Expert Review of Vaccines

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Understanding influenza vaccination behaviors: a comprehensive sociocultural framework Jeremy Ward & Jocelyn Raude To cite this article: Jeremy Ward & Jocelyn Raude (2014) Understanding influenza vaccination behaviors: a comprehensive sociocultural framework, Expert Review of Vaccines, 13:1, 17-29 To link to this article: http://dx.doi.org/10.1586/14760584.2014.863156

Published online: 26 Nov 2013.

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Date: 05 November 2015, At: 18:48

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Understanding influenza vaccination behaviors: a comprehensive sociocultural framework Expert Rev. Vaccines 13(1), 17–29 (2014)

Expert Review of Vaccines 2014.13:17-29.

Jeremy Ward1 and Jocelyn Raude*2,3 1 Universite´ Paris Diderot, Sorbonne Paris Cite´, France 2 Department of Social and Behavioral Sciences, EHESP French School of Public Health, Avenue du Professeur Le´onBernard, CS 74312, 35043 Rennes Cedex, Sorbonne Paris Cite´, France 3 Aix Marseille Universite´, IRD French Institute of Research for Development, EHESP French School of Public Health, UMR_D 190 “Emergence des Pathologies Virales”, Marseille, France *Author for correspondence: Tel.: +33 029 902 2200 [email protected]

Despite the existence of an effective pharmaceutical means for its prevention available now for about 70 years, influenza remains an important contributor to morbidity and mortality figures due to respiratory infectious diseases through the world. Understanding why people accept or reject being vaccinated in our societies may contribute to improve substantially public health interventions in this domain by addressing the main reasons that lead individuals and groups to neglect immunization. Research into the cognitive and social causes of influenza vaccination patterns has developed over the last decades. However, it has yielded mostly inconsistent or contradictory results. To make sense of the body of data available and to improve future research, the authors argue for the adoption of a comprehensive sociocultural understanding of vaccination behavior. This could be constructed from existing social stratification models used in social sciences and should take into account how culture determines cognition. KEYWORDS: influenza • sociocultural and psychological determinants • vaccination behaviors

Despite the existence of an effective pharmaceutical means for its prevention available now for about 70 years, seasonal flu is a major cause of morbidity and mortality across the world. According to WHO estimates, every year, it is responsible for 3–5 million serious cases and 250,000–500,000 deaths, depending on the virulence and length of the epidemic [201]. In a developed country such as France, flu would be responsible for 700,000– 4,800,000 medical appointments for flu symptoms every year, with a ratio of 4 ± 2.8 working days lost per flu-stricken patient [1]. This amounts to 1–8% of the general population [2]. Mortality per se is more difficult to estimate since it comprises deaths declared as directly caused by the flu, but also a portion of those recorded under other causes such as acute respiratory diseases or cardiovascular pathologies [3]. From 1972 to 2010, estimates of this mortality have varied from 0 to 24 deaths for every 100,000 people [4,5], with people aged ‡65 representing 90% of these deaths [6,7]. The main preventive measure

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endorsed by public authorities consists in immunization of people belonging to groups at risk of presenting complicated forms of the disease. The main at-risk groups targeted for immunization are people aged over 65, pregnant women, people with obesity, people suffering from chronic illnesses and health care professionals [8]. In many European countries, immunization of these target groups represents a major public health concern signified in the target of reaching a coverage rate of 75% by 2015 [202]. The vaccination campaigns during the 2009 influenza pandemic seem to have had a great impact on influenza immunization behaviors in several countries, especially in Europe [9,10]. This episode should remind us that the relative success or failure of any vaccination promotion campaign depends ultimately on how the public understands and responds to such interventions. Also, while seasonal influenza vaccination is focused year after year on the same target groups, pandemic strains of influenza can shift the contours of

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the target and expand it to different profiles, like pregnant women in 2009. Regrettably, most research into the determinants of influenza vaccination has been focused on explaining the behavior of the members of these traditional target groups and not on providing a comprehensive understanding of influenza vaccination. In this article, we will argue that current research into the social and psychological pathways to influenza immunization lacks a theoretical grounding that would help make sense of the copious amount of data already gathered. Although this is also true of much research into other vaccination behavior, we will focus on research into influenza vaccination, which is particularly representative of work in this field. We will argue for a change of approach to sociodemographic variables and for the construction of a cultural–cognitive model of vaccination behavior in order to introduce a cultural understanding of immunization perception into research protocols. Social & psychological pathways to immunization: current research & results

