The current paper investigates the

The current paper investigates the association between contextual state-level generalized trust and individual 2009 A(H1N1) pandemic immunization in the American states. Some prior studies have investigated the association between social capital/generalized trust and immunization. To start with Ronnerstrand (2013) found an association between two aspects of trust – generalized trust and trust in health care – and intentions to accept vaccination against the 2009 A(H1N1) in Sweden. Jung and colleagues found that the degree of neighborhood social capital mediated the association between 2009 A(H1N1) pandemic knowledge among parents and immunization acceptance for their children (2013). Nagaoka and colleagues investigated the association between two measures of contextual social capital – voting rate and volunteer rate – and uptake of a measles-containing vaccine. They found that the voting rate was associated with higher levels of immunization coverage rates in large municipalities in Japan (2012). Chuang, Huang, Tseng, Yen, and Yang (2015) found that social capital might influence the response to influenza pandemic in Taiwan, for example the intention to receive a vaccine. Social capital has also been linked with the substantial state-level variation in A(H1N1) immunization coverage rates in the American states. In a cross-sectional, ecologic study, an association between three measures of contextual social capital and state-level immunization uptake was found (Rönnerstrand, 2014). All three contextual state-level social capital measures – Putnam\'s social capital index, contextual generalized trust, and volunteer rate – were very strongly positively correlated with immunization coverage rates. In a regression model including the confounders – state-level health care spending per capita, state population, nk1 receptor antagonist per square mile, and median age in the American states – the association between contextual social capital and immunization coverage rates was found to be persistent and strong. Similarly to Rönnerstrand (2014) the present study investigates the link between U.S. state-level contextual social capital and immunization against the 2009 A(H1N1) pandemic. But contrary to the above-mentioned study, by making use of multilevel statistical procedures, the aim of this paper is to investigate the association between contextual generalized trust and individual immunization against the A(H1N1) pandemic. It is hypothesized that contextual state-level generalized trust is associated with individual acceptance of vaccination against the 2009 A(H1N1) pandemic, also when controlling for individual-level and state-level confounders. Although the link between social capital and health is well studied, there is much less knowledge about the causal pathways linking social capital with health (Kim et al., 2008). Several potential causal pathways have been suggested. Scholars separate between vertical, policy-oriented pathways and behavioral-mediated pathways. The former of these pathways links social capital with health through civic engagement and participation in the political process. Behavior-mediated pathways include rapid circulation of health information, healthy norms, lower crime rates, emotional support within a network, and control over deviant health behavior in the community (Kawachi et al., 1999; Kawachi & Berkman, 2000; Kim et al., 2008). With regard to pandemic vaccination acceptance in general (Zijtregtop et al., 2009) and of the 2009 A(H1N1) flu immunization in particular (Maurer et al., 2010), it has been argued that knowledge of and information about disease and vaccination from family, friends, and co-workers increased the probability of pandemic immunization acceptance. Hypothetically, information about pandemic influenza and the possibility to vaccinate was more easily circulated in states characterized by high levels of trust. In turn, information about the pandemic and vaccinations was presumably a factor stimulating vaccination acceptance in those high-trusting states.