Social Science & Medicine 108 (2014) 1e9

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Attitudes toward vaccination and the H1N1 vaccine: Poor people’s

unfounded fears or legitimate concerns of the elite?
Patrick Peretti-Watel a, b, c, *, Jocelyn Raude d, e, Luis Sagaon-Teyssier a, b, Aymery Constant d, f,
Pierre Verger a, b, c, François Beck g, h
a
INSERM, UMR912 “Economics and Social Sciences Applied to Health & Analysis of Medical Information” (SESSTIM), 13006 Marseille, France
b
Aix Marseille University, UMR_S912, IRD, 13006 Marseille, France
c
ORS PACA, Southeastern Health Regional Observatory, 13006 Marseille, France
d
Department of Social and Behavioral Sciences, EHESP Rennes, Sorbonne Paris Cité, France
e
Aix-Marseille Univ, UMR EPV Emergence des Pathologies Virales e 190, France
f
INSERM U897-IFR99, Equipe Avenir Prévention et Prise en Charge des Traumatismes, ISPED, Bordeaux, France
g
Institut National de Prévention et d’Education pour la Santé (INPES), 93203 St Denis Cedex, France
h
Cermes3 e Equipe Cesames (Centre de recherche Médecine, Sciences, Santé, Santé mentale, Société, Université Paris Descartes, Sorbonne Paris Cité,
CNRS UMR 8211/Inserm U988/EHESS), Paris Cedex 06, France

a r t i c l e i n f o a b s t r a c t

Article history: In 2009e2010, the H1N1 episode occurred in a general context of decreasing public confidence in
Received 20 February 2013 vaccination. We assumed opposition to vaccination in general to be an ‘unfounded fear’, reflecting
Received in revised form ignorance and perceived vulnerability among low-socioeconomic status (SES) people, and opposition to
18 February 2014
the H1N1 vaccine a ‘legitimate concern’ reflecting the elite’s commitment to ‘risk culture’ in a ‘risk so-
Accepted 21 February 2014
Available online xxx
ciety’. 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
Keywords:
France
general. We used data from a telephone survey conducted in 2009e2010 among a random sample of
Attitudes toward vaccination French people aged 15e79 (N ¼ 9480). Attitudes toward vaccination in general and toward the H1N1
Influenza H1N1 vaccine specifically varied significantly between October 2009 and June 2010 with strong correlation
Healthism 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 35e49 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 misin-
formation and further research is needed to acquire a greater understanding of the motives of opponents.
Ó 2014 Published by Elsevier Ltd.

1. Introduction Larson et al., 2011). Some authors claim that anti-vaccination

1.1. The contemporary vaccine confidence gap
According to many public health experts, public confidence in
vaccination is waning (Black and Rappuoli, 2010; Shetty, 2010;
* Corresponding author. INSERM UMR912/ORS Paca, 23 rue Stanislas Torrents,
13006 Marseille, France.
E-mail address: patrick.peretti-watel@inserm.fr (P. Peretti-Watel).
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 measlesemumpserubella (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,

