Attitudes toward vaccination and the H1N1 vaccine: Poor people's unfounded fears or legitimate concerns of the elite?

https://doi.org/10.1016/j.socscimed.2014.02.035Get rights and content

Highlights

  • Attitudes toward vaccination in general shaped public's reactions to H1N1 vaccine.

  • The H1N1 episode undermined French public's attitudes toward vaccination.

  • People with a low socioeconomic status were more prone to oppose vaccination.

  • Educated middle-classes were more prone to oppose the H1N1 vaccine specifically.

Abstract

In 2009–2010, the H1N1 episode occurred in a general context of decreasing public confidence in vaccination. We assumed opposition to vaccination in general to be an ‘unfounded fear’, reflecting ignorance and perceived vulnerability among low-socioeconomic status (SES) people, and opposition to the H1N1 vaccine a ‘legitimate concern’ reflecting the elite's commitment to ‘risk culture’ in a ‘risk society’. We indirectly tested these assumptions by investigating the socioeconomic profiles associated with opposition to vaccination in general and opposition to the H1N1 vaccine specifically. Our second aim was to determine whether or not opposition to the H1N1 vaccine fuelled opposition to vaccination in general. We used data from a telephone survey conducted in 2009–2010 among a random sample of French people aged 15–79 (N = 9480). Attitudes toward vaccination in general and toward the H1N1 vaccine specifically varied significantly between October 2009 and June 2010 with strong correlation being observed between these attitudes throughout the whole period. In multivariable analysis attitudes toward vaccination in general remained a significant predictor of attitudes to the H1N1 vaccine and vice versa, for distinct profiles as follows: males, older people, low-SES people for opposition to vaccination in general, versus females, people aged 35–49 and those with an intermediate SES for opposition to the H1N1 vaccine. Results also differed regarding indicators of social vulnerability, proximity to preventive medicine and vaccination history. The first profile supported the “unfounded fears expressed by low-SES people” hypothesis, while the second echoed previous work related to middle-classes’ “healthism”. Opposition to vaccination should not be reduced to irrational reactions reflecting ignorance or misinformation and further research is needed to acquire a greater understanding of the motives of opponents.

Introduction

According to many public health experts, public confidence in vaccination is waning (Black and Rapuolin, 2010, Shetty, 2010, Larson et al., 2011). Some authors claim that anti-vaccination movements are re-emerging, using the internet as a very effective way to spread their message (Wolfe et al., 2002, Blume, 2006, Kata, 2010, Bean, 2011). This crisis of public confidence in vaccination is also illustrated by the decline of vaccination coverage, for example for the measles–mumps–rubella (MMR) vaccine, and the resulting measles outbreaks recently reported in Europe (Steffen et al., 2010). Other evidence of this crisis in public confidence in vaccination can be seen in the marked increase in controversy surrounding various vaccines in specific contexts since the 1990s. For example, the MMR vaccine in the United Kingdom, the hepatitis B vaccine in France, and, of course, the H1N1 vaccine in many countries in 2009–2010, including France (Larson et al., 2011).

Opposition to vaccination has been frequently described as the result of misinformation and ignorance (Elliman and Bedford, 2001, Hak et al., 2005), irrational fears concerning vaccine safety, emotion–driven reaction and religious beliefs (Spier, 2001, Wolfe et al., 2002, André, 2003). More recently, the public's attitude during the H1N1 episode has been described using various terms which suggest irrationality, such as “moral panic”, “emotional reactions” and “psychological contagion” (Ofri, 2009, Gilman, 2010).

On the contrary, several qualitative studies have found that parents who refused vaccination for their children were accustomed to making informed and active choices in most aspects of their lives, and wanted to assess the risks and the benefits of vaccination on their own in order to make the most informed choice possible (Evans et al., 2001, Sporton and Francis, 2001, Poltorak et al., 2005). More generally, several authors have claimed that hesitancy has become a major feature in the public's attitude toward vaccination. Most hesitant people are frequently well-informed about vaccination and consider it to be an important issue. They want to first balance the risks and benefits of each vaccination. Accordingly, their hesitancy is often directed at specific vaccines or circumstances (Smith and Marshall, 2010, Velan, 2011).

During the 19th century, opposition to vaccination was especially strong among the working class (Durbach, 2000). Many studies have found that contemporary opposition to vaccination is associated with a low socioeconomic status (SES). Various indicators of low SES have been found to be negatively associated with agreeing to receive vaccination against swine influenza (Cummings et al., 1979), with vaccination against seasonal influenza (Winston et al., 2006), and with an up-to-date immunization status in adults (Prislin et al., 1998) and children (Danis et al., 2010). Similarly, in one study in France, up-to-date immunization status was significantly less frequent among the unemployed, among those with lower educational levels and among those who lived alone (Baudier and Léon, 2008).

This characterization of concerns toward vaccination echoes a common result in risk perception studies: generally speaking, a lower SES is strongly associated with higher risk perceptions and vice-versa (this result is usually referred to as the “white male effect” or the “societal inequality effect”) (Finucane et al., 2000, Olofsson and Rashid, 2011). Material deprivation and social isolation can fuel a feeling of powerlessness and vulnerability when faced with any kind of threat. For example, deprived and socially isolated people are more likely to fear HIV infection because they are more prone to consider their own body as a ‘porous thing’, completely open to every dangerous invasion (Douglas, 1992, Hahn et al., 1994). From this point of view, we could expect low-SES people to be more likely to oppose any kind of vaccine. This hypothesis is supported by a previous French study in which less educated people and those living alone were more prone to oppose vaccination in general (Baudier and Léon, 2008).

