# Motivation and emotion/Book/2021/COVID-19 vaccine motivation

* Multimedia presentation (3 min)

## Overview

Worldwide efforts to minimise the harm caused by viruses like COVID-19 have focused on the development and mass distribution of vaccines (Freeman et al, 2021; Syed Alwi et al, 2021). Mass vaccination programs rely on widespread population uptake (While, 2021), but the challenge these programs face is understanding the many reasons why people may be acceptant or hesitant towards COVID-19 vaccines. In response, the Covid-19 Behavioural Science and Disease Prevention Taskforce (The Covid Taskforce) developed a model that suggested (among other things) several reflective and automatic processes which influence vaccine uptake (British Psychological Society, 2021). This chapter examines those defined processes, including their focus and relevant theories that underpin them. This chapter also outlines how those processes can explain both vaccine acceptant and vaccine hesitant viewpoints.
* Reflective Exercise
* Consider the woman in Figure 1. What do you think are her reasons for getting a COVID-19 vaccination? Do you think she would feel relief getting the vaccine, or is getting the vaccine a way for her to avoid fear? How much influence do the people she might identify with have on her decision? Finally, consider the reasons for your vaccine motivations as you go through this chapter.
* Focus questions:
* What are considered 'reflective motivational processes'?
* How do reflective motivational processes affect vaccine motivation?
* What theories can explain reflective motivational processes?
* What are considered 'automatic motivational processes'?
* How do reflective automatic processes affect vaccine motivation?

## Reflective motivational processes

The Covid Taskforce wrote that attitudes and beliefs are important reflective motivational processes affecting vaccine motivations (British Psychological Society, 2021). Attitudes and beliefs reflect people weighing the benefits and downsides of vaccination, beliefs of vaccinations on health outcomes, and trust in vaccines and their promotors. Differences in attitudes and beliefs mean that two people viewing the same situation can interpret that situation in very different ways.
The Covid Taskforce also wrote that identity is a key reflective process in vaccine motivation (British Psychological Society, 2021). A person's identity is influenced by their social environments, and this includes identities involving vaccine acceptance or hesitance. When faced with uncertain times and situations, a person holding a particular identity will act in ways that maintains and protects their identity (Abrams, Lalot, & Hogg, 2020).

### Regulatory focus theory

Regulatory focus theory (RFT) proposes that a person will aim for a goal based on one of two mindsets: promotion or prevention (Higgins, 1998). People employing a promotion mindset employ goal-accomplishing strategies and frame motivations by future gains. Conversely, people employing a prevention mindset employ loss-preventing strategies and frame motivations by preserving what currently exists. Outlined in Table 1, Higgins (1998) wrote that motivation increased as people pursued goals with strategies that aligned with their regulatory mindset.
Table 1.
Elements of the promotion and prevention mindsets (adapted from Higgins, 1998)
| | Promotion mindset | Prevention mindset |
| Concerns | accomplishments, hopes, aspirations | safety, responsibilities, obligations |
| Strategic inclination | approach matches towards desired end-state (goal) | avoid mismatches to desired end-state (goal) |
| States | eagerness to attain advancement and gains | vigilance to assure safety and non-losses |
| Outcomes | presence and absence of positive outcomes | presence and absence of negative outcomes |
Research indicates that prevention-focused people are more likely to positively correlate with vaccine acceptancy. People with prevention mindsets are more likely to emphasise anticipated regrets over not getting influenza vaccinations (Leder et al., 2015) or HPV vaccinations (Kim et al., 2020), and vaccine acceptance positively correlates with the strength of the prevention-focused mindset (Kim et al, 2020). Promotion mindsets can result in increased vaccine acceptance, but not to the same degree as prevention-focused mindsets (Kim et al., 2020; Leder et al, 2015; Ludolph & Schulz, 2015; ). Prevention-focused people exhibit greater vaccine acceptance because of regulatory fit, which a person experiences when their goal pursuit aligns with their mindset (Ludolph & Schulz, 2015). Most vaccination messages carry a prevention message, which more strongly connects with prevention-focused people (Kim et al, 2020; Ludolph & Schulz, 2015).

