Elsevier

Social Science & Medicine

Volume 221, January 2019, Pages 87-94
Social Science & Medicine

“You don't trust a government vaccine”: Narratives of institutional trust and influenza vaccination among African American and white adults

https://doi.org/10.1016/j.socscimed.2018.12.020Get rights and content

Highlights

  • Trust in flu vaccines may reflect trust in the institutions that produce them.

  • Pharmaceutical companies are widely distrusted, often due to perceived motives.

  • Trust in government differs by race, age and institution.

  • White privilege may shape high levels of passive trust among Whites.

  • Racialized history continues to shape current attitudes about institutions.

Abstract

Vaccine confidence depends on trust in vaccines as products and trust in the system that produces them. In the US, this system consists of a complex network connecting pharmaceutical companies, government agencies, and the healthcare system. We explore narratives from White and African American adults describing their trust in these institutions, with a focus on influenza vaccine. Our data were collected between 2012 and 2014 as part of a mixed-methods investigation of racial disparities in influenza immunization. We interviewed 119 adults, primarily in Maryland and Washington, DC, in three stages utilizing semi-structured interviews (12), focus groups (9, n = 91), and in-depth interviews (16). Analysis was guided by grounded theory. Trust in institutions emerged as a significant theme, with marked differences by race. In 2018, we contextualized these findings within the growing scholarship on trust and vaccines. Most participants distrusted pharmaceutical companies, which were viewed to be motivated by profit. Trust in government varied. Whites described implicit trust of federal institutions but questioned their competency. African Americans were less trusting of the government and were more likely to doubt its motives. Trust in institutions may be fragile, and once damaged, may take considerable time and effort to repair.

Introduction

Medical research continues to affirm the safety, efficacy, and value of vaccination, yet vaccine hesitancy and refusal continue to undermine immunization campaigns worldwide (MacDonald, 2015). The World Health Organization (WHO) uses the concept of “vaccine hesitancy” to characterize this issue, defining it as the “delay in acceptance or refusal of vaccines despite availability of vaccination services” (WHO, 2014). In this conceptualization, vaccine hesitancy is influenced by three factors: complacency, convenience, and confidence, where confidence represents, “trust in the 1) effectiveness and safety of vaccines, 2) the system that delivers them, including the reliability and competence of health services and professionals, and 3) the motivations of policy-makers who decide on the needed vaccines” (MacDonald, 2015, p. 4162). Scholars worldwide have embraced this framework, but conceptual ambiguities remain, particularly related to the role of trust (Peretti-Watel et al., 2015).

In the US, seasonal influenza vaccine is recommended to all adults and is widely available at low or no cost (Grohskopf et al., 2018). However, adult influenza immunization rates continue to be suboptimal. In the 2017-18 flu season, only 37% of adults were vaccinated, far below the 70% goal set by Healthy People 2020 (CDC, 2018a; U.S. DHHS, 2015). African Americans are significantly less likely to be immunized than Whites, with a longstanding disparity in vaccination rates (Lu et al., 2014). We believe that low confidence in influenza vaccines may contribute to low vaccination rates overall and the ongoing racial disparity, as evidence suggests African Americans may be less trusting of institutions that are involved in vaccine production and promotion (Freimuth et al., 2017; Quinn et al., 2018; Musa et al., 2009).

The WHO's Strategic Advisory Group of Experts (SAGE) on immunization has led efforts to conceptualize and assess the role of public trust in immunization. SAGE is responsible for the working definitions of vaccine hesitancy and efforts to develop scales of both vaccine hesitancy and confidence (Larson et al. 2014, 2015; MacDonald, 2015). While researchers agree that trust is fundamental to public acceptance of vaccines, there is less agreement on how trust should be defined or measured, which aspects of trust should be considered, and which relationships should be studied (Larson et al., 2018). This is not unique to the study of vaccines, but rather reflects the ambiguities of trust as a concept.

Embedded in the SAGE definition of confidence is the delineation between “the reliability and competence of health services and professionals” (MacDonald, 2015 p.4162). This distinction reflects the dual aspects of trust described in the Trust Confidence and Cooperation (TCC) Model, which distinguishes between “social trust” based on similarity and “shared values” and confidence based on past experience (Siegrist et al., 2003). These two dimensions have also been described as “trust in motives” and “trust in competence” (Twyman et al., 2008). In both conceptualizations, increased social trust (or trust in motives) and confidence (or trust in competence) are believed to increase cooperation (or greater trust overall) (Twyman et al., 2008; Siegrist et al., 2003). Both dimensions have been hypothesized to correlate with increased vaccine uptake and intentions (Larson et al., 2018).

The decline in public trust towards vaccination is a global issue (Larson, 2016). Many possible explanations for this decline have been hypothesized, including vaccine safety scares, the rise of anti-vaccine groups, the use of social media, the idea that vaccines have been “victims of their own success”, and rising distrust of “expert” culture in general (Larson et al., 2014; Dube et al., 2015; Yaqub et al., 2014). The relationship between distrust and decreased vaccine uptake has made vaccine skeptics and non-vaccinators a common research focus. One major theme is that in the absence of trust towards experts and other authority figures, individuals may feel the need to “re-interpret” vaccine information themselves (Yaqub et al., 2014). Others have highlighted how broader social trends may influence trust, as modern patients are encouraged to be “advocates” for their children's health and to take an active role in decision-making (Hobson-West, 2007). Sometimes, a vaccine scare, negative publicity, or other public incident can contribute to longterm declines in trust (King and Leask, 2017). It is important to note that factors may vary by community, as “local vaccine cultures” based on shared experiences and social norms are a powerful influence on vaccine acceptance and refusal (Streefland et al., 1999).