http://dx.doi.org/10.1016/j.socscimed.2014.02.035
0277-9536/Ó 2014 Published by Elsevier Ltd.
2 P. Peretti-Watel et al. / Social Science & Medicine 108 (2014) 1e9
and, of course, the H1N1 vaccine in many countries in 2009e2010,
including France (Larson et al., 2011).
1.2. Irrational fears or legitimate concerns?
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,
emotionedriven 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 re-
actions” and “psychological contagion” (Ofri, 2009; Gilman, 2010).
On the contrary, several qualitative studies have found that
parents who refused vaccination for their children were accus-
tomed 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).
1.3. Attitudes toward vaccination and low socioeconomic status
During the 19th century, opposition to vaccination was espe-
cially 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 in-
dicators 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 influ-
enza (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 ef-
fect” or the “societal inequality effect”) (Finucane et al., 2000;
Olofsson and Rashid, 2011). Material deprivation and social isola-
tion 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 hy-
pothesis 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).
1.4. Risk culture, risk society and opposition to specific vaccines: the
case of the H1N1 vaccine
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, commit-
ment 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 soci-
eties” 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 citi-
zens 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).
1.5. Assumptions and aims of the present study
On the one hand, we hypothesized that opposition to vaccina-
tion is an ‘unfounded fear’, reflecting misinformation, ignorance,
perceived powerlessness and vulnerability and that such opposi-
tion 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 au-
thorities 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 vac-
cine 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
 P. Peretti-Watel et al. / Social Science & Medicine 108 (2014) 1e9
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 vaccina-
tion 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.
2. Methods
2.1. 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 15e85 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 procedure. The first
stage involved household selection (by phone number). An eligible
subject from within a household was then randomly selected to
participate in the survey, using the Kish method (the interviewer
asked for the names of all household members and for their
birthdays, the selected respondent was the person whose birthday
was most recent, see Kish, 1949). The study design and protocol
were approved by the French Commission on Individual Data
Protection and Public Liberties (CNIL).
2.2. Data collection
The study protocol included a formal letter sent by postal mail
which explained the objectives of the study and which asked in-
dividuals to participate. It did not provide any details about the
topics to be investigated. Unsuccessful calls were repeated 30 and
90 min later; up to 40 attempts were made, on different days and at
different times. Data collection lasted from October 2009 to June
2010. With respect to the chronology of the H1N1 pandemic in
France, data collection began just after the epidemic threshold had
been reached (in September), and just before the beginning of the
vaccination campaign targeting health professionals. When data
collection finished in June the pandemic was over but there was
ongoing controversy regarding the management of the crisis by
health authorities. Overall, 27,653 people participated in the survey
(refusal rate: 39%), but only a randomly selected subsample of
people aged 15e79 answered the questions related to vaccination
(N ¼ 9480) (as the whole questionnaire was too long to be fully
answered by all the participants).
Data were weighted with respect to the inclusion probability
(the initial weights were the inverse of the inclusion probability of
each observation; this inclusion probability was proportional to the
number of telephone numbers, and inversely proportional to the
number of eligible persons in each household). Secondary weights
were computed so that the distribution of the main socio-
demographic characteristics (gender, age, educational level,
geographical region and urbanization level) was the same in the
sample and in the general French population (available from the
National Institute of Statistics and Economic Studies).
2.3. Questionnaire
With respect to vaccines, respondents were asked about their
attitude toward vaccination in general, choosing from one of the
following reply options: ‘very favourable’, ‘quite favourable’, ‘not
3
very favourable’, ‘not at all favourable’. Responses were merged into
a binary outcome: ‘against vaccination in general’ equalled 1 if
participants answered ‘not very/not at all favourable’, otherwise
the value was 0. They were also asked whether or not they were not
favourable to certain vaccines in particular, and if so, to which ones
(with an open-ended question). We computed another binary
outcome equal to 1 if they answered ‘yes’ and mentioned the H1N1
vaccine, 0 otherwise. Thus, we measured two quite different kinds
of opposition to vaccination: on the one hand, people who asserted
that they opposed vaccination in general and who did not neces-
sarily mention spontaneously their opposition to a specific vaccine,
in particular H1N1, and, on the other hand, people who opposed the
H1N1 vaccine specifically, but not necessarily other vaccines.
Participants also reported their own immunization status (up-
to-date or not, vaccinated or not against hepatitis B, vaccinated or
not against seasonal influenza in 2008). Moreover, we assumed that
having already been tested for hepatitis B or C and having a child
aged <4 were proxies for respondents’ proximity to preventive
medicine. Indeed, in France, screening for hepatitis B and C is one of
the main general physicians’ missions in preventive medicine
(Gautier and Jestin, 2011) and children <4 are supposed to consult a
physician regularly to monitor their growth and to follow a vacci-
nation schedule (including mandatory vaccines against diphtheria,
tetanus and poliomyelitis).
The questionnaire collected data on respondents’ socio-
demographic and socioeconomic background: gender, age, educa-
tional level, household composition and income. For each respon-
dent, we computed the equivalized household income (EHI), as
defined by the Organisation for Economic Co-operation and
Development (OECD). EHI involves a weighting scale that allows
the relative well-being of households of different size and
composition to be analyzed. We allocated 1 point for the first adult
in the household, 0.5 points for each additional person aged 15,
and 0.3 points for each child aged <15. EHI is computed by dividing
total household income by the sum of the points allocated to the
household members. Respondents were also asked to assess their
household’s financial situation. Finally, we used two indicators to
assess respondents’ social vulnerability: whether or not they had
contact with family or friends during the previous 8 days), and
whether or not they had been victim of verbal or psychological
violence during the previous 12 months (as such victimization
