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Reasonings behind COVID-19 Vaccine Hesitancy: A Qualitative Study

Name: Francesca Weisel Student ID: 13302906

Supervisor: Doctor Eline Smit

Word count (approved by supervisor): 8493

Master’s Thesis

In Persuasive Communication

At the Graduate School of Communication University of Amsterdam

04.02.2022

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Abstract

Background: COVID-19 has had a devastating impact on public health. Despite availability, COVID-19 vaccination rates have plateaued across nations, hindering

sufficient immunization to facilitate herd immunity. To maximize uptake and prevent the spread of the virus, it is essential to understand COVID-19 vaccine hesitancy.

Objective: The aim of this study is to explore what drives COVID-19 vaccine hesitancy, in an effort to understand the intricate reasonings behind individuals’ choice not to vaccinate against COVID-19 and investigate which factors influence this decision.

Methods: Employing qualitative research design, semi-structured in-depth interviews were held over Zoom during the months of December 2021 and January 2022. Based on non-probability methods, purposeful and snowball sampling were used to recruit ten participants aged 20 to 62. Subsequent data analysis was based on deductive and inductive codes, identifying six larger themes of COVID-19 vaccine hesitancy.

Results: Interviewees discussed their low perceived risk of COVID-19, not believing it to be a severe threat to their own health. Furthermore, available COVID-19 vaccines were not deemed safe or efficacious enough, while long-term effects were especially of concern. Rather than vaccination, participants relied on natural health to boost their immune system. Mistrust of the government and pharmaceutical companies enforced these opinions, as interviewees did not trust these systems to act in their best interest.

Conclusions: The study shows that reasonings behind COVID-19 vaccine hesitancy are complex and individual. Nonetheless, system mistrust is woven into COVID-19 related skepticism and vaccine concerns, and as such must be addressed by governing bodies and pharmaceutical industries. Vaccine campaigns should focus on tailoring health education, addressing individual concerns to establish institutional trust.

Keywords: Vaccine hesitancy, COVID-19 pandemic, COVID-19 vaccines, system mistrust

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Introduction

Since the pandemic was declared in March 2020, the development of COVID-19 vaccines received upmost priority. Deemed by healthcare professionals as the best solution to ending the global health crisis, it as such received major federal funding and was accomplished in historically record-breaking time, with initial clinical trials

beginning early November 2020 (Cohen, 2020; Statista, 2021). More than a year later however, it has transpired that vaccine availability does not guarantee sufficient

immunization (Nossier, 2021). Across nations, vaccine hesitancy has led to vaccination rates plateauing between 60 and 80 per cent (Holder, 2021). Reports indicate one third of US citizens do not plan to get vaccinated (Strobbe & Fingerhut, 2021), while research conducted in Europe claims a quarter of questioned adults feel likewise (Eurofound, 2021). Vaccine hesitancy pauses a large threat towards the eradication of COVID-19, as herd immunity will only be reached at the 90 per cent population immunity (Mayo Clinic, 2021a). Therefore, long-term prevention of COVID-19 hinges upon vaccine uptake and understanding vaccine hesitancy (Chou & Budenz, 2020).

The aim of this study is to explore what drives COVID-19 vaccine hesitancy.

Vaccine hesitancy defines a state which lies anywhere between vaccine appetence and refusal, despite available vaccination services (MacDonald et al., 2015). Vaccine hesitancy has been studied extensively, given the various vaccination options available which protect against viral infections, such as HPV or MMR (Jarrett et al., 2015; Larson et al., 2014). However, regarding the coronavirus, the topic is lacking in scientific understanding given its novel nature. Research into COVID-19 vaccine hesitancy began in early 2020, with initial publications exploring COVID-19 vaccine communication (Chadwick et al., 2021; Schwarzinger & Luchini, 2021), regional vaccine acceptance rates (Hammer et al., 2021; Sallam, 2021) and determinants of hesitation (Kalam et al., 2021; Robertson et al., 2021). While this research adds valuable insights to our growing

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understanding of the concept, it has previously aimed to determine the “what” of the matter, yet not the “why”, thus neglecting to understand the human reasoning behind COVID-19 vaccine hesitancy. This is mainly due to the studies’ methodology, as the current body of research is predominantly quantitative, being mostly based on survey designs with large sample sizes (Bendau et al., 2021; Lazarus et al., 2021), with very few studies following qualitative methods. However, Teti and colleagues (2020) argue that qualitative inquiries are most suited when examining social responses during pandemics, as life is thus disrupted that typically applied behavior models do not fit anymore (Leach et al., 2020). Novel experiences during lockdown as well as the sensationalized media attention towards the virus have led to complex opinions on the topic, such as the growing public mistrust in governments and information during the pandemic (Boyd, 2021; Edelman, 2021). Moreover, many who choose to remain unvaccinated are often labeled “anti-vaxxers”, regardless of their position on the hesitancy spectrum, and

assumed to be uneducated and conspiracy subscribing (Sobo, 2016). Qualitative methods can explain the gap between assumptions and social realities (Teti et al., 2020), exploring the intricate relations between a person’s choice not to get vaccinated and their

reasonings for doing so (Dubé et al., 2018).

Current research on the topic is oftentimes regionally constricted or conducted while vaccine rollout was still in its early stages when citizens did not have free access to vaccination as it stands today (Lockyer et al., 2021; Sanders et al., 2021). Therefore, these studies lack the current context of vaccine availability, the present understanding of the vaccines through new clinical trials, as well as novel developments such as COVID- 19 variants. Considering this gap in qualitative research on the subject, further

investigation of what drives COVID-19 vaccine hesitancy is needed. The findings of such qualitative exploration will not only fill the current gap in literature but give

academia a new understanding of the underlying causes of COVID-19 vaccine hesitancy.

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Specifically, the present study aims to explore the drivers of COVID-19 vaccine

hesitancy on a global spectrum and takes into account pandemic related factors such as institutional mistrust. As current publications lack such factors (SAGE, 2014), this research will grant greater insight into COVID-19 vaccine hesitancy, thus contributing to academic theory and building upon its models. Additionally, other researchers may use this study as a basis for further qualitative research or to conduct quantitative research with the added knowledge the detailed findings of this study provide.

