Will the public take a universal influenza vaccine?: the need for social and behavioral science research

ABSTRACT

Every influenza season, uptake of the flu vaccine falls short of the Healthy People 2020 goal of at least 70% of adults being vaccinated. Mixed methods research finds multiple factors associated with this phenomenon including misconceptions about the vaccine, skepticism about an annual vaccine, concerns about efficacy and safety, lack of knowledge, perceived risk, among others. The national goal to develop, test and produce an effective universal influenza vaccine requires a significant scientific and financial investment in research. However, there is no true investment in the social and behavioral science research necessary to ensure that once a universal vaccine is available, the public will take that new vaccine. This article highlights some qualitative and quantitative research results to provide some understanding of the challenges to increasing vaccine uptake. We also identify research questions necessary to ensure adoption of new universal vaccines.

KEYWORDS:

• Universal influenza vaccine
• vaccine hesitancy
• vaccine acceptance
• perceived risk
• trust
• patient-provider communication

The Healthy People 2020 goal is for at least 70% of US adults to be vaccinated annually against seasonal influenza, yet research shows that coverage consistently fails to reach that goal. For racial and ethnic minorities, the gap between coverage and the goal is persistent.^1,2 Our recent research has shown there are multiple factors affecting flu vaccine uptake including vaccine attitudes; perceived risk of vaccine side effects; trust in the vaccine and the vaccine production process; low confidence in the flu vaccine; racial factors associated with the health care setting; and failure of providers to recommend and offer the vaccine among others.^3-9 A 2019 poll with 1,002 Americans found additional barriers, including that 51% believe the flu vaccine doesn’t work, 34% are concerned about side effects, and 22% believe they will get the flu from the vaccine.¹⁰ Clearly, there are multiple cultural, social, knowledge, health care practice, and other barriers to routine vaccine uptake, including the ongoing challenge of needing an annual vaccine.

In September 2019, the National Institute of Allergy and Infectious Diseases (NIAID) announced its establishment of the Collaborative Influenza Vaccine Innovation Centers (CIVICs), a network of multidisciplinary research centers focusing on development and clinical trials of universal influenza vaccines.¹¹ Funded for seven years, the centers reflect NIAID’s strategic plan, which prioritizes the development of a universal vaccine that would provide “long-lasting protection against multiple strains of the virus,” in contrast to current strain-specific vaccines that provide limited protection and need to be updated each year.¹² NIAID identifies three research areas: “transmission, natural history, and pathogenesis studies using prospective cohorts; influenza immunity and correlates of immune protection; and strategies in rational vaccine design to elicit broad, protective immune responses” (p. 348).¹² Sah et colleagues estimate that once the seasonal vaccine is replaced entirely with a universal vaccine, it would “prevent 17 million cases, 251,000 hospitalizations, 19,500 deaths and $3.5 billion in health care costs” (p. 20786).¹³

Clearly, basic and clinical research is essential, but it is equally important to study the acceptability of any new vaccine. If this investment pays off, will Americans embrace the new universal flu vaccines? In the CIVICs program, there is no investment in the social and behavioral science research necessary to help ensure that a successful vaccine is actually acceptable to the public. How will we overcome the attitudinal, behavioral, cultural, and health care system barriers that limit uptake of current flu vaccines?

To provide some examples of the factors that influence acceptability, we look to both our qualitative and quantitative research understanding racial disparities in adult influenza vaccination.³ We conducted exploratory qualitative research with 118 American adults, White (n = 39) and African American (n = 79), both those vaccinated against flu and unvaccinated. Our qualitative analysis revealed how many adults see the flu vaccine as substantially different from other vaccines, which has implications for acceptance of a universal flu vaccine. We share several key themes.

Virus mismatch

Some participants recognized the challenge of an accurate and effective match between the circulating virus strains and that season’s vaccine, describing it as a “guessing game.” One White woman described this: “I know people that take the flu shot and they still get the flu, because the strain is always changing, and so there is no guarantee if you get that flu shot you’re not going to get some strain of flu. So, … why put myself through that? I could get it anyway.” An African American woman focused on the long time lag between virus prediction and immunization: “You’re always getting inoculated for last year’s stuff, and it’s putting, you’re putting negative stuff in your body so your body can learn to react to it and attack it, but they are attacking last year’s stuff.” She justified her decision to skip a flu vaccine by concluding, “ … when a new strain comes out, you’re really not inoculated for it.”