could be both the cause and the effect of perceived vulnerability).
2.4. Statistical analysis
First, we examined how attitudes toward vaccination in general
and toward the H1N1 vaccine specifically varied between October
2009 and June 2010. As monthly subsamples were quite small for
October (N ¼ 261) and June (N ¼ 274), we merged them with the
November and May subsamples respectively. The resulting sub-
samples sizes varied from N ¼ 938 (MayeJune) to N ¼ 2220
(OctobereNovember). We used the Pearson’s c2 to test the statis-
tical significance of observed variations across time (testing the
independence between opposition to vaccination in general (or to
the H1N1 vaccine) and the month of collection). We also used the
Pearson’s c2 to test the relationship between opposition to vacci-
nation in general and opposition to the H1N1 vaccine specifically,
for each monthly subsample separately.
Secondly, we investigated factors associated with attitudes to
both, using bivariate and multivariable analyses. For the attitude to
each type of vaccination (general or H1N1), potential covariates
included socio-demographic background (including age and age2/
100, to capture a potential non-monotonous effect of age), socio-
economic and social vulnerability indicators, as well as vaccination
history, proximity to preventive medicine, and the attitude to the
4 P. Peretti-Watel et al. / Social Science & Medicine 108 (2014) 1e9
other vaccination element being investigated (i.e. vaccination in
general or H1N1 specifically). Our modelling strategy implied a
potential circular causality, as the attitude toward vaccination in
general may have influenced the attitude toward the H1N1 vaccine
and vice versa.
We had to test to see if the relationship between these two
outcomes was unidirectional (in one direction or the other) or
reciprocal. To test this we had to take into account the potential
endogeneity of these two outcomes. This was especially necessary
regarding the second aim of our study (i.e. to test whether or not
opposition to the H1N1 vaccine fuelled opposition to vaccination in
general). Details of how we tackled the endogeneity issue are
described in the Appendix. Three types of covariates were required:
covariates specific to attitudes toward vaccination in general,
covariates specific to attitudes toward the H1N1 vaccine, and
covariates common to both attitudes. In order to identify these
three sets of covariates we separately estimated two logistic models
for attitudes to vaccination in general and to H1N1 vaccination.
Only logistic models resulting from the procedure described in
Appendix 1 are displayed. We also provide the results of the two
likelihood ratio tests (testing the exogeneity of attitudes toward
vaccination in general and attitudes toward H1N1 vaccine specif-
ically, when each of these variables is considered as a possible
explanatory variable for the other).
3. Results
3.1. Attitudes toward vaccination in general and toward the H1N1
vaccine specifically, September 2009eJune 2010
Overall, 38% of the respondents were not favourable to vacci-
nation 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 (re-
spondents could mention several vaccines). Nineteen percent of
respondents opposed both vaccination in general and the H1N1
vaccine; 40% did not oppose them; 22% opposed the H1N1 vaccine
but not vaccination in general; 19% opposed vaccination in general
but did not mention the H1N1 vaccine specifically. Negative atti-
tudes toward vaccination in general and toward the H1N1 vaccine
were strongly associated (p < 0.001): among those who opposed
vaccination in general 49% were not favourable to the H1N1 vaccine
and, reciprocally, among those who opposed the H1N1 vaccine 46%
did not favour vaccination in general.
Attitudes regarding vaccination in general and specifically H1N1
vaccination varied significantly between October 2009 and June
2010 (p < 0.001, see Fig. 1). Opposition to vaccination in general
reached a peak in December (42%), during the mass immunization
campaign (launched in November and ended in January) which
turned out to be a resounding failure. Opposition to the H1N1
vaccine specifically reached a peak in February/March (44%), while
the management of the pandemic was strongly criticized: a par-
liamentary commission of enquiry was set up in February to
investigate the involvement of the pharmaceutical industry, and in
March several cities claimed a full refund from the State for all the
expenses incurred by the vaccination campaign.
The statistical link between both attitudes to vaccination
remained strongly significant (p < 0.001) for each monthly sub-
sample. Fig. 1 also displays the variations observed for opposition to
vaccination in general among the subsample of respondents who
did not oppose the H1N1 vaccine (see the dotted line with circles in
Fig. 1): the resulting curve was very similar to that for the whole
sample, but approximately 6% below the latter for each month over
Fig. 1. Opinions toward vaccination in general and H1N1 vaccination, October 2009e
June 2010 (%, INPES 2010, N ¼ 9480).
the period. Finally, opposition to the H1N1 vaccine was more
frequent among respondents who opposed vaccination in general,
it did not vary significantly during the period (p ¼ .559, dotted line
with triangles).
3.2. Opposition to vaccination in general and to the H1N1 vaccine
specifically: bivariate analyses
Table 1 displays the results of bivariate analyses for opposition
to vaccination in general and H1N1 vaccination specifically. Op-
position to the former was more frequent among people aged 50e
64 and people with a low level of education (no diploma, or below
high-school graduation). Instead, it was less frequent among people
who had a high income and those who reported having a
comfortable financial situation. By contrast, opposition to the H1N1
vaccination was more frequent among females, people aged 35e49,
as well as among respondents with an intermediate education level
(high school, 1st university degree), those with an intermediate
income level, and those who perceived their financial situation as
“manageable”.
With respect to indicators of social vulnerability, respondents
who had not had any recent contact with family or friends were
more prone to oppose vaccination in general, but less likely to
oppose the H1N1 vaccine. Conversely, victims of verbal/psycho-
logical violence expressed negative attitudes toward the H1N1
vaccine more frequently but negative attitudes toward vaccination
in general less frequently.
Proximity to preventive medicine and vaccination history were
negatively associated with opposition to vaccination in general, but
positively associated with opposition to the H1N1 vaccine (except
for having child(ren) under 4 and vaccination against the seasonal
flu in 2008).
3.3. Multivariable analyses and the endogeneity issue
Multivariable analyses with logistic models led us to distinguish
three kinds of explanatory variable: covariates which were signif-
icant predictors of attitudes to both general and H1N1 vaccination
(gender, age, educational level, equalized household income, recent
contact with family or friend, being up-to-date on vaccination),
covariates that were only predictive of attitudes toward vaccination
in general (child(ren) under 4 in the household, having been tested
for hepatitis B or C, vaccinated against hepatitis B and against
 P. Peretti-Watel et al. / Social Science & Medicine 108 (2014) 1e9 5

