Vaccine Hesitancy Through the Lens of Social Cognition
- Jacinda Taggett
- Dec 13
- 10 min read
by Kimberly Hall
In 1998, The Lancet famously published a study conducted by Andrew Wakefield which claimed links between the Measles-Mumps-Rubella (MMR) vaccine and the development of autism and gastrointestinal problems in children. Though the research was later found to be fraudulent, its results refuted, and the paper eventually retracted, MMR vaccine compliance dropped so much as a result that in 2008, measles was declared endemic in the United Kingdom for the first time in over a decade (Godlee et al., 2011).
Vaccine hesitancy, while certainly not a new phenomenon, has become a significant point of discussion within the field of public health. Given the overall shift of COVID-19 from pandemic to endemic, and recent outbreaks of highly-infectious diseases like measles and RSV, full and updated vaccination remains extremely important to general public health. However, the number of people putting off or outright refusing vaccination continues to grow; according to the CDC’s surveillance coverage, for example, MMR vaccination rates among children during the 2024/25 school year dropped to just 92.5% across the United States, well below the necessary threshold for preventing further transmission of measles.
In this article, I plan to explore vaccine hesitancy from a social psychological perspective. I will apply elements of social cognition to help analyze and understand the various factors behind increased vaccine rejection–both internal, relating to psychological and emotional processes, and external, relating to various social influences. Finally, I will explore what can be done to challenge this trend.
Overview of Social Cognition
Social cognition is an approach to social psychology which focuses on the roles that cognitive elements and processes play within social contexts. Advanced by social scientist Albert Bandura, social cognitive theory asserts that learned human behavior is the product of reciprocal relationships between people and their environment–they both shape and are shaped by each other. Related theories and models make similar assertions about the interdependence of thought, action, and environment (Hagger & Hamilton, 2022; Latkin et al., 2022). In health-related research, social cognition theories, like those of planned behavior (Lin et al., 2020; Shiloh et al., 2022) and triadic reciprocal determinism (Zhu et al., 2022), feature prominently in studies aimed at identifying the internal and external mechanisms which help determine health-related behaviors. Research in social cognition has also found success in developing interventions for health-related behavioral change (Keselman et al., 2023; Latkin et al., 2022).
Internal Factors
Cognitive Dissonance
Cognitive dissonance is the phenomenon in which individuals, knowingly or not, hold conflicting cognitions, producing psychological discomfort. Strategies used to relieve cognitive dissonance may be informed by the particular content and social context of the subject. One such relief strategy is rationalization. This strategy relies on individuals’ tendency towards consistency in self-schemas, which are mental frameworks that an individual uses to characterize themselves based on memories, experiences, and patterns of belief and behavior; an individual may consciously or subconsciously edit their beliefs in order to justify (“rationalize”) their behavior, both to themselves and to those around them (Cancino-Montecinos et al., 2020; George et al., 2023; Miller & Cabell, 2023). An unvaccinated person may rationalize their continued decision to reject vaccinations by asserting a preference for alternative treatments, by claiming herd immunity, or questioning the utility of a vaccine (George et al., 2023; Gomes-Ng et al., 2024; Miller & Cabell, 2023). Interestingly, recent research by George et al. suggests that rationalization may be most significant when individuals attempt to minimize feelings of guilt regarding social responsibility. After all, if vaccines are effectively useless, then there is no reason for an unvaccinated person to feel uncomfortable with having potentially exposed others to an infection.
Another common method for alleviating cognitive dissonance is simple avoidance, a cognitive-behavioral strategy known as selective exposure (Cancino-Montecinos et al., 2024; Miller & Cabell, 2023). If a person is already inclined towards vaccine skepticism, they may selectively avoid news reports or social media posts which do not support those beliefs. This process removes the discomfort of conflicting ideas and protects their hesitancy towards vaccination from external challenge (Gomes-Ng et al., 2024; Latkin et al., 2022; Miller & Cabell, 2023).
Cognitive Flexibility–Biases and Heuristics
Think back to the early days of the COVID-19 pandemic lockdown. How challenging was it to keep track of COVID-related updates? How the disease spread, what steps to take to prevent it, how severe its effects would be? Flexibility in the thinking process helps people react to new information, and incorporate that information into future actions, including vaccination (Gomes-Ng et al., 2024; Latkin et al., 2022). Lower scores on cognitive flexibility tests generally predict greater vaccine hesitancy (Gomes-Ng et al., 2024). In a related vein, lower educational attainment and information literacy skills also predict reduced vaccination rates (Latkin et al., 2022).
Cognitive processes and related behaviors are often informed by a number of mental shortcuts which allow us to think quickly, but leave room for errors in judgment. Say, for instance, an emotionally-charged story about a rare side-effect becomes the first thing someone thinks of when the topic of vaccination comes up. The availability heuristic, which is the tendency to attribute greater significance to things that are easier to recall, may leave that person more inclined to question the safety of a vaccine, and subsequently delay or refuse vaccination (Azarpanah et al., 2021).
