Epistemic divides and ontological confusions: The psychology of vaccine scepticism

ABSTRACT

Vaccine scepticism is an increasingly important barrier to optimal coverage in developed countries. In this commentary, we make the case that negative attitudes towards vaccines reflect a broader and deeper set of beliefs about health and wellbeing. We suggest that this alternative worldview is influenced by ontological confusions (e.g. regarding purity, natural energy), and knowledge based on personal lived experience and trusted peers, rather than the positivist epistemological framework. Our view is supported by recent social-psychological research, including strong correlations of vaccine scepticism with adherence to complementary and alternative medicine, magical health beliefs, and conspiracy ideation. For certain well-educated and well-resourced individuals, opposition to vaccines represents an expression of personal intuition and agency, in achieving a positive and life-affirming approach to health and wellbeing. These core beliefs are not amenable to change - and especially resistant to communications from orthodox, authoritative sources. Although this view does suggest tactical improvements to messaging, we suggest that a better long-term strategy is to combine with other disciplines in order to address the root causes of vaccine scepticism. Vaccine scepticism is unlikely to thrive in a cultural context that trusts and values the scientific consensus.

Sub-optimal vaccination coverage can result from several fundamental causes, including practical ones such as inadequate public awareness, availability, affordability, and convenience.¹ A further additional and distinct cause is connected to personal attitudes and beliefs related to hesitancy, scepticism, refusal, or (lack of) acceptance or confidence. The attitude of the public towards vaccination is an emerging public health issue internationally.² For example, a recent large-scale survey in New Zealand found that one-third of respondents had some degree of concern regarding vaccinations, with 26% being sceptical, and 5.5% strongly opposed.³ There are, of course, multiple social factors currently driving this scepticism. The tremendous success of vaccination programs has, ironically, made the benefits less obviously apparent. Simultaneously, social media has provided new scope for the spread of ‘alternative facts’ regarding purported risks. However, these social explanations neglect the underlying psychological motivations for the spread of vaccine scepticism; which, we feel, are crucial to properly understanding this complex phenomenon.

Before beginning, we must mention that terms like vaccine hesitancy or vaccine scepticism have suffered from an unfortunate lack of consistency in their use.⁴ Negative attitudes have been conflated with ambivalence or lack of knowledge, and likewise, the distinction between attitudes and behaviour is sometimes lost.⁵ In line with Bedford et al,⁵ we treat hesitancy/scepticism purely as an attitude or belief, that nevertheless contributes to behaviours involving the delay or decline of some or all recommended vaccines. In common with Gust et al,⁶ we feel it is best understood as an attitudinal continuum, capturing doubts regarding the safety, efficacy, necessity and general advisability of vaccination for oneself and one's family. Further, we suggest that firm (i.e. unhesitant) opposition to vaccination simply represents a point at the extreme end of this spectrum.

Given their demonstrated safety and success, why does the public not share the scientific community's degree of confidence in vaccination? Recent research has indicated that one of the strongest correlates (r = .40) of vaccine scepticism is an adherence to complementary and alternative medicine (CAM). Although there is some evidence that CAM practitioners are directly influencing their clients,⁷ it seems that CAM does not directly cause vaccine scepticism,⁸ but that this relationship is best explained by a common link to a more general worldview, labelled magical health beliefs.^9,10 These reflect a particular way of thinking about health, typified by ontological confusions about how the world actually works. Magical health beliefs are reflected by agreement with item probes such as ‘Colours change the organism's energy vibration in a direction that is beneficial to health’ or ‘If we don't somehow clean our bodies, unhealthy toxins remain in them’. Despite being without empirical or logical basis, these ideas develop and spread due to being intuitively satisfying, and through appealing connotations with purity, naturalness and positivity. It can be seen that various forms of CAM are well-suited to this kind of thinking about health. For CAM adherents, it represents a way to naturally fortify and augment their bodies' strengths, whilst preserving it from toxins and adulterants.⁸ Vaccination, on the other hand, comprehensively fails to meet these intuitive criteria, being associated with biological contamination, ‘artificial’ chemicals and processes, intrusiveness, and discomfort. A symptom of this lack of intuitive appeal is that individuals more susceptible to disgust tend to have more negative attitudes to vaccination.¹¹