Next to scientific necessity, the study bears great and immediate social relevance, as the ceasing of the pandemic is contingent on vaccine uptake (Dror et al., 2020).

Likewise, the current strategy followed by governments to reduce infection rates and hospitalization numbers focuses mostly on increasing COVID-19 vaccinations, meaning understanding people’s choice not to get vaccinated will help guide federal campaigns targeted at such individuals. The insights this study will provide about their motivations, information behavior and trust dimensions, could shape this communication in a manner more considerate of the needs of those who have chosen not to get vaccinated against COVID-19. Moreover, this knowledge will further aid healthcare professionals in creating new guidelines and practices when dealing with viral outbreaks and other pandemics. As many healthcare workers care for unvaccinated patients, the findings of this study will help medical staff understand their concerns. As it stands, unvaccinated adults have a 5 times higher risk of COVID-19 infection and are 33 times more likely to be admitted to an intensive care unit, compared those who are fully vaccinated (CDC, 2022; RIVM, 2021). Therefore, most urgently, the social relevance lies in understanding COVID-19 vaccine hesitation to heighten vaccination motivation and impact health behavior (Chou & Budenz, 2020).

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Theoretical Framework

Vaccine Safety

Recurring themes within the vaccination narrative are health related concerns about vaccine safety. In their conceptual model, SAGE (2014) defines vaccine safety as part of confidence, one of the three “Cs” influencing vaccine hesitancy. The perceived risk of vaccines harming one’s bodily health and the fear of vaccination related side effects display major barriers towards vaccine uptake (Dubé et al., 2013; Salmon et al., 2015). A lack of confidence in the safety of the vaccine may outweigh the perceived risk of infection, in turn leading to lower vaccine intention (Betsch et al., 2018; MacDonald et al., 2015). Research has demonstrated this effect across a variety of vaccines, such as those immunizing for influenza (Schmid et al, 2015), HPV (Karafillakis et al., 2018) and most recently, COVID-19 (Kricorian et al., 2021). The risk versus benefit evaluation is a crucial part of the vaccine decision making process, and highly individual to each person, as based on their cultural predisposition, knowledge, and past experiences (Dubé et al, 2013). Historically, the dissemination of misinformation has fueled public perception of vaccine related risks, such as the 1998 publication falsely linking the MMR vaccine to autism (Casiday, 2005). Similarly, today’s sensationalized media coverage of

controversial research and anecdotal tales of grotesque vaccination side effects feed into public perceptions and incite fear of vaccines (Jang et al., 2017; Olutola, 2021).

Current public perception of COVID-19 vaccine safety is considerably lower compared to other vaccines (Syan et al., 2021). Fischhoff (2020) suggests this may to a consequence of the novelty of the virus, given the public’s limited understanding and the comparably low predictability of the vaccine, which increases the perception of risk.

Likewise, the newly available mRNA vaccines are the cause for further public discourse.

While mRNA vaccines are not new to researchers, having been studied in the medical field for decades, the COVID-19 outbreak saw their first introduction to the public

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(CDC, 2021). The perceived novelty of the vaccines combined with false reports circulating social media, such as claims that mRNA immunization techniques

permanently modify one’s DNA, further fuel fear and discourage the public’s trust in the mRNA vaccines (Mayo Clinic, 2021b; Reuters, 2021). Similarly, the accelerated rate of the vaccines’ development has sown distrust in its safety and diminished vaccination intention (Lockyer et al., 2021; Kreps et al., 2021). Normally, vaccines take a minimum of five to ten years to develop (John Hopkins, n.d.). However, the COVID-19 vaccine development was accelerated, due to the urgency of the global health crisis, leading to the historically fastest vaccine rollout, less than a year after the coronavirus outbreak was declared a pandemic (Solis-Moreira, 2021). Many now question the safety of the

vaccines, not wanting to be an experimental “guinea pig”, in doubt of the quality of the initial clinical trials (Moore et al., 2021; Sanders et al., 2021). With new adverse effects of the vaccines being found till this day, such as blood clots resulting from the Oxford–

AstraZeneca vaccine (Ledford, 2021), people’s concern of the growing list of side effects remains prevalent (Frankovic, 2021). Notably, many who are vaccine hesitant refer to the lack of longitudinal studies of COVID-19 vaccines when justifying their hesitancy

(Sanders et al., 2021). This line of argumentation follows that if there were longer trails of clinical testing to ensure vaccine safety and identify harmful adverse effects, perceptions of the COVID-19 vaccines being unsafe would be less prevalent (Moore et al., 2021).

Covid-19 Skepticism

Another driving factor of vaccine hesitancy is the perceived risk of COVID-19.

Perceived risk describes subjective evaluations on the estimated likelihood of contracting the virus the vaccine protects against, i.e., perceived susceptibility, and the perceived severity of the illness’ symptoms (Dubé et al., 2013). The concept is commonly measured in

quantitative research through emotions such as concern or fear and conceptualized in theoretical models as vaccine complacency, another “C” of vaccine hesitancy (Betsch et

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al., 2018), which defines a state in which “perceived risks of vaccine-preventable diseases are low and vaccination is not deemed a necessary preventive action” (SAGE, 2014, p. 11). In academic theory, perceived risk is one of the main aspects in the Extended Parallel Process Model (EPPM), which predicts an individual’s response to a fear inducing messages (Witte & Allen, 2000). According to the EPPM, one first appraises a threat by evaluating both the perceived severity and susceptibility of the threat. If either are deemed low, one will not be fearful of the issue and disregard it (Outcome One). However, the higher one deems the threat’s severity and susceptibility, the more fear will motivate one to appraise its efficacy. The efficacy appraisal stage of the EPPM is based on self- and response efficacy.