The process of selective exposure, which has been previously mentioned in this piece, supports and is supported by confirmation bias. Confirmation bias is the psychological tendency towards confirming beliefs which one already holds. For example, a vaccine-hesitant person maintaining that the COVID-19 vaccine is in fact more dangerous than the disease, even when presented with learning tools and evidence to the contrary (Azarpanah et al., 2021; Gomes-Ng et al., 2024; Malthouse, 2023; Miller & Cabell, 2023). The belief perseveres because all new information is evaluated through it, i.e., what can be interpreted to support vaccine skepticism will be, and what cannot be interpreted as such will be questioned or ignored.
All of these processes are prone to reinforcing themselves through feedback loops, which are often perpetuated through one’s particular social environment–but we’ll get into that later.
Affect and Attitudes
One aspect of cognitive dissonance and cognition in general that does not necessarily get discussed enough is emotion (Cancino-Montecinos et al., 2020; Hagger & Hamilton, 2022). Regarding one’s decision whether or not to vaccinate, affect and attitude can play significant roles (George et al., 2023; Gomes-Ng et al., 2024; Zhu et al., 2022). Of distinct importance is trust–holding negative or mistrustful attitudes towards public health officials or institutions consistently correlates with greater vaccine skepticism and lower intentions to vaccinate (George et al., 2023; Latkin et al., 2022). This trend is particularly pronounced in regards to the COVID-19 vaccine (Keselman et al., 2023; Shiloh et al., 2022).
Another important aspect of emotional social cognition is perceived loss. For some, active refusal to vaccinate can operate as a way to regain a sense of personal freedom or autonomy, which many felt was lost during pandemic lockdowns (George et al., 2023). For others, the refusal to vaccinate is fueled by the desire to avert greater loss. Potential loss, like the risk of serious side-effects from a vaccine, tends to hold greater cognitive and emotional weight than potential gain, like lowered risk of serious illness upon infection (Azarpanah et al., 2021; George et al., 2023). Non-vaccination therefore becomes emotionally safer than vaccination.
Self-Efficacy
This leads into another category of constructs which have demonstrated particular importance to vaccination decisions: self-efficacy, or perceived behavior control. Self-efficacy ties into a person’s self-image, relating to their belief or confidence in their own abilities (Hagger & Hamilton, 2022; Kojan et al., 2022; Lin et al., 2020). Self-efficacy seems to play an interesting moderating role in rates of vaccine uptake. One might expect high levels of risk from infectious disease to lead to increased vaccination rates throughout society. However, when combined with individuals’ perceptions of low self-efficacy, or low belief in one’s own capacity to meaningfully lower that risk, this expected increase does not take place (Kojan et al., 2022; Lin et al., 2020). What appears to actually increase are anxiety-mitigating behaviors, like avoidance of potentially frightening news, or maintenance of familiar schedules and activities (Lin et al., 2020)–if you cannot fix the problem, at least you can make yourself feel better about it.
External Factors
Social Norms
Written or unwritten, social groups generally have rules. Perceived social norms tend to have significant influence on how a person thinks, acts, and makes decisions. There are many possible sources of normative influence: family and friends, coworkers, social clubs, pop culture figures, news media, etc. People who choose not to vaccinate themselves and/or their children generally perceive this as socially normative behavior, expected and acceptable (Latkin et al., 2022; Lin et al., 2020; Shiloh et al., 2022; Zhu et al., 2022). Sometimes, they will even actively distance themselves from attitudes or group-labels on either end of the vaccination-support spectrum that they perceive as abnormal or extreme (George et al., 2023).
Identification with particular social categories sets norms both for in-groups (social groups that an individual identifies themselves with) and against out-groups (social groups that an individual does not identify with). Since what is perceived as socially normal is socially learned (Bandura, 1986), non-vaccination in a social context which encourages, or at least does not discourage, vaccine hesitancy perpetuates the collective idea that non-vaccination is normal, whereas encouraging greater vaccination is not.
There are two general identity-group factors which seem to play significant roles in setting vaccine-related social norms: religiosity (Gomes-Ng et al., 2024; Shiloh et al., 2022), and political partisanship (Keselman et al., 2023; Latkin et al., 2022; Zhu et al., 2022). More frequent religious participation (Gomes-Ng et al., 2024) and greater orthodoxy (Shiloh et al., 2022) correlate with lower intentions to vaccinate. Political conservatism also correlates with lower intentions (Keselman et al., 2023; Zhu et al., 2022), and lower actual vaccine uptake (Latkin et al., 2022).
Social Influence–Family, Friends, and Authorities
When it comes to health, the influence of one’s social circle cannot be overstated, especially in times of heightened stress, like a pandemic (Latkin et al., 2022). Odds are, if someone’s friends or family are not vaccinating, neither are they–vaccine uptake generally positively correlates with the number of close friends or family who have been vaccinated (George et al., 2023; Keselman et al., 2023). Similarly, intentions to vaccinate decrease when individuals believe their family or friends would discourage it or react negatively (Latkin et al., 2022).
