethnography approach)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCentral Alberta, Canada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 First Nations parents and 6 health center staff (nursing, clerical staff, and management)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eImmunization for preschool aged children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo identify opportunities for innovation by exploring the work that nurses and parents must do to have children vaccinated.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMacDonald et al., 2023 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQuantitative study (Retrospective cohort study)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCentral Alberta, Canada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFirst Nations\u003c/p\u003e\u003cp\u003echildren from a rural First Nations community in central Alberta\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eChildhood immunization for 2- and 7-year-old\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo use linked data to accurately measure vaccine coverage by age 2 and 7\u0026thinsp;years for children living in a large First Nations community in Alberta, Canada.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTarrant and Gregory, 2003 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQualitative study (Interviews)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNorth-Western Ontario, Canada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28 First Nations mothers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eChildhood Immunization for under 5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo explore First Nations parents' beliefs about childhood immunizations and examined factors influencing immunization uptake.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Barriers to Immunization Uptake\u003c/h2\u003e\u003cp\u003eOur rapid review revealed multiple barriers to childhood immunization within First Nations communities in Canada, which can be grouped into three main categories: parental and caregiver factors, health provider factors, and health system factors.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e3.3.1 Barriers to parents and caregivers\u003c/h2\u003e\u003cp\u003eIn our analysis, we identified a range of parental and caregiver-related barriers that delay childhood immunization. These include emotional concerns such as fear and mistrust, gaps in culturally appropriate information, and logistical challenges such as transportation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section4\"\u003e\u003ch2\u003e3.3.1.1 Fear of needles\u003c/h2\u003e\u003cp\u003eTwo qualitative studies indicated that the considerable anxiety caregivers experienced while watching their children receive injections discouraged many from returning for follow‑up doses [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section4\"\u003e\u003ch2\u003e3.3.1.2 Misinformation\u003c/h2\u003e\u003cp\u003eParents frequently encounter rumors in their communities and online that vaccines can cause severe illness or death [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Skepticism was strongest for newer products and for ingredients such as thimerosal, which weakened overall confidence in immunization programs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section4\"\u003e\u003ch2\u003e3.3.1.3 Safety concerns\u003c/h2\u003e\u003cp\u003eCaregivers commonly expressed anxiety about a perceived link between vaccination and autism, uncertainty regarding the cumulative toxicity of multiple injections, and fear that an intensive schedule could overwhelm a young child\u0026rsquo;s immune system [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These concerns prompted many parents to delay appointments or to accept only selected vaccines [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Parents also cited milder reactions such as fever after vaccination as additional reasons for hesitancy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section4\"\u003e\u003ch2\u003e3.3.1.4 Scheduling conflicts\u003c/h2\u003e\u003cp\u003eCaregivers struggle to attend weekday clinics because of competing work, household, and childcare responsibilities [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and policies requiring separate appointments for each child further increase missed or postponed visits [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section4\"\u003e\u003ch2\u003e3.3.1.5 Transportation difficulties\u003c/h2\u003e\u003cp\u003eLong travel distances, limited public transit, and unreliable access to community vans or fuel assistance make it difficult for families, particularly those in remote communities, to reach immunization services in time [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section4\"\u003e\u003ch2\u003e3.3.1.6 Child Illness\u003c/h2\u003e\u003cp\u003eFrequent respiratory or ear infections result in routine deferral of scheduled vaccinations; parents and nurses alike prefer to postpone immunization when a child has fever or other acute symptoms, which contributes to cumulative delays in completing the schedule [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\u003ch2\u003e3.3.2 Healthcare provider barriers\u003c/h2\u003e\u003cp\u003eIn our review, we found that communication breakdowns and negative interactions with healthcare providers contributed to delays in or avoidance of childhood immunization in First Nations communities.\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section4\"\u003e\u003ch2\u003e3.3.2.1 Scheduling conflicts\u003c/h2\u003e\u003cp\u003eCaregivers described repeated attempts to schedule appointments by telephone that went unanswered or were met with busy signals [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These communication breakdowns created frustration and often led parents to delay or abandon plans to vaccinate their children [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section4\"\u003e\u003ch2\u003e3.3.2.2 Perceived disrespect and negative healthcare experience\u003c/h2\u003e\u003cp\u003eSome families felt dismissed or disrespected during clinic encounters [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], which led to mistrust of the health system and reduced adherence to recommended immunization schedules [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003e3.3.3 Health system barriers\u003c/h2\u003e\u003cp\u003eIn our study, we identified key health system barriers that hinder timely childhood immunization. These include rigid scheduling policies, long wait times, and fragmented record-keeping, all of which complicate access to services and reduce caregiver confidence in the healthcare system.