Self-Efficacy is one’s feeling of being able to perform an action, i.e., the perceived ease of getting vaccinated against COVID-19 vaccine, while response efficacy is one’s feeling that the action will be effective against the threat, i.e., perceived vaccine efficacy. If the efficacy appraisal results in low evaluations of self- and response efficacy, one will be motivated to control the fear through defensive tactics such as denial (Outcome Two). However, if the efficacy appraisal is high, one will be motivated to control the danger of the threat, accepting the message, and taking the recommended action to avoid the threat (Outcome Three).

Therefore, the EPPM predicts that low perceived risk of COVID-19 will lead to a direct dismissal of the issue during the threat appraisal.

In line with this, current research indicates a significant effect of perceived risk of COVID-19 on vaccination intention, as those who believe an infection will be

detrimental to their health are more likely to get vaccinated against COVID-19, compared to those who are complacent (Caserotti et al., 2021; Karlsson et al., 2021).

Similarly, numerous surveys have found that a main self-reported reason for COVID-19 vaccine hesitancy is that people do not consider vaccination necessary due to the

harmless nature of the virus (Troiano & Nardi, 2021). However, many previous

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publications have failed to differentiate between the perceived susceptibility and severity of COVID-19. In their quantitative study, Willis and colleagues (2021) for example merely queried to what extent participants feared COVID-19, yet neglected to define whether this refers to the fear of contracting COVID-19 or the fear of harmful symptoms.

This is a crucial distinction, as beliefs about perceived susceptibility and severity may vastly differ in conviction and consequently effect vaccine hesitancy differently (Shahin

& Hussien, 2020). Moreover, both are evaluated based on subjective factors, such as personal experiences in lockdowns and touchpoints with the illness (Caserotti et al., 2021; Cerda & García, 2021). Similarly, perceived susceptibility is subject to one’s own adherence to hygiene and social distancing rules, as well as the local contagion rate, while the perceived severity of COVID-19 symptoms may depend on health literacy and information seeking behavior (Bruine de Bruin & Bennet, 2020; Shahin & Hussien, 2020).

Notably, perceived severity and susceptibility have been susceptible to COVID- 19 conspiracy beliefs. Since the start of the pandemic, the COVID-19 outbreak has been shrouded in misinformation and conspiracy, from the virus originating in a laboratory as a bioweapon of mass destruction to COVID-19 being a complete hoax altogether used as a rouse by Bill Gates to get people vaccinated with microchips (Mayo Clinic, 2021b;

Reuters, 2021). The spread of conspiracy during pandemics is not uncommon, as they flourish in times of social crisis and heightened collective uncertainty during which the public is trying to make sense of threatening and otherwise unexplainable events (Bertin et al., 2021). The phenomenon incites a rapid dissemination of misinformation,

especially on social media, and in the case of COVID-19, saw widespread reports of fake news and medical misinformation (Kouzy et al., 2020). Research shows that people who subscribe to COVID-19 conspiracy beliefs and those who have a general predisposition towards conspiracy theories are less likely to vaccinate themselves against COVID-19 (Bertin et al., 2021; Salali &Uysal, 2020). Moreover, Scrima and colleagues (2022)

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found that the positive effect of fear of COVID-19 on vaccine intention would diminish when such fear was associated with anxieties about conspiracies.

System Mistrust

A concept linked to the previously explored skepticism and conspiracy

surrounding COVID-19 is system mistrust (Moore et al., 2021). During the pandemic, governments and institutions have come under fire as the public criticized their handling of hygiene restrictions, lockdowns, and the oftentimes contradictory communication (Klepper, 2021). Mistrust in the competence of policymakers is further sown with everchanging rulings on vaccination rollout, such as the approval of certain vaccines for specific age groups (Davies et al., 2021; Edelman, 2021). A revolving door of

authorization has seen vaccines like AstraZeneca and Moderna having been initially distributed to specific demographics yet later banned due to their vulnerability to certain harmful adverse effects (Dal-Ré & Launay, 2021; Hart, 2021). Lockyer and colleagues qualitative research found that respondents felt bewildered by their government’s

decision making and distrusting their policies (2021). Research has further indicated that trust in governmental agencies decreases with rising COVID-19 infections and that current public trust in the government is considerably lower compared to pre-pandemic times (Davies et al., 2021; Edelman, 2021). Notably, higher levels of political trust are positively associated with COVID-19 related health behavior, such as handwashing, social distancing, and self- quarantining (Han et al., 2021). Distrust of federal institutions has further been linked to vaccine hesitancy (Doherty et al., 2021; Latkin et al., 2021).

Participants of Williams and Dienes’ study expressed their concerns about COVID-19 vaccines being too politicized and that their suspicions of the governing administration decreased their trust of the vaccines (2021).

Another relevant part of this concept is the healthcare system. Patient trust in the healthcare system is defined by the patient’s belief to which extent the system will act in

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the patient’s best interest (Thom et al., 2004). Trust in one’s healthcare provider is an important factor of the vaccine decision making progress and has been positively linked to vaccine uptake (Larson et al., 2018). Moore and colleagues found that vaccine-hesitant respondents based their choice on their distrust of the healthcare system, labeling

pharmaceutical manufacturers of the vaccine as untrustworthy and doubting their

intentions due to the for-profit nature of the vaccine development (2021). Unfortunately, trust in western healthcare systems remains low in minority groups and among people of color (Opel et al., 2021; Read et al., 2021), as they experience comparative higher

instances of unjust and poor medical treatment (Razai et al., 2021). Currently, African American individuals are more than twice as likely to be vaccine hesitant than

Caucasians (Willis et al., 2021). This is quite concerning, as black communities bear a disproportionate burden of COVID-19 infection and hospitalizations, with mortality rates more than three times higher than in white communities (Edelman, 2021).

Late Adopters

Throughout literature, a recurring theme of vaccine hesitant individuals merely waiting awhile to get vaccinated against COVID-19 is prevalent (Moore et al., 2021;

Sanders et al., 2021). The line of reasoning follows that they do not wish to be the first to get vaccinated but first wish to observe the effects of the vaccine on others. As

mentioned previously, this choice may be based on a lack of confidence in the safety of the vaccine, however, it may also originate from a lack of motivation to adopt new innovations (Deshpandé et al., 2021). Based on the diffusion of innovations theory by E.M. Rogers (1962), which defines the phases of innovation acceptance, the Late

Majority describes people skeptical of change, who only adopt an innovation once it has been tried out by the majority. Next to this group, the Laggards are the last and most unlikely to adopt innovation, as they are most bound by tradition and reluctant to change.

