The Influence of Social Norms on Flu Vaccination among African American and White Adults

"Social norms - which include both perceived and observed rules, and the customs and practices of others - are powerful tools to encourage behavior change, but are understudied when it comes to vaccines in general, and flu vaccine, in particular."

Although influenza vaccination is a low-cost preventive measure that can reduce illness, hospitalisation, and mortality, the majority of American adults do not get vaccinated. Racial disparities in vaccination rates exacerbate this problem, with only 37% of African-American adults compared to 45% of whites immunised against the flu in the 2015-16 season, according to Centers for Disease Control and Prevention (CDC) data. Social norms - the acceptable beliefs by people belonging to a particular group, both explicit and implicit - have been utilised in promoting vaccination behaviour. This study examined whether social norms seem to exist around influenza vaccination, how influential they are, and whether social norms could be harnessed to reduce vaccine racial disparities.

From 2012-14, the researchers gathered and analysed qualitative data following a Grounded Theory approach. Participants were from rural, suburban, and urban areas of Georgia and Maryland. The overall sample (n = 118) included native-born, English-speaking adults of diverse age, gender and income, who self-identified as white (n = 39) or African American (n = 79). The researchers conducted 12 semi-structured exploratory interviews, 9 focus groups (n = 90) divided variously by race and vaccine status, and 16 in-depth individual interviews to explore topics that emerged in focus groups.

Descriptive norms are what others do, and subjective norms are what others think one should do; initial probes explored whether clear descriptive social norms existed for flu vaccination. When asked about their perceptions of whether others in the community were getting flu vaccines, many participants reported little awareness of social norms. Some people noted a lack of advertisements and media coverage. There was a perceived descriptive norm that "about half" of the population gets vaccinated. Individuals let their own vaccine behaviour influence their attitudes about others. For instance, vaccine takers were more likely to see other vaccine takers as more health conscious and considerate, and non-takers tended to view fellow non-takers as having made a rational decision to not vaccinate. Both takers and non-takers recognised that mistrust was a significant influence for non-vaccine-takers, particularly among African Americans. Nearly everyone, white and black, takers and non-takers, described family as an important influence on their vaccine decisions. In fact, family was second only to personal physicians as the most trusted source of information related to vaccines.

Participants describe differing norms by race and vaccine behaviour. For example, in African-American families in particular, there was a significant push back against "selling out" or becoming a "guinea pig". There were also significant debates over the severity and likelihood of side effects. White participants were less likely to describe discussion among their families, instead describing families quietly supportive of vaccination, or families that were ambivalent but didn't engage in a debate. In short, among participants, family culture proved to be a strong and lasting influence on social norms surrounding vaccination, but racial differences were evident in their discussion.

Those findings informed a national survey, conducted in March 2015, of African-American and white adults (n = 1,643). Quantitative results confirm a perceived descriptive norm that 40-60% of the population gets vaccinated. Both African Americans and whites accurately identified race-specific vaccination rates relative to the general population. Over 60% of whites and 50% of African Americans who did not get vaccinated reported that few people close to them wanted them to get the vaccine. Conversely, over 40% of whites and over 30% of African Americans who took the vaccine reported that most or nearly all wanted them to get the vaccine. These findings were statistically significant for both groups, suggesting that subjective norms are influential for both white and African-American adults.

From the perspective of social norms theory, the misconception between actual norms and perceived norms would typically be seen as an opportunity to correct the misconception and change behaviour. Current influenza vaccination rates are not ideal, and yet respondents are actually overestimating vaccine uptake. However, from a public health viewpoint, there is a risk that emphasising this perceived norm based on mediocre vaccination rates may normalise non-vaccination and could trigger a "boomerang effect", where some vaccinators may realise they are already exceeding the norm.

From the perspective of the Theory of Planned Behavior, health communicators may wish to focus on increasing perceived subjective norms within the African-American group as a way to increase intention and actual vaccine uptake. Potential approaches may include: (i) focusing on changing the family culture around vaccination by emphasising family needs and expectations, particularly in families where members experience chronic diseases that put them at higher risk of complications from influenza, and (ii) seizing opportunities to reach African-American families through family reunions, other holiday gatherings, and trusted venues, such as barber/beauty shops or faith communities, with messages that encourage conversations with loved ones about the importance of flu vaccinations.

The researchers encourage future research to explore differences within the African-American group to determine characteristics in addition to race that may contribute to the influence of descriptive and subjective norms. The influence of subjective norms in any group - including African Americans - may vary with age, education, geography, health status, or other characteristics. In conclusion, health promotion efforts, particularly those geared toward African Americans, may benefit from focusing on subjective norms and encouraging friends and family members to talk about the benefits of influenza vaccination: "increasing communication among loved ones about flu vaccine may be an effective tactic to increase flu vaccination."