How Social Norms Can Diffuse through Social Networks: A Study of Childhood Vaccination Attitudes and Norms in Varanasi, India

Abstract Background Childhood immunization rates in the urban slums of India are suboptimal. Rapid urbanization is associated with decreased connection to government resources and fewer social interactions between neighbors. The role of social capital in the dissemination of vaccine information is understudied, particularly in this urban slum context. This research explores the social networks of caregivers in Varanasi, India with an eye toward the connection between network structures and the development of social norm networks related to childhood immunization. Methods We performed a social network analysis for community detection to visualize the social structure that may influence normative beliefs around childhood immunization. We surveyed 2,058 caregivers living in slum areas of Varanasi, India about childhood immunization practices. Respondents also provided the names of three close contacts with whom they had discussed childhood immunization. We created an index to measure participants’ adherence to descriptive norms and another one to measure their adherence to injunctive norms related to childhood immunization. We then used Gephi software to visualize and analyze the social networks of all respondents and the norm networks based on participants’ strength of adherence to descriptive and injunctive norms. Results The analysis uncovered a narrow network of influence comprising mostly of distant and immediate family members, which may speak to a lack of community development in the urban areas we surveyed. The lack of interaction within the broader community – friends, and neighbors, among others - may have implications regarding vaccine intentions, vaccine hesitancy, and beliefs about vaccine safety. Our study of these norm networks indicates caregivers hold strong beliefs regarding childhood immunization, but for half of those in this study, normative beliefs were not as strong. Conclusions Understanding social networks and norms is important for encouraging childhood immunization in low-and middle-income countries. Close-knit social networks hold the potential to influence beliefs about childhood immunization, which may impact the role of public health, state, or government-sponsored communication that might promote greater engagement in childhood immunization efforts. We recommend that healthcare practitioners go beyond an individual-to-network model to consider a network-to-network model of influence.