Together, the two groups make up 50 per cent of the population and, for the purpose of

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this discussion, have been coined Late Adopters. The diffusion of innovations theory has not been applied to vaccine hesitancy previously, but qualitative research indicates it could apply, given that the reasonings individuals cite for not getting vaccinated align with the Late Adopter mindset. For instance, the mentality of this subgroup seems to be of a “wait and see” kind, seeing no rush to get vaccinated against COVID-19 (Moore et al., 2021). Moreover, new COVID-19 variants have also sparked conversation that the current vaccines are not efficacious enough, which may further delay Late Adopters as they wait for more advanced options (Doucleff, 2021). The argument of low vaccine efficacy also links back to the EPPM, which predicts that low appraisals of response efficacy lead to defensive issue rejection (Witte & Allen, 2000). Lastly, some argue vaccination is not necessary, as local infection rates are low and others are already vaccinated (Wood & Schulman, 2021). This apathetic approach is associated with the free rider problem, in which vaccination is not deemed necessary for oneself or one’s children as those within the community who are vaccinated safeguard the herd immunity (Hershey et al., 1994; Ibuka et al., 2014). Free riders thrive in large, anonymous groups, where they cannot be easily called out for their transgressions (Naso, 2020). Research indicates that “the free-rider problem is overcome only when those who refuse to comply no longer are permitted to enjoy the same benefits as those who contribute their fair share”

(Naso, 2020, p.72). Thus, free riders will remain unvaccinated until the disadvantages of doing so outweigh the benefits of getting the COVID-19 vaccine.

Methodology

Research Design

As discussed in the introduction, the most suitable method to answer the research question of what drives COVID-19 vaccine hesitancy is qualitative research, as it allows for an in-depth exploration of cases while at the same time facilitating flexible data

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collection (Hammersley, 2013). The study follows both deductive and inductive approaches. Deduction was first used by exploring existing research to deduce

theoretical concepts, which were then built into the interview outline to explore whether these conceptualized expectations corresponded to reality (Azungah, 2018). Later, the inductive approach of Grounded Theory was utilized, an exploratory research design which is based on the discovery of emerging patterns in collected data (Walsh et al., 2015). It sees the data collection and analysis tightly interwoven and near simultaneous, a method especially effective in combatting confirmation bias (Creswell et al., 2007). In-depth interviews were used as the method of data collection, as they the most suitable method of attaining subjective opinions and detailed explanations (Easterby-Smith et al., 2015).

Using open-ended questions, participants were asked about their reasonings behind not getting vaccinated against COVID-19, as well as their thoughts on the concepts

deductively contextualized within the theoretical framework. A semi-structured interview guide aided the questioning, by outlining the concepts and accompanying questions (see Appendix A). Moreover, this guide helped with creating a fluid

conversational atmosphere, as the main questions could be addressed in accordance with the respondents’ answers. For example, if the respondent mentioned the side effects after being initially asked about their reasons for not getting vaccinated, the next question would be skipped in favor of following up on perceived vaccine safety. Next to the main questions relating to the theoretical concepts, subsequent follow-up questions were incorporated for each concept, encouraging interviewees to give more thorough responses. As opposed to the main questions, follow-up questions could be skipped if they had already been addressed in previous answers, as to avoid respondents having to repeat themselves.

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Participants

Prior to recruitment, this study was approved by the University von Amsterdam’s Ethics Review Board (reference number 2021-PC-14086). Because participants must by choice be unvaccinated against COVID-19, purposive sampling was used to initially select sample members. Purposeful sampling is a common non-probability sampling method within qualitative research used to identify and select individuals who have exceptional knowledge on the phenomenon of interest (Palinkas et al., 2015). For this study, the researcher directly contacted individuals via social networks and within their own social circle, who had identified themselves to be unvaccinated against COVID-19. Outreach via social networks occurred on Instagram and Facebook, primarily via general recruitment posts on the researchers own profile (see Appendix B), and secondly via direct recruitment messages to unvaccinated members in Facebook Groups about COVID-19 vaccines. The former method garnered merely one participant, while the latter was ineffective and incited some rather rude replies being sent back to the researcher. Friends and family of the researcher aided the process by reaching out to potential sample members within their own social circle and asking them to participate, recruiting four participants in total. Lastly, participants who had completed their interview were asked to share the researcher’s contact with other individuals who were not vaccinated against COVID-19. This snowball sampling was especially

effective, recruiting half of the participants, as it accesses hard-to-reach populations and uses the familiarity between sample members to build trust in the research (Sadler et al., 2010).

Given the study’s sensitive nature, specifically the medical data of vaccination status, as well as the controversial topic of COVID-19 vaccines, the recruitment process saw many sample members unwilling to participate, with many friends and family reporting that most people they asked cited a lack of trust in the research and an unwillingness to discuss their choices with a stranger.

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Of the ten sampled participants, seven identified as female and three as male.

Participants’ ages ranged from 20 to 62, with a mean sample age of 43 years (SD = 14.03 years). The pool of respondents further demonstrated a wide variety of nationalities, having recruited Dutch (N = 1), British (N = 2), German (N = 5), US American (N = 1), and Turkish (N = 1) natives. All participants were white, while their educational background was rather mixed. Lastly, half of participants subscribed to no religion, three identified as Atheist, one was Islamic and another followed Spirituality.

