Preventive Behaviors After the 2009 H1N1 Influenza Pandemic
Preventive Behaviors After the 2009 H1N1 Influenza Pandemic
This study provides important insights regarding racial/ethnic differences in the adoption of preventive behaviors related to hygiene, social distancing, and health care during the 2009 H1N1 influenza pandemic. Not all of these measures were recommended by public health authorities, but they reflect a selection of behaviors that members of the public adopted. Our central (uncontrolled) findings suggest that African Americans, Hispanics, and American Indians/Alaska Natives were more likely than whites to adopt most of these preventive behaviors. Compared with whites, Asians were more likely to adopt several social distancing measures and to talk to a health professional about 2009 H1N1 influenza, but their adoption of behaviors was otherwise similar to that of whites. Notably, none of the behaviors asked about in this poll are likely to be considered to be very burdensome, especially compared with behaviors related to workplace closure, and none were mandated by government. Thus, our study suggests receptivity in these racial/ethnic minority communities to adopting individual-level behaviors of this kind.
In contrast to other behaviors in this study, the primary analyses in this study show that racial/ethnic minorities were not more likely than whites to get the 2009 H1N1 influenza vaccine. Furthermore, African Americans were less likely than whites to get the seasonal flu vaccine. Our data do not identify disparities in 2009 H1N1 influenza vaccination rates between African Americans and whites as does another study, and it may be considered a success that racial/ethnic groups, such as American Indian/Alaska Native populations, received vaccines at a statistically equivalent rate to whites. However, the contrast between getting vaccinated and adopting other behaviors is nonetheless striking. The factors that motivate people in racial/ethnic minorities to adopt other preventive behaviors at rates greater than whites are not sufficient to overcome barriers to vaccination and may differ from those that motivate vaccination. Further, the overall vaccination rates are not high in any group, suggesting that barriers are prevalent across all racial/ethnic groups, even if the barriers are different. Public health officials should try to address underlying differences in motivation and barriers across racial/ethnic populations.
Factors that are considered primary reasons for vaccine-related disparities – socioeconomic status, demographic characteristics, access to health care, and attitudes – appear to play a role in racial/ethnic differences in the adoption of additional behaviors examined here, insofar as some racial/ethnic differences were eliminated once these variables were controlled for. However, many differences between racial/ethnic groups in the adoption of preventive behaviors persisted even after these controls, suggesting that other factors are likely playing a role in the differences between racial/ethnic groups. Literature from disaster preparedness suggests that differential trust in government and communication sources play a role in people's response to public health recommendations, particularly for racial/ethnic minorities. These factors may be important in the area of infectious disease emergencies as well and may partially explain racial/ethnic differences in response to H1N1. Other cultural and social factors that vary across racial/ethnic groups, including religious beliefs or health-related values, may also shape differences between racial/ethnic groups in the adoption of these measures. Future research is needed to explore these factors.
Several factors aside from race/ethnicity also appear to contribute to the adoption of many of the behaviors. These factors include health status (i.e., a higher risk of influenza complications) and gender, which were significant in the final models for a majority of behaviors. Moreover, attitudes toward the illness play a role in adoption of all behaviors, and perceptions of vaccine safety play a role in vaccine adoption. Finally, data suggest attitudes about the illness and the vaccine vary across racial/ethnic groups, indicating a need for public health officials to address attitudes in pandemic planning. Additional research to better understand the ways in which attitudes, including risk perceptions of the illness and vaccines, impact the adoption of preventive behaviors is warranted.
This study has limitations. First, the study was conducted in English, Spanish, and Mandarin, but not in other languages; thus, views of groups who speak other languages were not represented. Second, there was the potential for differential non-response bias across racial/ethnic subgroups that may not be fully addressed through weighting techniques; however, the magnitude of differences in non-response across racial/ethnic groups is likely small, and weighting corrections within the groups should render it unlikely; this accounts for the differences in reported behaviors between groups. Third, making multiple comparisons in a given analysis could, in theory, result in finding more statistically significant racial/ethnic differences than truly exist; however, the differences between racial/ethnic groups we did find are generally so large and repeated, so clearly across many groups, problems from multiple comparisons are unlikely to have played a meaningful role in the conclusions we draw from the data. Fourth, there were a small number of people who refused the questions about race/ethnicity, but they are unlikely to all have been of one race/ethnicity and to have different behavioral practices, and their absence from analysis is thus unlikely to have biased the results. Last, the variables we used as control measures may not fully account for the underlying construct. For example, health insurance and employment status may not fully measure access to vaccination, as they may not capture access to public health clinics. In such cases, these factors could play an even greater role in behavior adoption than we were able to evaluate in our study. As none of these limitations fundamentally alter the key findings of this study, results nonetheless provide direction for public health officials and others interested in increasing adoption of preventive measures during a pandemic.