Vaccine scepticism is also related to having a spiritual epistemology (‘I feel that most knowledge comes from spiritual experiences’), and openness to experience - a personality trait associated with non-conformism, and a preference for diverse and complex ideas.^3,12 More open individuals are also more likely to endorse conspiracy theories,¹³ which are discussed below. The relationship to non-conformity is congruent with the relationship established between vaccination scepticism and ‘reactance’, which is a tendency to want to distinguish oneself as an independent thinker by rejecting consensus views.¹¹ These quantitative findings concur completely with recent qualitative evidence. Interviews with vaccine-refusers⁸ found that a faith in a spiritual or mystical approach to health was a prominent theme, leading to a rejection of positivism in favour of embracing paranormal lived experiences. They also found that vaccine-refusers strongly valued independence and agency with respect to one's own health. Government-sponsored vaccination programs are perceived as rigid, controlling, and impersonal; threatening one's ability to make the best health choices based on personal wisdom and intuition. Similar themes have been found in an earlier survey of anti-vaccination websites.¹⁴ Exhortations to conform to vaccination schedules are perceived as diminishing the agency of the individual. Further, they fundamentally rely on a different epistemological basis: that is, a positivist, empirical worldview, in which an abstract body of technical and statistical evidence takes precedence over the immediate personal experience and intuitions of individuals.

In practice, attempts to influence individuals to vaccinate most often rely on appeals to experts and authoritative sources (i.e. medical professionals, the scientific consensus, government agencies). However, another psychological trait strongly associated with vaccine scepticism is conspiracist ideation (r = .33).¹¹ The hidden, malevolent motivations of ‘Big Pharma’, government, and scientists feature prominently in anti-vaccination misinformation on the internet.¹⁴ Conspiracist ideation also provides a rationale for discounting empirical evidence as being ‘part of the hoax’; an effect seen not only with regard to vaccination, but also with respect to climate change, and genetically modified foods.¹⁵ The result is to encourage a epistemic approach that discounts a normative evidence base, in favour of personal lived experience, and the shared personal anecdotes within trusted groups of like-minded individuals. For a conspiracy-minded individual, communities of similar and like-minded persons will be perceived as a more trustworthy source of information than the government, experts, or the mainstream media.

There are two key points to be taken from the above. First, vaccination scepticism is not an isolated issue, but rather a particular example of science-rejection, sharing many features with climate-change denial, anti-evolutionary creationism, and the endorsement of a spectrum of ‘anti-enlightenment’ beliefs including homeopathy and the paranormal.^12,15,16 Vaccine-rejection is currently a small minority position, but some other anti-scientific beliefs (e.g. climate change scepticism, the supernatural) are far more prevalent, in some cases representing the majority view. Furthermore, the spread of even seemingly innocuous beliefs about health (e.g. that ‘positive energy currents prevent disease’) are problematic because they draw people into an alternative epistemological worldview, making them vulnerable to more pernicious ideas, including anti-vaccination messaging. Accordingly, preventing the growth of vaccine-scepticism should be viewed as part of the broader mission to promote public understanding and confidence in science and evidence-based practice.

A second point we wish to make is that vaccine scepticism is driven by broader psychological drivers associated with a particular set of cultural values. Thus, the particular arguments advanced by sceptics who are committed to this worldview reflect the outcome of processes of rationalisation, motivated reasoning and selective attention, rather than the root cause.¹¹ Just like specific political views (e.g. on abortion, gun control) reflect a broader set of values and a commitment to a certain cultural group, vaccination scepticism typically reflects core beliefs about personal agency, and a spiritual, natural, life-affirming approach to health. For these individuals, evidence-based pro-vaccination messaging is perceived as arrogant, myopic, driven by vested interests, and intrinsically demeaning of their own lived experience and wisdom.⁸