\u003c/p\u003e\u003cdiv id=\"Sec24\" class=\"Section4\"\u003e\u003ch2\u003e3.3.3.1 Scheduling policies\u003c/h2\u003e\u003cp\u003eInstitutional rules often require parents to book separate appointments for each child [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This approach substantially increased the number of trips families had to make, creating additional childcare and transportation challenges [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section4\"\u003e\u003ch2\u003e3.3.3.2 Long Wait Times\u003c/h2\u003e\u003cp\u003eExtended waiting periods discouraged attendance, as caregivers reported arriving on time yet sometimes waiting up to an hour before their children were seen, which led to frustration and ultimately missed or postponed immunization visits [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003e3.3.3 Fragmented Records\u003c/h2\u003e\u003cp\u003eImmunization data are frequently divided into on‑reserve and off‑reserve health systems [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Incomplete access to a child\u0026rsquo;s full vaccination history results in missed doses or unnecessary repeat vaccinations, undermining both completion rates and caregiver confidence in the health system\u0026rsquo;s reliability [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Enablers of Immunization Uptake\u003c/h2\u003e\u003cp\u003eIn our study, we identified key enablers that support vaccine uptake, which span parental awareness, positive healthcare provider relationships, and supportive health system practices. These facilitators play crucial roles in overcoming barriers and enhancing immunization coverage.\u003c/p\u003e\u003cdiv id=\"Sec28\" class=\"Section3\"\u003e\u003ch2\u003e3.4.1 Enabling of parents and caregivers\u003c/h2\u003e\u003cp\u003eAwareness of disease risk emerged as a crucial enabler of immunization at the caregiver and parental levels. One study reported that caregiver recognition of the dangers posed by vaccine-preventable diseases significantly influences vaccination uptake [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The evidence suggests that when caregivers understand the potential severity of these illnesses, especially during local outbreaks, they are more motivated to ensure that their children receive timely and complete immunizations (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section3\"\u003e\u003ch2\u003e3.4.2 Healthcare provider enablers\u003c/h2\u003e\u003cp\u003eIn our review, we identified healthcare provider-related enablers that supported childhood immunization uptake (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). We found that building strong, trusting relationships with caregivers was consistently reported as a key factor. We also noted that clear communication about vaccine safety and benefits, consistent follow-up, and the delivery of care in respectful, culturally sensitive, and welcoming environments were important strategies used by providers to foster trust and encourage vaccine acceptance [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec30\" class=\"Section3\"\u003e\u003ch2\u003e3.4.3 Health System Enablers\u003c/h2\u003e\u003cp\u003eWe identified several health system-level enablers that supported improved childhood immunization uptake.\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section4\"\u003e\u003ch2\u003e3.4.3.1 Ongoing immunization services\u003c/h2\u003e\u003cp\u003eWe found that offering immunization services within on-reserve communities reduced travel time and costs for families, contributing to higher vaccine completion rates [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section4\"\u003e\u003ch2\u003e3.4.3.2 Flexible service delivery models\u003c/h2\u003e\u003cp\u003eWe also noted that flexible service delivery models such as mobile clinics, extended hours, and proactive reminders via text or phone help accommodate caregivers managing work and household responsibilities [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec33\" class=\"Section4\"\u003e\u003ch2\u003e3.4.3.3 Data‑sharing agreements\u003c/h2\u003e\u003cp\u003eWe observed that data-sharing agreements between on-reserve and off-reserve health systems, particularly through electronic record linkages, enhanced continuity of care by allowing providers access to complete vaccination histories, reducing both missed and duplicate doses [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section4\"\u003e\u003ch2\u003e3.4.3.4 Community engagement and leadership\u003c/h2\u003e\u003cp\u003eWe found that engaging community leaders and elders in the planning and promotion of immunization efforts fostered a sense of shared responsibility and strengthened culturally grounded messaging that increased caregiver confidence in vaccines [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eOur rapid review explored the barriers to and enablers of childhood immunization within First Nations communities in Canada, with particular attention given to the experiences of parents, caregivers, healthcare providers, and health system factors influencing vaccine uptake. Our findings revealed a complex interplay of sociocultural, emotional, logistical, and institutional influences. Although several themes align with broader patterns of vaccine hesitancy documented across Canada, this review identified the unique, context-specific factors essential to understanding immunization dynamics within First Nations communities.