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What made people (more) positive toward the COVID-19 vaccine? Exploring positive and negative deviance perspectives

Abstract

Background

Despite the associations of certain beliefs and worldviews (e.g., religiosity and belief in conspiracy theories) with non-vaccination behavior, some individuals who hold these views still choose vaccination, and vice versa. This study aims to explore why individuals choose to be vaccinated against COVID-19, despite holding opposing beliefs and worldviews, or refrain from doing so, when their beliefs align with vaccination. By examining both positive and negative deviant behavior, we seek to identify strategies and barriers for public health officials to develop interventions to improve vaccination uptake.

Methods

We conducted semi-structured online interviews with 21 Dutch adults aged 28鈥75听years (13 positive deviants and 8 negative deviants) between January and July 2022. Interviewees were recruited on the basis of their response patterns in a survey that was part of a larger project on understanding vaccine hesitancy in the Netherlands. The interviews focused on how they formed their intention toward the COVID-19 vaccine and what could change it in the future. The data were analyzed via semi-inductive coding with Atlas.ti.23.

Results

Positive deviants got vaccinated because they perceived COVID-19 as a threat, wanted to protect (vulnerable) others, or wanted to regain their freedom. Negative deviants did not get vaccinated because they did not perceive the vaccine as appropriate, the disease not as a threat, for religious reasons, or did not trust the authorities. The most important barriers and strategies that were identified that could improve vaccination uptake were unrelated to underlying beliefs and worldviews but related to characteristics of the vaccine such as effectiveness and (potential) side-effects.

Conclusion

This study demonstrates the applicability of traditional health psychology models, such as the health belief model, in explaining deviant vaccination behavior. Additionally, leveraging prosocial motivations and imposing restrictions on non-vaccinated individuals have been effective strategies for promoting vaccination uptake, albeit restricted to pandemic contexts. As some individuals will remain resistant to vaccination efforts, tailored interventions for vaccine-hesitant individuals may yield greater success rather than attempting to persuade strict opponents of vaccination.

Peer Review reports

Introduction

In 2020, COVID-19 entered the Netherlands and caused almost 800 thousand infections and approximately 12,000 deaths within a year [39]. The Dutch strategy to combat COVID-19 initially focused on social distancing, limiting social interactions, (temporary) lockdowns, and protecting vulnerable people [28]. In January 2021, the vaccination campaign began, prioritizing healthcare workers and the elderly, with everyone eligible for vaccination by summer 2021 [28]. To encourage vaccination, the Dutch government highlighted both its collective benefits (e.g., herd immunity) and individual advantages (e.g., easier access to public places and international travel) [28]. A representative study of data collected before vaccine availability revealed that approximately 19% of the Dutch population was hesitant to get vaccinated [24]. Eventually, 19% of the Dutch population did not receive the primary series of the COVID-19 vaccine [27]. Understanding how to foster vaccination uptake is crucial for enhancing vaccination rates and fostering health in the general population. In this study, we apply a positive deviant approach to unravel the factors that promote vaccination uptake.

The positive deviant approach consists of three phases and aims to learn from people or organizations that have the same resources as others but obtain 鈥榖etter鈥 outcomes [1, 36]. In the first phase, deviants are identified, in the second phase deviants are studied in-depth qualitatively, and in the third phase hypotheses about the causes are formulated (which can be tested in further research) [33]. The approach has already been applied successfully to solve complex problems (e.g., child malnutrition; [26]) and to understand why some general practitioners and organizations were more successful in their vaccination distribution than others were [33]. However, to the best of our knowledge, this study is the first to apply this approach both on an individual level and for COVID-19 vaccination.

