Increasing Vaccinations Requires Understanding How Culture Shapes Thinking | Opinion

In the mid 2000s, I was working with local researchers on the Swahili coast of Kenya studying a health care puzzle: Why were so many kids with kifafa (Swahili for epilepsy) forgoing life-saving medicine? And why were public health campaigns and efforts so ineffective?

The answer: culture.

What families viewed as the cause of seizures, and how providers talked about these causes, were better predictors of the treatments they sought than distance to a health facility, cost of treatment, or their awareness that were anti-epilepsy drugs. Families with strong beliefs that nyagu (spirits) or majini (curses) caused epilepsy were more likely to seek traditional treatment from an mganga (traditional healer) and less likely to use biomedical treatment. When biomedical practitioners discussed treatment in culturally meaningful terms—and didn't disparage traditional treatment—families were more likely to access medications that reduced seizure frequency.

The Swahili coast sounds a million miles away from anything going on in the U.S., but our own belief systems are shaping our health decisions. Cultural mindsets in the States create hard-to-explain behaviors. Especially when it comes to COVID-19.

We use cultural mindsets to make sense of our world. They normalize–or problematize–certain aspects of the social order, shaping our decisions and actions. They become most apparent when they result in behaviors that, on the surface, don't make a lot of sense. Why do working class Americans so frequently vote against their own best interests? Why is it so hard for Americans to support public policies that prevent public health disasters and save massive amounts of money? Culture.

Cultural mindsets can help us understand low COVID vaccination rates; addressing them is part of how we remedy the problem. That vaccination rates differ widely across cultures and regions with similar health care situations further evidences the importance of cultural mindsets in explaining this phenomenon. Access matters, but mindsets are a crucial piece of the puzzle.

Researchers have argued that the stubborn vaccination gap in the U.S. is undergirded by a toxic combination of lack of trust in government and health individualism, the idea that well-being is the result of personal lifestyle and consumer choices.

While our research supports these findings, it suggests that there are additional mindsets behind America's low vaccination rates. And the full range of these mindsets needs to be addressed in any campaign to increase vaccination confidence.

COVID mRNA vaccines are synthetic products, which for many positions vaccines as an unnatural threat to the "purity" of our bodies. Across demographic groups, participants in our research reasoned that because the human immune system is "naturally effective," introducing synthetically-produced materials can corrupt this system, doing more harm than good. Research suggests that conservatives, who have the lowest vaccinations rates, place the greatest importance on values of purity.

Thinking of vaccines as "man-made" also introduces the idea of error. People assume that mistakes happen when people make things—to err is human. We've found that this fear of human error is especially strong in how people view medical issues. In our more recent vaccine research, participants explained that introducing a man-made substance into the body comes with a reasonable chance of something going wrong. This mindset may be especially powerful in those who have not yet been COVID-vaccinated thanks to prevalence of conspiracy theories. Research suggests that, for some, conspiracy theories—including that COVID vaccines cause infertility or contain tracking microchips—play a strong role in vaccine decisions. For these individuals, the "human error" mindset may be especially powerful since it establishes vaccines not just as fallible, but as downright dangerous because they're made by government scientists with malicious intent.

We've also found that, for many people, trust in vaccines, and medicine more generally, is shaped by a skeptical "have to see it to believe it" mindset. In this mindset, confidence comes from direct personal experience. This may not seem problematic, given the majority of people eligible in the U.S. have been vaccinated, but it works against vaccine confidence in two ways. First, the relative newness of the vaccine and the speed at which it was designed feed into people's caution around the need to "wait and see." Second, because of the correlation between hesitancy and political ideology, and because of current U.S. patterns of political segregation, those who are hesitant may actually have limited direct experience with individuals who have been vaccinated and thus limited experiential evidence to draw on in making judgments about the vaccine's safety. If confidence comes from knowing people who've been vaccinated, socializing primarily with others who are hesitant and unvaccinated makes it unlikely for one to witness the vaccine's positive outcomes—and easier to resist pro-vaccine messages.

A COVID-19 vaccine is prepared
A COVID-19 vaccine is prepared for administration. FREDERIC J. BROWN/AFP via Getty Images

Finally, our research shows that people's thinking about vaccines is connected to ideas of control, and more specifically, concerns about loss of control. Public health pressure and "vaccine mandates" activate fear of losing personal control over decisions, deepening hesitancy for those who most strongly hold these ideas. For these individuals, vaccines become yet another way that government is stepping on individual rights and personal freedoms, rather than protecting the public health. The relationship between people's understanding of vaccines as a personal choice and more general anxieties about loss of social status is part of what prompts vaccine hesitancy.

Mindsets, though, can change. And the way we communicate paves the way.

Across political backgrounds, Americans view vaccines as a triumph of science and ingenuity. In the race for a solution to a worldwide pandemic, America's role in vaccine creation was deemed evidence of American exceptionalism and our country's tradition of roll-up-your-sleeves problem solving. Highlighting America's role in scientific progress may lead to more positive and less political discussions of vaccines. Public health communicators can frame vaccine messages by appealing to other examples of American ingenuity and collective problem solving or by stressing ingenuity and innovation explicitly as values.

A more metaphorical mindset—the idea that vaccines are a way of training our bodies' systems–also seems promising. This mindset allows people to maintain beliefs about the strength and purity of the body's natural system by seeing the COVID vaccine as a way to strengthen rather than replace these natural systems.

How we craft public health messaging is part of the difference between our currently inadequate vaccination rates and the numbers that could defend us against the next variant, whenever it comes.

Using examples, values and metaphors to hook into productive understandings and pull them forward in decision making was a key part of addressing the epilepsy treatment gap in Kenya. When medical practitioners were able to use familiar concepts to explain how anti-epilepsy treatment works, parents were more likely to access biomedical treatment. And when traditional healers—trusted messengers—discussed the complementarity of traditional and biomedical treatments, families bought in and went to clinics.

From the coast of Kenya to the American heartland, cultural mindsets influence our decisions and behaviors. Always. This relationship between how we think and what we do holds both the challenge and the solution. If we understand how culture fuels hesitancy, we can create communications that address these beliefs, shift thinking and change behavior. Our nation's health depends on it.

Nat Kendall-Taylor is CEO of the FrameWorks Institute.

The views expressed in this article are the writers' own.