BRIEF RESEARCH REPORT

published: 01 July 2021

doi: 10.3389/fpubh.2021.700213

Risk, Trust, and Flawed Assumptions:

Vaccine Hesitancy During the
COVID-19 Pandemic
Omid V. Ebrahimi 1,2*, Miriam S. Johnson 3† , Sara Ebling 4† , Ole Myklebust Amundsen 4† ,
Øyvind Halsøy 1† , Asle Hoffart 1,2† , Nora Skjerdingstad 1† and Sverre Urnes Johnson 1,2†
1
Department of Psychology, University of Oslo, Oslo, Norway, 2 Modum Bad Psychiatric Hospital, Vikersund, Norway,
3
Department of Behavioural Science, Oslo Metropolitan University, Oslo, Norway, 4 Department of Clinical Psychology,
University of Bergen, Bergen, Norway

Background: The pace at which the present pandemic and future public health crises
involving viral infections are eradicated heavily depends on the availability and routine
Edited by: implementation of vaccines. This process is further affected by a willingness to vaccinate,
Susan Garthus-Niegel,
Medical School Hamburg, Germany
embedded in the phenomenon of vaccine hesitancy. The World Health Organization has
Reviewed by:
listed vaccine hesitancy among the greatest threats to global health, calling for research
Yongxin Li, to identify the factors associated with this phenomenon.
Henan University, China
Bijaya Kumar Padhi, Methods: The present cross-sectional study seeks to investigate the psychological,
Post Graduate Institute of Medical contextual, and sociodemographic factors associated with vaccination hesitancy in a
Education and Research (PGIMER),
India
large sample of the adult population. 4,571 Norwegian adults were recruited through an
*Correspondence:
online survey between January 23 to February 2, 2021. Subgroup analyzes and multiple
Omid V. Ebrahimi logistic regression was utilized to identify the covariates of vaccine hesitancy.
omideb@uio.no
Results: Several subgroups hesitant toward vaccination were identified, including
† These authors have contributed males, rural residents, and parents with children below 18 years of age. No differences
equally to this work
were found between natives and non-natives, across education or age groups.
Specialty section: Individuals preferring unmonitored media platforms (e.g., information from peers, social
This article was submitted to media, online forums, and blogs) more frequently reported hesitance toward vaccination
Public Mental Health,
a section of the journal
than those relying on information obtainment from source-verified platforms. Perceived
Frontiers in Public Health risk of vaccination, belief in the superiority of natural immunity, fear concerning significant
Received: 26 April 2021 others being infected by the virus, and trust in health officials’ dissemination of
Accepted: 31 May 2021
vaccine-related information were identified as key variables related to vaccine hesitancy.
Published: 01 July 2021

Citation: Conclusion: Given the heterogeneous range of variables associated with vaccine
Ebrahimi OV, Johnson MS, Ebling S, hesitancy, additional strategies to eradicate vaccination fears are called for aside from
Amundsen OM, Halsøy Ø, Hoffart A,
Skjerdingstad N and Johnson SU
campaigns targeting the spread of false information. Responding to affective reactions
(2021) Risk, Trust, and Flawed in addition to involving other community leaders besides government and health officials
Assumptions: Vaccine Hesitancy present promising approaches that may aid in combating vaccination hesitation.
During the COVID-19 Pandemic.
Front. Public Health 9:700213. Keywords: vaccine hesitancy, general adult population, COVID-19 pandemic, information platforms, erroneous
doi: 10.3389/fpubh.2021.700213 beliefs, psychological predictors, risk perception, governmental trust

Frontiers in Public Health | www.frontiersin.org 1 July 2021 | Volume 9 | Article 700213