To date, much work has been undertaken to explain the adoption of health-protective behaviors in general and vaccinationrelated behaviors in particular. From a theoretical perspective, a rough distinction may be made between ‘agency’ and ‘structural’ explanations of health behaviors. In general, ‘agency’ explanations refer to the capacity of individuals to think independently and to make choices of their own free will. In contrast, structural explanations refer to the pattern of social and cultural constraints that limit the choices that people can make [11]. In the domain of vaccination, the literature is largely dominated by the former type of explanations, which mainly focuses on proximal/cognitive factors such as beliefs about the health threat, whereas structural explanations that mostly focus on distal/social factors such as social norms or values have been largely overlooked. Generally, proximal factors tend to be specific and immediate determinants of certain health behaviors, which are derived from psychological/individualist theories, whereas distal factors refer to more stable and global influential variables. A more comprehensive and systematic framework, which would include a wider range of potentially influential variables, is still lacking in this field. As Weinstein pointed out [12], empirical comparisons of theories remain relatively rare: researchers typically select a single theory to test or guide their choice of explanatory variables as if the other theories did not exist. To reduce this gap, it will be argued that there is a need to develop a theoretical framework for vaccination behavior that articulates proximal and distal determinants of vaccination. Psychological determinants of influenza vaccination

Acceptance of immunization against seasonal influenza is very similar to public acceptance of various other public health interventions. However, it differs from other types of immunization in at least one important way. The prevention of seasonal influenza requires that volitional vaccination behaviors be 18

repeated over time [13]. This is due to the extraordinary mutability of the various strains of the influenza viruses that circulate through the world, making periodic updating of the vaccine formulations necessary to preserve immunity against virus remodeling [14]. Nevertheless, the fact that most immunization practices result from a single preventive action may explain to a large extent why cognitive variables such as beliefs about health risks have received such a considerable attention in the recent literature [15]. Rosenstock et al.’s pioneering work in the 1950s [16] claimed that most health-protective behaviors could be explained and predicted to a large extent by the nature of beliefs (i.e., ideas, opinions, representations, attitudes and other cognitive constructs) people have about illnesses and their prevention. Hundreds of studies carried out since show that motivations underlying engagement in vaccination behaviors can be approached by conventional risk–benefit analysis in line with rational choice theories [17,18]. According to this basic model of decision-making, the acceptance or rejection of any protective action can be interpreted as the outcome of deliberate reasoning consisting of a tradeoff between the health risks and personal or societal benefits associated with products or activities that are recognized for their preventive value. In the literature, vaccination decision-making about seasonal or pandemic influenza has been consistently found to be shaped by the perceived risk of contracting the disease. This is generally known to result from three main cognitive components [19]: the personal likelihood of becoming infected (perceived vulnerability), the seriousness of the consequences of that infection (perceived severity), as well as the perception of preventive measures including concerns about their safety or effectiveness [20–22]. From this theoretical perspective, vaccination behaviors are expected to vary roughly in relation to both perceived risk and perceived benefit. Moreover, the perceived benefit associated with immunization depends in turn, for a large part, on perceived risk of contracting the disease [23]. This would account for the fact that at-risk patients tend to have much higher immunization rates. Thus, in their systematic review of literature devoted to the determinants of the 2009-pandemic influenza vaccination, Brien et al. found that four major cognitive factors were significantly and repeatedly associated with uptake of the vaccine [24]: believing in the safety or absence of risk of side effects of the vaccine; perceiving that the vaccine is effective and provides benefits; believing oneself to be at risk from contracting the disease; and perceiving the pandemic influenza as a severe disease. In the same vein, Bish et al. found in a systematic review of 37 studies that ‘both the degree of threat experienced in the 2009 pandemic influenza outbreak and perceptions of vaccination as an effective coping strategy were associated with stronger intentions and higher uptake of vaccination’ [22]. Nevertheless, it should be noted that most empirical research on influenza vaccination and its psychological and social determinants shows that past behaviors are the best predictors of current behaviors, regardless of the seasonal or pandemic nature Expert Rev. Vaccines 13(1), (2014)

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Understanding influenza vaccination behaviors

of the virus [25,26]. In other words, people who have been vaccinated once against influenza are likely to maintain their immunization over time. The aim of these psychometric studies is to identify precisely which beliefs act as barriers to immunization in a given context. Are immunization rates low because people think the vaccine is dangerous or is it in fact because people do not believe the flu to be dangerous? In turn, this invites public authorities to focus communication efforts on debunking these problematic beliefs. In order to gain predictability, it is however necessary to identify how these problematic beliefs are spread along sociodemographic lines. For example, Slovic and his colleagues [27–29] showed in a series of studies conducted in the USA that a small number of sociodemographic factors systematically influenced the way people perceive the risks of technology hazards. Notably, males, white and better educated subjects were repeatedly found to perceive the benefits from science and technology as outweighing their potential health risks, a phenomenon labeled as the ‘white male effect.’ However, such sociological analyses are very rarely applied to immunization behaviors.