\u003c/p\u003e\u003cdiv id=\"Sec36\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Barriers to Immunization\u003c/h2\u003e\u003cp\u003eParents and caregivers face multiple challenges that hinder timely childhood immunization. A prominent barrier identified was the emotional distress experienced by parents and caregivers during the immunization process. Similar emotional barriers have been documented in the literature [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], where parental guilt and anxiety over their child's pain diminished trust in healthcare providers and vaccine programs. Evidence-based interventions aimed at minimizing procedural pain have been shown to improve vaccine acceptance [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Within the First Nations context, this emotional distress must be viewed through the lens of historical trauma and ongoing mistrust toward healthcare systems, which may amplify negative emotional responses to vaccination [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Thus, emotional reactions to immunization should be interpreted not only as individual experiences but also as reflections of broader historical and cultural realities that contribute to vaccine hesitancy.\u003c/p\u003e\u003cp\u003eMisinformation, particularly regarding vaccine safety, has also emerged as a significant barrier. This challenge was intensified by the circulation of unverified information within communities, reinforcing skepticism about vaccine efficacy and safety. These findings are consistent with broader research on vaccine hesitancy, where misinformation is a critical factor in undermining vaccine confidence [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In First Nations contexts, historical marginalization and systemic inequities further exacerbate mistrust toward medical authorities, magnifying the impact of misinformation. Therefore, efforts to counter misinformation must go beyond scientific communication, integrating culturally sensitive approaches that acknowledge and address the sociopolitical conditions shaping these perceptions. Strategies such as narrative-based interventions have been proposed to mitigate vaccine-related misinformation among providers and parents [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLogistical challenges, including transportation barriers and limited access to healthcare infrastructure, were also identified as significant impediments to immunization. Similar issues have been reported in other rural and underserved populations, where difficulties in accessing healthcare services contribute to missed immunization opportunities and lower uptake rates [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In First Nations communities, these logistical obstacles are further compounded by longstanding disparities in access to healthcare resources, highlighting the urgent need for systemic solutions that address both immediate logistical barriers and their deeper structural roots.\u003c/p\u003e\u003cp\u003eHealthcare providers play a crucial role in supporting immunization uptake; however, certain provider-related factors may act as barriers. Our review identified healthcare provider-related factors, particularly perceived disrespect and inadequate communication, as significant barriers to immunization uptake. This finding aligns with those of previous studies, which emphasized the critical role of provider attitudes and communication styles in influencing vaccine acceptance [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In First Nations communities, these barriers are further compounded by a legacy of systemic discrimination and colonial healthcare practices [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNumerous studies have argued that cultural safety, where healthcare professionals recognize and respect the distinct cultural and historical experiences of Indigenous peoples, is fundamental to rebuilding trust and improving immunization uptake [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Our findings strongly support the importance of integrating culturally safe practices into immunization services in First Nations communities. Moreover, at the health system level, several factors significantly impeded families\u0026rsquo; access to immunization services. Rigid appointment scheduling practices, as identified in our review, have been reported in other healthcare settings, where inflexible scheduling structures contributed to missed immunization opportunities and reduced vaccine coverage [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Without adaptable appointment systems, First Nations families face compounded barriers that further widen immunization gaps.\u003c/p\u003e\u003cp\u003eFragmented immunization recording systems have also emerged as a major systemic challenge. Consistent with our findings, researchers emphasize that robust vaccine record tracking, high-quality data management, and seamless system integration are essential for improving routine childhood immunization rates and protecting against vaccine-preventable diseases [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Enablers to Immunization\u003c/h2\u003e\u003cp\u003eRecognizing the risks associated with vaccine-preventable diseases strongly motivated parents and caregivers to pursue immunization. Our findings corroborate broader research showing that heightened awareness of disease consequences drives vaccine acceptance [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Studies have demonstrated that culturally sensitive educational campaigns tailored to community needs and experiences substantially improve vaccine uptake [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Community-based outreach efforts that emphasize the local impact of disease outbreaks appear particularly effective in First Nations contexts.\u003c/p\u003e\u003cp\u003eTrust in healthcare providers has emerged as a crucial facilitator of vaccine acceptance. Our review aligns with evidence indicating that positive, respectful interactions between healthcare providers and parents significantly reduce vaccine hesitancy [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In First Nations communities, the delivery of culturally competent care proves essential. Our findings reinforce other studies, emphasizing that providers who engage respectfully and communicate effectively can strengthen parental vaccine confidence [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOn-reserve healthcare services play a pivotal role in supporting immunization efforts. Our findings are consistent with research highlighting that proximity to culturally safe and community-based healthcare services improve health outcomes in rural and underserved populations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. On-reserve clinics offer accessible, trusted environments for vaccination and facilitate consistent follow-up care.