The Health Belief Model and The Dunning-Kruger Effect: Understanding vaccine hesitancy in The United States.


Currently, in the United States, there is a high degree of distrust surrounding the safety of vaccines, the vaccine development process, and even the necessity of preventative vaccines. Many individuals are also concerned about side effects associated with vaccination, and most do not understand that these side effects indicate an excellent immune response. Many people view vaccination as a personal choice rather than a public responsibility and do not understand how it affects others within their family or larger community. Although the evidence is clear on vaccination benefits, many people cannot understand the context and science behind prevention.


 The hesitancy by many Americans to obtain a COVID-19 vaccine is problematic and reveals a far more concerning trend: a distrust of science and scientific experts (Jamison et al., 2019). People of color are statistically more vulnerable to severe COVID-19 clinical outcomes. As a result, those individuals who have experienced generations of health inequality had become hesitant to follow guidelines of government-sponsored organizations like the Centers for Disease Control and Prevention (CDC), according to Randal et al. (2021). Because people of color have higher comorbidity, they are often susceptible to severe outcomes from COVID-19 infection; when combined with a distrust of vaccines, this places vulnerable populations in a precarious situation. According to many authors (Bajaj & Stanford, 2021; Jamison et al., 2019; Jimenez et al., 2021; Wells & Gowda, 2020), historical atrocities inflicted on the African-American community are frequently conveyed to explain this mistrust. History is filled with examples of medical practitioners and researchers in medicine and social sciences conducting immoral and unethical research on African-Americans and other marginalized groups. J. Sims conducted painful experiments on African-American slaves (Wailoo, 2018), dozens of African-American men were denied treatment in the Tuskegee syphilis trials (Barrett, 2019); modern-day experiences of persons of color in the American healthcare system frequently complain of having their symptoms ignored or diminished, suffering misdiagnosis, or being accused of drug-seeking behavior (Hooper et al., 2020; Lopez et al., 2021). Alltucker, reporting in USA Today (June 26, 2020), reported that only 2.9% of physicians currently practicing in the United States identify as African-American, only 3.8% identified as Hispanic or of Spanish descent. Numerous studies have shown that patients are more likely to follow the instructions of healthcare practitioners if they trust them (Hammock & Saturn, 2021). Statistically, groups who distrust physicians and the medical system in general, even though they are at a higher risk of severe complications from COVID-19 infection, are nevertheless less likely to accept medical advice to get vaccinations (Jimenez et al., 2021; Hooper et al., 2020). To help explain this situation, the health belief model (HBM) may provide a framework for addressing this serious health issue.

The Health Belief Model

 While applying several different belief models could be used to understanding vaccine hesitancy among Americans of color, the HBM provides tools for understanding the factors behind the decision-making process based on beliefs about health and perceptions of risk. HBM is a widely used public health and health psychology model for understanding the relationship between health behavior and usage of healthcare systems (Jorvand et al., 2018; Sheppard & Thomas, 2021). Since its development in the 1950s as a strategy to explain the lack of engagement with public health service, the model has been used to explain and predict behavior related to preventative health through the lens of identified belief patterns (Champion & Skinner, 2008). Through the HBM, the behavior to health-promoting can be understood by understanding the beliefs about health problems, benefits of actions to address these identified problems, the perceived barriers to addressing health issues, and the ability for self-efficacy, which can be initiated through a cue to action (Champion & Skinner, 2008). This model also considers not only the intention to seek prevention (i.e., vaccination) but also the individual’s perception of their likelihood of infection. Personal and group held (political, religious) beliefs about health range from those who deny the existence of the coronavirus that causes COVID-19 infection to those who are fully understanding of the threat of infection but refuse the vaccine for fear of the established medical profession (Baldi & Savastano, 2020). In several studies, the possibility of severe illness as a predictor of the likelihood of receiving a vaccine; however, distrust and misinformation have significantly reduced perceived severity among some members of various groups (Baja & Stanford, 2021; Jamison et al., 2019).

 As with most things that involve biological organisms, there is no black and white distinction; instead, there is a gradient of psychological and behavioral delineations. On one end of the scale, there are those individuals that no amount of scientific evidence or harsh reality will convince of the necessity of vaccination (Mukattash et al., 2021), to those at the other end of the spectrum who are cognizant of the threat and were eager to be among the earliest adopters of the vaccines (Baldi & Savastano, 2020). Understandably, most may find themselves somewhere between these two extremes. The HBM, therefore, is an effective method to understand the reasons for individuals to refuse vaccination, either for COVID-19 or for preventable childhood diseases. Many in public health and health education must contend with several factors that seem to coincide around the safety and efficacy of vaccines, including perceptions of risk, perception of the severity of symptoms, biased towards pharmaceutical companies, and misunderstanding of the scientific process (Carrion, 2018). Finally, cues to action, the last predictor of our behavior change, includes both internal and external incentives that motivate individuals toward change.