In making these observations, we emphasise that we are not implying that vaccine sceptics are an undifferentiated group. As already mentioned, there is certainly an attitudinal continuum, and there are many more ‘hesitant’ than fully committed vaccine-sceptics. Conventional evidence-based messaging or authoritative advice may be effective for those with only mild concerns about vaccination, or those with a lukewarm commitment to an alternative health worldview. However, the online and offline discourse is inevitably driven by those most committed individuals. We also do not wish imply that the situation is yet at a crisis point. In countries like Australia, vaccinations coverage is at around 90–93%, and appears to be slowly improving. However, it is very revealing that some of the lowest rates of coverage are observed in very high SES ‘sophisticated’ localities such as inner-Sydney (70.5%) and around Byron Bay (73.2%).¹⁷ This trend is not associated with a lack of access to information or resources, but rather an increased (but sometimes sadly misguided) confidence on the part of high-SES individuals to take greater agency in informing and promoting their own health.

Vaccine advocates must keep in mind that concerned parents are typically exposed to a wide variety of persuasive messaging from anti-vaccination sources, which can include high-profile celebrities and politicians. They must also acknowledge that their audience does not necessarily trust scientific findings, and may hold a different set of core ideologies and values. Unfortunately, there is a paucity of information regarding effective strategies to address vaccine hesitancy,¹⁸ and some evidence that messaging is ineffective.¹⁹ However, understanding the root causes of anti-vaccine attitudes provides new avenues to explore. For example, messaging could work to personalise and explicate the altruistic motivations of doctors and health professionals - challenging the conspiratorial narrative that they are complicit in a global hoax. Steps could be made to avoid challenging the recipients' core beliefs using ideas from social marketing. For example, if the source of messaging was a similar concerned parent (e.g. holding similar ‘natural’ values), describing a situation in which she received bad information from the internet, this would both challenge the alternative epistemology, and communicate the message that vaccination is not necessarily opposed to the recipient's core beliefs or social in-group. These can be thought of as tactical remedies: ‘fighting fire with fire’ by employing similar intuitively appealing rhetorical techniques.

In the long term, the field of vaccines and immunotherapy should join with other concerned scientific disciplines, to work towards increasing public confidence in science-based medicine, and promoting a science-based public culture. Vaccine scepticism can only flourish in a cultural context that does not understand or value a scientific approach to knowledge. This strategy would entail less tolerance of seemingly harmless health fads and CAM-related pseudoscience by academic and medical institutions, which - we believe - function as a gateway to more dangerous ideas. From this point of view, enhancing vaccine messaging to combat vaccine scepticism in adults may be a case of ‘the ambulance waiting at the bottom of the cliff’. Far better returns may be achieved by inoculating people (especially the young) against such pernicious beliefs, by emphasising the development of science literacy in educational systems - particularly as it is applied in everyday life.

For much of the 19th and 20th centuries, ‘enlightened’ public opinion was characterised by a trust in the scientific worldview, and an admiration of the technological and medical benefits it brought. However, the early 21st century appears to have been characterised by greater suspicion in institutions, and a greater willingness to challenge Enlightenment ideals.²⁰ The target of this movement sometimes includes science and science-based medicine, at least when the conclusions are not aligned with one's cultural values. This post-modernist trend has been catalyzed by social media, in which an unprecedented democratisation of communication has facilitated the spread of ideas, as a function of their intuitive appeal. Advice from one's general practitioner, or from public health information initiatives, represent isolated voices in a tumult of other - sometimes intuitively compelling - narratives. One - but certainly not the only - casualty of these developments, has been decreasing public confidence in vaccination. This should represent a call to action for all who value a rational and evidence-based society; to strengthen science literacy in schools, to increase engagement of scientists with the community, and to promote confidence in scientific institutions. Calling for broadscale social initiatives to promote science might seem overly optimistic, especially in the current political climate. However, it is our view that only through building a cultural foundation that values and trusts reason and science, that the public can be innoculated against highly contagious and toxic ideas like vaccine scepticism.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.