Table 1
Factors associated with attitudes expressed toward vaccination in general and H1N1 vaccination specifically, bivariate analysis (row %, France 2009e2010, INPES, N ¼ 9480).

Against vaccination in general Against H1N1 vaccination

Row % pa Row% pa

Gender:
- Female (N ¼ 5222) 37% 45%
- Male (N ¼ 4258) 39% 0.054 35% <0.001

Age:
15e24 (N ¼ 1174) 28% 38%
25e34 (N ¼ 1528) 32% 44%
35e49 (N ¼ 2756) 36% 47%
50e64 (N ¼ 2589) 48% 39%
65e79 (N ¼ 1433) 44% <0.001 31% <0.001

Educational level:
- No diploma (N ¼ 878) 48% 35%
- Below high-school graduation (N ¼ 3952) 41% 41%
- High-school, 1st university degree (N ¼ 2793) 32% 45%
- 3e4 years completed at University (N ¼ 1043) 28% 40%
- >4 years completed at University (N ¼ 814) 23% <0.001 30% <0.001

Equalized household income:

- <900 V/month (N ¼ 1945) 41% 39%
-[900e1500[/month (N ¼ 2909) 41% 44%
- 1500 V/month (N ¼ 3953) 34% 38%
- Don’t know/refuse to answer (N ¼ 673) 39% <0.001 38% <0.001

Participant’s perception of household’s financial situation:

- Comfortable (N ¼ 1566) 34% 35%
- Fine (N ¼ 4113) 37% 39%
- Manageable (N ¼ 2474) 39% 45%
- Difficult/in debt (N ¼ 1327) 44% <0.001 42% <0.001

Contact with family or friends during the previous 8 days:

- None (N ¼ 1401) 44% 36%
- At least one person (N ¼ 8079) 37% <0.001 41% <0.001

Victim of verbal/psychological violence during the previous 12 months:

- Yes (N ¼ 1685) 34% 46%
- No (N ¼ 7795) 39% <0.001 39% <0.001

Child(ren) under 4 in the household:

- None (N ¼ 8453) 39% 40%
- At least one (N ¼ 1027) 28% <0.001 43% 0.140

Screening test for hepatitis B or C:

- Never tested (N ¼ 6698) 40% 40%
- Tested at least once (N ¼ 2782) 33% <0.001 42% 0.018

Up-to-date on vaccinations:
- Yes (N ¼ 7595) 34% 41%
- No, don’t know (N ¼ 1885) 57% <0.001 38% 0.041

Vaccinated against seasonal flu in 2008:

- Yes (N ¼ 2203) 24% 33%
- No (N ¼ 7277) 43% <0.001 43% <0.001

Vaccinated against hepatitis B:

- Yes (N ¼ 4077) 30% 44%
- No (N ¼ 5403) 44% <0.001 38% <0.001

Attitude toward vaccination in general:

- Quite/very favourable, don’t know (N ¼ 5928) e 35%
- Not very/not at all favourable (¼against) (N ¼ 3552) e 49% <0.001

Attitude toward H1N1 vaccine:

- Did not report opposition to H1N1 vaccine (N ¼ 5577) 33% e
- Not favourable to H1N1 vaccine (¼against) (N ¼ 3903) 47% <0.001 e
a
p-value (Pearson’s c2).

seasonal flu in 2008), and covariates which were exclusively
correlated to attitudes toward H1N1 vaccine (perception of one’s
household’s financial situation, reporting recent verbal/psycho-
logical violence, month of data collection).
When modelling attitudes toward vaccination in general, the
likelihood ratio test did not reject the hypothesis that attitudes
toward the H1N1 vaccine was an exogenous covariate (c2 ¼ 0.32,
p ¼ 0.570). Accordingly, a simple logistic model was computed
(see Table 2). On the contrary, when modelling the attitudes
regarding H1N1 vaccine, the likelihood ratio test rejected the
hypothesis that opposition to vaccination in general was an
exogenous covariate (c2 ¼ 3.84, p ¼ 0.05). This implied that the
coefficient estimated for this covariate was biased, and could
overestimate or underestimate its ‘real’ effect. This endogeneity
probably came from an uncontrolled confounding variable that
affected both the outcome variable (opposition to the H1N1
vaccine) and separately affected the covariate (opposition to
vaccination in general).
6 P. Peretti-Watel et al. / Social Science & Medicine 108 (2014) 1e9

Table 2 Table 3
Factors associated with negative attitude toward vaccination in general, logistic Factors associated with negative attitude toward H1N1 vaccination, logistic
regression (France 2009e2010, INPES, N ¼ 9480). regression (France 2009e2010, INPES, N ¼ 9480).

Odds ratios [CI 95%] Odds ratios [CI 95%]

Gender: Gender:
- Female 0.82 [0.75; 0.90]*** - Female 1.54 [1.41; 1.69]***
- Male (ref.) -1- - Male (ref.) -1-
Age 1.00 [0.98; 1.01]ns Age 1.04 [1.03; 1.06]***
Age2/100 1.03 [1.01; 1.05]** Age2/100 0.94 [0.93; 0.96]***

Educational level: Educational level:

- No diploma (ref.) -1- - No diploma (ref.) -1-
- Below high-school graduation 0.71 [0.63; 0.80]*** - Below high-school graduation 1.41 [1.24; 1.60]***
- High-school, 1st university degree 0.55 [0.47; 0.63]*** - High-school, 1st university degree 1.52 [1.32; 1.76]***
- 3e4 years completed at University 0.46 [0.37; 0.56]*** - 3e4 years completed at University 1.27 [1.04; 1.57]*
- >4 years completed at University 0.38 [0.29; 0.48]*** - >4 years completed at University 0.96 [0.78; 1.25]ns

Equalized household income: Equalized household income:

- <900 V/month (ref.) -1- - <900 V/month (ref.) -1-
- [900e1500[/month 1.07 [0.95; 1.21]ns - [900e1500[/month 1.20 [1.06; 1.35]**
- 1500 V/month 0.88 [0.79; 0.99]* - 1500 V/month 1.06 [0.93; 1.21]ns
- Don’t know/refuse to answer 0.96 [0.80; 01.16 ns - Don’t know/refuse to answer 1.09 [0.91; 1.29]ns

