Structural determinants of vaccine access: an integrated review of the Canadian literature

BACKGROUND: Vaccination is a critical public health tool, yet vaccine uptake in Canada is declining, with persistent inequities among marginalized populations. While individual-level vaccine hesitancy is well studied, there is limited synthesis of how structural determinants such as governance, institutional practices, and cultural norms shape access. OBJECTIVE: To examine how structural determinants shape vaccine access among marginalized populations in Canada. METHODS: We conducted an integrative review following the Joanna Briggs Institute (JBI) methodology and reported according to PRISMA-ScR guidelines. Studies were included if they addressed vaccine access in the Canadian context and examined systemic inequities affecting marginalized populations. Data from 40 sources were charted and analyzed thematically using a structural determinant of health framework, which categorized findings into four domains: (1) values, beliefs, culture, and norms; (2) governance; (3) laws, policies, regulations, and budgets; and (4) institutional practices. RESULTS: Structural determinants affected vaccine access in multiple, intersecting ways. Cultural mistrust, religious concerns, and social norms influenced perceptions of vaccine safety and relevance. Governance issues including top-down strategies, lack of community engagement, and inconsistent communication undermined public trust. Legal and policy barriers, such as identification requirements, excluded marginalized populations. Institutional practices, including inaccessible clinic locations, and absence of race-based data, further contributed to inequities. Positive examples of community- and peer-led interventions were identified but often underfunded or excluded from formal systems. CONCLUSIONS: Addressing these barriers requires participatory governance, culturally safe services, and sustained investment in community-led models. Our framework can inform equity-focused vaccine policy and practice in Canada and similar high-income contexts.