Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Letter
  • Published:

Association of moral values with vaccine hesitancy

Nature Human Behaviour volume 1, pages 873–880 (2017)Cite this article

Subjects

Abstract

Clusters of unvaccinated children are particularly susceptible to outbreaks of vaccine-preventable disease1,2. Existing messaging interventions demonstrate short-term success, but some may backfire and worsen vaccine hesitancy3. Values-based messages appeal to core morality, which influences the attitudes individuals then have on topics like vaccination4,5,6,7. We must understand how underlying morals, not just attitudes, differ by hesitancy type to develop interventions that work with individual values. Here, we show in two correlational studies that harm and fairness foundations are not significantly associated with vaccine hesitancy, but purity and liberty foundations are. We found that medium-hesitancy parents were twice as likely as low-hesitancy parents to highly emphasize purity (adjusted odds ratio: 2.08; 95% confidence interval: 1.27–3.40). High-hesitancy respondents were twice as likely to strongly emphasize purity (adjusted odds ratio: 2.15; 95% confidence interval: 1.39–3.31) and liberty (adjusted odds ratio: 2.19; 95% confidence interval: 1.50–3.21). Our results demonstrate that endorsement of harm and fairness—ideas often emphasized in traditional vaccine-focused messages—are not predictive of vaccine hesitancy. This, combined with significant associations of purity and liberty with hesitancy, indicates a need for inclusion of broader themes in vaccine discussions. These findings have the potential for application to other health decisions and communications as well.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Model 1A.
Fig. 2: Model 1B.

Similar content being viewed by others

References

  1. Omer, S. B., Salmon, D. A., Orenstein, W. A., deHart, M. P. & Halsey, N. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. N. Engl. J. Med. 360, 1981–1988 (2009).

    Article  CAS  PubMed  Google Scholar 

  2. Parker, A. A. et al. Implications of a 2005 measles outbreak in Indiana for sustained elimination of measles in the United States. N. Engl. J. Med. 355, 447–455 (2006).

    Article  CAS  PubMed  Google Scholar 

  3. Nyhan, B., Reifler, J., Richey, S. & Freed, G. L. Effective messages in vaccine promotion: a randomized trial. Pediatrics 133, E835–E842 (2014).

    Article  PubMed  Google Scholar 

  4. Day, M. V., Fiske, S. T., Downing, E. L. & Trail, T. E. Shifting liberal and conservative attitudes using moral foundations theory. Pers. Soc. Psychol. Bull. 40, 1559–1573 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  5. Dickinson, J. L., McLeod, P., Bloomfield, R. & Allred, S. Which moral foundations predict willingness to make lifestyle changes to avert climate change in the USA? PLoS ONE 11, e0163852 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  6. Feinberg, M. & Willer, R. The moral roots of environmental attitudes. Psychol. Sci. 24, 56–62 (2012).

    Article  PubMed  Google Scholar 

  7. Feinberg, M. & Willer, R. From gulf to bridge: when do moral arguments facilitate political influence? Pers. Soc. Psychol. Bull. 41, 1665–1681 (2015).

    Article  PubMed  Google Scholar 

  8. Omer, S. B. et al. Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence. JAMA 296, 1757–1763 (2006).

    Article  CAS  PubMed  Google Scholar 

  9. Omer, S. B., Richards, J. L., Ward, M. & Bednarczyk, R. A. Vaccination policies and rates of exemption from immunization, 2005–2011. N. Engl. J. Med. 367, 1170–1171 (2012).

    Article  CAS  PubMed  Google Scholar 

  10. Wang, E., Clymer, J., Davis-Hayes, C. & Buttenheim, A. Nonmedical exemptions from school immunization requirements: a systematic review. Am. J. Public Health 104, e62–e84 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  11. Seither, R. et al. Vaccination coverage among children in kindergarten—United States, 2015–2016 school year. MMWR Morb. Mortal. Wkly Rep. 65, 1057–1064 (2016).