 Cues to action include providing information on the safety and efficacy of the vaccine process, ensuring that individuals fully understand how the vaccine prevents rather than causes infection or severe cases, the use of social media to emphasize the critical nature of vaccination, and testimony by experts in both public health and the medical professions who recommend the vaccine and explain in simple terms why they advise vaccination (Stecula et al., 2020; Tibbets, 2021). Several researchers (Baldi & Savastano, 2020; Hartman, 2018; Lopez et al., 2021) suggest that subjects are more likely to agree with and receive vaccinations if their position or respected family member recommended these. Cues to action, therefore, can be influential for individuals to receive a vaccine. In similar studies (Cataldi et al., 2019; Demurtas et al., 2020; Li et al., 2018), researchers examining disposition of obtaining an influenza vaccine found remarkably similar conclusions, that recommendation from healthcare experts when known personally, for example, family physician or pediatrician were more likely to be followed then similar recommendations from media. Interactions between patients and healthcare professionals are central to prompting cues to action for the acceptance and utilization of vaccines in general, especially the COVID-19 vaccine. Interestingly, in these studies, pharmacists were also found to be central to interactions with individuals concerning recommendations; however, many pharmacists either declined to engage individuals on the efficacy and safety of vaccines in general (Demurtas et al., 2020) or, in some cases downplayed the importance of vaccinations (Lasco, 2020). Some Americans reported no evidence could prompt them to receive a vaccine (Grochowska et al., 2021). Among such individuals where politics and opinion take precedent over science in reality, there is little that can be done to protect people who are determined to expose themselves and society to a pathogen aside from mandating vaccinations (Gostin et al., 2019). Moreover, a review of preventative studies that used the HBM framework suggested that preventive health behaviors may still rely on personal perceptions of susceptibility, benefits, and barriers; however, for COVID-19, politics and a profound misunderstanding of medicine and health science are also significant factors (Carrion, 2018; Greer et al., 2020; Roper, 2020). How then to effectively encourage change using the HBM construct.

Behavior Change using the HBM.

 Evidence would suggest that, at least for some individuals, no amount of campaigning, explanation, or undeniable proof would be sufficient to prompt behavior change surrounding vaccines in general and the COVID-19 vaccine in particular. For those open to understanding the necessity for vaccines, a strategy led by family physicians and public health professionals could improve the number of vaccine recommendations and awareness available to the public. To provide accurate information to prompt behavior change, several aspects of media messaging should be embraced, including clear messaging on the benefits of vaccines both individually and to the community (Riordon et al., 2021). As mentioned previously, some of the most effective health campaigns that targeted diseases such as lung cancer have utilized brief first-person interviews with patients at the end of life. These were a stark reminder of the eventuality of tobacco use, and such “in your face” presentations are highly effective (Kim et al., 2020). Such displays could include various points of patient care, including interviews with individuals diagnosed with COVID-19, those who have survived ventilation, and family members of COVID-19 patients who did not survive the disease (Airhihenbuwa et al., 2020). The media presentation of the critical necessity of vaccination and other aspects of healthcare should not be underestimated (Ngonso & Chukwu, 2021).

Coordinated intervention

 As previously summarized, HBM examines beliefs about health issues, benefits of addressing these issues, perceived barriers to addressing these health issues, and the person’s ability to apply self-efficacy initiated through a cue to action. Media made personal and understandable on the dangers of unvaccinated persons may challenge mistaken beliefs about the seriousness of the health issue. Personal interviews with individuals who have been vaccinated, and more importantly, those who refuse vaccines and were hospitalized with COVID-19, and testimony from surviving family members of patients who died from COVID-19 may address the benefits of vaccination. Making vaccination sites convenient and offering a wide range of hours during which time the population can receive vaccines, along with public health nurses who can come to individual homes to vaccinate, will significantly decrease the perceived barriers to obtaining the vaccine, taken in entirety of this approach may well prompt cues to action for those who are open to the possibility of vaccination. As stated previously, those determined to place politics and ignorance ahead of science and society are unlikely, even when leaders within their political parties change and speak in favor of vaccination (Mukhtar, 2021; Wood & Schulman, 2021).

In conclusion

 Using the health belief model may prove highly effective and efficient when improving vaccine rates, particularly among most adults concerning the COVID-19 vaccine. At the same time, those individuals who see themselves as victims of a conspiracy surrounding healthcare in general and vaccination, in particular, are unlikely to be swayed by applying any framework that challenges current entrenched beliefs. The reasons are both simple and complex and are based on the understanding that viewpoints outside their own are personal attacks (Mukhtar, 2021). Evidence suggests that regardless of how the subject is approached, due to the politicization of COVID-19, and public health in general, some people identify so totally with a political agenda that they see any uncomfortable thought as a personal attack. They feel the need to defend, and when that does not provide an adequate response, evade. According to researchers (Ali & Davis-Floyd, 2020; Newton, 2020), many people, particularly those of extreme political beliefs, are so entrenched in their convictions that they may feel both mental and physical pain when attempting to modify them. Using various tests, including MRI, scientists (Georgiou et al., 2021; Gordon et al., 2019) found that some individuals operate through a process known as disconfirmation, where a theory or construct can be challenged without any evidence to the contrary. In the study using functional MRI, when convictions were challenged, part of the brain involved in self-identity and emotion were most active, suggesting that entrenched beliefs are unlikely to be changed without first-hand events so significant that the individual’s self-identity must first disintegrate to allow expansion or change (Kaplan et al., 2016). When combined with the cognitive bias where people with a low ability to understand a subject overestimate their ability to understand it, known as the Dunning Kruger effect (Brant, 2020), results in at least some among the population who will not be persuaded by any behavior change framework that does not include either severe personal trauma to themselves or a loved one. For some, not even then.


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