### Attitudes and beliefs about vaccinations

A person's vaccine attitudes and beliefs can be influenced by their trust of the vaccine and/or the bodies that promote said vaccine. Factors demonstrating increased vaccine acceptance include trust in advice from state medical bodies (Fedele et al, 2021) and confidence in medical providers (Manthiram et al., 2014). A generalised fear of catching a vaccine-preventable disease can also increase vaccine acceptance (Manthiram et al., 2014). Conversely, vaccine hesitant people will question the safety and efficacy of vaccines, or question the motives of health bodies overseeing vaccinations (Fedele et al, 2021; Syed Alwi et al, 2021). Vaccine mistrust can also correlate with political beliefs (Thelwall et al., 2021) or scepticism towards the interests of companies that produce vaccines (Fedele et al, 2021).

#### Health care workers

Vaccine acceptance or hesitancy can also vary between individuals, even in fields where people might assume otherwise, like health care workers (as seen in Figure 2). Verger and his colleagues (2020) found that while most French-speaking health care workers would recommend COVID-19 vaccinations to their patients, a significant proportion expressed reluctance to get vaccinated. These workers expressed concerns that the safety of vaccines developed in an emergency could not be guaranteed; some also expressed distrust in government agencies. Similar results were found in health care workers in America (Manthiram, Edwards, & Hassan, 2014) and in the UK (While, 2021), and discussions suggested building and maintaining confidence in vaccine safety and efficacy was key to disseminating vaccine acceptance in the wider community.

#### Parents

Studies on parental attitudes towards COVID-19 vaccination indicate vaccine hesitancy is a significant decision-making factor. Parents expressing vaccine hesitancy commonly cite perceived health risks and concerns about side effects of the vaccines (Fedele et al, 2021), or beliefs that perceived health risks associated with COVID-19 vaccines could negatively affect their ability to care for their children (Dror et al, 2020). This vaccine hesitancy does not equate to hesitancy towards other vaccinations, but transference of acceptance for influenza vaccines to COVID-19 vaccines is mixed, with studies suggesting a positive effect (Dror et al, 2020; Oster, 2018), or no effect (He et al, 2021). Evidence from other disease outbreaks also suggests that outbreaks result in increased vaccine acceptance, but vaccination rates fluctuate pre- and post- pandemic. Emily Oster’s (2018) study of American parents during outbreaks of pertussis found a positive relationship between the outbreak of a pandemic and vaccination rates; she suggested that the increase in vaccination rates was attributable to a mix of both rational perspectives and non-rational acting.

### Social identity theory

Social identity theory (SIT) (as depicted in Figure 3) proposes that social groups consist of people with the same social identities and holds the same ideals and attributes (Hogg et al, 2004). Social identity is a salient and context dependent, both in the context of a situation and also in a form that the identity takes (Hogg et al, 2004). These groups identify themselves using prototypes, which Hogg et al (2004) describe as "fuzzy sets of interrelated attributes that simultaneously capture similarities and structural relationships within groups and differences between the groups, and prescribe group membership–related behavior"[explain?]. Importantly, these prototypes commonly describe hypothetical out-groups rather than real outgroups.
Group interactions are framed by the relationship between the in-group and other out-groups (Abrams, Lalot, & Hogg, 2020). As intergroup comparisons occur, differences in group behaviours are highlighted and emphasised to maintain the ingroup's uniqueness (Abrams, Lalot, & Hogg, 2020). By emphasising intergroup differences, people can reduce uncertainty and enhance their self identity (Hogg et al, 2004). Enhanced self-esteem and reduced uncertainty results in a person's social identity being satisfied and them continuing to identify within their group. People dissatisfied with their social identity will leave their ingroup and join or become subordinate to the outgroup.
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#### Social media and misinformation effects

