VACCINE HESITANCY: WHAT IT IS, WHAT CAUSES IT, AND WHAT TO DO ABOUT IT

Authors

John Rovers, PharmD, MIPH, CPH Drake University College of Pharmacy & Health Sciences Des Moines, Iowa

Deborah H. Thompson, MPA President, DHT Consulting & Training Urbandale, Iowa

There are no conflicts of interest to report for either author.

Abstract

Although vaccine hesitancy is not new, immunizing pharmacists are increasingly confronted by patients who vary from vaccine hesitant to loudly and angrily anti-vaccine. In this paper, we discuss what vaccine hesitancy is and why patients may present with negative attitudes towards vaccines. Using Haidt’s Moral Foundations Theory, we then discuss six principles of how people make moral decisions, including decisions about vaccines. Pharmacists who can identify which moral principle causes a patient to be vaccine hesitant can focus their patient education specifically on that principle, rather than providing general vaccine information which is unlikely to change a patient’s mind.

Although pharmacists have served as vaccinators for many years, the recent COVID pandemic and the essential role that pharmacists have played in vaccinating their communities has put pharmacists face to face with patients whose opinions about vaccines are negative.1 Even death threats to vaccinating pharmacists are not unheard of.2

As disquieting as the current anti-vaccine environment may be, it is important to note that such attitudes are not new. A smallpox outbreak in 1721 Boston may have been the first example of anti-vaccine sentiment in the United States.3 The Reverend Cotton Mather understood disease to be caused by sin and cured by prayer and devotion. But he also believed there were times that scientific enhancements, like the recent experiments in variolation by Jenner, were religiously permissible. Disagreements were so vigorous that someone threw a (defective) bomb through Mather’s window with the note, “Cotton Mather, you dog, dam you! I’ll inoculate you with this; with a pox to you.’’ 4

Clearly, pharmacists are having to deal with those whose objections to vaccines are closely held and hard to counter. In this article, we will provide an overview of what vaccine hesitancy is, some of its root causes, and how pharmacists can best speak with their vaccine hesitant patients.

VACCINE HESITANT VS ANTI-VACCINE

Accepting or rejecting vaccines appears to occur on a continuum.5 People may accept some vaccines under some circumstances while simultaneously rejecting other vaccines under other circumstances. It is important to make the distinction between those who are genuinely anti-vaccine and those who are vaccine hesitant. The former are typically opposed to all vaccines, under all circumstances, and are estimated as no more than 5-10% of the general population.6 They often receive vaccine information from sources that have become known as “The Disinformation Dozen” which is a collection of typically very well-funded groups and individuals who are engaged fulltime in promulgating incorrect or misleading information about vaccines.7 Vaccine promotion efforts among the truly anti-vaccine population are probably not productive.

Pharmacists’ efforts are better directed towards the vaccine hesitant who may be more amenable to discussing the both the benefits and the risks of vaccines. According to the World Health Organization (WHO), vaccine hesitancy is “the reluctance or refusal to vaccinate despite the availability of vaccines.” WHO also counts vaccine hesitancy as one of the top ten threats to global health in the 21st Century.8

Reasons For Vaccine Hesitancy

Before reasons for vaccine hesitancy are reviewed, it is probably best to acknowledge the fact that much of the research in the hesitant was done in the parents of children eligible to be vaccinated. It is not always clear how well the models and explanations included below apply to adults, children, or both.

Theoretical Models for Vaccine Hesitancy

One model, developed by a WHO working group, explains vaccine hesitancy using three domains.5 Contextual influences include the socio-economic class an individual belongs to, the political environment (including vaccine mandates), religion, culture, gender, the opinions of others, opinions about the pharmaceutical industry, and geographic barriers to vaccination. Individual/social and group influences include beliefs that vaccines are not necessary or are harmful, beliefs about health and prevention, knowledge about vaccines, personal experiences with vaccines and trust in providers, perceived risks and benefits of vaccines, and prior experiences with vaccines. Vaccination specific influences include the vaccination schedule required, mode of administration, if the vaccine is new, the role of healthcare professionals, and costs.