Ebrahimi et al. Vaccine Hesitancy During the COVID-19 Pandemic

1. INTRODUCTION of obtained information about vaccines and the pandemic.

With the ubiquitous presence of news on social media, there
The development of vaccines is considered among the greatest are increased concerns about the reliability and accuracy of
scientific achievements in promoting global health (1–3), with information (19), with a previous study suggesting social media
vaccination programs decreasing the burden of infectious platforms to be more biased toward false, misleading, and
diseases, loss of life, and contributing to strengthening the conspiratorial information about COVID-19 vaccines (20). The
health system as a whole (4–6). However, reaping such benefits present study thus seeks to empirically investigate the association
depends upon a willingness to vaccinate, as encapsulated in between vaccine hesitancy and these theorized factors, adapting
the phenomenon of vaccine hesitation, referring to a delay a multifactorial approach in order to identify the relative
in acceptance or refusal of vaccines despite availability of importance of included predictors while controlling for all other
vaccination services (7). Vaccine hesitancy is according to the variables in the analyzes. Consequently, the strongest factors
WHO (7) among the top 10 threats to global health, with the associated with vaccine hesitancy are identified, presenting
necessity of identifying the psychological and sociodemographic important implications for public health during the present and
factors interconnected with such hesitancy deemed as urgent. forthcoming pandemics.
Additionally, the public’s dependability on an efficacious vaccine
has been alarmingly demonstrated during the present pandemic,
with the pace of the pandemic’s course directly interwoven
2. MATERIALS AND METHODS
with the availability and routine implementation of vaccines. This report is carried out in conformity with the guidelines
Meanwhile, the procedural implementation of mass vaccination of the Strengthening the Reporting of Observational Studies in
programs is heavily dependent on low vaccine hesitancy, with Epidemiology statement [STROBE; (21)]. Ethical approval of the
the phenomenon becoming a growing concern in relation to study was granted by The Regional Committee for Medical and
emerging infectious diseases and further being considered as a Health Research Ethics (reference: 125510).
major threat toward the successful roll-out of vaccines during the
present and forthcoming pandemics (8). 2.1. Participants and Procedure
Parallel with the rapid and ongoing developments of several The present article is part of The Norwegian COVID-19, Mental
vaccines against COVID-19 globally, recent studies on hesitancy Health and Adherence Project, consisting of data from the fourth
toward the COVID-19 vaccines have provided preliminary wave of data collection. At the first wave of data collection (i.e.,
insight concerning some of the covariates characterizing vaccine between March 31 and April 7, 2020), 10,061 participants were
hesitant individuals. The literature has hitherto indicated that recruited through an online survey disseminated via national,
those who perceive COVID-19 as a severe disease have a regional, and local information platforms (i.e., television, radio,
higher vaccination intention (9). Studies have also indicated and newspapers), in addition to dissemination to a random
that the novelty and rapid development of vaccines may have selection of Norwegian adults through a Facebook Business
impacted the perceived risk of vaccination, with highlighted algorithm. This procedure is elaborated in detail elsewhere (22).
fearful cognitions concerning the pace and novel technologies All respondents were re-contacted for participation for the fourth
utilized (i.e., mRNA vaccines) contrasting with conventional wave of data collection between January 23 and February 2,
vaccine development approaches (10). Among promotive factors, 2021, of which 4,571 were eligible for the present study. The
trust in health officials has been highlighted as a possible factor criterion variable of the present study (i.e., vaccine hesitancy) was
which may decrease individuals’ perception of vaccination risks measured during the fourth wave of data collection, thus yielding
(11). Despite these preliminary advances, several factors of a cross-sectional study consisting of responses at the fourth wave
importance remain uninvestigated. of the project. Eligible participants included all individuals of
The hesitancy to vaccinate is theorized to be connected 18 years and above (i.e., adults), who were living in Norway
to a broad array of cognitive, social, and contextual factors. and thus experiencing identical social distancing protocols. The
Subjective risk perception of vaccine acceptance (12) may be interval between January 23 and February 2, 2021 characterized
affected by psychological dispositions, fear of side effects, health- a period where strict social distancing protocols had been re-
related fears, beliefs and cognitions (13), and confirmatory implemented to a maximum. Among the implemented protocols
biases involving pursuance of information congruous with one’s were restrictions of leaving one’s home unless necessary, home
established beliefs about vaccines (14, 15). Questioning the isolation if infected, quarantine after exposure to possible
legitimacy of science (16), trust in government and health care infection, restrictions on traveling, and prohibitions of social
officials, increased accessibility of dramatic individual experience gatherings and events.
across social media platforms, and major public health and
vaccine scares in the media include factors of relevance that 2.2. Study Design
may covary with vaccination hesitation (13). Furthermore, the The present cross-sectional study was designed to control
relationship between general adherence to pandemic mitigation for the impact of viral mitigation protocols (i.e., physical
protocols and vaccination intention warrants investigation distancing protocols), in addition to expectation effects with
given the association between other preventive behaviors, respect to these strategies. Consequently, a stopping rule for data
including social distancing and hygienic behaviors (17, 18). collection was construed to end collection immediately if viral
Another plausible factor of importance concerns the source mitigation protocols were modified or if new information about

Frontiers in Public Health | www.frontiersin.org 2 July 2021 | Volume 9 | Article 700213