A 2018 literature review documented 35 articles covering a broad range of topics related to trust and vaccines (Larson et al., 2018). The subset of studies focused on trust in the healthcare system and trust in government were largely quantitative, with the majority concluding that greater trust was associated with increased intention to vaccinate (Larson et al., 2018). Among the qualitative studies focused on institutional trust, common themes were identified around distrust of pharmaceutical companies and the importance of history in shaping trust relationships (Larson et al., 2018). The vaccine hesitancy framework emphasizes that confidence in vaccines is context specific, so while this growing body of literature reflects some commonalities, each population, vaccine, and geographic area constitutes a unique case.

Confidence in an influenza vaccine also depends on trust in the many actors and agencies responsible for the production, regulation, and administration of the vaccine. Briefly, we highlight the key actors and their roles in this network. Our focus is on the role of institutions in the US, with a focus on influenza vaccines for adults. There are three key players: the pharmaceutical companies that develop and produce the vaccines, the Food and Drug Administration (FDA) that regulates flu vaccine production, and the Centers for Disease Control and Prevention (CDC) that sets vaccine recommendations and promotes the vaccine to the public.

Influenza vaccines are unique in that they are reformulated annually, and recommendations are updated every year. The WHO predicts the dominant influenza strains each season, and the Food and Drug Administration (FDA) decides which strains to include in FDA-licensed vaccines (Weir and Guber, 2016). All vaccine manufacturers undergo extensive testing and need to be relicensed from the FDA annually (Weir and Gruber, 2016). Only a few pharmaceutical companies (Sanofi Pasteur, GlaxoSmithKline, and Seqirus) produce influenza vaccines for the US, partially due to the costs involved in vaccine development and partially due to the challenges associated with influenza vaccine (FDA, 2018; Houser and Subbaro, 2015). Once vaccines are ready for the public, the Advisory Committee on Immunization Practices (ACIP), a 15 member panel of experts appointed by the CDC, releases updated recommendations for vaccination (CDC, 2015). The CDC also conducts public health campaigns to promote influenza vaccination, in some instances subsidizing the cost of flu vaccines for certain populations including low-income children and uninsured adults (CDC, 2018b). Once on the market, the CDC and the FDA continue to monitor vaccine safety through the Vaccine Adverse Event Reporting System (VAERS) (CDC, 2015).

We recognized a gap in the literature surrounding the particular context of our work: narratives of institutional trust as it relates to adult seasonal influenza vaccination in the US. This data had been collected as part of a broader study of factors influencing racial disparities in adult influenza immunization, where we identified trust as one of many influences on vaccine decision-making (Quinn et al., 2016). Those findings informed the development of survey items, which when administered in a national survey confirmed significant differences in trust between African Americans and Whites (Freimuth et al., 2017). In this manuscript, we explore institutional trust related to influenza vaccine using narratives from African American and White adults.

Section snippets

Study design & procedure

This manuscript is based on data collected between 2012 and 2014 as part of a mixed-methods investigation of racial disparities in influenza vaccine uptake. For our qualitative data collection and analysis, we employed grounded theory to guide our research. Grounded theory depends on successive stages of data collection interspersed with analysis, allowing for emergent themes in the data to be fully explored (Glaser and Strauss, 1968). Our process involved data collection in three phases:

Results

Our findings suggest that for most adults, trusting a flu vaccine necessarily involves trust relationships with multiple entities and individuals. Two distinct areas of focus were clear in the narratives: trust in pharmaceutical companies and the healthcare industry, and trust in the government, including federal public health agencies. In total, we talked with 119 adults about their attitudes, which included more African Americans than Whites, more females than males, and more older adults

Discussion

These narratives add depth to ongoing discussions of institutional trust and influenza vaccination, particularly in the context of racial disparities in the United States. We find that when assessing trust in influenza vaccines, trust levels vary significantly by institution. Most respondents, White and African American, young and old, vaccinated and not, were aligned in distrusting pharmaceutical company motives. Trust in government agencies was more nuanced with clear divisions across racial

Conclusions

We assessed racial differences in trust in the influenza vaccine and trust in the system that produces it. Trust in pharmaceutical companies is low, as many participants perceive that companies are motivated by profit and not by serving patients. Trust in the government varies by race. For many Whites, trust in government's role in influenza vaccination is implicit and unquestioned. For some African Americans, trust in government's role in influenza vaccination is earned only after reconciling

Funding

This study was funded by the Center of Excellence in Race, Ethnicity, and Health Disparities Research (NIH-NIMHD: P20MD006737; PIs, Quinn and Thomas). The funders had no role in design, implementation, or conduct of this research or in the development of this manuscript.

Acknowledgements

We'd like to thank Dr. Leah Curran for her work designing, organizing, and conducting qualitative research. Thank you for pushing us to think critically and intersectionally. We'd also like to thank Dr. James Butler, Dr. Craig Fryer, and Dr. Susan Passmore for their work moderating focus groups. Thank you all.

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