In our study, we examine individuals whose vaccination intentions are not aligned with their underlying worldviews and beliefs. Specifically, we analyzed the motives of individuals who, despite holding worldviews that are associated with opposition to vaccination, have relatively high intentions to get vaccinated (i.e., positive deviants), and those who, despite holding worldviews that are associated with favoring vaccination, have relatively low intentions to get vaccinated (i.e., negative deviants). By studying both positive and negative deviants we might unravel unknown, but important strategies that play a role in the formation of intentions that are not observed by quantitative studies on COVID-19 vaccination intentions (e.g., [11, 23]). While these studies focused on factors (e.g., conspiracy beliefs) that influence COVID-19 vaccination intentions for the general population, they say little about why some people have COVID-19 vaccination intentions that are not congruent with their respective scores on these factors (e.g., people reporting high COVID-19 vaccination intentions despite scoring high on believing in conspiracy theories). Therefore, conducting an in-depth analysis of the reasons for this incongruence is a very important complement to the already existing quantitative work. Furthermore, it can reveal insights into strategies that people adopt to overcome the barriers that might hinder other people from getting vaccination and has theoretical implications by providing insights into the boundary conditions (e.g., in which situations or vaccinations these theories might not apply) of theories that are often applied toward vaccination (e.g., Health Belief Model; [30]). Therefore, the aim of this study is to better understand deviant COVID-19 vaccination intentions by addressing three research questions. First, we ask what causes individuals to have vaccination intentions toward the COVID-19 vaccine that are not in line with their personal characteristics and beliefs? Second, what can we learn from positive deviants to develop strategies that might make other people more positive toward the COVID-19 vaccine? Third, what reasons do negative deviants mention that have to be addressed to make them more positive toward the COVID-19 vaccine?

Materials and methods

Participants and sampling

Step 1 of the positive deviant approach

This study was part of a multi-study project on vaccine hesitancy in the Netherlands. In the summer of 2021, over 2000 people participated in an online survey in which they were asked about their vaccination intentions towards multiple diseases and predictors of vaccination intentions (see [20]). The interview was specifically developed for this study and has not been published elsewhere. The participants in the current study were identified on the basis of their self-reported and their predicted vaccination intentions on the basis of a set of established predictors in this survey. These predictors are rooted in the 鈥榓ttitude-roots鈥 model, which assumes that anti-vaccination attitudes are grounded in six underlying casual processes [14]. These predictors were fear of needles (e.g., [21]), trust in authorities (e.g., [22]), conspiratorial beliefs (e.g., [15]), orthodox religious beliefs (e.g., [31]), spiritual beliefs (e.g., [32]), and prosocial personality traits (e.g., [7]).

The respondents were selected on the basis of their answer pattern. We compared their self-reported vaccination intentions with their predicted vaccination intentions and calculated deviance scores (self-reported intentions minus predicted intentions). Self-reported vaccination intentions were measured by asking all respondents about their vaccination intentions towards 16 diseases on a seven-point Likert scale (1鈥=鈥not likely at all, 7鈥=鈥extremely likely). The included diseases are mumps, measles, rubella, HPV, pertussis, polio, diphtheria, tetanus, hepatitis B, meningococcal disease, the flu and COVID-19, yellow fever, rabies, hepatitis A and typhoid fever. The items were presented in random order to control for order effects. To construct the self-reported vaccination intention score, we created the average of these 16 diseases for each individual. Predicted vaccination intentions were measured via a linear regression model in which we regressed the self-reported vaccination intention score on belief in conspiracy theories, fear of needles, religious orthodox beliefs, spirituality, trust in authorities, prosocial personality traits, parental status, age, sex, educational attainment, religion, church attendance, and religious beliefs.Footnote 1The deviance score was computed with the following equation: self-reported vaccination intention 鈥 predicted vaccination intentions. Someone was classified as a positive deviant when they had a positive score (i.e., their self-reported vaccination intention was higher than the predicted vaccination intention) indicating a more positive intention toward vaccination compared to what would be expected based on their underlying worldviews and beliefs. Someone was classified as a negative deviant when they had a negative score (i.e., their self-reported vaccination intention was lower than the predicted vaccination intention) indicating a more negative intention toward vaccination compared to what would be expected on the basis of their underlying worldviews and beliefs.