Vaccine effectiveness

Perceived vaccine effectiveness is one component of vaccine confidence. In our nationally representative survey of 1,643 African Americans and Whites, we found that higher confidence is associated with receipt of the vaccine.¹⁴ Flu vaccine effectiveness was often a natural segue from discussing viral mismatch. For one White female participant who had gotten her flu vaccine, she still questioned its effectiveness, “ … because if it only protects against certain strains and you get a different strain then is that person assuming it wasn’t effective, even though maybe it was effective against the one strain. So I don’t really know.” For others, low perceived effectiveness of the vaccine needed to be balanced against a higher perceived risk of vaccine side effects. For instance, one White man described his fears of getting sick from a vaccine, “Given that it’s not totally effective, why would I then want to make myself sick for two days only to be protected from something that probably won’t happen anyway?”

Need for annual vaccination

Currently, there remains some confusion and skepticism about the need for an annual vaccine. One unvaccinated White woman commented: “I’m not sure the vaccine works. I think it might be a big hype by the pharmaceutical companies to get more money. I’m very skeptical of the pharmaceutical companies, and that they’re just making everybody think they need this, but what are your chances of actually getting the flu every year, I don’t know. So, I have my doubts.”

An unvaccinated White man echoed her, “I mean I trust that people get the flu and that this vaccine prevents it, but I don’t know that – I mean because they’re definitely making money off of it and therefore it is in their interest to get more people to take it so they make more money.”

Knowledge of the vaccine

In our quantitative study, Quinn et al (2017) found that higher knowledge about the flu vaccine was associated with vaccine uptake, and conversely, lower knowledge associated with failure to take the vaccine.⁵ One frequent misunderstanding is that the vaccine contains live virus that can actually produce the disease. Multiple participants of both races believed the vaccine contained live virus as described by one unvaccinated African American woman, “I just don’t, because they’re giving you the virus. The flu shot, they inject you with the virus. I’m afraid you’re going to give me the virus, so I won’t get it. If I’m going to get it, I’ll take my chances.” An unvaccinated White man stated, “Why would I put that in my body? It’s like the risk seems so low to me and I’m not in the targeted population. I just don’t want to put that in my body, a live virus in my body.”

Vaccine production and ingredients

In NIAID’s announcement, the CIVICs centers “ … also will explore approaches to improve seasonal influenza vaccines, such as by testing alternative vaccine platforms or incorporating new adjuvants (substances added to vaccines to boost immunity).”¹³ However, in our qualitative research, we found a variety of concerns related to the vaccine’s ingredients. One unvaccinated African American woman questioned, “what’s in it, because did you know what is actually in the flu vaccination. Is it natural? I mean is it something that they just, some agent they just counteracted or made up one day and said, ‘This will work’? What chemicals are in there?” Similarly, an unvaccinated White woman questioned whether ingredients harmed a family member, “A lot of the vaccines have a metal or a metallic component in them or something, and she is very allergic to some metals and she has a feeling that that metallic part of it was what really did her in. But she can’t prove it, because the doctors won’t support her. And that goes back to the doubts about the whole medical industry.”

Fear of side effects

Both our quantitative and qualitative research found that perceived risk of side effects is associated with lower vaccine uptake.^3,8 Perceived risk of side effects vary from one White man’s comment, “There was a disclaimer on the flu shot stuff that says you’re subject to, in very rare instances, that there is a type of paralysis that can happen and that is basically debilitating, and this other person got it. And I thought, ‘Well, you know, I’m not going to take a flu shot.’ … ” to a White woman who takes the vaccine, “Vaccine safety I would say is very important to me. I think before I get the vaccine every year I sort of do the panicked research about all the different syndromes and how likely you are to get them from getting the vaccine, so I think that is pretty important to me.” A frequent myth is that the vaccine causes the disease as noted by multiple respondents including one unvaccinated African American woman, “I have friends that get it every year, and they get the flu every year, they get sick. So I’m like, okay, I’m not taking it and I’ve never had the flu.”

Proposing some critical questions

Without question, the development of a successful universal flu vaccine would be a major achievement. In his reflections on vulnerability to pandemic influenza, Michael Osterholm raised serious concerns about challenges in public acceptance of vaccines:

I would like to say that these barriers are just short-lived challenges, but we have a science literacy issue today where so much antiscience has become the mainstay for how we make decisions. You can’t do anything about improving your status and response to any of these issues if you don’t have a population that is willing to support them. We used to talk about vaccine hesitancy where people were reluctant to get vaccines. Today it’s much greater than that. It’s a hesitancy to adopt any kind of science-based approach (p.E3).¹⁵

Therefore, it is vitally important that research begins to examine the potential social and behavioral reactions to a universal flu vaccine, and the public health and health care system adaptations necessary before its approval.