Contact with family or friends during the previous 8 days: Perception of household’s financial situation:
- None 1.24 [1.10; 1.41]** - Comfortable (ref.) -1-
- At least one person (ref.) -1- - Fine 1.05 [0.92; 1.19]ns
- Manageable 1.33 [1.15; 1.54]***
Child(ren) under 4 in the household:
- Difficult/in debt 1.21 [1.03; 1.43]*
- None (ref.) -1-
- At least one 0.78 [0.67; 0.91]** Contact with family or friends during the previous 8 days:
- None 0.83 [0.73; 0.94]**
Screening test for hepatitis B or C:
- At least one person (ref.) -1-
- Never tested 1.18 [1.06; 1.31]**
- Tested at least once (ref.) -1- Victim of verbal/psychological violence during the previous 12 months:
- Yes 1.24 [1.11; 1.38]***
Up-to-date on vaccinations:
- No (ref.) -1-
- Yes 0.45 [0.40; 0.50]***
- No/don’t know (ref.) -1- Up-to-date on vaccinations:
- Yes 1.23 [1.10; 1.37]**
Vaccinated against seasonal flu in 2008:
- No, don’t know (ref.) -1-
- Yes 0.24 [0.21; 0.27]***
- No (ref.) -1- Respondents interviewed in:
- October/November -1-
Vaccinated against hepatitis B:
- December 1.18 [0.98; 1.36]ns
- Yes 0.78 [0.71; 0.87]***
- January 1.31 [1.14; 1.49]***
- No (ref.) -1-
- February 1.40 [1.22; 1.61]***
Attitude toward H1N1 vaccine: - March 1.37 [1.18; 1.60]***
- Did not report opposition to H1N1 vaccine (ref.) -1- - April 1.22 [1.04; 1.43]*
- Not favourable to H1N1 vaccine 2.03 [1.85; 2.22]*** - May/June 0.86 [0.73; 1.03]ns

CI95%: confidence interval (95%). Attitude toward vaccination in general:

***,**,*, ns: respectively statistically significant at p < 0.001, p < 0.01, p < 0.05
thresholds, not significant (Wald’s c2).
In order to compute an unbiased effect for opposition to vacci-
nation in general, we first modelled it with common and specific
covariates. We then computed the corresponding estimation (for
each respondent, we computed the probability of expressing a
negative attitude toward vaccination in general). Finally we used
this estimation as a covariate when modelling opposition to H1N1
vaccination (see Table 3).
3.4. Opposition to vaccination in general and the H1N1 vaccine:
multivariable analyses
After adjustment for other covariates, females were less likely to
oppose vaccination in general (OR ¼ 0.82) (see Table 2). Such op-
position decreased as educational level increased (OR ¼ 0.38 for the
highest educational level). It was less frequent among respondents
with high incomes (OR ¼ 0.88), but increased with age. Opposition
to vaccination in general was also associated with social isolation
(reporting no recent contact with family or friends, OR ¼ 1.24) and
having been tested for hepatitis B or C (OR ¼ 1.18). On the contrary,
having (a) child(ren) under 4 in the household and immunization
history were inversely associated with opposition to vaccination in
general. Finally, after adjustment for other covariates, opposition to
Estimated probability P (‘not favourable’) 1.83 [1.68; 1.99]**
CI95%: confidence interval (95%).
***,**,*,ns: respectively statistically significant at p < 0.001, p < 0.01, p < 0.05
thresholds, not significant (Wald’s c2).
the H1N1 vaccine remained a strong predictor of opposition to
vaccination in general (OR ¼ 2.03).
The profile of opponents to the H1N1 vaccine was quite different
from the profile of those opposed to vaccination in general (see
Table 3). Opposition to the H1N1 vaccine was more frequent among
females, respondents with a low/intermediate educational level
(high-school or 1st university degree: OR ¼ 1.52), those with an
intermediate EHI (900e1500 Euros/month: OR ¼ 1.20) and those
who perceived their household financial situation as “manageable”
(OR ¼ 1.33). In terms of age, we found an inverted U-shaped rela-
tionship: opposition to the H1N1 vaccine increased until age 38 and
then decreased. Isolated people were less likely to express such
opposition, while victims of verbal/psychological violence were
more likely to do so, as were respondents who reported being up-
to-date on vaccinations and those who were interviewed between
January 2010 and April 2010. Finally, after adjustment for other
covariates, the estimated probability of opposing vaccination in
general was still a significant predictor of opposition to the H1N1
vaccine.
 P. Peretti-Watel et al. / Social Science & Medicine 108 (2014) 1e9
4. 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: op-
position 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 35e49 and those with
an intermediate SES. Results also differed regarding indicators of
social vulnerability, proximity to preventive medicine and vacci-
nation history. Regarding our second aim, multivariable analysis
tackling the endogeneity issue suggested that the relationship be-
tween both kinds of opposition to vaccination was bidirectional:
opposition to vaccination in general was a significant predictor of
opposition to the H1N1 vaccine, and vice-versa.
4.1. Limitations of the present study
Before discussing our results, we must acknowledge several
limitations of our study. First, despite the fact the announcement
letter describing the survey and requesting participation did not
give any details about the topics to be investigated, people who
opposed vaccination were more likely to distrust public author-
ities, and thus were perhaps more prone to refuse to answer a
survey carried out by a national health institute. Second, as with
any survey based on self-report, our data are subject to social
desirability bias and recall bias, especially regarding vaccination
(as various immunization campaigns are heavily promoted by
public authorities heavily). Third, the way we measured attitudes
toward vaccination in general and the H1N1 vaccine were not
homogeneous, as respondents categorized as opponents to the
H1N1 vaccine had to first respond “yes” to the question “are you
not favourable to certain vaccines in particular?” and then
mention H1N1 unprompted. Similarly, we did not directly mea-
sure proximity to preventive medicine, but we relied on untested
proxies. Finally, and this is probably the most important limitation
of the present study, our data did not allow us to directly test the
two interpretations discussed in the introduction section above.
We only tested their implications regarding the socio-
demographic and socioeconomic profiles associated with atti-
tudes toward vaccination. Of course, other interpretations of our
results are still possible. A more direct and in-depth analysis is
required: further research should investigate opponents’ motives
as well as their attitudes toward health authorities and the
pharmaceutical industry.
4.2. Two distinct but highly correlated attitudes toward vaccination
In France, opposition to vaccination in general reached similar
levels in 2000 (9%) and 2005 (10%) (Baudier and Léon, 2008) before
the dramatic 2010 increase observed in the present study. Of
course, such opposition may have also fluctuated over time be-
tween these survey years. In our study, after adjustment for atti-
tudes toward the H1N1 vaccine, attitudes toward vaccination in
general did not vary across time between October 2009 and June
2010. This suggests that, during this narrow time window, varia-
tions in opposition to vaccination in general were mainly, if not
only, due to the H1N1 episode. Moreover, in both bivariate and
multivariable analyses, negative attitudes toward vaccination in
general remained significantly and negatively correlated with
proximity to preventive medicine and vaccination history.
Conversely, reported negative attitudes toward the H1N1 vac-
cine appeared to be quite specific. Indeed, after adjustment for
7
attitudes toward vaccination in general, negative attitudes
expressed toward the H1N1 vaccine remained time-varying
(reaching a peak between January and March 2010). Furthermore,
they were no longer correlated with proximity to preventive
medicine and vaccination history (in previous studies, seasonal
influenza vaccination was found to be a strong predictor of atti-
tudes toward the H1N1 vaccine, see for example Schwarzinger
et al., 2010; Gidendil et al., 2012), except for immunization status.
Unexpectedly, up-to-date participants were more likely to oppose
the H1N1 vaccine.
Attitudes toward vaccination in general and toward the H1N1
vaccine specifically remained strongly correlated with each other,
in both bivariate analysis (including for each monthly subsample)
and multivariable analysis. In other words, previous attitudes to-
ward vaccination in general shaped public reaction to the H1N1
vaccine but, reciprocally, the 2009/2010 H1N1 episode undermined
the public’s attitude toward vaccination in general. Further