Twenty-six respondents with the highest positive and negative deviance scores were invited for an interview. They were informed via email that they would be contacted via phone to schedule an interview and obtain information about the interview (e.g., duration, procedure). If they did not answer the phone, they were called two other times later that week and were sent another email. We started with a gross sample of 26 respondents for the interviews. One refused to participate after all (3.8%), one did not show up (3.8%), and three did not respond (11.5%) after several reminders by email and or phone. This led to a net sample of 21 participants (80.8%). Four of the five individuals who were not interviewed were negative deviants. The respondents were approached in three waves: eight in the first wave (January 2022), seven in the second wave (March 2022), and six in the third and final wave (June 2022). We stopped data collection after 21 interviews because the final wave of interviews did not reveal any new information. Numbers were assigned to the interviewees for anonymity. Their key characteristics, including demographics and vaccination intentions, are presented in Table听1. For details on the measurement of the key characteristics, see the supplementary materials (S1 and S2). The study was approved by the Ethics Review Board of Tilburg School of Social and Behavioral Sciences (#RP356).

Table 1 Demographic information respondents

Data collection

Step 2 of the positive deviants approach

Semi-structured interviews were conducted online to adhere to the applicable COVID-19 regulations in the first six months of 2022. Before the interviews, a topic list was constructed with all the authors and was pretested on a convenience sample (n鈥=鈥3). Before starting the interviews, the participants were briefed on the interview objectives and signed an informed consent form. All participants provided informed consent before the questions of interest were asked. We subsequently asked questions about demographic variables (i.e., age, parental status, marital status, and employment status), vaccination intentions, whether these changed between the time of the interview and the survey, and what could change them in the future. The topic list can be found in the online supplementary materials. Despite being asked about their vaccination intentions, the participants talked mostly about their vaccination behavior. This is reflected in the results, in which we will be talking mainly about their vaccination behavior.

All the interviews were conducted and recorded by the first author in Dutch via Skype or Zoom and were transcribed verbatim in Atlas.ti 23. For the coding of the interviews, the first author developed a coding scheme that was discussed with the other authors. The coding was semi-inductive in which we only had predetermined codes related to traditional health psychology models and no other predetermined theoretical codes. To evaluate the validity of our results, we followed the guidelines of O鈥機onnor and Joffe [25], with multiple coders independently coding a total of eight interviews on the basis of the codebook developed by the first author. The coding of all authors was compared and the intercoder agreement, assessed via the Krippendorff鈥檚 binary alpha in ATLAS.ti, was between 0.68 and 0.94. This reliability indicates sufficient reliability for at least tentative conclusions [17].

Results

Sample

The sample consisted of 13 participants (62%) who were classified as positive deviants, nine (42.9%) who identified as female, 16 (76.2%) who had children, most of whom were aged between 40 and 60听years old (13; 61.9%), and 11 (52.4%) who were middle educated. See Table听2 for the demographic characteristics of the full sample and split by deviant type.

Table 2 Distributions of demographic characteristics (% between brackets)

Positioning as positive and negative deviants

Positive deviants

Three overarching reasons for getting vaccinated emerged from the interviews with the positive deviants: threat perceptions of the disease (n鈥=鈥12, N鈥=鈥10),Footnote 2 prosocial reasons (n鈥=鈥10, N鈥=鈥9), and additional benefits (n鈥=鈥6, N鈥=鈥6). Most of the positive deviants mentioned the threat that COVID-19 poses to their health as one important reason for getting vaccinated. They decided to be vaccinated to avoid hospitalization because of COVID-19 or to reduce the impact of a potential infection:

I am very afraid of hospitals (鈥) but yes I just do not want to end up in the hospital, I am just very afraid of hospitals鈥 (Respondent 4, Positive deviant).

To get less sick of it, because COVID-19 is truly a Russian roulette鈥 (Respondent 10, Positive deviant).

The second most important reason to get vaccinated was not for their own protection, but to contribute to the protection of others. Most deviants mentioned either protecting (vulnerable) family members or contributing to herd-immunity:

"My opinion is, if I would not do it for myself, at least I will do it for others. My wife has a sister and she is severely disabled, she really should not get COVID-19 either." (Respondent 2, Positive deviant).

I actually do it for the rest [of society] indeed and the children.鈥 (Respondent 7, Positive deviant).

The final important reason for getting vaccinated was related to other non-health benefits that vaccination offered. Some positive deviants explicitly mentioned getting vaccinated to regain their freedom back, to be able to work, to avoid the inconvenience of presenting negative test results each time they wanted to visit specific places or to travel abroad:

"Yes, I did and that is actually purely because we wanted to go abroad across the border. Otherwise, I probably would not have taken it鈥. (Respondent 8, Positive deviant).