  12. Lieu, T. A., Ray, G. T., Klein, N. P., Chung, C. & Kulldorff, M. Geographic clusters in underimmunization and vaccine refusal. Pediatrics 135, 280–289 (2015).

  13. Seither, R. et al. Vaccination coverage among children in kindergarten—United States, 2013–2014 school year. MMWR Morb. Mortal. Wkly Rep. 63, 913–920 (2014).

  14. Birnbaum, M. S., Jacobs, E. T., Ralston-King, J. & Ernst, K. C. Correlates of high vaccination exemption rates among kindergartens. Vaccine 31, 750–756 (2013).

    Article  PubMed  Google Scholar 

  15. Buttenheim, A., Jones, M. & Baras, Y. Exposure of California kindergartners to students with personal belief exemptions from mandated school entry vaccinations. Am. J. Public Health 102, e59–e67 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  16. Opel, D. J. et al. Validity and reliability of a survey to identify vaccine-hesitant parents. Vaccine 29, 6598–6605 (2011).

    Article  PubMed  Google Scholar 

  17. Gust, D. et al. Immunization attitudes and beliefs among parents: beyond a dichotomous perspective. Am. J. Health Behav. 29, 81–92 (2005).

    Article  PubMed  Google Scholar 

  18. Larson, H. J., Jarrett, C., Eckersberger, E., Smith, D. M. D. & Paterson, P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007–2012. Vaccine 32, 2150–2159 (2014).

    Article  PubMed  Google Scholar 

  19. Opel, D. J. et al. Development of a survey to identify vaccine-hesitant parents: the Parent Attitudes about Childhood Vaccines survey. Hum. Vaccin. 7, 419–425 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  20. Benin, A. L., Wisler-Scher, D. J., Colson, E., Shapiro, E. D. & Holmboe, E. S. Qualitative analysis of mothers’ decision-making about vaccines for infants: the importance of trust. Pediatrics 117, 1532–1541 (2006).

    Article  PubMed  Google Scholar 

  21. Kestenbaum, L. A. & Feemster, K. A. Identifying and addressing vaccine hesitancy. Pediatr. Ann. 44, e71–e75 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  22. Dubé, E. et al. Vaccine hesitancy: an overview. Hum. Vaccin. Immunother. 9, 1763–1773 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  23. Keane, M. T. et al. Confidence in vaccination: a parent model. Vaccine 23, 2486–2493 (2005).

    Article  PubMed  Google Scholar 

  24. Betsch, C., Böhm, R. & Chapman, G. B. Using behavioral insights to increase vaccination policy effectiveness. Policy Insights Behav. Brain Sci. 2, 61–73 (2015).

    Article  Google Scholar 

  25. Jarrett, C., Wilson, R., O’Leary, M., Eckersberger, E. & Larson, H. J. Strategies for addressing vaccine hesitancy—a systematic review. Vaccine 33, 4180–4190 (2015).

    Article  PubMed  Google Scholar 

  26. Spleen, A. M., Kluhsman, B. C., Clark, A. D., Dignan, M. B. & Lengerich, E. J. An increase in HPV-related knowledge and vaccination intent among parental and non-parental caregivers of adolescent girls, age 9–17 years, in Appalachian Pennsylvania. J. Cancer Educ. 27, 312–319 (2012).

    Article  PubMed  Google Scholar 

  27. Sales, J. M. et al. Rural parents’ vaccination-related attitudes and intention to vaccinate middle and high school children against influenza following educational influenza vaccination intervention. Hum. Vaccin. 7, 1146–1152 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  28. Opel, D. J. et al. The influence of provider communication behaviors on parental vaccine acceptance and visit experience. Am. J. Public Health 105, 1998–2004 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  29. Graham, J. et al. Mapping the moral domain. J. Pers. Soc. Psychol. 101, 366–385 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  30. Haidt, J. & Graham, J. When morality opposes justice: conservatives have moral intuitions that liberals may not recognize. Soc. Justice Res. 20, 98–116 (2007).