Outside of friends and family, the opinions of authority figures tend to hold a lot of weight. A person’s views on vaccination often fall in line with those of people or institutions they believe to be authoritative, be they GPs, religious figures, social media personalities, or politicians (Azarpanah et al., 2021; Keselman et al., 2023).
Remember, normative social influence helps dictate not just how an individual should believe and behave, but what they should expect of others. This feature generally helps people operate smoothly within society, interacting with people who are both like and not like them. It can, however, present challenges when the loudest voices trying to set those norms prove divisive, especially in the face of public health crises where that divisiveness is detrimental to the whole of society–again, like a pandemic.
Sources of Information
Where someone receives information is often as important as what information is received. The most trusted vaccine information sources are not always the most used (Keselman et al., 2023). At the same time, the most available mainstream sources are not always well-trusted (George et al., 2023; Zhu et al., 2022). News media, that most available information source, is itself a sphere of social influence which demands attention and reactivity. The sociopolitical bent of news which viewers consume contributes to the cognitions they create about vaccination, including vaccine safety, the salience of possible adverse events, and the intentions or trustworthiness of institutions promoting them (Keselman et al., 2023; Latkin et al., 2022; Zhu et al., 2022).
Social media is playing an increasingly popular role as a news source (Keselman et al., 2023). While information spreads quickly, it does not always spread equitably–algorithm-fueled platforms continually feed users ideas they have already chosen to engage with, which both facilitates misinformation and reinforces cognitive biases (Gomes-Ng et al., 2024; Latkin et al., 2022). One’s social media feed may become a closed feedback loop of information that is possibly inaccurate but cognitively consistent.
Targets for Challenging Vaccine Hesitancy
The combined internal and external factors involved in social cognition highlight some of the difficulties of challenging vaccine hesitancy. For example, providing vaccine-hesitant populations with scientific evidence or hard data about the benefits of vaccination tends not to actually change minds, and may even result in stronger opposition. That is not to say that misinformation should not be actively challenged when possible, but at-large public health campaigns for vaccination may find more success by changing tactics.
Rebuilding trust in public health figures and institutions is key. Tailored campaigns based on small-scale interpersonal connections between specific communities may have more luck than a one-size-fits-all sort of movement. Rather than simply refuting misinformation, which could fall prey to a number of cognitive biases, these programs should emphasize behavior which prioritizes community responsibility and open communication with friends and family members. Such program tactics operate in the sphere of normative social influence, helping perceptions of trustworthiness and affording greater emotional weight to the information presented by way of closer source proximity.
Additionally, rather than spotlighting threats of harm from disease, campaigns could try to target self-efficacy as it corresponds with disease-preventative behaviors, including vaccination.
Conclusion
In 2019, the World Health Organization officially characterized widespread vaccine hesitancy as one of the most significant threats to global health. As such, it is continually important that we understand the internal factors contributing to vaccine hesitancy, like biases and heuristics, cognitive dissonance, and perceptions of self-efficacy, as well as the external social influences that facilitate and reinforce them. With greater understanding of these mechanisms, we can hopefully develop more effective methods of challenging vaccine misinformation, rebuilding trust in scientists and public health institutions, and promoting vaccine uptake to foster a safer, more healthy world.
References
Azarpanah, H., Farhadloo, M., Vahidov, R., & Pilote, L. (2021). Vaccine hesitancy: Evidence from an adverse events following immunization database, and the role of cognitive biases. BMC Public Health, 21, 1686. https://doi.org/10.1186/s12889-021-11745-1
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice Hall.
Cancino-Montecinos, S., Björklund, F., & Lindholm, T. (2020). A general model of dissonance reduction: Unifying past accounts via an emotion regulation perspective. Frontiers in Psychology, 11, 540081. https://doi.org/10.3389/fpsyg.2020.540081
George, M.F., Rosenberg, B.D., Dale, S.N., Kirkland, L.H., Culross, P.L., & Chen, R. (2023). “They’ll take a gun to me before I take that shot”: Rationalization, emotions, and misinformation in COVID-19 vaccine hesitancy. Social and Personality Psychology Compass, e12815. https://doi.org/1https://doi.org/10.1111/spc3.128150.1111/spc3.12815
Godlee F., Smith, J., & Markovitch, H. (2011). Wakefield’s article linking MMR vaccine and autism was fraudulent. BMJ, 342, c7452. https://doi.org/10.1136/bmj.c7452
Gomes-Ng, S., Wood, J.K., & Cowie, S. (2024). Cognitive flexibility predicts attitudes towards vaccination: Evidence from a New Zealand sample. BMC Psychology, 12, 550. https://doi.org/10.1186/s40359-024-02048-2
Hagger, M.S., & Hamilton, K. (2022). Social cognition theories and behavior change in COVID-19: A conceptual review. Behaviour Research and Therapy, 154, 104095. https://doi.org/10.1016/j.brat.2022.104095
Keselman, A., Arnott Smith, C., Wilson, A.J., Leroy, G., & Kaufman, D.R. (2023). Cognitive and cultural factors that affect general vaccination and COVID-19 vaccination attitudes. Vaccines, 11(1), 94. https://doi.org/10.3390/vaccines11010094