Table 1

Overview of Sample Characteristics Nationality Age Gender

Identity

Religious Beliefs

Highest Level of Education

Ethnic Background Turkish 53 Female Islam Vocational Education White American 20 Male Atheist High School Diploma White

Dutch 43 Female Spirituality PhD Diploma White

British 23 Male Atheist Vocational Education White British and

German

54 Female None High School Diploma White

German 54 Female None Vocational Baccalaureate Diploma

White

German 27 Male Atheist Vocational Education White

German 62 Female None PhD Diploma White

German 52 Female None Vocational Education White

German 43 Female None German State

examination

White

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Interview procedure

Ten interviews were conducted between December 14th, 2021, and January 10th, 2022. To increase the potential number of interviews, they were held in both English and German. The translation of the interview guide was performed with the forwards-

backwards method, in which the researcher, who is bilingual, first translated from English to German and another translator translated the guide back without seeing the original version. This way, the translation remained structured, and discrepancies could easily be identified and corrected. A day prior to the first interview, two pre-tests were conducted with vaccinated friends of the researcher, to test the interview outline and check for any confusing phrases in questioning. The results of the pre-tests were

minimal, leading to no changes in wording but rather to the researcher posing questions in a slower and more comprehensive manner. Before being interviewed, participants received a factsheet outlining the study’s purpose and possible avenues of contacting the University of Amsterdam. Additionally, they were asked to return a signed informed consent form, agreeing to their data being collected and used for research purposes. This document assured participants’ privacy would be safeguarded, and their real name would not be linked to the published study, further explaining their option to withdraw from the research at any time during the interview (see Appendix C). The acknowledgment of both documents and an oral consent was again queried prior to recording, as a double measure of security.

All interviews were audio recorded with software installed on the interviewer’s iPhone, the length of recordings ranging from 44 minutes to 1 hour and 16 minutes and averaging at 1 hour 3 minutes (SD = 11.65). To alleviate any travel and abide by social distancing rules, all interviews were conducted via Zoom. Like personal interviews, remote interviews enable interviewer and interviewee to see each other face-to-face via Webcam, thus allowing verbal and non-verbal communication to take place (Easterby-

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Smith et al., 2015). However, this method is prone to stimulate socially awkward situations, such as elongated pauses or misunderstandings, resulting from occasionally lagging internet connections. Lastly, to make respondents feel more comfortable and to stimulate the interviewer-interviewee relationship, which was often that of strangers, introductions and small-talk were incited by the interviewer prior to beginning the audio- recorded questioning.

Interview Outline

The interview guide consisted of a semi-structured outline covering the main research question and the four key concepts discussed in the theoretical framework.

While otherwise flexible in sequence, the interview always started off by asking

participants to express their reasoning to not get vaccinated against COVID-19. The idea behind this approach was to let them first explain their reasonings in their own words, before delving into the conceptualized expectations set in the theoretical framework.

Moreover, it helped discern the main reasons for their hesitancy from the start, thus easing conversational flow by initially skipping those not relevant to their choice.

Several follow-up questions further prompted participants to elaborate on their hesitancy spectrum and explain what pressures they had felt while making their choice. Thereafter, the interview guide followed a flexible course consisting of questions which were based on four key topics: COVID-19 Skepticism, Vaccine Safety, System Mistrust, and Late Adopters. Participants were asked to access their perceived susceptibility and severity of COVID-19, and about their opinions on COVID-19 related conspiracies. It should be noted that the term conspiracy was not used, as to not irk participants, and instead replaced with “opinions”. The interviewer further queried participants’ opinions on COVID-19 vaccines, assessing their trust in vaccine safety, perceived risk of adverse effects, and thoughts on the vaccines’ developmental timeframe. On the topic of system mistrust, questions about their government’s response to COVID-19 vaccines explored

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trust in federal policy. Similar questions were posed regarding healthcare providers and vaccine manufacturers, inquiring how participants felt about the motives behind COVID- 19 related recommendations. Three questions related to Late Adopters, accessing to what extent latent motivation, emerging variants, and growing herd immunity shaped

participants choice not to get vaccinated. Lastly, respondents were asked if there was any topic they would still like to elaborate on, regardless of it having been already addressed or not. This last part let participants choose the subject of conversation, following the study’s inductive approach by allowing for new concepts to be explored independent of the conceptualized expectations formed by previous deduction.

Data Analysis

Interviews were transcribed verbatim on a running basis and analysis occurred simultaneously according to the principles of Grounded Theory. Data was collected until saturation, when patterns repeated within the data and further interviews did not yield new insights. With the aid of the qualitative research software Atlas.ti, a combination of deductive and inductive codes was used to analyze the data during the initial step of open coding (see Appendix D). Deductive codes were based upon the concepts explored within the theoretical framework and subsequently included in the interview guide, while inductive codes were derived from the unique reasonings behind COVID-19 vaccine hesitancy mentioned by participants (Charmaz, 2006). Next, focused coding was conducted by clustering codes into categories which reflected the participants reasonings not to vaccinate against COVID-19. Finally, selective coding connected common categories, searching for relations between concepts and grouping them under six larger themes. An overview of this conceptual mapping, including categories and themes, can be found in Appendix E.

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Results

COVID-19 Skepticism

A major theme of vaccine hesitancy was COVID-19 skepticism. It was derived from deductive codes, in support of the assumptions made in the theoretical framework.

While no one doubted the existence of the virus, the consensus among all participants was that COVID-19 does not represent a severe threat to their own health. This opinion was often based on participants’ own touchpoints with the virus, either having contracted it themselves or basing their opinion on the experience of friends or family being

infected. The perceived severity of COVID-19 was moreover likened to that of the influenza virus and its symptoms compared to those of a bad cold:

“I have recovered [...] I had mild symptoms, just slept relatively long, like when you have the flu. But I have been sicker in my life.” (Female, 62)

This lack of perceived severity was additionally reasoned based on participants’

younger age and healthy lifestyle, citing the low statistical likelihood of a lethal COVID- 19 infection decreasing the necessity of vaccination. Notably, half of the participants agreed vaccination was sensible for the old, obese, or sickly. Emerging COVID-19 mutations moreover lessened the fear of COVID-19, with participants hailing every new variant making the virus weaker.

“I don't think that it poses a significant threat to me, especially considering the new variant seems to be less lethal than previous variants.” (Male, 23)

However, opinions were divided regarding perceived susceptibility of COVID-19.