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with delay and noncompletion of children’s recommended vaccinations [33,34]. But, beyond these two specific contexts, age yields insignificant or contradictory results [31]. Gender

The same type of inconsistencies can be observed for gender. For instance, data from seasonal flu immunization campaigns from 2001 to 2008 in 11 different countries show that being a male had a positive effect on immunization in France, Italy, the UK, the Czech Republic Poland and Portugal, whereas it did not constitute an explanatory factor for vaccination in Germany, Austria, Finland and Ireland [32]. Other studies also seem to indicate that being a male seems to increase the likelihood of being immunized [35,36]. However, the strength of this factor has widely varied from country to country, has been insignificant in a considerable number of countries and has yet to be confirmed in multivariate analysis. These results are surprising, given that gender has long been shown to be a highly influential factor for a large range of health behaviors. Race

Social determinants of influenza vaccination

Sociodemographic variables should play a key role in survey type studies in identifying specific social groups that are consistently less likely to develop health promoting beliefs relative to influenza immunization. Nevertheless, with the notable exception of the 2009 pandemic influenza, the sociodemographic determinants of immunization have seldom been investigated per se. This is especially true for influenza immunization [30]. Sociodemographic factors are therefore mostly integrated in surveys as adjustment variables. Each variable is also analyzed separately, without reference to a specific sociological model. Authors look for the separate impact of each variable on immunization behavior. Unfortunately, this approach yields poorly significant results and these results are often contradictory from one local context to the other. The results of a recent extensive review of the literature on social determinants of flu immunization among people aged 65 and above performed by Nagata and his team at the WHO supports this conclusion [31]. It shows that separate analysis of each variable yields contradicting or insignificant results. This is true even when this analysis is applied to a predefined target group such as people aged 65 and over. Age

Age is the primary factor among these sociodemographic variables. Much research shows that it is the strongest predictor for influenza immunization across the board including Endrich’s work comparison of different countries in Europe [32]. However, most of this variable’s predictive power is restricted to the senior age group. People aged 65 years old and above, and therefore within the target population, have consistently been found to be more likely to comply with recommendations about flu [31]. Sometimes, age also seems to be predictive of immunization in general. In some countries like Greece and the USA, for example, the young age of parents is associated www.expert-reviews.com

Race and being a member of an ethnic minority are often integrated in surveys on flu immunization with the same outcome of mostly insignificant results across countries [31]. In the USA, being a member of a minority consistently seems to make subjects less likely to take the flu vaccine [37–39], whereas in most countries, this is not a determining factor [40,41]. The results for two variables, which are at the core of various social theories of health behaviors [42], education and income, are even more inconclusive. Education

It remains difficult to conduct a fine-grain international comparison based on the level of formal education since scales of measurement are inconsistent [31]. However, it is possible to compare the results obtained for each country using each national scale. It seems that education tends to be more of a determining factor than the previous variables. In a recent review, Endrich et al. found relatively strong correlations with this variable [32]. However, education seems to have opposing and contradictory effects in different national contexts [31]. The effect is positive in Austria and Poland, whereas negative in Ireland, Italy and Spain, and less consistently negative in Germany and Finland [32]. Other studies also found no constant influence of the level of education on influenza vaccination [43,44]. Income

Similarly, the effect of income on immunization rates seems to be tied to national contexts. Having a higher income was found to have a positive effect in Poland but a negative effect in Germany, Spain, Ireland and the UK, and no effect in Austria, the Czech Republic, Finland, Italy and Portugal [32,37]. In the USA, people having a higher income are more likely to be vaccinated [45]. However, some surveys found no link between income and vaccination behaviors [44,46]. 19

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One of the main methodological limitations for most epidemiological studies is that each of these variables is analyzed as a separate potential determinant of immunization. The role of age in vaccination behavior, for instance, is generally examined independently from the participants’ income, gender or education. This is an even more surprising feature since most studies focus on a specific age group thereby rendering multivariate analysis and fine-grained social categorization easier. This approach disregards most of the social science research dedicated to health and social behavior, which views health behaviors as a function of complex lifestyle patterns. These are shaped by a complex structure of economic, educational, professional, familial and institutional opportunities that limit or enhance an individual’s access to a range of material (instrumental support) and immaterial resources (emotional support) throughout the life course [47,48]. This means that to better understand the sociodemographic determinants of immunization, social scientists should develop more sophisticated typologies of lifestyles [49,50]. One should look not only for the effect of the age variable, but also of the specific subgroups such as young highly educated, middle-income white people, middle-aged medium-level education or low-income ethnic minorities, etc. This scaling approach based on the idea of a priori identifiable target groups, is found in some studies presented above and tends to yield more significant results. However, these studies are still based on the isolation of an insufficient number of variables. Some interesting studies have attempted to build multidimensional concepts based on combinations of these variables such as ‘Socio-Economic Status’ (SES), a substitute to the concept of social class, based on the combination of several social status variables. In Italy, for instance, people with lower SES tends to be more compliant with vaccination recommendations than people with a high SES [51]. However, this construct relies too heavily on income and education, considers a linear SES scale instead of a discontinuous scale of lifestyles and has not been used in a sufficient number of countries so far to allow for reliable international comparison. Analysis of these sociodemographic variables has also failed to identify social profiles associated with low immunization rates. As we have seen, one of the reasons for this is that most studies focus on medically defined target populations and fail to identify subgroups within this already limited population. The premise seems to be that they constitute relatively homogeneous social groups. There are several consequences of this nonsociological view of immunization behavior. First, the results being contradictory and inconsistent, they fail to provide a comprehensive body of knowledge on immunization behavior. Second, these failings leave behavioral models without any reference to social profiles and thus lacking in contextual grounding. Explaining the variety of immunization behaviors: revealing the underlying mechanism