A model developed by Dubé and colleagues place vaccine hesitancy on a spectrum.6 A person’s decision to be vaccinated depends on information from the media (including both traditional media and anti-vaccine sources), public health and vaccination policies (including safety monitoring), and the recommendations of professionals (including the provider’s training, communication skills, knowledge, and the vaccine status of the provider). In addition, a variety of historical, political and socio-cultural factors play a role in deciding to vaccinate or not. These include a person’s knowledge about vaccines, their past experiences, how important they believe vaccines are, how they process risk and who they trust, what they believe is normal behavior concerning vaccines, and finally, their religious and moral beliefs.

Explanations for Vaccine Hesitancy

A variety of less theoretical sources explain vaccine hesitancy more directly. Hayden describes vaccine hesitancy as context specific, complex, and multidimensional.9 Salmon and colleagues explain vaccine hesitancy as a function of how people process risk.10 Perceived risk is higher when the choice to vaccinate is involuntary, when the risk of side effects is not under an individual’s control, when side effects are unpredictable, when the disease is an unusually dreaded one, and when the health problem is exotic. In addition, people may perceive a disease as a natural risk and prefer that to a manmade risk posed by a vaccine. Getting sick by getting a disease is an error of omission and preferable to getting sick due to the vaccine, which is an error of commission.

Lin and colleagues offer that general factors explaining vaccine hesitancy include the attributes of both the vaccine and the disease (safety, barriers to access, disease severity), characteristics of the healthcare provider (prefer younger female providers, pediatricians seen as more trustworthy, extensive provider clinical experience and knowledge of disease and vaccine, and if provider is vaccinated), patient characteristics (low socio-economic status, race, comorbidities), and system factors (vaccine guidelines, confidence in vaccine, clear official recommendations, source of information, practice setting.)11

Nagar and colleagues explored religious objections to vaccines and found that White Evangelicals, Black Protestants, and Hispanic Catholics were likely to be the most vaccine hesitant.12 Religious reasons given include vaccine misinformation (inclusion of fetal tissue in vaccines), conspiracy theories that nefarious actors seek to harm the virtuous, and experiences of prior racism in healthcare settings.

From the diversity of opinions provided above, it is clear there is no single, simple explanation for why some people are vaccine hesitant. That said, for those who prefer simple explanations, perhaps the most convincing one is that vaccines have been a victim of their own success. Vaccines have been so successful that many diseases of the last century are now so uncommon as to lead some people to believe that vaccines are no longer necessary.

What To Do About Vaccine Hesitancy

Moral Foundations Theory (MFT) may also offer insight into vaccine hesitancy as well as provide the pharmacist with tools to discuss vaccines with their hesitant patients.13 MFT is a psychological theory that seeks to explain why the morals of people differ but still share some fundamental characteristics. It was first outlined by moral psychologist Jonathan Haidt. The theory proposes that each one of us comes equipped with ‘intuitive ethics.’ This innate capacity causes flashes of approval or disapproval towards certain ideas, behaviors, and images that trigger reactions, including vaccines.

Haidt’s research suggests that people have gut reactions. These gut reactions are a physical connection to our conditioned morals and values. Haidt offers that gut reactions come first in our thought processes and that reasoning comes second. The reasoning that follows works to rationalize the intuitive reaction in a supportive way to make it one’s “truth.” It is similar to confirmation bias and the method of searching for and accepting information that confirms already formed beliefs and disregards information to the contrary. Haidt uses a metaphor called “the Elephant and the Rider” to describe this internal process. Most people believe that the rational rider is in charge of making deliberate moral decisions. Instead, it is the elephant acting instinctively who usually decides what will happen. The massive elephant in the analogy represents the power of this gut reaction. It outweighs and will easily overpower the small rider. Only occasionally can the rational rider convince the “gut” reaction of the elephant to pursue a different path.

As the human mind moves into this defensive “gut” position, it becomes very difficult to use reason to convince someone of another viewpoint. It explains why facts and data about vaccines will nearly always fail to compel change in perspective. Indeed, when faced with “the facts,” people may actually double down on their deeply held, if misguided, beliefs. However, research also shows that morals and values can evolve and can be influenced over time and by speaking directly to one’s morals and values.