research is needed to investigate the long-term consequences of
the H1N1 episode, as few studies have documented the impact of
this episode on attitudes and behaviours toward vaccination, spe-
cifically in terms of seasonal influenza vaccination (Brandt et al.,
2010; Guthman et al., 2012). Further research should also deter-
mine whether the increase in opposition to vaccination in general
that occurred during the H1N1 episode decreased or persisted
afterwards.
4.3. Opposition to vaccination in general: unfounded fears
expressed by people with a low socioeconomic status?
We found that opposition to vaccination in general was more
frequent among males, older and isolated respondents, and those
with lower educational and income levels. These results are
consistent with previous studies dealing with vaccination-related
attitudes and behaviours, and more generally they also illustrate
the ‘societal inequality effect’ found in other risk perceptions
studies for various variables except gender (as we expected a
stronger opposition among women). Our results support the “un-
founded fears expressed by low-SES people” assumption: negative
attitudes expressed toward vaccination in general may reflect
misinformation, ignorance and perceived vulnerability. More
generally, these results illustrate the potential role of cognitive
variables (such as attitudes) in mediating SES differences in health
behaviours (Wardle et al., 2004): “poor people” may “behave
poorly” because of inadequate cognitions (Lynch et al., 1997). Thus
prevention campaigns targeting unfounded fears or inadequate
cognitions could contribute to reduce the public health priority of
health inequalities in infectious diseases (Semenza et al., 2010).
Nevertheless, the success of such campaigns is not at all guaran-
teed, as older and less-educated people are also more likely to
consider they are already well-informed on vaccination issues, at
least in France (Baudier and Léon, 2008).
Finally, our results also suggest qualifying the “unfounded fears
expressed by low-SES people” hypothesis, as we found that people
who may have had “legitimate concerns” toward the H1N1 vaccine
were more likely to oppose vaccination in general, and such a
phenomenon may result in a blurring of this low-SES people
profile.
4.4. Opposition to the H1N1 vaccine: a typical feature of middle-
class healthism?
Opposition to the H1N1 vaccine was more frequent among
women, among respondents aged 35e49 and those with inter-
mediate educational and income levels. This characterization
echoes the results of previous studies (Chanel et al., 2011, for the
8 P. Peretti-Watel et al. / Social Science & Medicine 108 (2014) 1e9
gender effect; Sypsa et al., 2009, for age and gender effects; Raude
et al., 2010; Schwartzinger et al., 2010, for gender and education
effects). The tendency of women to express “legitimate concerns”
towards H1N1 vaccination is one of the more striking observations
in our study. One possible interpretation of this gender effect is
that, according to traditional gender roles in the family, women are
expected to manage children’s health, thus they may spend more
time and energy struggling with vaccination issues, balancing the
risks and benefits of each vaccination.
With respect to indicators of social vulnerability, we found
mixed results, as isolated people were less likely to oppose the
H1N1 vaccine, while those who reported verbal/psychological
violence were more likely to do so. This pattern of results clearly
departs from the “unfounded fears expressed by people with a low
socioeconomic status” assumption, yet it does not fit the competing
hypothesis either (expecting a positive correlation between oppo-
sition to this vaccine and SES).
However, according to Greenhalgh and Wessely (2004),
commitment to ‘healthism’ is typical of middle-aged members of
the educated middle-classes, who are prone to try alternative
medicines and to seek information about health and illness online.
They are also prone to distrust science and medicine, to express
concerns about ‘unnatural’ substances and ‘manufactured’ risks
(including crises associated with vaccines). This description fits the
socio-demographic and socioeconomic profile of opponents to the
H1N1 vaccine in our study. Moreover, in previous studies, the use of
alternative medicine was shown to be predictive of negative atti-
tudes toward vaccination (Salmon et al., 2005; Jessop et al., 2010),
and people who sought information online were found to be less
likely to accept the H1N1 vaccine (Chanel et al., 2011; Walter et al.,
2012).
4.5. ‘Risk society’, scientific knowledge and middle classes
The ‘risk society’ is characterized by the feudalization of scien-
tific knowledge: initially used to debunk superstitions, scientific
scepticism has been extended to science itself, resulting in
increased controversy opposing competing scientific in-
terpretations, and now those who oppose ‘legitimate’ science are
scientifically armed themselves (Beck, 1992; Douglas, 1992). From
this perspective, regarding vaccination the Internet acts as a ‘Pan-
dora’s box’, releasing scientific-like arguments that challenge the
health authorities’ discourse (Kata, 2010).
But why would the middle-classes embrace such arguments?
Bourdieu’s theory of class distinction provides one possible
explanation: in order to have their revenge on the dominant
culture the educated middle-classes tend to use the cultural
skills transmitted by the education system to endorse and pro-
mote anti-establishment views, including anti-vaccination
sentiment (Bourdieu, 1984). Another explanation lies in the
meaning of educational attainment: the “socialization” view
argues that education provides cognitive skills but also transmit
to students the attitudes and orientations of the “official cul-
ture” (Phelan et al., 1995). From this point of view, high aca-
demic achievement should be positively associated with both
the ability to recognize ‘legitimate’ science among competing
arguments, and the propensity to support it. Going back to
Beck’s argument, one would expect an inverted U-shaped rela-
tion between educational level and the sensitivity to contro-
versial ‘manufactured risks’: when compared with less educated
people, more educated individuals would be more equipped to
perceive these risks and more willing to express concerns about
them. Instead individuals with the highest educational levels
would be more likely to embrace the views of legitimate science
and deny those risks.
5. 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 pro-
files 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 reflecting ignorance
or misinformation. Communication alone will probably not be
enough to dissipate their hostility to vaccination as some consider
themselves already well-informed, while others would consider
official information with scepticism.
Acknowledgement
The French National Institute for Prevention and Health Edu-
cation (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).
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2014.02.035.
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