Discussion
This study provides important insights regarding racial/ethnic differences in the adoption of preventive behaviors related to hygiene, social distancing, and health care during the 2009 H1N1 influenza pandemic. Not all of these measures were recommended by public health authorities, but they reflect a selection of behaviors that members of the public adopted. Our central (uncontrolled) findings suggest that African Americans, Hispanics, and American Indians/Alaska Natives were more likely than whites to adopt most of these preventive behaviors. Compared with whites, Asians were more likely to adopt several social distancing measures and to talk to a health professional about 2009 H1N1 influenza, but their adoption of behaviors was otherwise similar to that of whites. Notably, none of the behaviors asked about in this poll are likely to be considered to be very burdensome, especially compared with behaviors related to workplace closure, and none were mandated by government. Thus, our study suggests receptivity in these racial/ethnic minority communities to adopting individual-level behaviors of this kind.
In contrast to other behaviors in this study, the primary analyses in this study show that racial/ethnic minorities were not more likely than whites to get the 2009 H1N1 influenza vaccine. Furthermore, African Americans were less likely than whites to get the seasonal flu vaccine. Our data do not identify disparities in 2009 H1N1 influenza vaccination rates between African Americans and whites as does another study, and it may be considered a success that racial/ethnic groups, such as American Indian/Alaska Native populations, received vaccines at a statistically equivalent rate to whites. However, the contrast between getting vaccinated and adopting other behaviors is nonetheless striking. The factors that motivate people in racial/ethnic minorities to adopt other preventive behaviors at rates greater than whites are not sufficient to overcome barriers to vaccination and may differ from those that motivate vaccination. Further, the overall vaccination rates are not high in any group, suggesting that barriers are prevalent across all racial/ethnic groups, even if the barriers are different. Public health officials should try to address underlying differences in motivation and barriers across racial/ethnic populations.
Factors that are considered primary reasons for vaccine-related disparities – socioeconomic status, demographic characteristics, access to health care, and attitudes – appear to play a role in racial/ethnic differences in the adoption of additional behaviors examined here, insofar as some racial/ethnic differences were eliminated once these variables were controlled for. However, many differences between racial/ethnic groups in the adoption of preventive behaviors persisted even after these controls, suggesting that other factors are likely playing a role in the differences between racial/ethnic groups. Literature from disaster preparedness suggests that differential trust in government and communication sources play a role in people's response to public health recommendations, particularly for racial/ethnic minorities. These factors may be important in the area of infectious disease emergencies as well and may partially explain racial/ethnic differences in response to H1N1. Other cultural and social factors that vary across racial/ethnic groups, including religious beliefs or health-related values, may also shape differences between racial/ethnic groups in the adoption of these measures. Future research is needed to explore these factors.
Several factors aside from race/ethnicity also appear to contribute to the adoption of many of the behaviors. These factors include health status (i.e., a higher risk of influenza complications) and gender, which were significant in the final models for a majority of behaviors. Moreover, attitudes toward the illness play a role in adoption of all behaviors, and perceptions of vaccine safety play a role in vaccine adoption. Finally, data suggest attitudes about the illness and the vaccine vary across racial/ethnic groups, indicating a need for public health officials to address attitudes in pandemic planning. Additional research to better understand the ways in which attitudes, including risk perceptions of the illness and vaccines, impact the adoption of preventive behaviors is warranted.
This study has limitations. First, the study was conducted in English, Spanish, and Mandarin, but not in other languages; thus, views of groups who speak other languages were not represented. Second, there was the potential for differential non-response bias across racial/ethnic subgroups that may not be fully addressed through weighting techniques; however, the magnitude of differences in non-response across racial/ethnic groups is likely small, and weighting corrections within the groups should render it unlikely; this accounts for the differences in reported behaviors between groups. Third, making multiple comparisons in a given analysis could, in theory, result in finding more statistically significant racial/ethnic differences than truly exist; however, the differences between racial/ethnic groups we did find are generally so large and repeated, so clearly across many groups, problems from multiple comparisons are unlikely to have played a meaningful role in the conclusions we draw from the data. Fourth, there were a small number of people who refused the questions about race/ethnicity, but they are unlikely to all have been of one race/ethnicity and to have different behavioral practices, and their absence from analysis is thus unlikely to have biased the results. Last, the variables we used as control measures may not fully account for the underlying construct. For example, health insurance and employment status may not fully measure access to vaccination, as they may not capture access to public health clinics. In such cases, these factors could play an even greater role in behavior adoption than we were able to evaluate in our study. As none of these limitations fundamentally alter the key findings of this study, results nonetheless provide direction for public health officials and others interested in increasing adoption of preventive measures during a pandemic.