Haidt and his colleagues offer six different moral foundations categories that have evolved over the course of human development in response to individual or group survival needs. These moral foundations are:

• Care versus Harm

• Fairness versus Cheating

• Loyalty versus Betrayal

• Sanctity versus Degradation

• Authority versus Subversion

• Liberty versus Oppression

These foundations are old, primal and held deeply within the human psyche. Each foundation can cause both positive and negative reactions in a person. Not every foundation is triggered on every topic, although vaccines offer enough controversy to provide consideration of each category. Finally, when a moral foundation is triggered, it may be more intensely triggered for some people compared to others. Below, we will discuss how each of these moral foundations can be used in discussing vaccines with patients.

It has been observed that Republicans (who are presumably more conservative) are more likely to espouse anti-vaccine opinions than Democrats (who are presumably more liberal).14 This is important when discussing vaccines with patients since conservatives have been found to be motivated by all six moral foundations, while liberals are motivated by only three—care, fairness and liberty. When discussing vaccines with the vaccine hesitant, it is helpful if the pharmacist can intuit exactly which moral foundations are causing the hesitancy so they can be addressed directly. And the only way to intuit which moral foundation is in play is for the pharmacist to listen closely and give careful consideration to the patient’s concerns. Listening before speaking is vital for pharmacists using MFT to address vaccine hesitancy.

The foundations included in Haidt’s MFT framework offer support for Dubé and colleagues’ findings.6 What follows is a brief explanation of each moral foundation and how it relates to vaccine hesitancy and the aforementioned reasons offered by Dubé and colleagues where appropriate.

1. Care vs. Harm: Compels us to care for vulnerable populations like children, the elderly and those with medical conditions. Prevention of negative experiences in these populations is important. Justice is pursued to punish those who cause harm to them. For vaccines, this the care/harm foundation drives questions like: will this harm my children, myself or my loved ones?

For those who are vaccine hesitant, this produces strong safety concerns for vaccines compared to the hypothetical risk of COVID. This disconnect is produced by misinformation and disinformation widely shared on social media platforms that use algorithms to produce clicks on content created to trigger fear.

For those who are vaccine confident, this foundation provides relief that there is protection against the transmission of COVID which is the larger perceived threat compared to the vaccine. It also triggers anger toward those who spread disinformation.

2. Fairness vs. Cheating: This foundation recognizes that we live in societal conditions that offer opportunities for mutually beneficial cooperation. For example, covering a co-worker’s shift or job responsibilities if requested to, so that this reciprocity is granted when needed. “They would do it for me,” is a common explanation for these acts of assistance.

This makes people sensitive to signs of cheating and deception. Anger, contempt, and disgust are felt when a person is found to be a social loafer or “free rider.” It supports the belief that people should contribute to the group in some way if they are able to. When they do not, they could be excluded from any benefit gained by the group.

As it relates to vaccines, this foundation is clear and present in regulation. In consideration of laws and policies, debate is centered around whether it is fair to create different policies for those who choose not to vaccinate compared to those who say yes. The vaccine hesitant may focus on perceived unfairness of vaccine mandates. Vaccine confident health care workers may feel it is unfair to have care for critically ill unvaccinated patients.

3. Loyalty vs. Betrayal: Makes us sensitive to signs that another person is—or is not—a team player. People trust members of the same group over outsiders. When someone betrays the group, they are punished or ostracized from it. Groups form strong bonds using rituals and traditions. Group pride leads members to work hard to defend it and sometimes to the point of becoming irrational.

Vaccine hesitant people may worry that receiving a vaccine is counter to the beliefs of their identify groups (e.g., family, political identity, church congregation). If they are “outed” as vaccinated, this may cause some of their relationships to become tense, and people are generally averse to conflict. While it is irrational to put themselves in harm’s way by increasing the likelihood of becoming severely ill, their gut (the elephant) is telling them that it is more dangerous to be ostracized from their identity groups.

4. Sanctity vs. Degradation: Gives us the ability to endow ideas (e.g., liberty and justice), objects (e.g., crosses and flags), places (e.g., battlefields and monuments) and people (e.g., saints and celebrities) with infinite value. People are in awe of their greatness and in shock if they are degraded.

For vaccine hesitant people who are religious, this drives concerns about the use of fetal cells in vaccine development. This is a nuanced issue, but use of fetal cells in some vaccines is perceived as a violation of the sanctity of life in these cases.

Some vaccine hesitant people closely monitor what they put into their bodies and are concerned about vaccine ingredients as unnatural (i.e. the adage, “My body is a temple.”). Conversely, for some vaccine confident people, the sanctity of keeping the body free of disease is an important reason to take vaccines. Vaccine confident people may also revere the scientific method used to develop vaccines and their demonstrated success in the reduction of illness. Science is held as sacred.

5. Authority vs. Subversion: Figures in society like police officers, judges, teachers, and healthcare professionals are provided with some authority to keep daily order in the population to avoid chaos. When disagreements occur, they play a mediating role. They hold this distinction because standards, often in the form of laws, determine what qualities and credentials must be held to have authority and when and where it may be exercised. The population is conditioned to be compliant to their requests, orders and rulings, and when they are treated with disrespect, the subversion triggers discomfort and anger from other members of society.

When it comes to vaccine hesitancy, people are doing their own research on the Internet and then sharing their findings without achieving standards of expertise. They are subverting the authority of experts who are trained and educated to avoid pitfalls like confirmation bias. Without this education and training, the elephant in Haidt’s analogy works hard to confirm what is already believed to be true instead of having the discipline and expertise for objective analysis of information. For vaccines, the resulting spread of disinformation has impacted vaccine confidence.

It is also critical to remember, however, that to be a trustworthy authority figure in society, you must be trustworthy. Trust has to be earned and fostered with consistency in order to be kept. In exchange for the status of being an authority figure in society, ethical behavior is demanded by the population and consequences for violations result in the permanent or temporary loss of authority.

6. Liberty vs. Oppression: This foundation is often in tension with the previously mentioned authority/subversion foundation. People are wary that others will abuse their power and are triggered by individuals or institutions that try to impose what is perceived as illegitimate restraints on liberty. In order for an authority figure to be able to enforce a policy, there has to be agreement that the policy is fair given that compliance by a majority of people is necessary.

This was demonstrated by the reactions people had to lock downs during the COVID pandemic. People felt their liberty was being unjustly threatened by illegitimate authority figures. There remains an ongoing debate on which authority figures should be making these decisions, if anyone at all, in the future. Should it be public health and healthcare professionals or elected leaders?

When a new regulation or policy is being pursued, it is critical to persuade those it would impact that it is worth giving up some amount of personal freedom because the benefit to the community is more important. It is also good practice to make the case that what is good for the community is good for the individual. For example, requirements for vaccinations for school-aged children are mandated because the spread of infectious diseases in the community causes disruption to the individual if family members become ill or they themselves become ill.

Table 1 summarizes each moral foundation, shows how it relates to vaccine hesitancy, and provides a tip for how pharmacists may change their message depending on the moral foundation underlying a patient’s hesitation.

Six Intuitive Moral Foundations

Moral Foundation How it Relates to Vaccine Hesitancy

1. Care/Harm

• Protect and care for vulnerable people

• Sensitive to suffering, distress

• Desire to punish those who cause harm

2. Fairness/Cheating

• Benefits of reciprocity

• Sensitive to cheating, cooperation, deception

• Vaccine hesitant – Strong safety concerns for vaccine compared to a hypothetical risk of COVID

• Vaccine confident – Protect against COVID and transmission

• Vaccine confident – Threatened by people spreading disinformation

Quick Tip: Hear out concerns. Reduce perceptions of vaccine risk and amplify risks of not getting vaccinated. Avoid using numbers or statistics when discussing risk.

• Vaccine hesitant may focus on perceived unfairness of vaccine mandates raising resistance

• Vaccine confident health care workers may have feelings of unfairness by having to care for critically ill unvaccinated patients

Quick Tip: Hear out concerns. We all give up something we would like to do to benefit others. E.g., no smoking areas, picking up dog waste, obey speed limits.

Conclusions

Although the truly anti-vaccine patient is probably unwilling to consider any discussion about the risks and benefits of vaccines, the vaccine hesitant are a diverse group whose resistance to immunization may stem from a variety of underlying causes. Pharmacists who can listen closely to the reasons for such hesitation can employ Haidt’s Moral Foundations Theory and start a discussion to alleviate the patient’s concerns. Simply countering patient misinformation with “facts” is unlikely to be effective. The pharmacist’s listening and communication skills are vital best care for vaccine hesitant patients.

References:

1. weareiowa.com. Rural Iowa pharmacist says there’s real vaccine hesitancy among 20-50-year-olds. Published online April 6, 2021. Accessed June 29, 2022.

2. Peiser J. Self-proclaimed ‘Vaccine Police’ tells Walmart pharmacists they ‘could be executed’ for administering shots. The Washington Post. https://www.washingtonpost. com/nation/2021/08/19/walmart-christopher-key-anti-vaccine/. Published August 19, 2021. Accessed June 29, 2022.

3. Buhr S. To Inoculate or Not to Inoculate?: The Debate and the Smallpox Epidemic of Boston in 1721. Constructing the Past. 2000;1(1):61-67. Accessed June 29, 2022. https://digitalcommons.iwu.edu/cgi/viewcontent.cgi?article=1071&context=constructing

4. Best M, Neuhauser D, Slavin L. “Cotton Mather, you dog, dam you! I’l inoculate you with this; with a pox to you”: Smallpox inoculation, Boston, 1721. Quality and Safety in Health Care. 2004;13(1):82-83.

5. Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007-2012. Vaccine. 2014;32(19):2150-2159.

3. Loyalty/Betrayal

• Forming cohesive groups to fend off threats

• Sensitive to group pride, rage at traitors

4. Authority/Subversion

• Authority figures maintain moral order

• Sensitive to obedience, deference, rank, and status

• Reverence for “good” leaders

5. Sanctity/Degradation

• Triggers feelings of disgust and awe

• Infinite value placed on ideas, people, places and objects and preventing their degradation

6. Liberty/Oppression

• Tension with authority foundation

• Sensitive to signs of self-aggrandizement, tyranny

• Triggers feelings of oppression, righteousness

• Vaccine hesitant may be concerned that receiving a vaccine would cause tension with groups that provide identity (e.g., church, social groups, political groups)

Quick Tip: Hear out concerns. Remind them of HIPAA requirements and patient privacy laws.

• People are exposed to information from authority figures in their identity groups which carry significant weight and may fall prey to confirmation bias, disinformation, and may not have the skills to evaluate information critically.

Quick Tip: Hear out concerns. Pharmacists are among the most trusted providers. Be trustworthy and transparent about what you know/don’t know to build your credibility.

• May voice concerns about vaccines and fetal tissues

• Concerns about vaccine ingredients as unnatural

Quick Tip: Hear out concerns. The Children’s Hospital of Philadelphia is a great resource on this topic of fetal cells: www. chop.edu/centers-programs/vaccine-education-center/vaccine-ingredients/fetal-tissues

• Creates push back about feeling “forced” either socially or by policy to receive a vaccine.

Quick Tip: Hear out concerns. Point out what freedoms are lost from illness and lasting side effects (e.g., where you go, who you see, how you earn a living).

6. Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger J. Vaccine hesitancy: An overview. Human Vaccines and Immunotherapeutics. 2013;9(8):1763-1773.

7. Bond S. Just 12 People Are Behind Most Vaccine Hoaxes On Social Media, Research Shows. National Public Radio. Published May 14, 2021. Accessed June 29, 2022. https://www.npr.org/2021/05/13/996570855/disinformation-dozen-test-facebooks-twitters-ability-to-curb-vaccine-hoaxes

8. World Health Organization Newsroom. Ten Threats to Global Health in 2019. Ten Threats to Global Health in 2019. Published 2019. Accessed June 29, 2022. https:// www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

9. Hayden J. Introduction to Health Behavior Theory. Jones & Bartlett; 2009.

10. Salmon DA, Dudley MZ, Glanz JM, Omer SB. Vaccine hesitancy: Causes, consequences, and a call to action. Vaccine. 2015;33:D66-D71.

11. Lin C, Mullen J, Smith D, Kotarba M, Kaplan SJ, Tu P. Healthcare providers’ vaccine perceptions, hesitancy, and recommendation to patients: A systematic review. Vaccines (Basel). 2021;9(7).

12. Nagar S, Ashaye T. A Shot of Faith—Analyzing Vaccine Hesitancy in Certain Religious Communities in the United States. American Journal of Health Promotion Published online January 2, 2022:089011712110695.

13. Haidt J. The Righteous Mind: Why Good People Are Divided by Politics and Religion. Pantheon Books; 2012.

14. Motta M. Republicans, Not Democrats, Are More Likely to Endorse Anti-Vaccine Misinformation. American Politics Research. 2021;49(5):428-438.