The impacts of COVID-19 on people's motivation have resulted in widespread societal uncertainty and the inability to engage with people in face-to-face settings. As a result, people increasingly rely on smaller, insular social media groups to maintain their their social identities (Abrams, Lalot, & Hogg, 2020). People high in self-uncertainty become drawn to groups with clearly defined prototypes (Hogg et al, 2004), and will more actively change their identity to fit into their group's prototypes. People who appear to be highly prototypical in a group also appear to be more popular than low prototypical group members, resulting in people with high uncertainty increasing their efforts to maintain group prototypicality. These efforts also serve to further increase group cohesion through visible action (Hogg et al, 2004).
Social groups that hold vaccine hesitant or rejection ideologies will centralise and maintain that belief as part of the group's identity (Piltch-Loeb et al, 2021; Thelwall et al, 2021). Thelwall and his colleagues (2021) found that 79% of Twitter threads made between March and December 2020 with specific keywords (coronavirus, “corona virus”, covid-19, and covid19) expressing vaccine hesitancy were created by people who also expressed right-wing views, fear of a 'deep state', or belief in conspiracy theories - beliefs that can be connected to levels of certainty and self-esteem. These people were also more active in sharing misinformation with each other, and the effects of their sharing was represented in the formation of Twitter echo chambers that further amplified vaccine rejection beliefs (Thelwall et al, 2021).
* Reflective Exercise
* As the COVID-19 pandemic continues, peoples' needs to stay connected with their peers can result in motivational changes that may only become apparent with reflection and hindsight. Think about your usage of social media. If you use social media, who do you primarily communicate with? If the topic of vaccination beliefs has come up, how has discussion within the group taken shape? Have you noticed any changes in the 'activity' of the group during such discussions? Alternatively, has your social media group actively avoided discussions of vaccination beliefs, and what group ideologies affect this decision? Finally, have you noticed any changes in how you feel about social media when communicating with the groups you associate with?

#### Individualist versus collectivist identities

Research on correlations between superordinate social identities (e.g. nationality) and vaccine acceptance or hesitancy fails to demonstrate a connection[factual?]. Instead, evidence suggests that individuals or groups with individualist identities will be more likely to engage in vaccine hesitant behaviours, while individuals or groups with collectivist values will more likely hold vaccine acceptant identities[factual?]. Chinchih Chen and colleagues (2021) compared the amount of time spent at home during lockdown orders between 111 countries, and further compared stay-at-home times between American and Chinese communities. They found no correlation between individualist or collectivist governments and the likelihood of those governments implementing lockdowns. Rather, they found that people residing in American states with very high individualist values tended to stay at home much less during lockdowns compared to both American states with high lockdown obedience, and with Chinese states. The researchers suggested that these results arose from individual and group behaviours, rather than people identifying as members of any superordinate identity.
Several factors potentially explain the connection between individualists and vaccine hesitancy. In the US, individualist values have increased as a response to ethnic diversity and a history of individualism as the historical cultural norm (Huynh & Grossmann, 2021). Generally, individualists favour extrinsic goals and rewards, act to reduce anxiety-provoking threats (Long, Quan, & Zheng, 2021), and seek achievements to distinguish themselves from their peers (Huynh & Grossmann, 2021). Finally, punishments for disobeying protective measures like lockdowns may be stricter in collectivist countries than in individualist countries, resulting in less[say what?] fear of breaking rules associated with COVID-19 protective measures (Chen, Frey, & Presidente, 2021).

## Automatic motivational processes

The Covid Taskforce wrote that automatic motivational processes like emotions and habits can serve as motivation for people to engage in a particular behaviour (British Psychological Society, 2021). One theory explaining emotional processes for vaccine uptake is protection motivation theory, where people assess the severity of a perceived threat and weigh their options for coping with their situation. Fear can also serve as a motivator, and research suggests that fear of catching a disease can be a motivating factor in vaccine acceptance (Rosa, Chuquichambi, & Ingram, 2020). Emotional motivators that have seen increased attention during the COVID-19 pandemic are fear of needles, and disgust sensitivity.

### Needle fear

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) categorises needle fear under blood-injection-injury (BII) phobia, which includes fear of excessive blood, needles (including fear of pain from needles), and/or invasive medical procedures (American Psychiatric Association, 2013). BII phobia symptoms fall into two stages: an increase in blood pressure and heart rate, typical of fight-or-flight responses, followed by a significant decrease in blood pressure and heart rate that results in fainting (Ritz, Meuret, & Ayala, 2010). BII phobia can affect significant proportions of a population, with Love & Love (2021) estimating that between 3-20% of the US population could suffer from needle fear. Given the symptoms and scope of needle fear, evidence consistently demonstrates a positive correlation between needle fear and vaccine hesitancy (Freeman et al, 2021; Love & Love, 2021).

### Disgust sensitivity

Disgust sensitivity towards pathogens is considered a defensive response to prevent contracting illnesses (Rosa, Chuquichambi, & Ingram, 2020), and measured as a person’s tendency to express disgust in response to potential pathogen sources (Clifford & Wendell, 2016). Disgust sensitivity can indicate vaccine acceptance or vaccine hesitant beliefs. Disgust tendency indicators for vaccine hesitancy include beliefs that vaccines cause autism, or are not safe or effective (Clifford & Wendell, 2016). Conversely, disgust sensitivity indicting vaccine acceptance relates to mask wearing - people wearing masks may trigger fear disgust, but can also increase feelings of trustworthiness and social desirability due to the impression of mask wearers being responsible and maintaining new social norms (Rosa, Chuquichambi, & Ingram, 2020).
Generalised vaccine hesitancy shows overlaps between disgust sensitivity and conservative ideology. American conservative values were positively associated with disgust sensitivity and negatively associated with disease avoidant attitudes like COVID-19 awareness (Kempthorne & Terrizzi, 2021). People demonstrating higher ratings of disgust sensitivity also demonstrated strong beliefs in purity and liberty, potentially viewing vaccines as something that violated their purity or liberty (Reuben et al, 2020). Clifford & Wendell (2016) suggested that vaccination represented a societal obligation, and vaccine rejection represented less of vaccine disgust and more of a disgust of the morals that vaccines represent.
* Reflective Exercise
* Consider the person in Figure 4. If you were in the same park as them, how would you feel? Would you feel safer being near this person because they were wearing a mask, or more cautious? Is the person wearing the mask someone who is likely to be vaccine acceptant because they are wearing a mask, or are they wearing a mask simply because they want to able to go outside? The way we feel when we perceive other people in a pandemic can inform us in some way of the motivations behind our own vaccine acceptance or hesitancy.

### Personal habits

Research on personal habits and vaccine acceptance or hesitancy suggests that a person’s personal care habits influence their willingness to get vaccinated. Early in the pandemic, preventative behaviours of social distancing, wearing masks, and hand sanitisation were identified as effective measures for preventing the spread of COVID and enforced as external motivators (Álvarez-Pomar & Rojas-Galeano, 2021). People who maintained these behaviours pre-vaccination were more likely to internalise them as personal habits post-vaccination, which then strengthened preventative behaviours within their wider communities (Yuan et al, 2021). A history of seasonal influenza vaccinations in adulthood has also been shown to have a positive effect on COVID vaccination (Verger et al, 2021).

## Conclusion

To understand motivations behind vaccine acceptance or hesitancy, motivations can be categorised into reflective and automatic processes. Reflective processes revolve around a person's attitudes, beliefs, and identity. Automatic processes concern a person's emotions and habits.
RFT proposes that people process goals by potential gains or avoiding losses, with studies showing prevention mindsets lead to higher vaccine acceptance. Attitudes towards vaccines are also influenced by factors such as trust in health bodies or vaccine efficacy. Attitudes within groups of people can differ, as shown by attitudes of health care workers and parents.
Social identity theory (SIT) proposes that a person's identity is shaped by memberships in social groups, group prototypes and dynamics, and intergroup relations. As people turn to insular social media groups to maintain their social identity, these groups can become highly prototypical. Social groups holding vaccine hesitant viewpoints share increased amounts of vaccine misinformation among members. People with individualist beliefs also express vaccine hesitancy compared to collectivists.
Research on emotions and habits focuses on specific fears related to vaccine beliefs: needle fear and disgust sensitivity. Needle fear can affect significant proportions of a population, and is associated with vaccine hesitancy. Disgust sensitivity focuses on fear about a disease and potential pathogen sources, and can be expressed by both vaccine acceptant and vaccine hesitant people. Finally, people with internalised personal habits about COVID-19 safety are more likely to be vaccine acceptant, as are people who regularly maintain flu vaccinations in adulthood.
Pick a response
Which of the following statements might indicate vaccine hesitancy in someone? Select any that apply.
I'm not sure if I can trust the people who make the vaccine.
I've had the flu shot before, what's another one?
I'd rather not be sick from the virus.
My friends aren't keen on getting the jab. :