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A new study from Imperial College London has found a link between COVID-19 vaccine hesitancy and a perceived lack of free will over vaccine passports.

The findings, taken from surveys of 1, allied insurance reviews 358 people across the UK and Israel—two highly vaccinated countries—found that people who feel their sense of autonomy, or free will, is unmet by government incentives like vaccine passports are less likely to take the COVID-19 vaccine.

Domestic vaccine passports, where people must prove their vaccination status to stay in hotels and attend events for example, have been introduced across the world to restore freedom of movement within countries and encourage vaccination. However this new study, published in the journal Vaccines, highlights that such public health incentives might affect people’s vaccination decisions in unintended and undesirable ways.

Vaccination is the single most effective way to reduce deaths and severe illness from COVID-19, and current vaccines have demonstrated high levels of protection against symptomatic infection.

Most eligible adults in the UK (57.3 percent) and Israel (62.3 percent) are now fully vaccinated, but 11 percent of eligible adults in the UK and 15 percent in Israel have yet to receive a first dose. These unvaccinated groups could undermine herd immunity, which requires meeting a threshold of vaccinated individuals to secure the safety of people who are unable to take the vaccine. However, not much is known about the psychological factors at play in vaccine hesitancy, and how to tackle them.

Lead author of the study Dr. Talya Porat, of Imperial’s Dyson School of Design Engineering, said: “Although reluctant groups are relatively small, they are not insignificant: some estimates suggest that vaccine refusal rates greater than 10 percent could significantly hinder herd immunity. If we want to ensure enough people get vaccinated to control the spread of SARS‑CoV‑2, we need to understand the factors that affect people’s decisions.”

The research team set out to investigate the extent to which people’s vaccine hesitancy relates to their psychological needs, and how the use of vaccine passports might affect those needs. They surveyed 681 people in the UK and 677 in Israel to measure the needs of autonomy (a feeling of free will to make one’s own decisions), competence (a feeling of being capable of achieving one’s goals and overcoming challenges) and relatedness (feeling cared for, trusted and understood by others), as well as the extent to which these needs were met (‘satisfied’) or unmet (‘frustrated’).

They also asked how willing participants are (or were, if they had already been vaccinated) to get vaccinated, from 1 (not at all willing) to 5 (extremely willing).

Then they measured attitudes towards vaccine passports by asking participants the extent to which they support three scenarios: A “COVID passport’ enabling only fully vaccinated people to perform some social activities; A “COVID passport’ enabling fully vaccinated or recently tested people to perform some activities; and mandatory vaccination for all residents.

They found that people’s willingness to get vaccinated correlated with their sense of autonomy: participants who felt their need for free will was unmet were particularly unlikely to say they would take the vaccine.

Dr. Porat said: “If public health incentives like vaccine passports ‘frustrate’ psychological needs—for example by making people feel a lack of free will over their decisions—then they might paradoxically reduce people’s willingness to get vaccinated.”

The researchers say this suggests that even if government pressure causes people to get vaccinated now, they may be less willing to receive a booster dose or a vaccine against new variants in future. Autonomy-frustrating policies like vaccine passports might also have long-term public health implications in terms of trust in the health system, they explain. Moreover, failing to meet psychological needs can damage people’s wellbeing, so needs-frustrating policies might add to the already heavy burden of the pandemic on people’s mental health.

Dr. Porat added: “For some, vaccine passports act as incentives to get vaccinated so they can move freely in society. Our results suggest that for others, the passports might increase resistance to vaccination or alter the motivation behind their vaccine decisions in ways that might have detrimental long-term consequences.”

Addressing the issue

Senior author Professor Rafael Calvo, also of Imperial’s Dyson School of Design Engineering, said: “Governments and policymakers should strive for highly vaccinated populations by communicating about health and risk in ways that enhance basic psychological needs. This could include creating a health care environment that supports autonomy, like campaigns highlighting how vaccination aligns with the person’s values like ensuring the safety of loved ones. Governments should focus on building a caring and trusting relationship with the public, rather than applying pressure and external controls.”

While observational studies like this cannot identify causal links, the findings demonstrate a robust relationship between psychological needs and people’s willingness to get vaccinated.

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