"And so at one point you could choose, dance with Janssen,Footnote 3 so I thought, you know what, I will get vaccinated and then at least I can go to those festivals." (Respondent11, Positive deviant).

Negative deviants

Four general reasons for not being vaccinated emerged from the interviews with the negative deviants: coping perceptions of the vaccine (n鈥=鈥5, N鈥=鈥5), threat perceptions of the disease (n鈥=鈥3, N鈥=鈥3), religious reasons (n鈥=鈥2, N鈥=鈥2), and distrust in authorities (n鈥=鈥2, N鈥=鈥2). The primary reason among negative deviants was that they did not see the vaccine as an appropriate precaution against COVID-19. They decided not to get vaccinated because they worried about the potential (long-term) side-effects of the vaccine, potential changes to their DNA, and faith in their own immune system:

"I looked into that mRNA a very little bit and that sounded like they are also听doing something with the DNA literally ... Well, not being modified, but having an effect on it and other than that. Yeah, I do not know if that does not turn out in five years or so like, that you get chronic colds or get infections. In addition, that is a gamble you take.鈥 (Respondent 18, Negative deviant).

"It is not developed through, and I do not know if that is 鈥 no not messing around in my DNA and everything, I do not truly like that." (Respondent 21, Negative deviant).

The second reason was that the disease was not perceived as a threat to one鈥檚 health. People expressed that contracting COVID-19 would not severely impact their health enough to protect themselves. The main reason for this was that getting sick was part of life or that they were young enough to not need a vaccine:

"I always did believe that I would survive if I got sick, yeah then you are sick for a week, done, you know, too bad, that is part of life." (Respondent 21, Negative deviant).

The third reason for not being vaccinated against COVID-19 was religiosity. Whereas positive deviants reasoned from the perspective that God has given people knowledge and a brain that led to the development of vaccines and that they are therefore allowed to use them, negative deviants expressed their view of God as omniscient and with a plan for everyone and that people should not interfere with this plan:

We have been given this body and this constitution by God to go through life with it and that you should not then seek things out and bring in things from the outside in order to counteract something that in principle you should be able to cope with normally鈥. (Respondent 18, Negative deviant).

"Partly it also has to do with my conservative reformation background" (鈥) because it was such a big scale crisis and often, when things happen on a global scale then I do see the hand of God in that." (Respondent 16 Negative deviant).

The fourth theme was the (dis)trust in authorities. The negative deviants expressed a distrust in general practitioners and the government and the central argument was that these authorities did not have the best interest of the individuals at heart:

General practitioners just do whatever they want anyway.鈥 (Respondent 14, Negative deviant).

"Look if the Government had said the vaccine is not going to help you 100%, you can still get infected, you can still infect others, your hospitalization we are certainly not going to guarantee that it is not going to happen, it can still all happen, but if we all do a shot then we will be rid of that, but we still cannot guarantee anything, I might truly have looked at it differently." (Respondent 17, Negative deviant).

How to make people more positive toward the COVID-19 vaccine

From a public health perspective, it is important to understand what might change people鈥檚 vaccination attitudes in a positive direction. On the basis of knowledge of positive and negative deviants, public health professionals may develop targeted interventions aimed at increasing vaccination uptake among hesitant individuals.

Strategies by positive deviants

Among the positive deviants one central theme emerged, centered around coping beliefs (n鈥=鈥10, N鈥=鈥7). The positive deviants commonly mentioned coping beliefs, such as confidence in the vaccine's effectiveness, as the primary reason for their positive vaccination attitudes or for enhancing existing positive attitudes. People mentioned better testing of the vaccine, greater effectiveness, and (guarantees) that there are no (severe) side-effects as potential reasons for having a more positive attitude toward vaccination either for themselves or for others:

"About vaccines that do not affect DNA, so not of the mRNA (鈥). If it is just a safe vaccine that does not harm my body." (Respondent 9, Positive deviant).

