Background

Recent scientific studies across Europe and the US have shown that sociopolitical attitudes, such as political ideology and partisanship, often play an important role for the decision to (not) have a Covid-19 vaccine. In Germany, Covid-19 vaccination rates vary substantially across different federal states. We recently found that, while sociopolitical attitudes indeed generally and significantly affect vaccination decisions (in Germany), they do not explain well comparatively lower immunization rates in parts of East and South Germany, see also https://doi.org/10.1111/1751-7915.14210. 

Previous studies have found that psychosocial factors, for instance alternative worldviews and religious beliefs, or attitudes towards alternative forms of medicine, such as homeopathy, can substantially affect vaccination decisions. However, these studies explored these psychosocial factors separately, did not use the same questions and ran their studies in different countries. This presents a challenge to those trying to learn from current evidence and design public health policies and campaigns, as findings across studies might not be comparable, nor transferrable. As views on vaccination are the result of many highly interdependent factors, not exploring them together (on the same population, at the same point in time and using the same questions) runs the risk of over- or underestimating their specific impact on vaccine views. Germany is a particularly relevant case for understanding vaccine decisions as scholars have found that German anti-immunization groups are playing a central role in the currently unfolding third global wave of vaccine hesitancy.

What we did

We tested if psychosocial factors can help explain comparatively lower immunization rates in Germany, and in particular in parts of East and South Germany – above and beyond the sociopolitical factors we tested in our previous study. To this end, we designed a survey which we ran in July 2022 and in which we asked our ~7,400 respondents across Germany to indicate for the following outcomes of interest (dependent variables):

1. how many doses of Covid-19 vaccine they had received
2. what had motivated their decision to have the vaccine
3. what their views on child vaccination were (using the MMR vaccine as a case)

To measure which psychosocial factors might explain the outcomes of interest, we asked the respondents to indicate their attitudes towards the following explanatory factors (independent variables): 

• Waldorf education (as a proxy for the most dominant esoteric school of thought in Germany)
• Homeopathy (as a proxy for complementary and alternative medical systems)
• mainstream medicine
• religious affiliation

In addition to a host of sociodemographic controls (age, gender, highest educational degree, area of residence, etc.), we also measured respondents’ personality profiles (Big 5), degree of solidarity, and, once again, sociopolitical attitudes.

What we found

Stratified by our outcomes of interest, we ran three separate analyses. In Analysis I (outcome: Covid-19 vaccine doses received) we found that, indeed, the more positive respondents’ viewed homeopathy, and to a slightly lesser extent Waldorf education, the less likely it was that they had received a (further) dose. For mainstream medicine, which had a much stronger impact overall, this relationship was reversed. In concrete terms: 93.5% of those who held very positive views towards mainstream medicine had received at least three doses of vaccine, while 63% of those who held very negative pertinent views were unvaccinated. Our data also show that sociopolitical factors (e.g. party affiliation) continued to play an important role for vaccine decisions – the less centrist (i.e. more extreme) a party is, the less likely it was that its supporters had received a (further) dose of vaccine. Higher scores on solidarity and the personality trait neuroticism, as well as being in the age bracket 60+ increased the likelihood of having received a (further) Covid-19 vaccines dose. All in all and in contrast to results for other countries such as Brazil or the USA, religious affiliation did not play an important role in Germany. Figure 1, left-hand panel (Analysis I), shows the relationship between the different potential explanatory factors and the number of Covid-19 vaccine doses.

In Analysis II (outcome: motivation for vaccination) we grouped motivations into voluntary considerations (protecting self, protecting others, medical/public health advice) and external pressures (requirement for participation in public events, vocational mandate, peer pressure), see Figure 2. We found that across the respondents who had received at least one dose of Covid-19 vaccine (~6,660 individuals), those with positive views towards homeopathy and Waldorf education considered voluntary considerations to be irrelevant and, rather, indicated that external pressures (participation in public events and vocational mandates) drove their immunizations decisions. This was once again reversed for those in favor of mainstream medicine: although not equally important, all voluntary considerations were considered relevant, while external pressures were considered irrelevant. This is also the case for individuals with a higher solidary score. Regarding sociopolitical factors, for those who had a more traditional/authoritarian/nationalist (TAN) attitudes and/or supported the liberal party FDP, participating in public events was somewhat important. Figure 2 also shows that personality traits quite diversly affected the importance of different vaccination decision motives.

In Analysis III [outcome: head-to head comparison of the impact of the explanatory factors on (i) Covid-19 vaccination status, i.e. results of Analysis I, and (ii) views towards child immunization] we found that, overall, the explanatory factors indeed very similarly affect both outcomes, see Figure 1 (direct comparison of both panels). However, there exist some minor yet noteworthy differences: for instance, the strong negative influence of being a supporter of the right-wing populist AfD or Others parties on having a (further) dose of Covid-19 vaccine was considerably less negative for child vaccination. Also, a higher solidary score significantly increased the likelihood of viewing child vaccinations more positively, while being in the age bracket 60+ reversed this effect.

What this means

Our results show that while psychosocial and sociopolitical attitudes are important for Covid-19 vaccine decisions (in particular those relating to mainstream medicine), they also determine which type of motivations drive immunization decisions and are likewise solid predictors for views towards child vaccination. Our results have two main implications: firstly, vaccine hesitancy measurement instruments, which currently often focus on more vaccine specific aspects, such as effectiveness of vaccines or fear of side-effects, should also, and more explicitly, include assessment of psychosocial and sociopolitical attitudes. This would provide a better understanding of what is driving vaccine decisions in different societal groups. This leads to our second implication, namely that, based on a more granular understanding of immunization drivers, public health campaigns could be even more sensitive towards the varying attitudes of members of social and political groups and provide more targeted immunization messaging. One example from our study might be to highlight the benefits of vaccination, for instance to gain access to public events, for vaccine hesitant individuals in neighborhoods where alternative worldviews and medical systems, and more extreme political parties, are viewed more favorably.