Psychometric research and sociodemographic studies present the same disadvantages. In both cases, it is unclear how the core variables determine immunization behavior. Current 20

research suffers from the lack of conceptual framework integrating a variety of factors into a comprehensive model of immunization behavior. There is a need for a clear theory of the mechanism that leads people to take up vaccination or not. Both research strands contain implicit assumptions regarding this mechanism. In the case of psychometric studies, the premise seems to be that people form their beliefs according to their limited access to official information about influenza and vaccines (deficit model). In the case of sociodemographic studies, the premise seems to be that varying immunization rates can be explained by unequal access to the resources necessary to get vaccinated. Both strands therefore suppose that everyone’s common sense should guide them toward the vaccination booth and that the only thing preventing this from happening is the existence of barriers to immunization: information availability and/or time and money. Sociodemographic studies & barriers to immunization

Beyond the fact that bivariate analysis of sociodemographic variables yields inconsistent and contradictory results, a second problem with this method is that it is unclear how each variable is supposed to determine immunization behaviors. What is the mechanism through which gender, income or race influence vaccination behaviors? In most research, this mechanism is not stated explicitly. Too often, results are presented without reference to how typical social mechanisms can account for the findings. However, one implicit mechanism seems to be at the core of most research in ‘barriers to immunization’. It is founded on the idea that material conditions of life affect the health status and behaviors of individuals by constraining them. The lifestyle of an individual is fundamentally determined by his/her economic and social conditions, by what goods he/she can afford and what services are accessible to him/her [52]. Income is a case in point. It should be the most predictive variable if we abide by this mechanism. However, as we have seen, studies yield contradictory and inconsistent results in different countries. This is not completely surprising to the authors of some of these studies. Indeed, the cost of influenza vaccines is not so much an obstacle in some countries where many vaccines are free, at least for the target groups [31,53]. The same mechanism based on economic calculation is used when variables such as access to the health system or geographical location are studied [31,54,38]. Explanation then comes from two sets of variables: those related to the household’s income and those related to the health system in which the individual can be vaccinated. The social context functions as ‘barriers to immunization’. The implication is that if people could have the vaccine for free on their doorstep whenever they wanted and if taking the shot was not perceived as painful, then one could expect that everyone would effectively be vaccinated. However, this explanation is not consistent with the whole body of data available. Indeed, the fact that having a high income has a negative effect on immunization in Germany and Expert Rev. Vaccines 13(1), (2014)

Understanding influenza vaccination behaviors

other countries is deeply puzzling. Income should be the flagship for this type of explanation, but it fails to confirm its generalizability. So why cannot we apply this general mechanism for everyone and everywhere? Also, how does this mechanism apply to variables such as race or gender? To overcome these objections, researchers mostly make reference to the variety in access to official information regarding influenza and vaccination.

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The psychological approach & the deficit model

Behavioral research often suggests that appropriate knowledge is crucial to prevent and control the spread of diseases. Focusing on the idea of ‘knowledge’ suggests a specific hypothesis about the causal relationship between information and practice, which is commonly identified within the social sciences as ‘the deficit model of public understanding of science’ [55]. According to this model, a lack of scientific knowledge is likely to lead lay people to entertain irrational attitudes toward a range of technological products and activities, or to engage in maladapted behaviors in the case of emerging health threats. However, the experiments conducted in laboratories to reduce specific biases in health risk perceptions show a remarkable resistance of beliefs to a range of debiasing interventions [56]. These results have led to seriously question the foundations of the individualistic approaches we presented earlier. The principal issue in these studies is that risk perception remains an unexplained primitive variable. In other words, they tell us almost nothing about the underlying mechanisms through which beliefs about risk and benefit related to technologies are formed or how they change over time. Deficit model explanations suggest that if people are presented with the correct information, they will accept it as such and act upon it. However, since the late 1970s, a small number of psychologists have shown that people process information rather than record it. In a series of famous experimental studies, they have revealed a set of intuitive processes, named ‘heuristics’ (cognitive toolkits, mental shortcuts, rules of thumb, etc.) that allow people to quickly evaluate probabilities of adverse events and make decisions despite uncertainty [57,58]. The fact that people base their decision making on their own risk assessment has been shown to induce systematic risk estimation biases [59,60]. Here is a gap between people’s own risk assessment and the public health official risk information they come across. Heuristics point to the fact that cognition is actually grounded in the social context it is performed in. The heuristics of availability is a perfect illustration of this fact and is particularly relevant to vaccination. This cognitive mechanism occurs when people make intuitive judgments about the probability of a class of events taking place by appraising the ease with which they can remember examples of these events. It has often been used to explain – at least partly – how an intensive media coverage of rare but striking events such as Guillain– Barre´ syndromes shapes perception of health-related risks, leading populations to overestimate some hazards and underestimate others [61]. www.expert-reviews.com