"I think if the side effects are not too bad, that the effectiveness is truly good, yes that it truly protects against serious disease for example, in the case of COVID-19.鈥 (Respondent 10, Positive deviant).

Other topics were mentioned less often. The second mentioned theme was that they could not become more positive than they already were (n鈥=鈥4, N鈥=鈥4) as expressed by respondent 21: "Well I already think I am pretty positive, so I do not know how much more positive I need to get. No." Other topics that were mentioned and came up twice were clearer and transparent communication, to punish non-vaccination and reward vaccination, that it should not be linked to freedom-restricting measures, and that nothing can happen to make them positive. Other topics that were mentioned once were that the disease had to be more severe, that they had no idea what should happen, and that people had to be educated more to understand the importance of vaccination.

Barriers from the perspective of negative deviants

Among the negative deviants, fewer reasons could be identified that could change their attitude in a positive direction. Similar to positive deviants, the attitude could become more positive through coping beliefs (n鈥=鈥3, N鈥=鈥3). These findings suggest that vaccines should be made more 鈥榥atural鈥 with greater effectiveness and for a more negative attitude this focused predominantly on the severe side-effects and negative long-term consequences.

"Look if you start reading somewhere at some point about all kinds of side effects or long-term damage, people who have died of heart failure". (Respondent 16, Negative deviant).

Additionally, negative deviants also mentioned that their attitude could become more positive when the consequences of contracting the disease were more severe (n鈥=鈥2, N鈥=鈥2) and that vaccination would be more on voluntary basis than disguised coercion as it was felt by the respondent (n鈥=鈥1, N鈥=鈥1). Finally, some mentioned that their attitude could not become positive (n鈥=鈥2, N鈥=鈥2) or not more positive than it already was (n鈥=鈥1, N鈥=鈥1).

Discussion

In this study, the positive deviant approach was used to study the factors influencing individuals' positive or negative intentions toward the COVID-19 vaccine, despite conflicting beliefs. The aim was to extract insights that could inform the development of strategies to enhance vaccination uptake. This study yields four key findings.

First, both positive and negative deviants mentioned concepts from traditional health psychology models (e.g., [29, 30]) for their deviant vaccination behavior. In line with previous research (e.g., [9, 16, 37, 38, 40]), we found that threat perceptions of the disease and coping perceptions of the vaccine were important reasons for COVID-19 vaccination behavior and vaccination intentions. Another important reason to get vaccinated is the additional benefits linked to vaccination (e.g., easier to travel abroad), which is also featured in traditional health psychology models [34]. This finding corroborates previous work that showed that people were motivated to be vaccinated against COVID-19 to avoid restrictions [10]. However, there were differences among the positive and negative deviants. Whereas positive deviants mentioned threat perceptions of the disease and additional benefits as a reason to get vaccinated, negative deviants mentioned threat perceptions and coping perceptions as a reason to not get vaccinated.

Second, in line with previous research, we found that people were willing to be vaccinated for prosocial reasons, to protect others [10, 11]. This was observed only among positive deviants. This finding fits the notion that vaccination is a social dilemma and that people are vaccinated for prosocial reasons, such as protecting others [2,3,4, 6]. Given that part of the communication about vaccination in the Netherlands was centered on protecting others, our results might indicate that this strategy worked among some people.

Third, our results show that among both the positive deviants and negative deviants there was one dominant theme that could make their opinions toward vaccination more positive or more negative: characteristics of the vaccine (e.g., side-effects). This aligns with previous research that shows that the coping component is the driving force for vaccination decisions [9, 40].听Since vaccines, according to official standards, are effective and safe, public health officials might have to focus more on the how the beliefs about vaccines are shaped and tailor interventions to those factors instead of focusing solely on communicating facts. For example, a study that tested interventions that provided factual information about the COVID-19 vaccine risk or about the development process of the vaccine was not more successful in increasing vaccination intentions than providing people with no information [35]. One potential avenue for this might be the recently developed Empathic Refutational Interview [13].

