Vaccination was a major topic at the intersection of medical and social sciences even before 2020, but after the advent of the COVID 19 pandemic, it became clear that the issue was much more complicated than we imagined.
In the past two years, countless articles have been published on the acceptance and refusal of vaccination, especially in the context of the pandemic. One thing is clear – so much has been published that we are far from benefiting from all the information contained in these studies. Because it's so much so that it is virtually impossible to assimilate. A clarification and systematization of the typologies and causalities identified would be necessary.
We see that all this, however, moves in a space bounded by several concepts, well-founded in specialized studies, measurable and empirically measured over and over again: vaccine acceptance, vaccine confidence, vaccine hesitancy, vaccine refusal[i][ii][iii][iv][v].
One problem is whether we are dealing with a continuum or with separate phenomena. It's a scaling problem, common in the social sciences. In general, the attitude or intention of vaccination is measured in opinion polls with an ordinal question or with a nominal one of acceptance / indecision / refusal type, in which sometimes the indecision is detailed in 2-3 other variants of answer regarding motivations. But what if the acceptance and refusal of vaccination are not steps on a scale, but qualitatively different phenomena, with motivations from different spectra and attributable to clearly differentiated human typologies?
Also, the pandemic has shown us that the triangle of acceptance / hesitation / refusal also has a special dynamic, depending on the availability of the vaccine, what rumors / fake-news appear about covid and vaccine, trust in the authorities, fear, perception of the social norm, imposition of restrictions for the unvaccinated, etc. In rural areas, the dynamics of this triangle can also be influenced by the population's access to health services, and the development of Multifunctional Integrated Community Centers could be useful in this regard[vi].
The pandemic context and the imperative of regulating social relations through special norms specific to the state of emergency or the state of alert have determined in many situations the association of vaccination with the need to avoid the restrictions imposed by the authorities on the unvaccinated. Thus, appeared a non-medical motivation for vaccine intake: to avoid restrictions). Or, on the contrary, vaccine refusal appeared as a form of social resistance to the high normative pressure too high of the authorities. Such a paradoxical social polarization of this type raises serious questions about the most effective regulatory method implemented by the authorities in any future crisis situation that they would try to manage through increased pressure (increasing the motivation of compliance with the regulation by those who want to avoid restrictions being in counterweight to the accentuation of non-compliance with the regulation by those who want to emphasize the resistance to restrictions aimed at aspects sensitive on human rights). This paradox of social conduct is all the more relevant because in crisis situations social discipline and compliance with norms are much more important than in other social and historical situations.
Studies show that there are multiple explanations regarding the acceptance/refusal of vaccination. In short, the acceptance, hesitation or refusal of vaccination (in the case of covid 19 and beyond) have been explained by the following types of causal models:
1. Models that refer to distrust in the vaccine (in the content of the serum, or the production method), to distrust in medicine, and to scientific illiteracy (although, the relationship between scientific literacy and the intention to vaccinate is much more complicated than it seems);[vii][viii]
2. Models that refer to the distrust of the authorities, conspiracy theories, the assumption of hidden intentions of the organization of the vaccination process by the authorities;[ix][x][xi][xii][xiii]
3. Models that refer to differences in perception of vaccine and vaccination between different socio-demographic categories (age, education, gender, national membership, religion, etc.);[xiv][xv][xvi]
4. Models that relate primarily to the channel, the source of information on the virus, on the pandemic, on the vaccine and the vaccination process.[xvii][xviii]
4. Psychosociological models, which take into account purely psychosociological variables that are associated with acceptance or hesitation in the face of vaccination - for example, in a previous article we argued that there is a very strong correlation between positive attitudes to vaccination and the belief that most others want to get vaccinated.[xix]
The question is whether this typology based on the triangle acceptance/hesitation/refusal is too manifest and too simplistic. If we describe these three attitudes through more pragmatic indicators we could obtain a much more operational typology, which would also show us what are the resorts of this division of the public according to the attitude towards vaccination, a division that in the last year has already acquired sociopolitical valences.
So our research question is the following: we could get a more explicit typology of the attitude towards vaccination in Romania if instead of the direct question on the intention to vaccinate we use a set of questions that would break down on several dimensions the triplet acceptance / hesitation / refusal in the case of vaccination for covid 19. Such a typology could show us which are the resorts that underlie this public opinion/attitude vis-à-vis the covid vaccination.
We intend to build this typology through cluster analysis (k-means clustering). Details about the data used we have in the Materials and Methods section. But first, a brief review of three studies of this type published lately on the anti-covid vaccination. One is based on data collected in the US, two other refer to the case of Europe and Romania in particular, our study being based on data from this last country.
A survey conducted in 2021 on vaccine acceptance and hesitancy among 2491 Healthcare Workers in Southern California aims to prove there is a heterogeneous group (and sub-groups) with varying attitude toward vaccination, not only „anti” and „pro” vaccine. The clustering analysis conducted by the authors of this study starts from the idea of a continuum between total acceptance and complete refusal and describe groups and sub-groups of Healthcare Workers holding varying degrees of indecision about vaccination.
The respondents to the study were grouped in four clusters: (1) misinformed, (2) uninformed, (3) undecided and (4) unconcerned. Thus, there is a diversity in vaccine hesitancy and their conclusions is that „messaging should be tailored to specific sub-groups to increase the understanding of the science behind vaccine”[xx].
Vulpe and Rughinis, using the Eurobarometer 91.2 survey conducted between 15th-29th March 2019, identified three belief configurations as regards vaccine effectiveness, safety and usefulness: hesitant, confident and trade-off.
The authors’ conclusion upon conducting a cluster analysis includes the reference to the substantial variation at the country level, but they cannot find „strong sociodemographic differences among the three belief clusters”.
One of the findings of this study is the „needed to address the socially amplified risk of probable vaccine damage and to consider the trade-off patterns of concomitant trust and mistrust in assessing vaccines.”[xxi]
The study „Social worlds of attitude towards anti-Covid-19 vaccination: Romania in the European context” published in 2021 is based on the Flash Eurobarometer State of the European Union. The further clustering analysis starts from the idea that the attitudes towards vaccine are not only quantitative between the two polls: pro and anti-vaccine. The cluster analysis combines three indicators and generates six types of vaccine attitudes. Romania is positioned in the European context from the point of view of specific profile of attitude along with Poland, Cech Republic and Lithuania.
An important finding of the author is that there are not only pro-vaccine, anti-vaccine or hesitants, but interposing categories qualitativelely structured. It appears to the researcher that both the attitudes tawords vaccination and the intentions to get vaccinated are depend to the socio-demographic elements and the previous life experiences. The conclusion of this study is that we deal with “social worlds of the Covid -19 vaccine attitude in the senes of language communities on the topic” and these social worlds are structured differently in groups of countries. A more accurate understanding can be achieved by further studies including variables like stage of infection with SarsCoV2, migration experiences, the sense of belonging to national / regional spaces with different cultural models.[xxii]