    Article  Google Scholar 

  31. Haidt, J. & Joseph, C. in The Innate Mind Vol. 3 (eds Carruthers, P., Laurence, S. & Stich, S.) 367–391 (Oxford Univ. Press, New York, NY, 2007).

  32. Haidt, J. The emotional dog and its rational tail: a social intuitionist approach to moral judgment. Psychol. Rev. 108, 814–834 (2001).

    Article  CAS  PubMed  Google Scholar 

  33. Hauser, M., Cushman, F., Young, L., Kang-Xing Jin, R. & Mikhail, J. A dissociation between moral judgments and justifications. Mind Lang. 22, 1–21 (2007).

    Article  Google Scholar 

  34. Graham, J. et al. Moral foundations theory: the pragmatic validity of moral pluralism. Adv. Exp. Soc. Psychol. 47, 55–130 (2013).

    Article  Google Scholar 

  35. Iyer, R., Koleva, S., Graham, J., Ditto, P. & Haidt, J. Understanding libertarian morality: the psychological dispositions of self-identified libertarians. PLoS ONE 7, e42366 (2012).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Graham, J., Haidt, J. & Nosek, B. A. Liberals and conservatives rely on different sets of moral foundations. J. Pers. Soc. Psychol. 96, 1029–1046 (2009).

    Article  PubMed  Google Scholar 

  37. Nilsson, A., Erlandsson, A. & Västfjäll, D. The congruency between moral foundations and intentions to donate, self-reported donations, and actual donations to charity. J. Res. Pers. 65, 22–29 (2016).

    Article  Google Scholar 

  38. Rottman, J., Kelemen, D. & Young, L. Tainting the soul: purity concerns predict moral judgments of suicide. Cognition 130, 217–226 (2014).

    Article  PubMed  Google Scholar 

  39. Wolsko, C., Ariceaga, H. & Seiden, J. Red, white, and blue enough to be green: effects of moral framing on climate change attitudes and conservation behaviors. J. Exp. Soc. Psychol. 65, 7–19 (2016).

    Article  Google Scholar 

  40. Dube, E. et al. “Nature does things well, why should we interfere?”: vaccine hesitancy among mothers. Qual. Health Res. 26, 411–425 (2016).

    Article  PubMed  Google Scholar 

  41. Kata, A. Anti-vaccine activists, Web 2.0, and the postmodern paradigm—an overview of tactics and tropes used online by the anti-vaccination movement. Vaccine 30, 3778–3789 (2012).

    Article  PubMed  Google Scholar 

  42. Kata, A. A postmodern Pandora’s box: anti-vaccination misinformation on the Internet. Vaccine 28, 1709–1716 (2010).

    Article  PubMed  Google Scholar 

  43. Niemi, L. & Young, L. When and why we see victims as responsible. Pers. Soc. Psychol. Bull. 42, 1227–1242 (2016).

    Article  PubMed  Google Scholar 

  44. Kennedy, A., LaVail, K., Nowak, G., Basket, M. & Landry, S. Confidence about vaccines in the United States: understanding parents’ perceptions. Health Aff. (Millwood) 30, 1151–1159 (2011).

    Article  Google Scholar 

  45. Clay, R. The behavioral immune system and attitudes about vaccines. Soc. Psychol. Pers. Sci. 8, 162–172 (2016).

    Article  Google Scholar 

  46. Clifford, S. & Wendell, D. G. How disgust influences health purity attitudes. Polit. Behav. 38, 155–178 (2016).

    Article  Google Scholar 

  47. Betsch, C., Böhm, R., Korn, L. & Holtmann, C. On the benefits of explaining herd immunity in vaccine advocacy. Nat. Hum. Behav. 1, 0056 (2017).

    Article  Google Scholar 

  48. Clifford, S., Iyengar, V., Cabeza, R. & Sinnott-Armstrong, W. Moral foundations vignettes: a standardized stimulus database of scenarios based on moral foundations theory. Behav. Res. Methods 47, 1178–1198 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  49. Crone, D., Bode, S., Murawski, C. & Laham, S. The Socio-Moral Image Database (SMID): a novel stimulus set for the study of social, moral and affective processes. Preprint at https://psyarxiv.com/sja3m/ (2017).