Finally, among both the positive and negative deviants, some mentioned that nothing could make their attitudes toward the COVID-19 vaccine more positive (or less negative). This finding supports previous research suggesting that interventions to lower vaccine hesitancy and increase vaccination uptake should focus on fence-sitters (i.e., people who do not have a pronounced negative nor positive vaccination attitude; [5, 19]). From a public health perspective, this suggests that public health professionals might have to take extra steps to connect with people who believe that nothing can change their opinion to learn what drives them. Since this is an important group, learning more about their beliefs and concerns while also seeking alternative and innovative ways to reach them, might reveal new insights into how interventions can be made (more) tailor made and effective.

Limitations

This study has several limitations. First, since vaccine hesitancy can be vaccine and context specific [18], the results might not necessarily generalize to other vaccines (e.g., MMR-vaccine) or contexts (e.g., the opportunistic reason for vaccination might a pandemic-specific argument). Second, since countries differ in the organization of their vaccination campaigns [8], the Dutch vaccination campaign could have potentially exerted an influence as well making some reasons more profound. For example, calling upon prosocial motivations is more effective in more individualistic countries than in more collectivistic countries [4] and might not have worked in other countries. Third, not all respondents with the highest deviance scores were willing to be interviewed. Since vaccine hesitancy can be seen as a continuum ranging from accepting all vaccines to rejecting all vaccines [12], we might not have captured the reasons and motivations among vaccinated people with characteristics from which you would not expect that they get be vaccinated. Finally, deviants were selected based on their self-reported vaccination intentions instead of their vaccination behavior because at the timing of the survey on which respondents were selected not everyone was able to get vaccinated. Self-reported vaccination intentions matched vaccination status in most of the cases (18 out of 21). Future research might focus on vaccination behavior (e.g., why people got vaccinated when their underlying worldviews and beliefs would suggest differently) instead of vaccination intentions.

Conclusions

A better understanding of vaccination decision-making processes can assist public health officials in developing interventions that successfully increase vaccination uptake. Our results show that current findings on prosocial vaccination and traditional health psychology models (i.e., the health belief model) also extend to people who are vaccinated contrary to their beliefs and worldviews. To take step 3 in the positive deviant approach, future research might focus on testing the ideas (e.g., linking vaccination to additional benefits and tailoring interventions to underlying beliefs that caused anti-vaccination attitudes) in a larger sample of vaccine-hesitant people. This potentially enlarges the toolbox of public health officials in combating the threats of vaccine hesitancy.

Data availability

Data is available from corresponding author upon reasonable request.

Notes

  1. The complete wording of the measures and reliability statistics can be found in the online supplementary materials S1 and S2.

  2. The n for each reason refers too how often a reason is mentioned, the N for each reason refers to how many different respondents mentioned the reason.

  3. 'Dance with Janssen' (Dansen met Janssen)听was part of the Dutch vaccination campaign. People with one dose of the Janssen (Johnson & Johnson) vaccine were allowed to visit public places and public events after waiting 24听h, whereas people with other vaccinations had to wait a week before they were allowed to do so.

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Funding

This research was supported by a "cross-cutting theme" grant from the Tilburg University Herbert Simon Research Institute awarded to FVL, PA, IVDG, and MC.

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Authors and Affiliations

Authors

Contributions

MM, FvL, MC, IvdG and PA conceptualized the study. MM Collected the data. MM, FvL, MC, and IvdG were involved in data analysis. MM, FvL, MC, IvdG and PA were involved in the interpretation of the study findings. MM wrote the first version of the manuscript. MM, MC, IvdG, and FvL revised the manuscript. MM, FvL, MC, IvdG and PA read and approved the final version of the manuscript.

Corresponding author

Correspondence to Mitchell A. M. Matthijssen.

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Ethics approval and consent to participate

The study was approved by the Ethics Review Board of Tilburg School of Social and Behavioral Sciences (#RP356).

Written consent was obtained by all participants before the participation in the interview.

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Written consent was obtained by all participants before the participation in the interview.

Competing interests

The authors declare no competing interests.

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Matthijssen, M.A.M., Cloin, M., van Leeuwen, F. et al. What made people (more) positive toward the COVID-19 vaccine? Exploring positive and negative deviance perspectives. 樱花视频 25, 441 (2025). https://doi.org/10.1186/s12889-024-21027-1

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  • DOI: https://doi.org/10.1186/s12889-024-21027-1

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