The previous depiction of well-informed but hesitant people willing to balance the risks and benefits of each vaccination strongly echoes the concept of “risk culture”. In contemporary societies, people are encouraged to exert autonomy over their own lives, to stay continuously aware of risks and opportunities in their daily life and to assess risks and benefits in order to make their future secure (Giddens, 1991). This is especially true concerning health: the rhetoric of self-empowerment conveyed by health promotion praises the enterprising and entrepreneurial individual who exercises control over his/her own behaviours and choices in order to maximize his/her life expectancy. This specific cultural feature had been referred to as ‘healthism’ (Crawford, 1980). Regarding the H1N1 episode, commitment to “risk culture” may have led to vaccination refusal: an Israeli study found that 30% of non-vaccinated respondents provided a rational argument for refusing the H1N1 vaccine, based mainly on a risk/benefit assessment (Velan et al., 2011).

Contemporary societies have been also described as “risk societies” in which we face “manufactured risks”, i.e. risks produced by science and industry (Beck, 1992). In such societies, public distrust in government, industry and scientists becomes a key issue (Giddens, 1991), as these three actors are suspected of conspiring against the public (Douglas and Wildavsky, 1982). The H1N1 episode illustrates this perspective. First, the possible side-effects of the H1N1 vaccine could be considered as a manufactured risk produced and spread by vaccinology, the pharmaceutical industry and health authorities. Second, during the H1N1 influenza episode, people were concerned about the financial motives of the vaccine industry, suspecting that the latter had exerted pressure on public institutions (Larson et al., 2011, Sherlaw and Raude, 2012), and anti-vaccination websites promoted conspiracy theories and claimed that the H1N1 outbreak was a “manufactured threat” (Bean, 2011).

Moreover, according to Beck (1992), wealthier and more educated people are more equipped to perceive “manufactured risks”. Some recent empirical studies support this argument: one highlighted that in Germany, more educated and wealthier people were more likely to express concerns about the adverse health effects of exposure to mobile phone base stations (Blettner et al., 2009), while another showed that in Europe highly educated citizens were more prone to worry about climate change (European Commission, 2011). Similarly, regarding vaccination, some studies suggested that parents who refused MMR vaccination specifically for their children were frequently highly educated people from middle or upper classes (Pareek and Pattison, 2000, Blume, 2006).

On the one hand, we hypothesized that opposition to vaccination is an ‘unfounded fear’, reflecting misinformation, ignorance, perceived powerlessness and vulnerability and that such opposition is more prevalent among women, older and low-SES people. Furthermore we hypothesized that opposition to vaccination in general is a prototype of such ‘unfounded fear’. On the other hand, we hypothesized that opposition to vaccination is a ‘legitimate concern’, reflecting commitment to ‘risk culture’ in a ‘risk society’, and distrust toward the pharmaceutical industry and health authorities and that such opposition is more prevalent among the elite. We also hypothesized that opposition to the H1N1 vaccine specifically was a prototype of such a ‘legitimate concern’.

In the present study, we used data from a large survey carried out by the French National Institute for Prevention and Health Education (INPES) in 2009/2010. Unfortunately, these data did not allow us to set up a direct test of these two assumptions, as the corresponding questionnaire did not investigate respondents' motives to oppose either vaccination in general or the H1N1 vaccine specifically. Nevertheless, we were able to perform an indirect test of these assumptions, by considering the socio-demographic and socioeconomic profiles associated with these two attitudes. This was the main aim of the present study. Of course, such an investigation also required us to take into account the relationship between these two attitudes: we assumed that opposition to vaccination in general fuelled opposition to the H1N1 vaccine and, reciprocally, that the H1N1 episode undermined trust in vaccination in general. Analyzing the relationship between these two kinds of attitudes was also interesting for this very reason, providing us with the second aim of this study: to test whether or not opposition to the H1N1 vaccine fuelled opposition to vaccination in general.

Section snippets

Sampling

The ‘2010 Health Barometer’ was a telephone survey on health issues conducted among a large, national, representative sample of French people. Eligibility criteria included speaking French, being aged 15–85 and living in continental France. Residents of collective dwellings, hospitals and institutions were excluded from the target population. Private households with landline phones were included in the sample, as well as people owning only mobile phones. We used a two-stage random sampling

Attitudes toward vaccination in general and toward the H1N1 vaccine specifically, September 2009–June 2010

Overall, 38% of the respondents were not favourable to vaccination in general and 51% reported that they were not favourable to certain vaccines in particular: 40% mentioned the H1N1 vaccine spontaneously, 11% mentioned the seasonal influenza vaccine, 9% the hepatitis B vaccine, and other vaccines (MMR, tuberculosis, HPV, etc.) were mentioned by 1% of respondents or less (respondents could mention several vaccines). Nineteen percent of respondents opposed both vaccination in general and the

Discussion

Attitudes toward vaccination in general and toward the H1N1 vaccine specifically varied significantly between October 2009 and June 2010 but remained strongly correlated to each other throughout the whole period. However, attitudes to both general and H1N1 vaccination did not share the same determinants: opposition to the former was more frequent among males, older and low-SES respondents, while opposition to the H1N1 vaccine was more frequent among females, people aged 35–49 and those with an

Conclusion

There is an urgent need to investigate the factors, including socioeconomic background, which affect public attitudes toward general vaccination and new vaccines, and to explore how to restore public trust in vaccination. We found two contrasting profiles of opponents to vaccination in general on the one hand, and to the H1N1 vaccine specifically on the other. The concerns of these opponents to vaccination should be researched in greater detail and not be reduced to irrational reactions merely

Acknowledgement

The French National Institute for Prevention and Health Education (INPES) provided access to the datasets. This research was conducted thanks to a grant from the French National Agency for Medicines and Health Products Safety (ANSM).

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