Reasons why people may refuse <scp>COVID</scp>‐19 vaccination (and what can be done about it)
Authors: Matthew J. Hornsey
Journal: World Psychiatry (2022)

The Vaccination Act of 1853, which mandated smallpox vaccination for infants in England, prompted the emergence of the Anti-Vaccination League, widespread street protests, and the appearance of several anti-vaccination journals. Various criticisms were levelled: that vaccines were unsafe; that vaccinations were “unchristian”; that the mandate was a violation of personal liberties. Conspiracy theories and misinformation abounded. When we reflect on vaccine hesitancy in the COVID-19 era, it is worth remembering that these sentiments are not new. What is relatively new is the systematic empirical exploration of the psychological mechanisms underpinning vaccine refusal: examination of Web of Science data suggests that 35% of the papers ever written on the psychology of vaccines were published since 2020. Also new are concerns that vaccine refusal presents a mental health challenge. Since the emergence of the pandemic and associated debates about mandating vaccination, there has been concern that vaccine hesitant people are being caught in a self-reinforcing cycle of mistrust, stigma, isolation, and psychological distress. Parallel to this, emerging data show that those with pre-existing mental disorders are disproportionately likely to die from COVID-191. In this context, mental health professionals are asking: why would people refuse COVID-19 vaccination, and what can be done about it? Here I explore three factors implicated in vaccine refusal – flawed risk appraisal, conspiracy theorizing, and ideology – and reflect on their implications for informing communication strategies. A curious aspect of the human mind is that we struggle to rationally appraise risk. Arguments such as “you have a one in a million chance of developing lethal blood clots if you take this vaccine” or “the risks of vaccinating are far lower than the risks of not vaccinating” require us to think analytically and dispassionately about risk. But our evolutionary history did not prepare us for a world of science, statistics and base rates. Rather, our minds are designed to appraise risk as a function of vivid events and narratives, processed emotionally2. Base rate statistics have surprisingly little impact in the face of dramatic “case rate” stories of otherwise healthy people whose lives have been ruined or lost because of adverse reactions to vaccines. These images and narratives are a stock strategy of the anti-vaccination movement, but also a common feature of mainstream news coverage of COVID-19 vaccines. In this context, it would be human nature to experience anxiety at the thought of taking COVID-19 vaccination, particularly among those of us who are predisposed to intuitive or experiential cognitive styles. Overlaid on this basic tendency, it is possible that clinical or subclinical issues can complicate people’s ability to objectively appraise risk. It has been speculated that certain mental health conditions – for example, blood-injection-injury phobia – might predispose people to feeling instinctive aversion to vaccinations3. Related to this, a large-scale survey found that participants’ levels of disgust or repugnance at the sight of anaesthetic needles or blood was predictive of vaccine hesitancy across 25 nations, much more so than their levels of education4. Attempts to reassure the population that vaccines are safe are further complicated when people dispute the validity of scientific messaging. For some, scientists, governments and drug developers are part of a cabal of vested interests who exaggerate evidence that vaccines are helpful and cover up evidence that vaccines can be harmful. One of the most powerful predictors of vaccine hesitancy is the conspiracist worldview: the notion that it is commonplace for groups of elites to conduct elaborate hoaxes on the public in near-perfect secrecy. Particularly in the West, a surprisingly large amount of variance in vaccine hesitancy can be accounted for by merely knowing whether people think that Princess Diana was murdered, or that 9/11 was an inside job4. When people have this worldview, messages that would normally be persuasive – for example, government assurances of safety and scientific consensus around effectiveness – can be inverted to be proof of a conspiracy. Unable to trust official messaging, these people may place implicit faith in messengers that mirror their distrust, such as elements of the wellness industry and some populist politicians5. It should be noted that there may be some sensible foundation to the mistrust, although in this case it is over-generalized to embrace objectively implausible conspiracy theories. It is common sense to argue that we should be vigilant to signs that vested issues have a corrupting influence on health care (the thick layers of independent regulation around vaccine development are testament to the fact that the health system shares that concern). It is also worthwhile remembering that there are traumatic historical examples of medical racism, that are circulated widely within certain communities while they debate the safety of vaccines. For members of society who feel protected by the system, it is easier to communicate that the system can be trusted than for people who feel marginalized by the system, which may be a reason why in some countries culturally and linguistically diverse communities have been the slowest to vaccinate against COVID-196. Finally, there is a convergence of evidence that ideological fac­­tors have shaped people’s willingness to embrace COVID-19 vaccines. For people who are committed to small government, eco­nomic progress, and individual freedoms (as are many conservatives), the regulatory response to a pandemic can be perceived as ideologically noxious. Faced with an aversive solution to the pandemic, conservatives may be motivated to instead question the COVID-19 science. In some countries such as the US, this ideological divide is one of the most recognizable phenomena of the COVID-19 era: although there are small pockets of vaccination resistance among the far left, conservatives report less intention to vaccinate than liberals overall7. Having been drawn into the algorithm that defines one’s political persuasion, the decision to vaccinate has become not just a reflection of what people believe, but also a way of signalling to others one’s political and ideological identities. Understanding the factors discussed above helps make sense of what, for many scientists and health professionals, is one of the most exasperating and difficult-to-understand features of the vaccination debate: facts are not enough. Merely repeating evidence has been a notoriously ineffective way of shifting attitudes among those who self-identify as anti-vaccination8. One reason for this is that people do not always behave like cognitive scientists, weighing up evidence before reaching a conclusion. Frequently, we behave more like cognitive lawyers, selectively exposing ourselves, critiquing, and remembering evidence that reinforces a conclusion that feels “right” for us. Successful communication requires deep listening and an attentiveness to the fears, worldviews and ideologies that might be motivating COVID-19 refusal9. Persuasion attempts that are responsive to these underlying “attitude roots” are more likely to be successful than those that sail above them with an exclusive focus on facts and data3. Finally, mental health professionals recognize as much as any­one the importance of communication that is non-stigmatizing and inclusive. Although the public face of the anti-vaccination movement sometimes seems strident and unworthy of empathy, community members who align with those views are frequently characterized by anxiety and uncertainty. There is the potential for negative feedback loops, where the vaccine hesitant feel misunderstood and stigmatized, reinforcing their worldview that the system is corrupted and lacking in humanity. Feeling socially isolated, vaccine refusers may be driven toward the online communities and misinformation echo chambers that reinforce their fears. Respectful and inclusive communication is not just the “nice” thing to do; on a pragmatic level, it is a pre-requisite for enabling positive change.