More than half of the participants said they could catch it easily, citing a high likelihood of infection due to rising cases in their area. A couple respondents trusted that their preventative measures, such as social distancing, personal hygiene, and keeping a

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healthy lifestyle would protect them sufficiently. Notably, some held both opinions, reasoning they could technically catch it easily due, but that they trusted their prevention methods to keep them safe anyway.

“[I’m] as vulnerable as everybody else. As in, yes, we can all get this virus. But I'm healthy and have a good immune system, so it's very well possible that I have been exposed to it, but my body didn't catch it” (Female, 43)

Natural Health

A recurring theme amongst more than half of the participants was the significance of natural health, i.e., generally staying healthy and boosting one’s immune system.

Notably, this theme was one found based on inductive codes, as it was a unique issue raised by participants, and had not previously been deduced in the theoretical framework.

The line of reasoning followed that vaccination was not necessary due to the natural defensive capacity of the body. Participants emphasized that they took great measures to improve their health, by working out, avoiding stress, and taking nutritional

supplements.

“No one ever talks about the immune system. If you boost your immune system, you may get the COVID infection, […] but you may not end up in hospital.” (Female, 54)

Similarly, the topic of holistic health was broached by half of the participants who emphasized the importance of feeling one’s body, trusting your gut instinct, and

choosing natural remedies. Many expressed that they could feel intuitively that the vaccine was not the right option for their body. This opinion was held exclusively by females and often found in those with prior sensitivities towards medicines, severe illnesses, and/or poor experiences with the healthcare system.

“It’s not a brain decision, it’s a gut decision.” (Female, 54)

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“I'm being as healthy as possible in a holistic way. In that sense, I'm less a burden on the health care than other people” (Female, 43)

Those who had recovered from COVID-19 agreed they were glad their bodies got the chance to develop antibodies to the virus naturally. Some inferred this was the

superior way, making their immune system stronger and providing better protection against COVID-19 compared to the immunization a vaccine would provide.

Vaccine Safety

Throughout all interviews, the perceived lack of vaccine safety was a primary reason for participants’ hesitancy towards COVID-19 vaccines. This theme was based on deductive codes derived from the theoretical framework. All interviewees expressed their concern about the vaccine’s development, troubled the accelerated development had compromised its safety. Furthermore, they compared it to that of other vaccines which had taken considerably longer and mistrusted the quality of clinical testing of the COVID-19 vaccines.

“I'd rather have something that's been around for lots of years and where the side effects are well known, rather than be a guinea pig for something new.” (Female, 54)

Similarly, the mRNA vaccine was deemed suspicious by a couple of participants, having been newly introduced to the market and moreover being derived from perceived unrelated cancer research. One participant was notably not vaccinated because they were waiting for an inactivated vaccine to be approved for the European Union, citing the currently available vaccines were not similar enough with the body’s natural

development of antibodies. Moreover, a couple of participants emphasized their concern for the conditional approval the vaccines had received and took issue with the lack of liability regarding side effects.

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“[The mRNA vaccine] only has a one-year approval, where you have to sign that you are responsible for all the possible consequences.” (Female, 43)

The reported harmful side-effects of the COVID-19 vaccines deterred nearly all interviewees. Specifically, male participants worried about myocarditis, while a couple of female participants mentioned cases of thrombosis. For most, the perceived risk of vaccine side effects exceeded their perceived risk of COVID-19. Others pointed out that the lack of transparency regarding adverse effects further cemented their choice not to get vaccinated. Similarly, a major theme regarding the lack of vaccine safety was the unknown long-term effects. All participants expressed that the uncertainty of harmful long-term side effects, such as infertility or an increased risk of cancer, was a prime reason for their hesitancy. One interviewee based this concern on previously faulty vaccines, such as the influenza vaccination Pandemrix, which was later linked to an increased risk of narcolepsy, while another compared the COVID-19 vaccine to the previously popular ingredient Asbestos, which later turned out to be carcinogenic.

“We just don’t know what is going to happen in five years. There are some who say it could cause infertility or whatnot […] but we just cannot know for certain”

(Female, 53)

Vaccine Efficacy

Another recurring theme was the lack of perceived vaccine efficacy. Notably, this topic was never cited as a primary reason to not get vaccinated against COVID-19, but always mentioned in combination with the previous topic of vaccine safety. Along these lines, half of the participants expressed they were not willing to risk an unsafe vaccine, especially when it is not even effective. This was based on the vaccines not being effective enough against new variants, as well as the fact that vaccinations do not stop the spread of COVID-19, indicating low perceived response efficacy.

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“Everybody knows that the vaccinations don't stop COVID. It just makes your symptoms milder.” (Female, 54)

A couple of participants actively raised the issue of booster vaccinations, which cemented this lack of confidence in the vaccines’ efficacy, indicating to them that the effects of the vaccination do not last long. Some also expressed their irritation about the lack of new vaccines, explaining that the boosters are merely the old vaccines packaged new, and that they had not been adjusted to the variants. One participant even theorized that boosters were only being administered to get rid of the existing inventory.

Mistrust of the Pharmaceutical Industry

A category highly linked to the previous one is the lack of trust towards

pharmaceutical companies amongst participants. While this topic did not have complete consensus, with a couple of interviewees not taking issue, those who did held strong opinions towards the topic. Firstly, similarly to the natural health approach, a couple participants expressed an aversion towards modern medicine when not faced with a severe health threat. Other participants were generally cautious of vaccines, with one interviewee only choosing to get vaccinated against lethal viruses, while another was completely opposed to vaccines choosing instead to be treated by homeopathic options.

“I'm someone who doesn't take a lot of medication, who wants to solve things with a hot tea rather than antibiotics” (Male, 27)

Moreover, more than half questioned the motives of the vaccines’ manufacturers.

First, some participants took issue in the perceived power the pharmaceutical industry had over the world. Similarly, the fact that the industry is being run by non-medical personnel or being funded by the likes of Bill Gates worried a couple of interviewees.