\u003c/p\u003e\u003cp\u003eFurthermore, flexible service delivery models such as mobile vaccination clinics and extended service hours have emerged as critical enablers. Similar to findings in other underserved settings [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], these adaptable models, when embedded into routine immunization programs, can substantially increase vaccine access and completion rates among First Nations populations.\u003c/p\u003e\u003c/div\u003e"},{"header":"5 Implications for Research, Practice, and Policy","content":"\u003cp\u003eOur review offers a comprehensive and timely synthesis of the barriers, enablers and effective initiatives to immunization among First Nations communities in Canada, an often-underrepresented population in vaccine research. By integrating both qualitative and quantitative evidence, we provide a nuanced understanding of immunization dynamics, reflecting diverse regional contexts across Canada. This structured approach captures the complex interplay among parents and caregivers, health providers, and health system factors influencing vaccine uptake, offering an up-to-date resource for healthcare providers and policymakers.\u003c/p\u003e\u003cp\u003eOur findings have several implications for public health policy and practice. First, healthcare providers must receive cultural competence training to engage respectfully and effectively with First Nations families. Trust-building through culturally sensitive care can substantially enhance vaccine confidence. Involving elders and community leaders in vaccination initiatives is critical to overcoming hesitancy and strengthening trust in healthcare systems. Public health strategies should also prioritize minimizing emotional distress during vaccinations by adopting trauma-informed care practices and ensuring that vaccination appointments allow adequate time for supportive interactions. Addressing logistical barriers such as transportation challenges and rigid scheduling remains essential. Expanding access through mobile clinics, flexible service hours, and transportation support could significantly improve immunization rates. Furthermore, integrating immunization records across on- and off-reserve healthcare systems will enhance data quality and care continuity. Targeted public health campaigns must counter vaccine misinformation via trusted community voices and culturally tailored messaging that reflects the historical and social realities of First Nations communities.\u003c/p\u003e\u003cp\u003eOur study identified a significant gap in the limited research examining the role of traditional Indigenous knowledge in informing immunization practices. Although some studies have highlighted the value of integrating cultural practices into healthcare, evidence remains scarce on how traditional healing systems could support immunization efforts [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Future research should investigate strategies to bridge Western medical practices with Indigenous knowledge systems to foster vaccine acceptance more holistically.\u003c/p\u003e"},{"header":"6 Limitations","content":"\u003cp\u003eSome limitations warrant consideration. The relatively small number of included studies restricts the generalizability of our findings. While we aimed to incorporate a range of perspectives, the predominance of qualitative research may not fully represent the broader First Nations population. Additionally, the regional focus of many studies may limit the applicability of findings to all First Nations communities nationwide. Our exclusion of non-English studies and gray literature could also have omitted valuable insights not captured in mainstream academic sources.\u003c/p\u003e"},{"header":"7 Conclusion","content":"\u003cp\u003eOur rapid review identified the multifaceted barriers and enablers influencing childhood immunization uptake in First Nations communities in Canada. Barriers included caregiver-related concerns such as fear of needles, misinformation, and logistical challenges; provider-related issues such as negative healthcare experiences; and systemic obstacles such as fragmented immunization records and restrictive scheduling policies. Conversely, enablers such as strong caregiver\u0026ndash;provider relationships, accessible on-reserve services, flexible delivery models, and community engagement emerged as critical facilitators. Addressing these barriers while strengthening the enablers requires culturally sensitive, community-driven approaches that build trust, improve accessibility, and integrate Indigenous knowledge and leadership. Future public health initiatives must prioritize collaborative strategies that enhance system responsiveness and promote equitable immunization access for First Nations children, ultimately reducing vaccine-preventable diseases in these communities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN.N: Conceptualization, design of the review, final decisions about article inclusion, critically reviewed manuscript for important intellectual content; Supervision, accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved, Final approval of the version to be published.E.D: Design of the review, completed article screening and selection, data synthesis and analysis of results, prepared the original manuscript draft, reviewed manuscript for important intellectual content. S.W.: Conceptualization, design of the review, reviewed manuscripts drafts and contributed to refining the paper.C.G.: Completed article screening and selection. P.D.: Prepared the original manuscript draft, generated figures and tables, and contributed to refining the paper.G.A.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.J.N.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.A.A.