  50. Hosmer, J. D. W., Lemeshow, S. & Sturdivant, R. X. in Applied Logistic Regression 35–47 (John Wiley & Sons, Hoboken, NJ, 2013).

  51. Van Voorhis, C. R. W. & Morgan, B. L. Understanding power and rules of thumb for determining sample sizes. Tutor. Quant. Methods Psychol. 3, 43–50 (2007).

    Article  Google Scholar 

  52. LeBlanc, M. & Fitzgerald, S. Logistic regression for school psychologists. Sch. Psychol. Q. 15, 344–358 (2000).

    Article  Google Scholar 

  53. Opel, D. Identifying, understanding, and talking with vaccine-hesitant parents. In From Package to Protection: How do we Close Global Coverage Gaps to Optimize the Impact of Vaccination Conference Presentation (Fondation Mérieux, 2014); http://www.globe-network.org/sites/default/files/en/network/resource/4.opel-douglas-identifying-understanding-and-talking-to-vaccine-hesitant-parents.pdf.

  54. Kennedy, A. M., Brown, C. J. & Gust, D. A. Vaccine beliefs of parents who oppose compulsory vaccination. Public Health Rep. 120, 252–258 (2005).

    Article  PubMed  PubMed Central  Google Scholar 

  55. Wolfe, R. M., Sharp, L. K. & Lipsky, M. S. Content and design attributes of antivaccination web sites. JAMA 287, 3245–3248 (2002).

    Article  PubMed  Google Scholar 

  56. Hayes, A. F. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach (Guilford Press, New York, NY, 2013).

    Google Scholar 

Download references

Acknowledgements

No external funding source support was used for this work. No funders had any role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Author information

Authors and Affiliations

  1. Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA

    Avnika B. Amin, Robert A. Bednarczyk & Saad B. Omer

  2. Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA

    Robert A. Bednarczyk & Saad B. Omer

  3. Department of Psychology, College of Arts and Sciences, Loyola University Chicago, Chicago, IL, USA

    Cara E. Ray & Jeffrey R. Huntsinger

  4. Department of Psychology, College of Health and Behavioral Studies, James Madison University, Harrisonburg, VA, USA

    Kala J. Melchiori

  5. Department of Management, Eccles School of Business, University of Utah, Salt Lake City, UT, USA

    Jesse Graham

  6. Emory Vaccine Center, Atlanta, GA, USA

    Saad B. Omer

  7. Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, USA

    Saad B. Omer

Authors
  1. Avnika B. Amin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Robert A. Bednarczyk
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Cara E. Ray
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kala J. Melchiori
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jesse Graham
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jeffrey R. Huntsinger
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Saad B. Omer
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

S.B.O. and R.A.B. developed and designed study 1. A.B.A. collected and analysed the data for study 1. A.B.A. interpreted the data from study 1 with input from S.B.O. and R.A.B. J.R.H. developed the initial idea for study 2. C.E.R. and K.J.M. designed study 2 and collected and analysed the associated data. C.E.R., K.J.M. and J.R.H. interpreted the data from study 2. A.B.A. drafted the paper and most of the supplementary materials, with pertinent sections from study 2 drafted by C.E.R. and J.R.H. S.B.O., R.A.B., C.E.R., K.J.M., J.G. and J.R.H. provided critical revision of the paper.

Corresponding author

Correspondence to Avnika B. Amin.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Supplementary Information

Supplementary Figures 1–2, Supplementary Tables 1–13

Life Sciences Reporting Summary

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Amin, A.B., Bednarczyk, R.A., Ray, C.E. et al. Association of moral values with vaccine hesitancy. Nat Hum Behav 1, 873–880 (2017). https://doi.org/10.1038/s41562-017-0256-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41562-017-0256-5

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing