Krishnan A. Anti-vaxxers, wealth, and individualism: how self-perception may explain the immunization divide. Harvard Public Health Review. 2021; 31.
The proliferation of health misinformation on social media has amplified the voice of the vaccine refusal movement. While popular explanations recognize distrust of institutions and social media as drivers of vaccine skepticism, such refusal exemplifies a wealth gradient that these theories do not resolve: educated, high-income households are more likely to refuse vaccination. This distribution suggests that deeper underlying factors may influence one’s susceptibility to misinformation. Cultural psychology offers one explanation that may reconcile these theories with the wealth gradient: individuals define themselves in part through their communities, but the extent to which they do yields insight into their risk-perception and social decision-making. This concept of the self has been understood through a spectrum with individualists on one extreme and collectivists at the other, with individualists forming an identity that is distinct from their relationships and collectivists identifying with their relationships. Wealth may influence where one falls on the individualist-collectivist spectrum, thereby shaping both how one prioritizes public health with regards to personal freedom and how one evaluates new information that goes against commonly-held beliefs. Vaccination, with its public health repercussions, lends an opportunity to examine how people make decisions with regard to their communities, and how wealth shapes those decisions. This is relevant to future public health crusades: ultimately, any attempt to combat vaccine skepticism must begin with an examination of the factors that make individuals susceptible to misinformation.
The past years under the previous administration have witnessed a marked increase in sociopolitical polarization. Especially with the COVID-19 pandemic looming large, divisions over racial, political, and myriad other issues featured prominently in public discourse.
During the pandemic, the prudence of vaccination has been a particularly controversial topic. A survey conducted by the Associated Press-NORC Center for Public Affairs Research shortly before the approval of the Pfizer-BioNTech vaccine found that only 47% of American adults planned to receive the coronavirus vaccine (AP News, 2020).
It is widely believed that vaccine refusers, colloquially called ‘anti-vaxxers,’ are oblivious to the relevant data on vaccination safety. An internet search for ‘anti-vaxxer’ will yield numerous results advising on how to engage with and respond to vaccine skepticism. However, the suggested approaches, which seek to remedy a perceived “knowledge deficit,” overlook the impact demographic factors have on risk perception and fail to address how vaccine rejectors view the vaccinating mainstream (Baumgaertner et al, 2018).
For many vaccine refusers, vaccine rejection fits into a broader philosophy of health which rejects mainstream ‘Western’ medicine, aiming instead to boost physical immunity primarily by attending to other lifestyle factors (Ward et al, 2017), such as an organic diet, breastfeeding children, and reducing exposure to toxins. Vaccine rejectors view the vaccinating mainstream as the ‘unhealthy other’, who forsake their long-term wellbeing for the easy, short-term solution offered by Western medicine (Attwell et al, 2018). Moral judgments are often concomitant with these views: anti-vaxxers tend to view parents who vaccinate their children as neglecting their responsibilities (Attwell et al, 2018).
The Vaccination Wealth Gradient
Far from being a statement about neglect or some underlying philosophy, vaccination status may simply indicate inadequate access to medical care. Undervaccinated children (children who have received some, but not all, of the doses for recommended vaccines) tend to be black, come from households near the poverty line, and are raised by younger mothers without college degrees (Smith et al, 2004). On the other hand, children who have never been vaccinated are more likely to be white, have mothers who are married and college-educated, and come from households with annual incomes greater than $75,000 (Omer et al, 2009). These children tend to have parents who are skeptical of vaccines. (Omer et al, 2009). Several studies have concluded that personal belief exemptions from vaccinations are positively correlated with wealth and educational attainment (See Yang et al., Morrison et al., and Smith et al.).
This paradoxical reality raises the question: why would wealth, which presumably grants greater access to information, be a leading indicator of vaccine refusal?
Individualism and Collectivism
An oft-discussed theory exploring the motives behind the anti-vax movement attributes vaccine skepticism to a general distrust of institutions. A less popular theory informed by cultural psychology goes one layer deeper, examining how people come to hold contrarian beliefs (such as vaccine skepticism) in the first place (Hornsey et al, 2018). This theory explores the role community plays in an individual’s identity formation — whether one defines oneself primarily through or outside of one’s relationships. In essence, how deeply entwined social ties are with self-perception may be determinative of an individual’s values, priorities, and regard for social relationships, factors that ultimately guide decision-making.
