Do cognitive styles affect vaccine hesitancy? A dual-process cognitive framework for vaccine hesitancy and the role of risk perceptions
Introduction
Vaccine prophylaxis is one of the most successful preventive techniques in 20th-century healthcare. The World Health Organization (WHO) estimates that “routine vaccination of infants, children and adults prevents around 2 to 3 million deaths every year” (World Health Organization, 2013 in Brewer et al., 2017:151). Despite strong public support for vaccination, vaccine hesitancy (the delay or refusal of vaccine prophylaxis) is re-emerging as an issue, especially in those contexts where vaccination's most beneficial effects have been seen (Larson et al., 2014). Additionally, vaccine acceptance will be fundamental to resolving the COVID-19 pandemic, but early results suggest that “distrust is likely to become an issue” (Peretti-Watel et al., 2020:769). A large-scale research involving 67 nations has identified Italy as one of the countries most affected by vaccine hesitancy, reporting the second highest level of vaccine-related skepticism between Russia, first, and Azerbaijan, third (Larson et al., 2016).
Research in different fields has explored the drivers of vaccine hesitancy, finding that “similar determinants of vaccine acceptance or refusal emerged, including: contextual, organizational and individual ones” (Dubé et al., 2015:99–100). This study focuses on individual-level determinants of vaccine hesitancy.
Given that “being motivated to get vaccinated is in many ways the result of deliberation by individuals” (Brewer et al., 2017:158), several behavioral theories have been used to explain vaccination intentions, such as the “Health Belief Model and Sick Role Behavior” (Becker, 1974), “Protection Motivation Theory” (Rogers, 1975), and the “Theory of Planned Behavior” and the “Theory of Reasoned Action” (Fishbein and Ajzen, 2011). The main limitation of key models of health behavior is in considering individuals as rational actors, pursuing the best outcome for themselves, and maximizing expected utility. The model behind these theories – the ‘rational choice theory’ – was long considered a baseline, but since the work of Simon (1955), it has increasingly been suggested that individuals are not fully rational actors. It is more likely that individuals take decisions with limited information, limited time, limited cognitive capacity and ability, displaying a bounded rationality (Simon, 1955). In this framework, cognitive science, together with sociology and social psychology, has elaborated complex models to take into account the way cognition can inform a theory of action. The most widely supported view of how our cognition works, the “dual systems of cognition model” (Evans and Stanovich, 2013; Kahneman, 2011; Sloman, 1996), is based on the existence of two systems of thought, with different capacities and processes. System 1 (S1) is fast, intuitive, and automatic, whereas System 2 (S2) is slow, deliberative, and reflective (Stanovich, 1999). Furthermore, in decision making “people rely on a limited number of heuristic principles which reduce the complex task of assessing probabilities and predicting values [ …]. In general, these heuristics are quite useful, but sometimes they lead to severe and systematic errors” (Tversky and Kahneman, 1974:1124). As an example, availability heuristic (Tversky and Kahneman, 1974; Nisbett and Ross, 1980) expects individuals to give greater probability to evidence they can easily bring to mind. Thus, it may be easier to recall sporadic but salient media accounts of allegedly adverse effects, although these are far less frequent than cases in which vaccine uptake has no significant side effects, which are rarely reported. In conclusion, individuals are rational but within limits, which limits to rationality might be generated by the way our cognition works.
Individuals’ cognitive differences in vaccination uptake have seldom been addressed, but as Frederick notes, “a neglected aspect does not cease to operate because it is neglected, and there is no good reason for ignoring the possibility that […] various […] cognitive abilities are important […] determinants of decision making” (Lubinski and Humphreys, 1997 in Frederick, 2005:25). From a sociological standpoint, this notion is even more important if we recognize that specific cognitive traits can be both individual and socially distributed. Different individuals, distant in time and space, might show similar cognitive characteristics associated with the same preferences (Brekhus, 2015; Vaisey, 2009).
We address this gap by adopting a dual-process cognitive framework, which suggests that, compared to analytical thinking, intuitive thinking might be a source of vaccine hesitancy, and that a number of risk perceptions can indirectly intervene in this association.
We use data from original surveys carried out between September and November 2019 in Italy, assessing individuals’ ability to overcome intuitive thinking and collecting fine-grained measures of risk perceptions. We rely on Karlson et al. (2012) decomposition (KHB decomposition) to measure the total, direct, and indirect association of cognitive styles with vaccine hesitancy, and disentangle the contribution of each perceived element of risk.
Results are important not only to improve our understanding of vaccine hesitancy, but also to suggest where or how future research might usefully be directed to develop effective strategies to increase vaccination coverage.
Section snippets
Two systems of cognition
The distinction between two kind of thinking, one fast, intuitive and heuristic, the other slow, effortful and deliberative, has its origins in the 1970s and 1980s (Evans and Stanovich, 2013), and has recently seen wide application to a variety of processes, especially in psychological research (Gervais, 2015). “Dual-process modes of cognition” have been studied extensively by cognitive neuroscientists, and existing research agrees on cognition being characterized by two systems, System 1 and
Data
We use a dataset obtained from two primary data collections. This study was approved by the Institutional Review Board of the author's institution. A first survey was administered in September and October 2019, and a follow-up questionnaire circa 15 days after the completion of the main questionnaire, in November 2019. We used a non-probabilistic quota-sampling method and interviewed 1008 Italian citizens participating in an online panel run by a major Italian survey company. The response rate
Association of thinking styles with vaccine hesitancy
The first step examines the relationship between thinking styles and the probability of being vaccine-hesitant. Fig. 1 reports average marginal effects for a bivariate logistic regression (dark grey bar) predicting the probability of vaccine hesitancy, comparing intuitive thinking style with analytic thinking style, and the same model controlling for individuals' sociodemographic characteristics and individuals’ general susceptibility to disease (light grey bar).
In model 1, individuals showing
Discussion
Discussions of cognitive differences in vaccine hesitancy appear seldomly in academic literature, with remarkable exceptions (Anderson, 2016; Schindler et al., 2020; Tomljenovic et al., 2019, 2020). Nonetheless, an extensive set of contributions based on the dual-process of cognition framework has showed how cognitive characteristics play a significant role in shaping human perceptions, decisions, and behavior.
Importantly, recent research shows that individuals appear to use one style more
Conclusions
Addressing vaccine hesitancy is a primary concern, especially at present. Vaccine acceptance has been a significant issue throughout the last decade, but in the light of COVID-19 research further underlines how crucial it is to increase awareness of the importance of vaccination (Dubé and MacDonald, 2020). For this reason, understanding beliefs, motives, and reasons behind vaccine hesitancy is an important task from both an academic, and a very pragmatic public policy perspective. In this
Credit author statement
Mauro Martinelli: Conceptualization, Methodology, Software, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Giuseppe A. Veltri: Conceptualization, Methodology, Supervision, Resources, Funding acquisition.
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2022, VaccineCitation Excerpt :Lower intelligence had a small but consistent association with greater vaccination hesitancy across both samples, and both types of vaccine. This observation is in line with findings that those with a more intuitive style of cognition were less likely to vaccinate, those with a more analytical style of cognition were more likely to vaccinate [29], and those with lower cognitive sophistication scores were more susceptible to vaccine misperceptions [38]. However, given intelligence’s modest correlation with cognitive styles [45], it appears that intelligence provides a meaningful, independent contribution to understanding vaccination hesitancy.