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“Bill Gates suddenly appears and supports the pharmaceutical industry and has nothing to do with it. […] He's previously said that we are too many and he must reduce humanity.” (Female, 52)

One participant was particularly worried about the vaccine manufacturers including harmful ingredients, like artificial lipids or metallic microparticles within the vaccine, which they called a witch potion. Next to this, half of the participants doubted the altruistic motive of the manufacturers, concerned about the for-profit nature of the companies. Similarly, the fact that booster vaccinations are increasingly necessary, troubled a couple of interviewees that manufacturers were taking advantage of the pandemic.

“They have a financial interest in people being sick and in vaccines. […] I mistrust them in terms of there's so much money going there.” (Female, 43)

Lastly, the lack of liability for pharmaceutical manufacturers increased mistrust among half of interviewees. This issue was the sole category based on inductive codes within this theme. Many reported they were suspicious of the contradictory fact that manufacturers claimed the vaccine was completely safe, yet refused to be held accountable for any adverse effects.

“Pfizer would be given no legal liability if anything happened. So, you couldn't sue them if you took it and something happened to you, which strikes me as quite odd.” (Male, 23)

Mistrust of the Government

For most, the perceived poor handling of the pandemic resulted in a mistrust in the government’s competence and consequently was a main reason to not get the

COVID-19 vaccination. The consensus among all participants was that they did not trust

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the government was acting in their best interest regarding vaccination policies nor that information from the government regarding COVID-19 vaccines could be trusted fully.

“I see it as a moral duty to not be vaccinated because I have no confidence in my government to sort this situation properly. I think that they don't have my best interests at heart.” (Male, 23)

This lack of confidence in federal institutions was often explained by the perceived illogical policies of the government, which participants disapproved of. For example, more than half took issue with the ever-changing COVID-19 restrictions and harsh lockdowns, contradictory explanations about vaccine approvals, or the apparent blaming of the case numbers on unvaccinated citizens. The latter was a much-discussed topic, with participants citing the lack of federal funding into healthcare being the main cause for overwhelmed intensive care stations. Similarly, half of the participants were frustrated with the lack of alternative treatment options, such the development of over- the-counter remedies against COVID-19.

“Some potential treatments did not get as much money and attention as vaccines, so please then indeed widen the range.” (Female, 43)

The increasing pressure from governing bodies on the unvaccinated was often discussed, referring to rules prohibiting unvaccinated citizens to enter restaurants, shops, or countries. More than half of participants expressed their sadness that they now feel unhappy with their own country, while a couple likened this pressure to extortion.

Overall, all interviewees agreed that the pressure would not change their choice not to get vaccinated against COVID-19, apart from two participants, who might lose their job in the future if they remain unvaccinated. Notably, a couple of German participants claimed these restrictions made them want to be infected more than vaccinated, as a certificate of recovery is equal to vaccination status in Germany.

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Lastly, participants highlighted that their mistrust in the government was due to the highly politicized nature of the vaccines. Firstly, half believed politicians were taking advantage of and creating a further societal divide between vaccinated and unvaccinated citizens, drawing similarities between the political spectrum of left versus right wing.

“Back when Trump was talking about the vaccines, you had people like Joe Biden and Kamala Harris saying they're not going to “Take no Trump vaccine”

according to their words. And now it's all about the vaccine!” (Male, 20)

Secondly, a couple of interviewees mentioned cases of corruption within their local government, citing publicized scandals or alluding they had insider information on fraudulent politicians. Similarly, they expressed that they felt the government used COVID-19 scaremongering to gain political power and money, while at the same time lobbying for vaccines.

“I think that the government did a good job of keeping people scared of it. I think they continue to do so.” (Male, 20)

Discussion

Summary of Findings

The aim of this research was to explore the drivers of COVID-19 vaccine hesitancy. The study’s findings show that unvaccinated individuals do not consider COVID-19 a severe threat to their health and therefore do not deem vaccination necessary, especially with a vaccine they do not believe to be safe or efficacious.

Preferably, they rely on other preventative measures and/or trust their own immune system to deal with an infection naturally. Moreover, given that the vaccines are being offered to them by federal institutions and manufactured by pharmaceutical companies,

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the rejection of the COVID-19 vaccination is further deepened by a lack of trust in these providers. No themes regarding Late Adopters were found.

Discussion of Findings

Reflecting on these findings, one must consider the already established theoretical literature on vaccine hesitancy within academia. SAGE (2014) defines three factors influencing vaccine hesitancy in their conceptual “3C” model. Complacency describes a state in which the risks of vaccine-preventable diseases are perceived too low to

necessitate vaccination. Confidence encompasses trust in vaccines, the system that delivers them, and the policymakers who decide which vaccines are needed. Convenience is defined by the physical availability, geographical accessibility and monetary affordability of the vaccines and the services that provide them. The present findings especially indicate a state of complacency, as the risk of COVID-19 is perceived low by participants. This aligns with predictions set by the EPPM, as a low appraisal of COVID-19 severity and/or susceptibility ultimately leads to a dismissal of the threat. Similarly, the offered solution to the threat, i.e., vaccination, further fails the efficacy appraisal due to a low evaluation of response efficacy. With the perceived risk of vaccination deemed higher than a COVID-19 infection, a lack of confidence was also observed. Convenience was mostly absent in this study’s results, which may be explained by the vaccine rollout being highly prioritized in the pandemic. The singular exception to this was one participant who mentioned that they were waiting for an inactivated vaccine to become available in their country. According to this model therefore, it seems that complacency and confidence are the most important factors influencing COVID-19 vaccine hesitancy (SAGE, 2014).

Previous research supports these findings, yet in contrast to this study, others have failed to explain why both complacency and confidence are so low in those who chose not to get vaccinated against COVID-19 (Gerretsen et al., 2021; Karlsson et al., 2021; Lindholt et al., 2021).