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The study of heuristics has demonstrated that access to information is not sufficient to explain the formation of beliefs. Even though it remains highly influential in vaccinology, the deficit model approach does not produce an explanation for the observed patterns of beliefs and attitudes toward immunization. Why do people who live in the same country and are exposed, by and large, to the same channels of communication develop different ideas about influenza and vaccines? Why does the distribution of these beliefs vary so much between different but economically similar countries? Why is it so difficult for the health message to come across and induce immunization? The two versions of the ‘availability’ approach to vaccination behavior, access to vaccines and access to information, are not sufficient to explain the variety of immunization behaviors. These two strands of research suffer from two serious limitations. First, they do not provide the tools necessary to identify the social groups consistently less prone to comply with immunization recommendations. Second, they do not provide the tools to understand how these beliefs are formed and how they can be changed. They presume that if we make information or vaccines more available, then the problem will be solved. However, reports from real-life national and local public health policies show that such strategies only meet with limited success. Giving patients brochures filled with numbers does not seem to convince all of them, neither do free vaccines at their local pharmacy. As noted by Slovic [62], there is still a need for a broader perspective that considers a complex combination of psychological, socioeconomic, political and cultural factors. Toward a cultural understanding of influenza immunization

Availability of information and of the means to get vaccinated is undeniably important. It may even explain most vaccination behaviors. However, availability does not provide the grounds for a general theory of immunization behavior, a theory that explains the behavior of both the majority but also of the minority. We will now argue for the integration of culture in the analysis of immunization behaviors, emphasizing the fact that people filter information and do not accept information unquestioningly. From availability to persuasion: bringing culture in

Availability seems to be a determining factor once the person becomes convinced that being vaccinated is desirable. The issue therefore becomes that of convincing. This brings us to a second mechanism identified by the ‘Social Determinants of Health’ tradition and called the ‘cultural-behavioral explanation’ [63]. This type of explanation relies on the idea that health behaviors are determined by the social values shared by individuals and not only by the medical information available to them. Therefore, we cannot only think in terms of material barriers but must also take account of disparities in what is considered a healthy or unhealthy behavior and trustworthy information. The emphasis should therefore be laid on determinants of beliefs, on how each belief relative to 21

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vaccination, is included into a wider cultural system that reflects a certain lifestyle. There are two principal ways researchers can approach lifestyle in their studies. One already mentioned is by reassessing the use of the socioeconomic and demographic variables commonly included in their studies. These variables could be chosen and analyzed using social stratification models. This would allow us to identify social groups associated with specific lifestyles instead of assessing the impact of isolated variables or focusing on medically defined target groups. People over 65 years do not constitute a homogeneous social group, neither do ‘health workers’, not even ‘doctors’. It is likely that these models will be specific for each country even if the comparison of these models can help to build international frameworks. However, most public health authorities still rely on a deficit model view of immunization behavior and communication. This approach needs to be completed by more attention to lifestyle because it runs directly counter these deeply entrenched assumptions. It consists in looking for the cultural worldviews behind the formation of health-related beliefs. Lifestyles are associated with worldviews that give meaning and grounding to life choices. Cultural aggregates are therefore determinants of perception of vaccines and influenza. They function as latent variables. This will take us beyond the issue of the availability of information toward that of acceptance of information and production of contradictory information. Even though most of the research on the cultural embeddedness of vaccination is qualitative, it provides a strong argument in favor of putting culture at the forefront when studying vaccination behavior and influenza immunization in particular. Culture because controversies

The ‘cultural-behavioral explanation’ of health behavior draws attention to an essential component of contemporary health information. This is the fact that it is highly contentious, a point that the ‘availability’ approach to immunization behavior ignores. People are confronted with contradictory information. Public Health authorities are not the only institutions making health recommendations, nor are they the only sources of medical information used by the public. For a long time, the idea of controversy was not raised when thinking about influenza vaccines. However, the relative failure of the immunization campaign against the 2009 A(H1N1)v influenza pandemic has reminded us that no public health intervention goes without social and/or medical controversy. Indeed, during the vaccination campaign in France, a variety of groups, political figures and even prominent physicians overtly criticized public intervention and downplayed the need to vaccinate the population against the disease. Controversies are commonly seen by experts as exceptional disturbing events to be avoided. Most of the work done on this subject has been focused on the MMR danger controversy that has been heavily covered by the British and North American media. The news media being a widely used source of health information for patients [64,65], it 22

is easily understandable that highly mediatized controversies over the safety or utility of a given medicine may have a negative impact on its uptake. This intuition has been largely demonstrated for MMR in the late 1990s [66]. For the A(H1N1)v pandemic, the impact of national controversies on national vaccine coverage has not been fully documented yet. This impact is also difficult to establish since contradictory information circulated often both on the safety of the vaccine and on the severity of the disease. But surveys identifying the reasons for rejecting the A(H1N1) influenza vaccination show that doubt over vaccine safety was high in countries where such controversies have arisen [67–69]. Even though a more thorough investigation needs to be conducted, there is no reason why flu vaccines should not be open to the same doubts as other vaccines. The underlying explanation is the following: public health controversies being situations in which competing accounts of the danger of the disease (or of the safety of the vaccine) are widely made available to the public, more people are therefore likely to be exposed to contradictory information dissuading them from getting vaccinated. Also, public controversies are likely to produce a perception that there is a controversy within the scientific world even when it is not really the case thereby hampering the trust people might put in the health authority’s message. This tendency has been well studied for climate change controversies [70,71]. But research shows it to be also true for vaccine perception [72,73]. MMR, thiomersal and other vaccine-related controversies point out the potentially contentious nature of public health information. However, most of the research devoted to this subject refers to controversies as events and focuses mainly on cases where there is widespread coverage of the dispute. Unfortunately, this focus on mediatized controversies as events tends to hide the fact that contentious information is always there, waiting to be disseminated though various channels. This can be seen in the fact that most immunization rates are often below target [74] and that there always remains a minority of people who refuse compulsory vaccines [75]. Mediatized controversies are specific moments when contentious information on a specific vaccine or pharmaceutical intervention is made more widely available, therefore spreading contradictory information beyond the specific groups that foster it and allowing them to convince people beyond their usual sphere of influence [76]. A ‘cultural-behavioral’ model of understanding of vaccination behavior should take into consideration the fact that people are permanently exposed to contradictory information. This is especially true given the rapid development of electronic communication networks conveying information about health and illness throughout the world and at all times. This raises the question of how people select and interpret the information upon which they will base their health behavior. Culture determines perception

To date, too few studies have attempted to produce a cultural understanding of vaccination behavior. The main domain in Expert Rev. Vaccines 13(1), (2014)

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which cultural analysis has been mobilized is the variety of motives for resistance to vaccination efforts in both developed and developing countries. These studies have underlined a number of types of cultural identity responsible for rejection of vaccination. For instance, McMillen and Brinnes laid emphasis on national identity in reaction to colonization when analyzing resistance in India in the post-war era [77]. Historically, immunization campaigns have often been linked with the construction of a central state and the exercise of its power on the general population [78–80]. Immunization campaigns have been and still are often designed then implemented in a paramilitary fashion that reflects the political submission of the general population or specific groups to a social elite [81,82]. Social identities, defined in relation to the central state or the elite, have been shown to play a significant role in reactions to the passing of mandatory vaccination laws as early as the 19th century [78,81]. Religion is another aspect of cultural identity recognized as responsible for resistance to vaccination both in developed countries and in developing countries [79,83,84]. Cultural variables, where lay perception of health runs counter to science, are easily accepted by health experts and constitute the bulk of research into cultural determinants of immunization. However, they tend to only be applied to developing countries, to the past or to the ‘reactionary’ ‘antivaccine movements,’ which develop an alternative account of health and illness [85]. The general idea seems to be that ‘culture’ is equated with irrationality and opposition to science and cultural analysis is usually only applied to resistance, therefore to a minority of the population. In the same vein, much has been said on the counterintuitive nature of vaccination when it comes to lay epidemiology. This counterintuitive nature of immunization runs against lay representations of disease transmission and what good health means. For instance, in early 19th century France, immunization was resisted because of a common belief in the theory of humors and many people therefore feared that the pus extracted from orphans would transmit their general ill health and their moral flaws [86]. Most work in lay epidemiology in relation to vaccination was developed using the concept of ‘local drug culture’ [87,88] and transforming it into ‘local vaccination culture’. Interestingly, researchers have shown that immunization can be made more difficult but also facilitated by local perceptions of disease and medicine [89]. Cultural variables related to immunization should be investigated more carefully and applied both to resistance to and acceptance of immunization. This is even more the case in recent decades since social scientists and health practitioners have witnessed a tremendous transformation in the public’s attitude toward health care in the developed countries. The dramatic increase in average level of education has been shown to be responsible both for ability and wish for greater autonomy and involvement in health decisions. This, in turn, affects the nature of compliance to public health recommendations [90,91]. This cultural evolution has been materialized in a progressive rejection of the paternal nature originally at the www.expert-reviews.com

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core of the doctor–patient relationship [90]. This social change has produced a shift in the balance of trust within modern societies. Social trust can no longer be taken for granted. Relevance of expertise has to be constantly proven and can be challenged when the doctor’s attitude toward the patient is not appreciated. This individualistic turn in health behavior has also been encouraged in recent political reforms of health care systems and therefore has been seen as a positive trend toward more responsible health behaviors, for example, in the UK [92]. In this context, lack of trust does not mean irrational rejection of science or consumerist rejection of expertise. Indeed, studies show that recommendations provided by local medical experts are a very strong predictor of immunization [93–95], even in a context of controversy such as the one surrounding the 2009 A(H1N1)v campaign in many countries [96,67]. Trust is therefore still out there, but there is clearly a will to negotiate and influence the outcomes of health care encounters [97]. Health perception as part of a wider culture

These transformations are specific to health culture. However, as shown in FIGURE 1, health behavior is also susceptible to be influenced by larger cultural changes that also affect political trends. An overlap of health behavior and political culture has already been documented regarding the rise of ecology as a prominent worldview. Indeed, pioneer studies conducted in the 1990s highlighted how the evolution of world views affect individual health behaviors by revealing trends such as the growing distrust in biotechnology [98], the increase in the use of complementary medicine [99,100] and more widely the disillusionment among the general population about the value of scientific and medical advances [101,102]. Therefore, public health authorities also need to understand that lay health beliefs are not simply altered versions of medical knowledge but are shaped by people’s whole social existence [103]. Health beliefs are not always only about health. A comprehensive model of immunization behavior should put local idiosyncrasies against the backdrop of wider latent cultural traits. Making sense of influenza immunization with the cultural theory of risk perception

Immunization needs to be understood against the backdrop of risk-related behavior. The study of risk has generated several broad-ranging frameworks that enable researchers to produce strong international comparisons. We will now focus on one of these frameworks. The Cultural Cognition Project has developed a model of risk perception that allows for quantitative mapping of the public, fine-grained risk communication and a comprehensive understanding of the link between lifestyle and risk perception [104]. A unifying theory: Mary Douglas’ theory of risk perception

Several frameworks have been offered in cultural psychology, allowing some relevant prediction of human behavior based on 23

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Distal factors

Social-structural mechanisms (macro)

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Culture: – Norms and values – Ideologies – Worldviews – Health literacy

Proximal factors

Psychosocial mechanisms (mezzo)

Social support: – Instrimental and material – Emotional – Cognitive – Appraisal

Psychosocial mechanisms (micro)

Perceptions of threats: – Perceived likelihood – Perceived vulnerability – Perceived consequences – Perceived severity – Fears and worries

Socioeconomic factors: – Income and capital – Inequalities and poverty – Integration/exclusion – Structure of subsidies and taxes

Social influence: – Peer pressure – Social engagement – Social comparison processes – Social roles

Perceptions of vaccines: – Perceived safety – Perceived efficacy – Perceived consequences – Perceived benefits – Fears and barriers

Political factors: – Social trust – Discrimination – Social participation – Laws and public policies

Access to resources: – Social capital – Economic opportunities – Access to health services – Personal/institutional contacts

Perceptions of self: – Perceived control – Coping effectiveness – Self-efficacy – Self-esteem – Personality

Figure 1. A comprehensive framework for understanding influenza vaccination behaviors. Adapted with permission from [115].

shared values and beliefs analysis [105]. However, very few are specifically oriented toward risk perception. This is what makes the ‘Cultural Cognition Project’ model developed by Dan Kahan and colleagues at Yale University stand out [104]. This model is particularly heuristic in that it is grounded in the anthropological theory of Mary Douglas about culture and risk. This anthropological tradition has been very insightful in yielding further understanding of risk perception in contexts ranging from Bushmen to capitalist entrepreneurs [106,107]. Mary Douglas’ work focuses on how conflicts between groups within a given society can be attributed to cultural biases and worldviews embedded in specific lifestyles. It therefore combines a cultural cognitive basis and an emphasis on controversies. Four main types of worldviews were isolated (authoritarian, communitarian, individualist and fatalist) on a two axes graph, representing the degree of differentiation within the group of belonging (‘grid’) on the one hand, and the strength of the sense of belonging of individuals to the group on the other hand (‘group’) [106]. Four lifestyles are therefore compared, each associated to specific cultural biases, that is, types of risks to which they are sensitive and others to which they are not. For instance, members of ‘communitarian’ groups tend to take threats to natural environment as serious, whereas ‘competitive individualists’ tend to be more afraid of encroachment of individual freedom [106]. This work has become the cornerstone of 24

what has come to be known as the ‘cultural theory of risk’ [108]. For an overview of the fundamental attributes of each cultural type, see FIGURE 2 [109]. From anthropology to cultural psychology: Kahan’s quantitative study of cultural biases

Although most of the work done in this intellectual tradition lacks predictability, Mary Douglas’ emphasis on perception bias lays the foundation for an articulation between qualitative and predictive quantitative approaches. Indeed, the cultural biases identified by cultural theorists are easily translatable into a realistic and comprehensive framework for risk behavior. Its power lies in its ability to take into consideration both access and selection of information. Building this framework is precisely what Kahan and his colleagues have set out to do. They translated this theoretical framework into a highly operable survey protocol. Their work is founded on a clarification of the ‘cultural-behavioral’ mechanism based on its breaking down into two basic social cognitive processes: biased attribution of trust and biased selection of information. In this perspective, people’s culture determines what passes for good information (biased selection of information) and who passes for a reliable source of information (biased selection of sources) [105,110]. This being clarified, it became possible to Expert Rev. Vaccines 13(1), (2014)