The acceptance of an effective universal vaccine will require innovative approaches to increasing confidence and trust in the vaccine and its effectiveness, overcoming misconceptions, addressing perceived risk associated with a new vaccine, assuring the understanding of new language such as universal vaccine and adjuvants, and ensuring that the health care system adapts its practices to strengthen uptake. Based on our own mixed methods research, we propose a research agenda in Table 1. As CIVICs engages in its multidisciplinary efforts, we urge NIAID to add social and behavioral scientists to its CIVICs team, and to begin to lay a strong research foundation for acceptance of future universal and improved seasonal influenza vaccines.

Table 1. Areas of research necessary to assure uptake of universal flu vaccine.

Key groups	Challenge	Research questions
Health care providers	Incentives, tracking and reminder systems	● How will current tracking and reminder systems for vaccine uptake need to be modified? ● What training will be needed to prepare health care providers for its adoption? ● How might incentives assist in facilitating uptake?
Health care providers	Patient-provider communication	● What are the attitudinal and knowledge barriers among health care providers themselves? ● What knowledge gaps, myths or misinformation might providers encounter from patients? ● How might strengthening recommendations (e.g. presumptive announcements, motivational interviewing) increase uptake ? ● What are the key messages and communication strategies to enhance uptake?
Health care system	Cost as a barrier	● What impact may any cost difference between current vaccines and universal vaccines have on patients as a perceived or real barrier? ● What changes may be necessary in insurance coverage for the universal vaccine?
Public health leadership	Determination of recommendations by the Advisory Committee on Immunization Practices (ACIP)	● What evidence will be available for initial determinations on recommendations by population or age group? ● What type of monitoring and data will be needed to periodically assess and adjust recommendations? ● What type of public push-back or concern will the ACIP encounter during this process?
Public health practitioners communication to the public	Communication environment	● What will be the most appropriate and effective channels for communication at the time of the universal vaccine? ● How might they differ by audiences?
Public health practitioners communication to the public	Communication messages	● What theories might be most effective for message development? ● How will messages and communication campaigns need to differ by audience or population?
Public	Public understanding and interpretation of a universal vaccine, attitudinal and knowledge barriers	● What formative research will be necessary to assess public understanding of the vaccine and any new terminology associated with it? ● How can we effectively increase knowledge about the universal vaccine? ● How do we increase public knowledge about recommendations? ● What are the public’s attitudes toward a universal vaccine and how might those differ by population?
Public	Perceived risk of the vaccine and vaccine confidence	● How will different publics perceive the risk of the vaccine itself? ● How will perceived risk of the vaccine interact with perceived benefits of a universal vaccine to affect uptake? ● If necessary, how do we effectively change the public’s appraisal of risk in order to foster uptake? ● What level of confidence will the public have in the universal vaccine? How can that level of confidence be increased? What is the role of confidence in decision-making about the universal vaccine?
Public	Trust in the vaccine, the vaccine production process	● To what extent does the public trust the new universal vaccines? ● To what extent is the public knowledgeable about the testing and approval processes for the vaccine? ● How might a universal vaccine, with longer effectiveness, reduce the resistance due to the public’s perception of profit motivator as the driving factor for recommendations for the flu vaccine?
Public	Potential impact of misinformation about new vaccine	● What systems will public health practitioners and researchers need to put in place to monitor misinformation about the universal vaccine? ● What is the impact of misinformation and how does it differ by population group? ● What are effective interventions to reduce the impact of misinformation?
Public	Social norms and networks	● What strategies can effectively shift social norms to support uptake of a universal vaccine?
Public	Motivators and barriers	● How motivated will the public be to get the new vaccine? ● What barriers exist to uptake? How might these differ by population? ● To what extent will complacency affect uptake? How might that differ in seasonal influenza compared to pandemic influenza events?

Disclosure of potential conflicts of interest

No potential conflict of interest was reported by the authors

Additional information

Funding

This study was funded by the Center of Excellence in Race, Ethnicity and Health Disparities Research [NIH-NIMHD: P20MD006737]; PIs, Quinn and Thomas).