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Do people from different cultural backgrounds interpret and respond to risk in substantially different ways?
The first time we contemplated this question, from our scientific perspective, we thought, “Why would cultural background determine response to risk when risk is a relatively objectively-defined, quantitative phenomenon?” Of course, this tends to be the attitude of most scientists toward risk assessment, when in reality there are an abundance of data demonstrating that people do not assess risk in a straightforward, objective manner. Rather, assessment and experience of risk are based on an intricate mix of objective assessment and emotional response.
Given this fact, it should not be surprising that factors that seem to have nothing to do with risk assessment are actually quite important across various human activities. Cultural background is one of these factors. There is now very convincing evidence showing that perception of risk is highly influenced by cultural background.
This cultural variation in risk perception thus necessitates different approaches to risk communication depending on cultural context. This is precisely the phenomenon at play in the results of a recent cross-cultural study published in Nature about different methods of communicating the risks of not vaccinating children against several common childhood illnesses. In this nicely-designed study, researchers were able to demonstrate that people from East Asia, which the authors identify as a “collectivistic” culture, were more persuaded about the benefits of vaccination when it was framed as having social benefits (e.g. vaccinating yourself prevents disease in others). On the other hand, people from Western cultures, which were identified as being more “individualistic,” were significantly less persuaded by these types of messages. While this is just one study and it certainly has several limitations, including an over-simplified view of entire world regions and cultures, this is not the first piece of data to suggest that cultural differences change the way people perceive and calculate different benefits and risks.
Is vaccine hesitancy a real threat in the developing world?
Many have argued that increases in vaccine hesitancy in the U.S. and other developed Western countries in the past decade or so are really a perverse consequence of the success of vaccination itself. That is, as almost no new parents in wealthy countries have ever been exposed to a real-life case of measles and, thanks to the vaccine, most of them have not had the illness themselves, their perception of the risk of these illnesses is diminished. Availability bias, a well-known heuristic that causes people to disregard risks that they aren’t readily able to imagine, would suggest that the problem has to do with a lack of awareness of how bad some of these childhood illnesses really are.
While this is probably true to a certain extent, it fails to completely explain vaccine hesitancy for several reasons. First, if availability bias were solely responsible for vaccine hesitancy, then the solution to the problem would very clearly be to expose these “unaware” parents to stories and pictures of children dying of measles. This would restore the ability to imagine the risk and should theoretically lead them marching into their pediatricians’ offices demanding the vaccine. In reality, this method often fails and sometimes it even backfires.
Second, if availability bias were the entire explanation for vaccine hesitancy then the phenomenon would not exist in most places in the developing world where diseases such as measles, polio, and a variety of other devastating but preventable childhood illnesses still occur regularly and recently enough for most people to be able to readily imagine the risk associated with not vaccinating. Despite this, we are actually seeing more vaccine hesitancy in a range of developing countries than expected.
In the wake of the Ebola crisis, the WHO published some key recommendations for addressing vaccine hesitancy in 2015. According to the WHO, the working group and report were inspired by the recognition that vaccine hesitancy is a growing concern in many less developed countries.
The reasons for vaccine hesitancy in developing countries are varied and complex, as they are in developed countries. Marginalized and disenfranchised communities with fringe religious or philosophical views account for a portion of these cases of hesitancy. In these instances, vaccine hesitancy is usually very closely related to membership in particular groups with strong, highly persuasive and highly charismatic leaders at a local level. In these instances, persuading people otherwise sometimes requires the input and influence of another strong leader respected by the community. In other cases, vaccine hesitancy spreads among urban wealthy and well-educated elites, just as it does in some wealthy communities in California. High levels of education are in general not a strong predictor of vaccine acceptance, despite what many people think.
Given the potential for such differences in attitudes toward vaccines across cultures, it’s essential that we gain a better understanding of what drives vaccine hesitancy in different cultural contexts. Even within the U.S., our understanding of vaccine hesitancy is poor. Indicators and measures of vaccine hesitancy have been developed and are the basis for the Vaccine Confidence Survey, but these measures still need better adoption. To begin with, healthcare providers should collect information on attitudes toward vaccination in order to provide a fuller picture of the scope of the problem.
Once we have a better sense of the global scope of vaccine hesitancy, we need to develop a deeper understanding of the precise nature of the problem in key areas where hesitancy is high. Are people opposed to certain specific vaccines or are they opposed to the concept in general? Are they suspicious of pharmaceutical companies and governments? Do they have spiritual or religious objections to vaccination? Are they skeptical that vaccines really work? What are the demographic features of the relevant populations? Are they mostly mothers with young children? Are they mostly educated and wealthy or less educated and lower income people?
Finally, it’s essential to rigorously test any messages or interventions that are devised on the basis of these assessments. Too often we fail to apply the scientific methods we have at our disposal to communication and behavior change strategies. This is a major oversight. Rolling messages out without an understanding of how they affect and influence people may not only fail to work but it may actually make things worse.
In developing countries in particular, it’s also vital to understand the health system and any practical barriers to vaccination that might exist—in some cases, for example, people develop negative attitudes about vaccines in response to an inability to access them. The negative attitudes in these cases provide a kind of psychological justification for a situation that feels hopeless and unacceptable. In such a scenario, anti-vaccine ideas can give people a sense of control in situations in which they feel severely disenfranchised. These feelings of disenfranchisement can also of course occur among higher-income people in wealthy countries, and they are powerful states of mind that should not be overlooked.
Vaccine hesitancy may seem like a “first-world” phenomenon, but there is clearly reason to be concerned about the effects of these attitudes on people everywhere. As we continue to address this issue on a global scale, it will be essential to attend to cultural differences, to understand natural human psychological inclinations, and to rigorously test both our assumptions and our proposed solutions.
