Honor culture appears to shape flu vaccine decisions in opposite ways across two countries

People who strongly identify with cultural values emphasizing personal strength and reputation may be less likely to get a flu shot—unless those values center on family protection. A new study published in Current Research in Ecological and Social Psychology finds that people who endorse “honor culture” values are more likely to believe they are invulnerable to illness, which is linked to lower rates of flu vaccination in the United States. However, in Turkey—where honor is more tied to family responsibility—these values were associated with higher vaccine uptake.

The research explores how honor culture, which emphasizes maintaining a strong and resilient public image, may interfere with or support preventive health behaviors depending on how those values are expressed. In the United States, this often takes the form of individual self-reliance. In other cultures, like Turkey’s, honor may be expressed through loyalty to family and collective well-being. The study tested whether people who value honor also tend to believe they are unlikely to get the flu—and how that belief influences their willingness to get vaccinated.

The flu vaccine is widely recommended for nearly all individuals over six months of age. Vaccination helps prevent serious illness and death, particularly in vulnerable populations like the elderly, young children, and people with chronic conditions. It also helps reduce the spread of the virus in the broader population. Despite this, many people choose not to get vaccinated. Past research has linked this to concerns about vaccine safety, distrust of government or health institutions, political ideology, and the belief that they are not at risk of infection.

The idea that healthy individuals don’t need vaccines is often rooted in a sense of personal invincibility. Some people believe they have strong immune systems or live healthy lifestyles that eliminate the need for vaccination. These beliefs are especially prominent in cultures or individuals that prize toughness and self-reliance, traits that can be central to what researchers call “honor norms.”

Cultures of honor emphasize the importance of maintaining one’s social reputation, often by demonstrating strength and resilience while avoiding actions that may signal weakness. This can apply to both men and women, though in different ways—such as masculine expectations of physical toughness or feminine expectations of purity and loyalty. While often discussed in relation to aggression or conflict, honor culture has also been shown to influence health behaviors. For example, past studies found that people who endorse honor norms are less likely to seek help for mental health issues or undergo certain medical screenings, fearing that it might undermine their image.

“We were initially intrigued by flu vaccine uptake and how, because of public perception of it being a low-risk illness, people so easily write it off,” said study author Stephen Foster, an associate professor at Penn State York. “Those who endorse honor concerns have been found to be really quick to avoid certain health behaviors, so we figured that if this was the case for the flu, they may be more likely to dodge the flu shot as well. A surprising amount of folks die from the flu, so it is important we figure out the reasons why people don’t get their flu shot and contribute to community health.”

The new research included three studies. The first involved 965 undergraduate students from a university in the southern United States—a region widely considered to endorse honor values. Participants answered questions about their attitudes toward honor, their beliefs about vulnerability to the flu, and whether they had received a flu shot during the previous flu season.

The results showed that individuals who strongly endorsed honor values were less likely to have received a flu shot. This was partly explained by their belief that they were not at risk of getting the flu. In statistical terms, the researchers found that honor values were significantly linked to a sense of invulnerability, which in turn predicted lower vaccination rates. This pattern held for both men and women. The findings suggest that in a U.S. context, where honor is tied to self-reliance and toughness, individuals may avoid vaccination to preserve an image of strength.

In the second study, researchers tested whether these findings would replicate in another honor-oriented culture with a more collectivistic orientation. The study surveyed 794 participants from Ordu University in Turkey. As in the U.S. sample, honor endorsement was linked to greater feelings of invulnerability to the flu. However, in contrast to the U.S. sample, people with stronger honor values were actually more likely to get vaccinated. This suggests that in Turkey, where honor is more connected to group obligations and protecting family, vaccination may be viewed as a responsible and honorable action.

The third study analyzed data at the state level across the United States. Using publicly available data on flu vaccine uptake and flu-related mortality during the 2021–2022 flu season, researchers compared honor-endorsing regions (typically southern and western states) with non-honor regions (northern and eastern states). They also controlled for other relevant factors, including state-level political conservatism, rurality, racial demographics, and healthcare access.

The analysis showed that honor regions had significantly lower flu vaccination rates than non-honor regions, even after accounting for other influences. There was also a moderately higher rate of flu-related mortality in these honor regions. Although the overall direct link between honor region and flu mortality was not statistically significant, an indirect analysis found that honor culture’s association with higher flu mortality could be explained by lower vaccine uptake.

“The links with regional mortality rates surprised me somewhat, only because you truly aren’t exposed to much flu mortality in news media here in the United States,” Foster told PsyPost. “So, I guess I still had some doubts about whether vaccine hesitancy would really be tied to mortality outcomes in this context, but it appears that is the case.”

Together, these three studies suggest that the influence of honor culture on flu vaccine behavior depends on how honor is expressed within a particular cultural setting. In the United States, where honor emphasizes individual strength and toughness, perceived invulnerability to illness leads people to avoid vaccination. In contrast, in Turkey, where honor involves protecting and supporting the family, those same cultural values may actually encourage people to get vaccinated.

“Those higher in honor concerns, which often center around themes of self-reliance and shows of strength, are more likely to perceive themselves as invulnerable to the flu, but the evidence suggests that this only leads to lower flu vaccine uptake in individualistic cultures like the United States,” Foster explained. “In a more collectivist culture like Turkey, that perceived invulnerability doesn’t translate into lower vaccine uptake, and honor is actually linked with higher uptake. On the average, those concerned with their honorable reputations here in the United States may not be getting their flu shot, whereas that effect could be reversed in Turkey.”

The authors note that the concept of perceived invulnerability could stem from either genuine beliefs or self-presentation. It’s possible that people who endorse honor norms genuinely believe they are unlikely to get sick. But it’s also possible that they simply want to appear strong in the eyes of others. Either way, the behavior—vaccine avoidance—remains the same.

One implication of this research is that public health messaging should be tailored to different cultural contexts. In regions where honor is tied to self-reliance, promoting vaccination as a way to protect others may be more effective than emphasizing personal health. Messaging strategies that appeal to loyalty, responsibility, and protecting family members could encourage vaccine uptake even among those who see themselves as strong or invulnerable.

But the study, like all research, includes some caveats.

“This research is cross-sectional, so we can’t talk about causal effects here, although cultural values are often argued to fall at the beginning of the causal chain in these cases,” Foster noted. “We should also remember that perceived invulnerability is just what people are endorsing on a questionnaire — it is hard to know how they actually feel (as opposed to what they are choosing to report) about the flu unless some really comprehensive qualitative work was to be done.”

“Ultimately we want to try and use this information to target honor-related beliefs in intervention programs. There are tons of facets of honor that have unique impacts on health outcomes, so the first step is identifying which honor facet is being threatened by a health behavior then using that information to guide intervention strategies.”

“We need more larger-scale cross-cultural work like this,” Foster added. “A few terrific labs in Europe and Asia have done a great job looking across nations, like Mediterranean nations for example, and we should definitely be looking to do similar things when we test these effects in the United States as well. Otherwise we run the risk of honor research in the U.S. being quite isolated, which prevents us from seeing the full picture of how these concerns actually impact folks around the world, and may give us a false image of what honor really is.”

The study, “Differential effects of honor ideology on flu vaccine uptake in the United States and Turkey,” was authored by Stephen Foster and Pelin Gül.