Ebrahimi et al. Vaccine Hesitancy During the COVID-19 Pandemic

forthcoming modifications were provided. The data collection and preferred information obtainment from friends, family
period was planned to last for 14 days, but was interrupted after and peers.
11 days with respect to the stopping rule as novel information Adherence to pandemic mitigation protocols was measured
about modification of mitigation protocols was provided (23), by asking participants how well they were able to adhere to the
thus keeping expectation effects constant. hygienic behavior-recommendation (e.g., covering mouth and
nose with a tissue or elbows when coughing and sneezing, and
avoidance of touching the eye, nose and mouth area) and the
2.3. Measurement social distancing protocols (e.g., maintaining one meter distance
2.3.1. Demographic Information to individuals not in one’s household) implemented in Norway
The participants reported their age, sex, education, ethnical at the time of data collection, measured on a continuous scale
background, employment sector, parental status, and residency ranging from 0 to 100, with the left anchor labeled “Not at all
in urban vs. rural areas. (0% of the time)” and the right anchor labeled “Fully (100% of
the time).” All fully continuous measures were re-scaled from a
2.3.2. Measurement of Vaccine Hesitancy and 0–100 to a 0–10 scale for ease of interpretation.
Vaccine-Relevant Beliefs
Vaccine hesitancy was measured by asking participants whether 2.4. Statistical Analyzes
they planned to vaccinate themselves against COVID-19 when All statistical analyzes were performed using R [Version
offered a vaccine on a binary scale (Yes vs. No), with individuals 4.0.2; (25)]. Descriptive analyzes concerning subgroups were
responding ‘No’ being coded as hesitant toward vaccination. reported applying percentages and proportions, using chi-square
Perceived risk of vaccination was measured by asking statistics to test differences between subgroups. To inspect
participants how risky they judged vaccinating themselves the predictors of vaccination hesitancy, a two-step hierarchical
against COVID-19 on a continuous scale ranging from 0 to 100, logistic regression was conducted with vaccine hesitancy as the
with the left anchor labeled “No risk at all” and the right anchor criterion variable. The first step of the model involved the
labeled “Maximum risk.” demographic background variables (i.e., sex, age, and education)
Participants’ beliefs in the superiority of natural immunity to control for the potential confounding influence of these, in
as compared to vaccination was measured by asking them addition to identifying the demographic risk factors associated
to rate the statement “Overall, I believe it is less risky or with the criterion variable. The second step of the model included
dangerous for me to obtain natural immunity as compared to the mentioned variables (see Measurement section) concerning
vaccinating myself against the coronavirus”, rated on a five-point vaccine-relevant beliefs, contextual, and psychological variables.
Likert scale (1–5; 1 = Completely Disagree, 5 = Completely Improvements in model fit was evaluated using the Akaike
Agree). Participants further reported their degree of trust in the Information Criterion (AIC). Odds ratios along with their 95%
vaccination information disseminated by the government and confidence intervals are provided. To further estimate model fit
health-care officials on a five-point Likert scale (1–5; 1 = Not at and explanatory power, the confusion matrix was inspected, with
all, 5 = Completely). the diagonal revealing the correctly identified cases of vaccination
hesitancy and vaccination intention given the specified model as
2.3.3. Other Psychological and Contextual Variables compared to the observed data.
The Obsession with COVID-19 Scale [OCS; (24)] was used to
measure persistent and obsessive thinking about COVID-19, 3. RESULTS
consisting of a five-point Likert scale (0: Not at all to 4: Nearly
every day over the last 2 weeks). The internal consistency of this 3.1. Sample Characteristics
scale was good in this sample, with a Cronbach’s alpha of 0.78. The sample consisted of 4,571 participants, with the age ranging
Fear of significant others being infected was measured with from 18 to 86 with a mean of 36.66 years (SD = 13.72). The
the item "I fear that someone close to me may contract the demographic details of the participants is presented in Table 1.
coronavirus," rated on a four-point Likert scale (0–3; 0 = Not at Approximately 78% of the sample were females, with all analyzed
all, 4 = Nearly every day). subgroups richly represented in the study (e.g., N = 999 males),
Participants were further asked whether they were subject to and sensitivity analyzes on the same group of participants [see,
strict social distancing protocols, including visitation regulation, (22)] revealing the sample as accurate and representative for
quarantine, and isolation, providing the duration of which they the general adult population following a) analysis solely on the
were subject to these protocols in the unit of weeks. The time- randomly selected proportion of participants, in addition to b)
scale of the length of exposure to strict distancing protocols was analysis on an adjusted, post-stratified and weighted sample,
transformed from weeks to months. both of which replicated and demonstrated indifferent results
Media preference source was measured by asking participants as the main sample. The sample was further geographically
to disclose their preferred media platform in obtaining representative of Norway, with the ratio of individuals from each
information about the pandemic, with source-verified platforms region closely approximating the population distribution.
consisting of source-checked and recognized national, regional,
and local television, newspapers, and radio channels, and 3.2. Vaccine Hesitancy Among Subgroups
unmonitored sources consisting of social media platforms Overall, 478 (10.46%) participants reported being hesitant toward
(e.g., Instagram, Snapchat, Tiktok), online forums and blogs, vaccination. Table 2 presents the proportions and percentages

Frontiers in Public Health | www.frontiersin.org 3 July 2021 | Volume 9 | Article 700213

Ebrahimi et al. Vaccine Hesitancy During the COVID-19 Pandemic

TABLE 1 | Demographic characteristics. TABLE 3 | A hierarchical logistic regression model revealing the predictors of
vaccine hesitancy.
All participants
N 4,571 (100.00%) Step Predictor Logit SE OR (95% CI) p

Sex
1 Demographic control variables
Female 3,560 (77.88%)
Sexa 0.252 0.114 1.287 (1.026, 1.605) 0.027
Male 999 (21.86%)
Age 0.002 0.004 1.002 (0.995, 1.009) 0.608
Education
Education –0.060 0.052 0.942 (0.852, 1.044) 0.248
Completed Junior High School 227 (4.97%)
2 Psychological and contextual variables
Completed High School 807 (17.65%)
Perceived risk of 0.287 0.026 1.332 (1.265, 1.404) < 0.001
Currently studying 911 (19.93%) vaccination
Completed University Degree 2,626 (57.45%) Belief in superiority of 0.980 0.065 2.663 (2.350, 3.028) < 0.001
Age group, years natural immunity
18–30 1971 (43.12%) Trust in disseminated –0.772 0.067 0.462 (0.405, 0.526) < 0.001
31–44 1369 (29.95%) information
45–64 1037 (22.69%) about vaccination from
65+ 194 (4.24%) health officials
Obsession with –0.057 0.029 0.945 (0.892, 1.000) 0.054
COVID-19
TABLE 2 | Proportions and percentages of different subgroups expressing Fear of significant –0.344 0.095 0.709 (0.587, 0.853) < 0.001
hesitation toward vaccination.
others being infected
N Hesitancya Chi-square test by the virus
Adherence to –0.105 0.042 0.900 (0.829, 0.977) 0.011
All participants 4,571 10.46% pandemic
Health-care sector employee χ 2 (1, N = 4,571) = 6.10, strict distancing
p = 0.014 protocols
Yes 1,301 8.67% Length of exposure to 0.042 0.020 1.043 (1.002, 1.085) 0.041
No 3,270 11.16% strict distancing
Natives and immigrants χ 2 (1, N = 4,571) = 0.74, protocols
p = 0.385 a Male (1), Female (0).
Immigrants 270 8.89%
Natives 4301 10.56%
Rural and urban residency χ 2 (1, N = 3,431) = 13.93, 3.3. Psychosocial Predictors of Vaccine
p < 0.001
Urban resident 2943 9.11%
Hesitancy
Rural resident 488 15.55%
The hierarchical logistic regression model investigating
predictors of vaccine hesitancy may be found in Table 3. The
Media preference χ 2 (1, N = 3,354) = 13.58,
p < 0.001 confusion matrix revealed excellent model fit and performance,
Source-verified media platforms 2,937 9.13% with the specified model correctly predicting 92.30% of the
Unmonitored media platforms 417 14.87% cases of vaccination hesitancy and vaccination intention. The
Has children below 18 years χ 2 (1, N = 4,571) = 18.63,
model substantially improved from Step 1 to Step 2 with the
p < 0.001 AIC equal to 3,056 at Step 1 and 1,722 at Step 2. Among the
Yes 1,484 13.28% demographic variables, only sex was significantly associated with
No 3,087 9.10% vaccine hesitancy, with the odds of males being hesitant toward
vaccination larger by a factor of 1.29 as compared to females.
a Percentage of subgroup hesitant toward vaccination.
Age and education were unrelated to vaccination hesitancy.
Concerning the psychological and contextual variables, a one
unit increase in perceived risk of vaccination increased the odds
of specific subgroups’ vaccine hesitancy. Individuals with a of vaccine hesitancy by 1.33. Stronger belief in superiority of
preference for unmonitored media platforms as compared to natural immunity as compared to vaccination was associated
those preferring source-verified media platforms had a near 2- with vaccine hesitancy, with a one-unit increase elevating the
fold (i.e., 1.64) odds of being hesitant toward vaccination. Rural odds of vaccine hesitancy by a factor of 2.66. For a one unit
residents had a near 2-fold (i.e., 1.71) odds of being hesitant increase in trust of disseminated information about vaccination
toward vaccination compared to urban residents. Parents with from health officials and governments, the odds of being hesitant
children aged below 18 had 1.46 times higher odds of reporting toward vaccination was smaller by a factor of 0.46. For a one
vaccine hesitancy. Health-sector employees were less hesitant unit increase in fearing that significant others may be infected by
toward vaccination by a factor of 0.78. No difference was found coronavirus, the odds of vaccine hesitancy was smaller by a factor
between immigrants and natives concerning vaccine hesitancy. of 0.71. Per months increase in having predominantly socially