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.A.F.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.G.M.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.I.K.: Reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.G.G.: reviewed and edited the draft manuscript for important intellectual content; contributed to refining the paper.All authors have read and approved the final manuscript prior to submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAndre FE, Booy R, Bock HL, Clemens J, Datta SK, John TJ, et al. 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Assessing the completeness of infant and childhood immunizations within a provincial registry populated by parental reporting: a study using linked databases in Ontario, Canada. Vaccine. 2020;38:5223\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVest JR, Kirk HM, Issel LM. Quality and integration of public health information systems: A systematic review focused on immunization and vital records systems. Online J Public Health Inf. 2012;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWong King Yuen SM, Doucette EJ, Ford C, Fullerton MM, Vetro G, Koyama A, et al. Addressing Barriers Newcomer Families Face When Obtaining Routine Childhood Vaccines in Alberta, Canada. Vaccines (Basel). 2024;12:1380.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarlson SJ, Tomkinson S, Hannah A, Attwell K. What happens at two? Immunization stakeholders\u0026rsquo; perspectives on factors influencing suboptimal childhood vaccine uptake for toddlers in regional and remote Western Australia. BMC Health Serv Res. 2024;24:968.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7097815/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7097815/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and objective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChildhood immunization is essential to public health; however, vaccination coverage among First Nations communities in Canada remains suboptimal. To support the broader project aimed at increasing immunization rates among First Nations children in northern Saskatchewan, we conducted a rapid review to examine the current evidence on barriers and enablers to childhood vaccine uptake within Canadian First Nations communities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing Cochrane Rapid Reviews Methods Group guidelines, we searched the Web of Science, PubMed, and Scopus for peer-reviewed studies published between 2003 and 2023. Eligible studies were limited to those published in English and focused on Canadian First Nations populations, reporting on factors influencing childhood immunization. We synthesized findings thematically, identifying patterns in barriers and enabling conditions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe included four studies in this review. We categorized the barriers to childhood immunization into three domains: parental or caregiver factors, healthcare provider factors, and health system factors. Parental barriers included fear of needles, misinformation, safety concerns, scheduling conflicts, transportation challenges, and child illness. Provider-related barriers involved scheduling challenges and perceived disrespect from healthcare staff. System-level barriers included rigid appointment policies, long wait times, and fragmented immunization records. We also identified key enablers such as trust in healthcare providers, culturally safe care, fear of disease outbreaks, on-reserve service delivery, data-sharing agreements, flexible service models, and community engagement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo improve immunization rates in First Nations communities, public health interventions must address cultural, systemic, and logistical barriers. Strategies should prioritize culturally safe care, community engagement, enhanced communication, and flexible service delivery models supported by robust information-sharing systems.\u003c/p\u003e","manuscriptTitle":"Barriers to and Enablers of Childhood Immunization Uptake in First Nations Communities in Canada: A Rapid Review of the Literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 08:19:55","doi":"10.21203/rs.3.rs-7097815/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-05T08:59:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-28T23:29:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-26T11:38:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-21T14:15:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228277791824989842122129701431296959858","date":"2025-10-14T10:02:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253374827146085242562025103681695521454","date":"2025-10-13T10:16:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264424513786332633257504607614642943665","date":"2025-10-11T10:33:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-10T05:06:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227127131530484289759283565147990890291","date":"2025-09-03T11:11:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16533523252428863443574025179933454174","date":"2025-08-29T14:50:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-27T14:48:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-01T19:31:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-14T08:43:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-14T08:43:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2025-07-11T04:54:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"48fbc3c8-f0a4-4857-a299-719c221d63a6","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:16:58+00:00","versionOfRecord":{"articleIdentity":"rs-7097815","link":"https://doi.org/10.1186/s12982-026-01455-7","journal":{"identity":"discover-public-health","isVorOnly":false,"title":"Discover Public Health"},"publishedOn":"2026-01-31 15:58:29","publishedOnDateReadable":"January 31st, 2026"},"versionCreatedAt":"2025-09-08 08:19:55","video":"","vorDoi":"10.1186/s12982-026-01455-7","vorDoiUrl":"https://doi.org/10.1186/s12982-026-01455-7","workflowStages":[]},"version":"v1","identity":"rs-7097815","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7097815","identity":"rs-7097815","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}