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Understanding influenza vaccination behaviors

test Mary Douglas’s theories about the existence of cultural bias and to verify the consistency of her typology. In both cases, her analysis was confirmed in a variety of areas ranging from perception of climate change to HPV vaccines [111–113]. For HPV vaccines, their study shows that hierarchists and individualists indeed feel more concerned about HPV vaccination risks than communitarianists do. Also, their work demonstrates the existence of a polarizing effect of information since the gap between these groups was even wider once respondents were confronted to conflicting information. It also enables a full description of the population along the two axes evoked earlier, thus giving an estimate of the proportion of each cultural type represented in each population. This breakthrough has led to some very interesting first steps in international comparisons of cultural biases in risk perception [203]. The Cultural Cognition Project uses the same methodology as the conventional psychometric paradigm. The difference is that instead of evaluating the proportion of people who believe a given vaccine to be dangerous and a given disease to be benign, it identifies profiles of people who, for example, are likely to be reluctant to allopathic medicine in general. For instance, Kahan’s team found that people in the USA who endorsed egalitarian or communitarian worldviews were much more willing to vaccinate their children against HPV than those who displayed authoritarian or individualist worldviews [114]. Beyond these differences, it identifies the types of arguments to which each sociocultural type of people is sensitive and consequently the type of framing that can help the public health message to come across. The fact that it is grounded in Mary Douglas’ approach that focuses on the link between the structure of a given community, its lifestyle and its culture are crucial. It makes it possible both to identify a priori the groups of people likely to develop aversion for vaccines and to tailor social pathways to get the message across. It therefore allows both for a tailored message and a tailored messenger.

Strong

Perspective

Fatalism Apathy, powerlessness, distrust in human nature, no trust in public authorities, no progress why bother?

Hierarchy Emphasis on strong regulation, strong institutions are necessary to control nature and people, clear social division

Nature is erratic

Nature is controlable

Grid Individualism Ego-focused, atomistic vision of society, selfinterest is legitimate, markets rather than regulation Weak

Nature is resilient Weak

Egalitarianism Emphasis on solidarity and a simpler life, care, equality and redistribution Man depends on nature which is fragile and must be actively preserved Group

Strong

Figure 2. Cultural traits depending on the social organization of the group of belonging. Data taken from [109].

policies that will be both sounder and more accepted by target populations. Expert commentary

Determinants of health-protective behaviors have been extensively examined from different perspectives and from various disciplines. In the field of vaccination, however, the literature remains dominated by an emphasis on proximal explanatory factors, such as the perceived risks and benefits associated with vaccines. This article reviews previous psychological and sociological research of vaccination behaviors related to influenza and other infectious diseases, highlights key lessons from this literature and argues for their integration within a more comprehensive sociocultural framework.

Conclusion

Five-year view

In this article, we have argued for a substantial change in the research on the social and psychological determinants of influenza immunization. Current theoretical frameworks fail to identify the specific groups likely to refrain from taking the vaccine, the reason why and the types of arguments likely to convince them. For this reason, we have argued for a broader analytical framework that might take into account a larger range of social cognitive factors and involving an extension of the range of variables investigated in surveys. Surveys should include more questions related to social structure based on the national stratification data and models, as well as more cultural–cognitive variables based on the existing cross-cultural theoretical models of health behaviors. Such a shift would enable articulation and cross-fertilization between quantitative approaches to immunization behavior and qualitative social science research on immunization and the evolution of contemporary health culture. This in turn will help design health

In the next few years, public health officers should benefit from significant progresses in the understanding of the complex and multiple interactions between psychological and sociological mechanisms, which underlie vaccination behaviors related to influenza. In particular, a number of ongoing studies recently conducted in Europe and North America should help us to better explain and predict the sociocultural variability in the willingness to get vaccinated against a range of diseases. By improving the comprehension of personal and social pathways to vaccination, social and behavioral research could contribute to the design and implementation of more successful immunization services and programs.

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Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This 25

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Ward & Raude

includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues • Current studies of the social and psychological pathways to influenza immunization have yielded inconsistent or contradictory results thereby failing in providing a comprehensive body of knowledge on the subject. • Most studies are unclear on the individual-level mechanism through which social factors affect immunization behavior and on how immunization-related beliefs are formed. • Most explanations for immunization behaviors are based on the idea of availability of information or vaccines, which fails to make sense of a great portion of these behaviors. • Availability becomes an issue once people are already convinced of the utility of being vaccinated. What is at stake is how people become convinced of this fact. • Studying persuasion means understanding how people select the information they are confronted to. • Social studies of health culture have provided strong support for the claim that selection of information is culturally biased. • Mary Douglas’ cultural theory of risk provides a strong basis for a comprehensive and predictive model of vaccination behavior. • Contemporary scholars following this path have highlighted ways in which communication strategies can be improved to increase

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recourse to influenza immunization.

influenza — United States, 1976-2007. MMWR Morb. Mortal. Wkly Rep. 59(33), 1057–1062 (2010).

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