The role that relationships play in identity formation has been classified and construed in two ways: as either individual and independent, or as collective and interdependent. In the former view, individuals prioritize autonomy, viewing themselves as self-contained, unique, and separate from their social context (Markus and Kitayama, 1991). In the latter view, individuals define themselves through their network of relationships and see their actions and behaviors as dependent on others within the relationship (Markus and Kitayama, 1991). In this interdependent construal, fitting into relationships is prioritized over autonomy and uniqueness (Markus and Kitayama, 1991). This would suggest a way to think about how people might engage in decision-making when community interests are at stake, such as whether to vaccinate a child. One study found that participants from South Korea, which is classified as a collectivist nation, perceived vaccination as a prosocial act to a greater extent than US participants, and thus were more likely to be in favor of vaccination (Böhm et al, 2016).
However, one overlooked fact is that socioeconomic status also impacts where one falls on the individualist/collectivist spectrum. According to Kraus et al. (2012), social class imposes constraints on material resources, impacting one’s vulnerability to external influences such as job loss or financial instability. These constraints, in turn, influence the degree to which one feels a sense of autonomy, independence, and uniqueness in life. Kraus et al. hypothesize that lower-class individuals facing greater economic challenges may have a more interdependent sense of self, defining themselves in part through their relationships, and preferring to make choices that blend in rather than ones that stand out. Upper-class individuals, on the other hand, may form a more independent sense of self due to their perceived abundance of resources, prioritizing personal-agency over communal lines of thought (Kraus et al, 2012).
These differences in decision-making approaches may explain why wealthy individuals are more apt to sacrifice communal health in favor of their own beliefs. That is not to say that wealth accumulation directly causes anti-vaccination beliefs. Rather, being richer may lead one to adopt an individualist mindset and thus be more likely to entertain contrarian ideas in the first place (see also Hornsey et al). Those with more collectivist mindsets, on the other hand, may be unwilling to differentiate themselves ideologically, and therefore may be hesitant to consider ideas that seem radical or unconventional. In the real world, this might translate to how willing someone is to have their mind changed and consequently how critically one approaches misinformation. The rise of social media has not only accelerated the spread of vaccine misinformation, but the corresponding need to draw the line between fact and fantasy.
Vaccine refusal exemplifies such a contrarian action that the collectivist may be hesitant to consider it. Often described as selfish, opting-out is an act of immense privilege. It is a luxury afforded by the efforts of others, and refusal hinges on the comfort of herd immunity (May and Silverman, 2003). If refused in the collective, decades of progress in immunity-building fostered by the medical community would be lost. While philosophical, religious, and medical exemptions are legal in every state (National Vaccine Information Center), they aren’t advised. Both the medical community at large and the Centers for Disease Control and Prevention stress the importance of immunizations for disease prevention (CDC, 2020). In light of this, vaccine refusal is clearly at odds with communitarian principles: it goes against the mold instead of fitting in, it is a show of autonomy at the expense of society, and it is detrimental to the collective.
To go against the advice of medical experts and institutions at the expense of community health is reflective of a special sense of personal agency characteristic of an individualist mindset. Reich (2014) characterizes affluent mothers who request vaccine exemptions as subscribing to certain neoliberal values and aiming to “create a domestic sphere free from both state regulation and disease risk, neither contributing to public health nor acknowledging the broader communities in which they live.” Both the obliviousness to one’s community and the subtle rebellion against the state that Reich describes suggest that individualist thinking plays a role in the decision not to vaccinate. Perceived resource abundance may shape a view of the self that is self-reliant, autonomous, and separate from one’s social context, leading wealthy households to prioritize personal value systems over community health. In contrast, poorer individuals may conceive of themselves as more interdependent within their communities and may thus feel a sense of duty toward protecting the health of their communities. Additionally, they may be less willing to differentiate themselves by exercising the privilege of vaccine refusal.
The solution to improving vaccination uptake numbers lies not only in offering evidence of the effectiveness of vaccines, but in presenting the need for vaccination in a fundamentally different light. Public health campaigns and attempts to combat misinformation must begin with a thorough examination of how individuals come to cultivate distrust in experts and institutions in the first place. While further research is necessary to discover the optimal means of approaching skepticism, any approach that serves to convince must integrate different perceptions of the self across the socioeconomic spectrum.