Frontiers in Public Health | www.frontiersin.org 4 July 2021 | Volume 9 | Article 700213

Ebrahimi et al. Vaccine Hesitancy During the COVID-19 Pandemic

distanced oneself (e.g., as a result of quarantine), the odds of implemented campaigns translating vaccination and pandemic-
being hesitant toward vaccination increased by 1.04. For a one related information in the native languages of minority groups
unit increase in adherence to pandemic mitigation protocols, the seems to have been an appropriate precautionary strategy in
odds of vaccination hesitation was smaller by a factor of 0.90. preventing the development of such forecasted problems.
Obsession with COVID-19 was unrelated to vaccine hesitancy. Moreover, the importance of combating false information
from unmonitored media sources is underscored in the
present study, further accentuated through findings illustrating
4. DISCUSSION that exposure to as little as 5–10 min of negative and
inaccurate information about vaccines increases the risk
The pace of which the pandemic crisis is eradicated heavily perception associated with vaccination (35). The present study
depends on vaccination and the successful combating of extends the literature by empirically revealing that information
vaccination hesitancy. Furthermore, incidences of public health obtainment from unmonitored platforms further is associated
scares related to vaccines as exemplified by the AstraZeneca with vaccination hesitation, beyond and above the influence of
public health scare (26) is likely to increase the observed rates such platforms on risk perception. Additionally, this association
of vaccine hesitancy. Thus, empirical findings concerning the is found between other important types of information platforms
predictors of vaccination hesitation, including the subgroups at other than social media. Thus, the present study highlights the
greater risk for such hesitancy is of imperative value in the present importance of extending the efforts to prevent the spread of
and forthcoming pandemics. misinformation beyond social media platforms. Social media
The presented results indicate that around 11% of the sample platforms will however continue to be an important battleground
displayed vaccine hesitancy, meaning that the majority of the to hinder misinformation. Given lower levels of editorial
sample (89%) intend to vaccinate when given the opportunity. oversight, social media use has previously been found to be
The results portray somewhat less skepticism toward vaccination related to overestimation of vaccine risks, thus explaining the
in the Norwegian population compared to other countries across greater likelihood of hesitancy among social media users (20, 36),
Europe. Vaccine hesitancy rates in European countries in the first revealing in conjunction with the present findings that it will
half of 2020 (i.e., February until the end of May) ranged from 17 be important to sustain the misinformation-prevention efforts
to 38%, and in the second half of 2020 (i.e., June until December) directed at these ubiquitous platforms. The present study further
ranged from 25 to 46% (8, 27). A plausible explanation for the found an association between a prevalent contextual factor,
lower prevalence of vaccination hesitancy in Norway includes namely adherence to general pandemic protocols (e.g., hygiene-
the high level of trust in health and governmental officials in behavior adherence) and vaccination hesitancy, highlighting
the Norwegian population and the Nordic countries in general that those who adhere to pandemic protocols more likely to
(28, 29). Indeed, this was reflected in the aforementioned studies be associated with intentions to vaccinate, identifying non-
on vaccine hesitancy, identifying less frequent vaccine hesitancy adherent individuals as an in-risk group. It is however interesting
in the Nordic countries compared to other nations. to note that length of exposure to strict distancing protocols
Comparisons across subgroups led to the identification of (e.g., isolation and quarantine) was associated with vaccination
the following groups more frequently reporting vaccination hesitation. A possible explanation of this finding may include
hesitancy: people not working in the health sector, those living in that some of the individuals experiencing such strict protocols
rural vs. urban districts, people preferring information obtained of prolonged length are those in isolation as a result of
from non-monitored information sources rather than source- having contracted the disease, thus possibly developing beliefs of
verified media platforms (e.g., national newspapers and television being immune to the disease. Given the possibility of multiple
channels), and parents of children below 18 years of age. People infections by the virus, efforts to clarify such misconceptions are
in the health sector are likely more able to realistically evaluate imperative. In sum, the presented results point toward several
the benefits and risks of vaccines and less prone toward the subgroups that could benefit from tailored campaigns aimed at
type of erroneous conclusions (e.g., belief in greater benefits of reducing vaccine hesitancy.
natural immunity) and overestimation of risks which were here In examining the psychological predictors of vaccine
found to be related to vaccine hesitation. Moreover, parents tend hesitancy, central demographic characteristics were controlled
to feel more responsible for their children than for themselves for. Being male was slightly associated with hesitancy toward
and their perception of vaccine risk accordingly seems to vaccination. This finding is diverges from a recent review
be increased, echoing previous findings (30, 31). The finding exploring vaccine hesitancy and intention during the ongoing
that rural residents were more likely to be hesitant toward pandemic [see (37)], with more frequent hesitancy found among
vaccination is further consistent with findings showing more females compared to males. A possible explanation of this
vaccine resistance among people residing in the suburbs than inconsistency could reflect the fact that Norwegian females to a
in cities (32). Importantly, although highlighted as a concern greater extent than males seek out health services [Norwegian
in the literature (33, 34), the present study found no empirical health service use (38)]. This finding could also be mirrored
support for the notion that immigrants display more skepticism by the fact a larger proportion of females are employed in the
toward vaccination compared to natives. This has been a Norwegian health sector, with health-care workers found to
theorized concern assuming less access to public information display less prevalent hesitance toward vaccination in a previous
as a relevant factor (33, 34). Thus, the Norwegian governments (39) and the present study.

Frontiers in Public Health | www.frontiersin.org 5 July 2021 | Volume 9 | Article 700213

Ebrahimi et al. Vaccine Hesitancy During the COVID-19 Pandemic

The results further highlight the importance of considering highlights the importance of strengthening the government as a
the cognitive and emotional risk-benefit evaluation processes credible sender of information, something which is threatened
ongoing in individuals, with those perceiving that the risk by digital misinformation (47, 48). Importantly, other sources of
of vaccination greater than the risk of being infected by the information should be incorporated in the vaccine campaigns,
disease more likely to report hesitancy toward vaccination. such as religious or political leaders, healthcare workers, or other
Consistent with previous findings, increased risk perception influential members of the community [European Centre for
was associated with vaccination hesitancy (9, 40). Moreover, Disease Prevention and Control (49)], not solely leaning on
the present study found specific belief sets to be related to the information dissemination by the government and health
vaccine hesitancy, with stronger belief that obtaining natural officials. Such a wide dissemination strategy may be a potent
immunity is less dangerous than vaccinating being associated strategy in lowering vaccination hesitancy by increasing the
with vaccination hesitation. Given the stressed necessity of probability of reaching out to skeptical and hesitant individuals
vaccination implementation procedures in eradicating the through alternative sources which they trust.
coronavirus (41), accurate information regarding the actual Finally, this study reveals that individuals fearing that
effect of natural immunity vs. vaccination and the associated someone closely related to them could potentially be infected by
risk factors should be disseminated to the general population. the virus less frequently reported hesitance toward vaccination.
Achieving natural immunity through infection rather than Accordingly, the encouragement of the prosocial implications of
vaccines puts individuals at greater risk when considering vaccination and caring about the welfare of others may be a utile
the reports of long-term complications after infection with strategy of lowering hesitance, previously found to be positively
COVID-19, and the large proportion of COVID-related deaths associated with vaccination intent in the population [e.g., (50,
that follows a herd immunity strategy (42, 43). Thus, such 51)]. These results point toward lifting the focus from the
maladaptive beliefs must be combated to impede the health- individual costs of vaccination toward the negative consequences
related risks for those withholding them in addition to society at of non-vaccination for others (e.g., family members, elderly,
large. In light of recent public health scares and the rapid pace at people with underlying diseases) and society at large, which may
which information spreads (e.g., digitally), fearful and inaccurate further aid in reducing vaccine hesitancy.
vaccine beliefs are likely to increase and flourish across social
media and other digital platforms (44). Thus, health officials must 4.1. Strengths and Limitations
identify outlets and information channels where groups with The present has several limitations, including its cross-sectional
such beliefs and more prevalent degrees of vaccine hesitancy are design precluding causal conclusions, and that random selection
found and further given the possibility of dialogue, which may was not conducted on the full sample due to the online
minimize the reactivity associated with distrusting the messenger dissemination strategy chosen. As this strategy plausibly is
and thus have the possibility to foster the grounds upon which less accessible to elderly, we had to recruit elderly adults
inaccurate perceptions of vaccination risks may be corrected. through broadcastings on national television, radios, and
Acknowledging fears, anger and other negative emotions while newspapers, thus leaving parts of the sample non-randomly
emphasizing the safety of COVID-19 vaccines may provide aid selected. Notwithstanding, these efforts to provide the full adult
in reducing vaccine hesitancy. Indeed, several scholars have population an equal opportunity to participate proved futile, with
highlighted the limitation of communication strategies solely the resulting sample revealed as representative with no influence
relying on fact checking, emphasizing the need for effective demonstrated in sensitivity analyzes by the few undersampled
communication to address emotional responses and cognitive subgroups (e.g., less males and elderly) on the results (22). Given
biases that may arise during pandemics [e.g., (45)]. Additional the lack of existing measures for some of the variables related
aid toward this aim may be achieved by appealing to altruism, to the research questions of this investigation, several variables
framing vaccination as a step toward a meaningful goal for the were adapted and developed for the present study, thus being
society as a whole, creating a sense of communion in the battle untested across other settings and serving as a limitation of
against the virus (46). this study. The study also includes several strengths, including
The present study demonstrates that trust in disseminated the fit and performance of the model, large sample size, and
information about vaccination from the government and health simultaneous investigation of a multitude of relevant variables
officials was associated with less frequent vaccination hesitancy. providing more robust estimates of factors while controlling
Clever strategies are required to reach individuals who distrust for the impact of all relevant predictors. It is noteworthy that
information from their government and health officials with investigations involving sensitive criterion variables, including
accurate information concerning risks, which have the ability of the present study on vaccine hesitancy, may be susceptible to
modifying risk perceptions and beliefs about natural immunity. the Hawthorne effect, which postulates that participants may
It is thus imperative for health officials to propagate such alter their responses and attitudes toward a phenomenon when
information in a manner which minimizes reactivity from the knowing they are being investigated. The potential presence of
more distrusting and skeptical subgroup of the population. such an effect could thus have led to underestimations of vaccine
One possibly utile strategy may include information campaigns hesitancy in the general population. However, the present study
through platforms which information dodgers less typically was designed to contain the set of sensitive questions concerning
avoid, such as the dissemination of information in-between vaccination between larger sets of measures related to other
entertainment programs (e.g., TV-series). This finding further phenomena (e.g., sleep difficulties), thus increasing the chance of

Frontiers in Public Health | www.frontiersin.org 6 July 2021 | Volume 9 | Article 700213

Ebrahimi et al. Vaccine Hesitancy During the COVID-19 Pandemic

suppressing such reactivity given the efforts undertaken to mask data are to be kept at a secure server only accessible by the authors
the research question. at the University of Oslo. Access to the data can be granted from
the principal investigators Omid V. Ebrahimi and Sverre Urnes
4.2. Concluding Remarks Johnson following ethical approval of a suggested project plan
Vaccine hesitancy is interwoven with an array of psychological, for the use of data from NSD and REK. Requests to access the
demographic, and contextual factors, including political and datasets should be directed to omideb@uio.no.
systemic factors. The phenomenon is tied to impeding pandemic
eradication, in addition to increasing the risk of vaccine-
preventable disease and death toll during pandemics. Thus, the ETHICS STATEMENT
empirical underpinnings of vaccine hesitancy are not only of
The studies involving human participants were reviewed and
importance during the present, but also forthcoming pandemics.
approved by The Regional Committee for Medical and Health
The present study investigated a multitude of factors
Research Ethics (reference: 125510). The patients/participants
associated with vaccine hesitancy, laying the grounds for possible
provided their written informed consent to participate
strategies that may be of benefit in reducing hesitation and
in this study.
worth pursuing in upcoming studies for further validation. On
the individual level, the present findings suggest that emphasis
should be placed on the perceived risk of vaccination, and AUTHOR CONTRIBUTIONS
further highlight the importance of combating the inaccurate
assumption of superiority of natural immunity. Interventions OVE designed the study, conducted the data collection, and
on the community level impact larger numbers of individuals performed the data analyzes under the supervision of AH
and should be prioritized. At this level, proposed ways to and SJ. The literature review was conducted by OVE, SE,
counter vaccine hesitancy includes transparency in policy- NS, MJ, OMA, and ØH. All authors contributed to the
making decisions regarding the vaccination program and clear discussion of the results in addition to writing and revision
provision of information about the rigorous process that underlie the manuscript under the supervision of OVE and SJ. The
the approval of new vaccines. Given the highly heterogenous final revision and preparatory work of the manuscript was
covariates associated with vaccination hesitancy, additional cues done by OVE. OMA and OVE formatted the manuscript
besides provision of rational and fact-based information are for submission.
called for. Finally, to compensate for the detrimental association
between vaccination hesitancy and low trust in governments and FUNDING
health officials, the involvement and aid of other community
leaders are called for and of importance. This paper is a collaborative effort by the COPE (Complexity
in treatment Outcome, Psychopathology and Epidemiology)
DATA AVAILABILITY STATEMENT Research Team. The authors are employed by the University
of Oslo, University of Bergen, and Modum Bad Psychiatric
Our received ethical approval precludes us from submitting the Hospital. The funders of the project had no role in any part of
data to a public repository. In line with the ethics approval, the the study.

REFERENCES 8. Lazarus JV, Ratzan SC, Palayew A, Gostin LO, Larson HJ, Rabin K, et al. A
global survey of potential acceptance of a COVID-19 vaccine. Nat Med . (2021)
1. Plotkin S. History of vaccination. Proc Natl. Acad Sci USA. (2014) 27:225–28. doi: 10.1038/s41591-020-1124-9
111:12283–7. doi: 10.1073/pnas.1400472111 9. Karlsson LC, Soveri A, Lewandowsky S, Karlsson L, Karlsson H, Nolvi S, et al.
2. Greenwood B. The contribution of vaccination to global health: past, Fearing the disease or the vaccine: the case of COVID-19. Pers Individ Diff.
present and future. Phil R Soc B Biol Sci . (2014) 369:20130433. (2021) 172:110590. doi: 10.1016/j.paid.2020.110590
doi: 10.1098/rstb.2013.0433 10. Pardi N, Hogan MJ, Porter FW, Weissman D. mRNA vaccines—a new era in
3. Plotkin SA, Plotkin SA. Correlates of vaccine-induced immunity. Clin Infect vaccinology. Nat Rev Drug Dis. (2018) 17:261. doi: 10.1038/nrd.2017.243
Dis. (2008) 47:401–9. doi: 10.1086/589862 11. Marlow LA, Waller J, Wardle J. Trust and experience as predictors of HPV
4. McGovern ME, Canning D. Vaccination and all-cause child mortality from vaccine acceptance. Hum Vaccin. (2007) 3:171–75. doi: 10.4161/hv.3.5.4310
1985 to 2011: global evidence from the demographic and health surveys. Am J 12. Larson HJ, Jarrett C, Eckersberger E, Smith DM, Paterson P. Understanding
Epidemiol. (2015) 182:791–8. doi: 10.1093/aje/kwv125 vaccine hesitancy around vaccines and vaccination from a global perspective:
5. Rémy V, Largeron N, Quilici S, Carroll S. The economic value of vaccination: a systematic review of published literature, 2007-2012. Vaccine. (2014)
why prevention is wealth. J Market Access Health Policy. (2015) 3:29284. 32:2150–9. doi: 10.1016/j.vaccine.2014.01.081
doi: 10.3402/jmahp.v3.29284 13. Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger JA. Vaccine
6. Bloom DE, Fan VY, Sevilla J. The broad socioeconomic benefits of hesitancy: an overview. Hum Vaccin Immunother. (2013) 9:1763–73.
vaccination. Sci Transl Med. (2018) 10:eaaj2345. doi: 10.1126/scitranslmed.a doi: 10.4161/hv.24657
aj2345 14. Brewer NT, Chapman GB, Gibbons FX, Gerrard M, McCaul KD, Weinstein
7. WHO. Ten Threats to Global Health in 2019. (2019). Available online ND. Meta-analysis of the relationship between risk perception and health
at: https://www.who.int/news-room/spotlight/ten-threats-to-global-health- behavior: the example of vaccination. Health Psychol. (2007) 26:136.
in-2019 (accessed April 22, 2021). doi: 10.1037/0278-6133.26.2.136

Frontiers in Public Health | www.frontiersin.org 7 July 2021 | Volume 9 | Article 700213

Ebrahimi et al. Vaccine Hesitancy During the COVID-19 Pandemic

15. Salvador Casara BG, Suitner C, Bettinsoli ML. Viral suspicions: 35. Betsch C, Renkewitz F, Betsch T, Ulshöfer C. The influence of vaccine-critical
vaccine hesitancy in the Web 2.0. J Exp Psychol Appl. (2019) 25:354. websites on perceiving vaccination risks. J Health Psychol. (2010) 15:446–55.
doi: 10.1037/xap0000211 doi: 10.1177/1359105309353647
16. Kata A. Anti-vaccine activists, Web 2.0, and the postmodern paradigm-An 36. Wilson SL, Wiysonge C. Social media and vaccine hesitancy. BMJ Glob Health.
overview of tactics and tropes used online by the anti-vaccination movement. (2020) 5:e004206. doi: 10.1136/bmjgh-2020-004206
Vaccine. (2012) 30:3778–89. doi: 10.1016/j.vaccine.2011.11.112 37. Zintel S, Flock C, Arbogast AL, Forster A, von Wagner C,
17. Dryhurst S, Schneider CR, Kerr J, Freeman AL, Recchia G, Van Der Bles AM, Sieverding M. Gender differences in the intention to get
et al. Risk perceptions of COVID-19 around the world. J Risk Res. (2020) vaccinated against COVID-19-a systematic review and meta-
23:994–1006. doi: 10.1080/13669877.2020.1758193 analysis. Europe PMC, SSRN. (2021) doi: 10.2139/ssrn.38
18. Ebrahimi OV, Hoffart A, Johnson SU. Factors Associated With Adherence 03323
to Social Distancing Protocols and Hygienic Behavior During the COVID-19 38. SSB. Dette er Kvinner og Menn i Norge. (2018). Available online at: https://
Pandemic. (2020). Available online at: psyarxiv.com/h7wmj www.ssb.no/befolkning/artikler-og-publikasjoner/_attachment/341883?_ts=
19. Browne M. Epistemic divides and ontological confusions: the psychology 1632b8b8550 (accessed April 22, 2021).
of vaccine scepticism. Hum Vaccin Immunother. (2018) 14:2540–2. 39. Dror AA, Eisenbach N, Taiber S, Morozov NG, Mizrachi M, Zigron
doi: 10.1080/21645515.2018.1480244 A, et al. Vaccine hesitancy: the next challenge in the fight against
20. Puri N, Coomes EA, Haghbayan H, Gunaratne K. Social media and COVID-19. Eur J Epidemiol. (2020) 35:775–9. doi: 10.1007/s10654-020-0
vaccine hesitancy: new updates for the era of COVID-19 and globalized 0671-y
infectious diseases. Hum Vaccin Immunother. (2020) 16:2586–93. 40. Rey D, Fressard L, Cortaredona S, Bocquier A, Gautier A, Peretti-Watel P, et al.
doi: 10.1080/21645515.2020.1780846 Vaccine hesitancy in the French population in 2016, and its association with
21. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, vaccine uptake and perceived vaccine risk-benefit balance. Eurosurveillance.
Vandenbroucke JP. The strengthening the reporting of observational (2018) 23:17–00816. doi: 10.2807/1560-7917.ES.2018.23.17.17-00816
studies in epidemiology (STROBE) statement: guidelines for 41. WHO. Draft Landscape and Tracker of COVID-19 Candidate Vaccines.
reporting observational studies. Ann Intern Med. (2007) 147:573–7. (2020). Available online at: https://www.who.int/publications/m/item/draft-
doi: 10.7326/0003-4819-147-8-200710160-00010 landscape-of-covid-19-candidate-vaccines (accessed April 22, 2021).
22. Ebrahimi OV, Hoffart A, Johnson SU. Physical distancing and mental 42. Fontanet A, Cauchemez S. COVID-19 herd immunity: where are
health during the COVID-19 pandemic: factors associated with psychological we? Nat Rev Immunol. (2020) 20:583–4. doi: 10.1038/s41577-020-0
symptoms and adherence to pandemic mitigation strategies. Clin Psychol Sci. 0451-5
(2021) 9:489–506. doi: 10.1177/2167702621994545 43. Randolph HE, Barreiro LB. Herd immunity: understanding COVID-19.
23. The Norwegian Government. Timeline: News From Norwegian Ministries Immunity. (2020) 52:737–41. doi: 10.1016/j.immuni.2020.04.012
About the Coronavirus Disease Covid-19. (2021). Available online at: https:// 44. Romer D, Jamieson KH. Conspiracy theories as barriers to controlling
www.regjeringen.no/no/tema/Koronasituasjonen/tidslinje-koronaviruset/ the spread of COVID-19 in the US. Soc Sci Med. (2020) 263:113356.
id2692402/ (accessed March 03, 2021). doi: 10.1016/j.socscimed.2020.113356
24. Lee SA. How much “Thinking” about COVID-19 is clinically dysfunctional? 45. Chou WYS, Budenz A. Considering Emotion in COVID-
Brain Behav Immun. (2020) 87:97–8.doi: 10.1016/j.bbi.2020.04.067 19 vaccine communication: addressing vaccine hesitancy and
25. R Core Team. R: A Language and Environment for Statistical Computing. fostering vaccine confidence. Health Commun. (2020) 35:1718–22.
Vienna: R Foundation for Statistical Computing (2021). doi: 10.1080/10410236.2020.1838096
26. YouGov. Extent of Damage to AstraZeneca Vaccine’s Perceived Safety in 46. Luchetti M, Lee JH, Aschwanden D, Sesker A, Strickhouser JE, Terracciano
Europe Revealed. (2021). Available online at: https://yougov.co.uk/topics/ A, et al. The trajectory of loneliness in response to COVID-19. Am Psychol.
international/articles-reports/2021/03/07/extent-damage-astrazeneca- (2020) doi: 10.1037/amp0000690
vaccines-perceived-safet (accessed March 26, 2021). 47. Balog-Way DH, McComas KA. COVID-19: Reflections on
27. Sallam M. COVID-19 vaccine hesitancy worldwide: a concise trust, tradeoffs, and preparedness. J Risk Res. (2020) 23:838–48.
systematic review of vaccine acceptance rates. Vaccines. (2021) 9:160. doi: 10.1080/13669877.2020.1758192
doi: 10.3390/vaccines9020160 48. Bunker D. Who do you trust? The digital destruction of shared situational
28. Edlund J. Trust in government and welfare regimes: attitudes to redistribution awareness and the COVID-19 infodemic. Int J Inf Manage. (2020) 55:102201.
and financial cheating in the USA and Norway. Eur J Political Res. (1999) doi: 10.1016/j.ijinfomgt.2020.102201
35:341–370. doi: 10.1111/1475-6765.00452 49. ECDC. Catalogue of Interventions Addressing Vaccine Hesitancy. (2017).
29. Stein J, Buck M, Bjørnå H. The centre-periphery dimension and trust Available online at: https://www.ecdc.europa.eu/sites/default/files/
in politicians: the case of Norway. Territ Politics Govern. (2019) 9:37–95. documents/Catalogue-interventions-vaccine-hesitancy.pdf (accessed April
doi: 10.1080/21622671.2019.1624191 22, 2021).
30. Crescitelli MD, Ghirotto L, Sisson H, Sarli L, Artioli G, Bassi M, et al. A meta- 50. Böhm R, Betsch C, Korn L. Selfish-rational non-vaccination: Experimental
synthesis study of the key elements involved in childhood vaccine hesitancy. evidence from an interactive vaccination game. J Econ Behav Organ. (2016)
Public Health. (2020) 180:38–45. doi: 10.1016/j.puhe.2019.10.027 131:183–95. doi: 10.1016/j.jebo.2015.11.008
31. Napolitano F, D’Alessandro A, Angelillo IF. Investigating Italian parents’ 51. Betsch C, Böhm R. Detrimental effects of introducing partial compulsory
vaccine hesitancy: a cross-sectional survey. Hum Vaccin Immunother. (2018) vaccination: experimental evidence. Eur J Public Health. (2016) 26:378–81.
14:1558–65. doi: 10.1080/21645515.2018.1463943 doi: 10.1093/eurpub/ckv154
32. Murphy J, Vallières F, Bentall RP, Shevlin M, McBride O, Hartman TK, et al.
Psychological characteristics associated with COVID-19 vaccine hesitancy Conflict of Interest: The authors declare that the research was conducted in the
and resistance in Ireland and the United Kingdom. Nat Commun. (2021) absence of any commercial or financial relationships that could be construed as a
12:1–15. doi: 10.1038/s41467-020-20226-9 potential conflict of interest.
33. Alabdulla M, Reagu SM, Al-Khal A, Elzain M, Jones RM. COVID-19 vaccine
hesitancy and attitudes in Qatar: a national cross-sectional survey of a Copyright © 2021 Ebrahimi, Johnson, Ebling, Amundsen, Halsøy, Hoffart,
migrant-majority population. Influenza Other Respir Viruses. (2021) 15:361– Skjerdingstad and Johnson. This is an open-access article distributed under the terms
70. doi: 10.1111/irv.12847 of the Creative Commons Attribution License (CC BY). The use, distribution or
34. Netfa F, Tashani M, Booy R, King C, Rashid H, Skinner SR. Knowledge, reproduction in other forums is permitted, provided the original author(s) and the
attitudes and perceptions of immigrant parents towards human copyright owner(s) are credited and that the original publication in this journal
papillomavirus (HPV) vaccination: a systematic review. Trop Med Infect is cited, in accordance with accepted academic practice. No use, distribution or
Dis. (2020) 5:58. doi: 10.3390/tropicalmed5020058 reproduction is permitted which does not comply with these terms.

Frontiers in Public Health | www.frontiersin.org 8 July 2021 | Volume 9 | Article 700213