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This study’s main insight points to an overarching theme of mistrust as a driver of COVID-19 vaccine hesitancy. Given that information on the virus and the vaccines are predominantly provided by governing bodies and pharmaceutical manufacturers, which participants feel an inherent mistrust towards, the information is in turn deemed

untrustworthy (Thiede, 2005). Wang and colleagues (2021) explain this system mistrust through historic institutional failures and the tightly interwoven relationship between government and industry, similar to the reasonings provided by the participants in this study. Labelled an Infodemic, misinformation on COVID-19 and the vaccines further fuels mistrust, since federal recommendations and health communication vastly

contradict false reports circulated online (Cinelli et al., 2020). Confirmation bias deepens this cycle of mistrust, as Meppelink and colleagues (2019) found that when seeking online health information on vaccines, individuals select more belief-consistent

information compared to belief-inconsistent information. Moreover, they perceive belief- consistent information to be more credible than belief-inconsistent information. As public trust in federal and scientific institutions decreased during the pandemic,

researchers and health professionals are not surprised that some deem information about vaccine safety and efficacy untrustworthy, nor that COVID-19 skepticism gained such popularity (Binagwaho et al., 2021).

A further link can be made between system mistrust and the study’s new finding of natural health. Casiday (2005) argues that trust is strongest in oneself and one’s community and distrust prevails most towards the “others”, such as governing

institutions. Therefore, a prevailing distrust of systems may incite a growing importance of holistic health, as a defensive response to the “other” systems which are trying to govern individual health decisions. The importance of trusting one’s immune system to deal with COVID-19 was expressed often during interviews, especially emphasized by female participants who followed a holistic or natural health approach. Given that gender

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discrimination runs deeply within the healthcare system, such as male bias in clinical trials, it is not surprising that the importance of natural health was emphasized mostly by female participants (Jackson, 2019). Regarding COVID-19 vaccine hesitancy, the theme of natural health has notably not been discussed in other literature on the topic, neither

qualitative nor quantitative. Previous research on other vaccines however shows that the use of natural medicine has been linked to lower vaccination uptake (Frawley et al., 2018) and associated with the factor of system mistrust (Wardle et al., 2016). Working professionals further derive vaccine hesitancy from a lack of trust in health care professionals who are perceived to be pushing for vaccination, instead of concerning themselves with the holistic health of their patients (Worley, 2021). A mistrust of the persistence that vaccines are the only solution against COVID-19 has echoed by this study’s participants, who emphasized the importance of alternative treatment options being funded alongside vaccine research.

Theoretical and Practical Implications

While two of the three “Cs” were found, convenience was notably absent from the insights garnered about COVID-19 vaccine hesitancy, as governments facilitated

convenience so much during rollout. Yet as convenience neither appears in this nor in other studies on the topic, one must question if it is really of equal importance to

complacency and confidence as SAGE would suggest (Lindholt et al., 2021). Furthermore, the model defines confidence as trust in vaccines, vaccines providers and policymakers.

However, with this study’s insights, it can be argued that system mistrust, both of governments and health providers, also impacts complacency, as information about the perceived risk of vaccine-preventable infections is shaped by institutional trust. Considering this, future qualitative research could conceptualize a new theoretical framework of vaccine hesitancy, revising SAGE’s “3Cs” by including system mistrust as an explicit factor outside of the defined confidence. Moreover, findings from further quantitative studies could weigh

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the importance of each “C” and the impact of mistrust on each factor, as well as discover new relationships between the variables. Combined, this research would lead to a more accurate conceptual model of vaccine hesitancy and thus aid future studies in their research endeavors.

Next to these theoretical implications, the study’s insights also bear great importance to those aiming to increase COVID-19 vaccine uptake. Specifically, the findings suggest focusing on individuals who hold COVID-19 skepticism, i.e., complacency, and deem the vaccine to be unsafe, i.e., lacking confidence. Betsch and collegues (2015) suggest

information interventions explaining disease risks and underlining social benefits to target complacency, while confidence can be fostered by debunking misinformation. However, these solutions seem too easy, demonstrated further by the fact they have already been tried unsuccessfully during the pandemic. Moreover, they do not consider the varied drivers of COVID-19 vaccine hesitancy. As such, there is no vaccine hesitant stereotype that fits all boxes, but a plethora of individual reasonings behind the choice to remain unvaccinated.

Research indicates tailoring as an effective intervention to decrease vaccine hesitancy, individually tailoring educations messages to the persons concerns (Gowda et al., 2013).

However, the intangible persistence of system mistrust discovered in this study complicates persuasive health communication, as message impact is inherently contingent on trust in its sender (Thiede, 2005). Because vaccine development and information are intrinsically linked to pharmaceutical industries and the governments that fund them, accurate

communication can only be provided by them. Thus, vaccine hesitancy can only be effectively addressed once trust in these systems has been established again. Open transparency about vaccine adverse effects is advised, having been proven to increase trust in healthcare providers and hinder the spread of conspiracies (Petersen et al., 2021).

Likewise, a localized approach to COVID-19 education by public officials and health authorities has been shown to increase system trust (Vergara et al., 2021).

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Limitations and Future Research

Being one of few qualitative studies on the topic, this research expands greatly to our understanding of what drives COVID-19 hesitancy, providing a unique opportunity to hear participants explain in their own words their reasonings not to get vaccinated against COVID-19. Nonetheless, this study is subject to some limitations. Firstly, the researcher faced major difficulties while recruiting, as time was scarce and many were unwilling to participate. As a result, collected data is limited, the study merely boasting ten participants. And while the study reached saturation on the main themes discussed, further interviews may have provided more unique reasonings. Moreover, all participants were white. As marginalized communities and people of color are especially affected by vaccine hesitancy (Willis et al., 2021), a more racially diverse sample would have increased the depth of insights. Future research endeavors should therefore consider these limitations, planning for a longer recruitment process, communicating trust in the study and/or providing incentives for participation. Finally, everchanging regulations and new information during the pandemic will likely eventually lead to changes in attitude along the line, possibly heightening or decreasing COVID-19 vaccine hesitancy.

Therefore, this study should be viewed as a snapshot of reality, reflecting the current state, yet making future research no less necessary.

Conclusion

This study finds that unvaccinated individuals do not consider COVID-19 to be threatening enough to their health to risk an unsafe vaccination. As the theme of system mistrust runs deep through most concerns, governments and industries must rebuild public trust. However, considering the diverse reasonings, there is no “one-size-fits-all”

solution to COVID-19 vaccine hesitancy.

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