The Psychological Ability to Cope Reduced Infections During the Pandemic: A Two-Year Population-Based Study of The Determinants of 123 Million COVID-19 Test Results in Denmark (preprint)

During the COVID-19 pandemic, a key concern for authorities was to identify and activate the psychological states most likely to motivate the public to engage in protective behavior such as physical distancing and hygienic protection. While feelings of fear and threat were rampant during the pandemic, theories of health psychology have highlighted appraisals related to the ability to cope (e.g., the feeling of being able to cost-effectively adhere to government advice) and argued that coping appraisals are superior predictors of motivations to protect the self against risks. In this study, we provide a massive population-based comparison of the association between, on the one hand, threat appraisals, and coping appraisals and, on the other hand, protection against actual infection during the COVID-19 pandemic. To this end, we utilize a unique data infrastructure from Denmark that couple surveys of 8 % of the adult Danish population (N= 386.633) with the individual results of all 123 million COVID-19 tests performed in Denmark during 23 months of the COVID-19 pandemic. Overall, controlling for a comprehensive range of sociodemographic measures and employing panel data to bolster internal validity, we observe that stronger coping appraisals are consistently associated with lower individual probability of COVID-19 infection risk. We find no con-sistent evidence for a similar association for threat appraisals. Threat appraisals rather seem to index – to some extent, accurately – individual feelings of infection exposure. As appeals to fear also have unintended negative consequences (includ-ing anxiety, fatigue, and stigmatization), the findings provide strong empirical support for relying on coping-oriented public health communication in future societal crises in the domain of health and beyond.

Prejudice Against the Vaccinated and the Unvaccinated During the COVID-19 Pandemic: A Global Conjoint Experiment (preprint)

Despite early hope that vaccines may end the COVID-19 pandemic, large unvaccinated minorities persist even in countries with high vaccine access. Consequently, public debates and protests have been intensifying over the issue of vaccination. Here, we ask whether people's status as either vaccinated or unvaccinated has come to reflect a socio-political cleavage that spills over even to interactions between people in everyday life. Using a standard measure of exclusionary reactions in family relationships, we quantify the antipathy between vaccinated and unvaccinated citizens in 21 countries (10,740 respondents), representative of 58\% of the world's population. Using conjoint experimental data, we demonstrate that vaccinated people have high antipathy towards the unvaccinated, 2.5 times more than towards a traditional target: immigrants from the Middle East. This antipathy reflects, in part, stereotypic inferences that unvaccinated individuals are untrustworthy and unintelligent, making the antipathy resemble prejudice towards other deviant groups. Antipathy towards the unvaccinated is larger in countries that suffered fewer COVID-19 deaths and that have higher social trust. In contrast, we find no evidence that unvaccinated respondents display antipathy towards vaccinated people, although they are equally prejudiced against immigrants. While previous research recommends framing vaccination as a moral obligation in order to increase uptake, our research documents the costs of this strategy. Whether understandable or not, the antipathy faced by the unvaccinated may exacerbate marginalization and mistrust, which are core causes of their initial vaccine hesitancy, and further entrench the conflict. The novel socio-political cleavage we document may thus be an indication that societies worldwide will leave the pandemic more divided than they entered it.

How the Development, Features and Roll-Out of a SARS-COV-2 Vaccine Shape Public Acceptance: A Conjoint Experiment in a Large Representative Sample of Danes (preprint)

Background While effective vaccines against the SARS-COV-2 virus have been developed and countries around the world have invested heavily to secure vaccine rollout, a fundamental challenge remains. How do policy-makers around the world ensure high vaccine uptake? What is lacking is a comprehensive assessment that captures a total spectrum of features related to the development of a vaccine, the vaccine's characteristics as well as the implementation of the vaccination program.Methods To provide such an assessment, we designed a conjoint experiment embedded in large-scale surveys based on a random sample from the central database of Danish social security numbers (N = 3,099), providing a sample that is representative for the adult Danish population. In the conjoint experiment, we vary features relating to three dimensions: 1) the stage of vaccine development, 2) the specific characteristics of the vaccine, and 3) the implementation of the vaccination strategy.Results We show that the features relating to characteristics of the specific vaccine have the strongest impact on vaccine acceptance. The features relating to vaccine development were the second most powerful, while the features relating to the implementation of the vaccination strategy were the least.Conclusions The public has a strong preference for vaccines with high efficacy. This may point to a mounting challenge for ensuring high vaccine uptake. Yet, the results also provide evidence that there might be a pathway to naturally alleviate this challenge. Thus, over time the “testing period” of the vaccines are naturally extended, which simultaneously implies an increase in vaccine safety (provided that the roll-out only reveals marginal side-effects). Our results suggest that such an increase in vaccine safety in itself will increase acceptance (in particular, if the roll-out only reveals marginal side-effects). Furthermore, the results indicate that vaccine acceptance can be increased if politicians leave it to the health authorities to communicate about recommendations.

Willingness to Take the Booster Vaccine in a Nationally Representative Sample of Danes (preprint)

We estimate the willingness to taking the booster dose in a representative sample of Danes. We estimate an overall willingness in the adult Danish population of 85.5 percent and a willingness of 94.7 percent among primary vaccine takers. We, moreover, show that these percentages will be significantly lower among younger populations as well as among groups who do not see COVID-19 as a threat towards society and who do not perceive the advice of the health authorities as effective against disease spread.

The COVID-19 Pandemic Eroded System Support But Not Social Solidarity (preprint)

While the World has been busy mitigating the disastrous health and economic effects of the novel coronavirus, a less direct, but not less concerning peril has largely remained unexplored: the COVID-19 crisis may disrupt some of the most fundamental social and political relationships in democratic societies. We interviewed samples resembling the national population of Denmark, Hungary, Italy and the US three times: in April, June and December of 2020 (14K observations). We employed a broad set of survey questions tapping into perceptions about the two major relationships structuring society: Horizontal relationships between citizens, and vertical relationships between citizens and the state. We benchmarked these data against pre-COVID levels measured in the World Values Survey and the European Values Survey. We present strikingly similar findings across the four diverse countries. We show that support for the political system has markedly decreased already by April and fell further till December. Exploiting the panel setup, we demonstrate that within-respondent increases in indicators of pandemic fatigue (specifically, the perceived subjective burden of the pandemic and feelings of anomie) correspond to decreases in system support and increases in extreme anti-systemic attitudes. Meanwhile, we find much smaller changes in social solidarity and trust compared to pre-pandemic levels, and we find that these attitudes are largely unaffected by pandemic burden. Our results imply that the pandemic is not only a health-crisis, but poses a substantial challenge to the relationship between citizens and the state.

Considerations Underlying Parents’ Acceptance of COVID-19 Vaccines for Their Child: Evidence from Denmark (preprint)

Background: Since the initial phases of vaccination campaigns, health authorities across the world have recommended vaccination of children between 15 and 18; and since the summer of 2021, vaccinations of children between 12 and 15 have been recommended. Recently, American and European Health Authorities have approved the use of a vaccine against COVID-19 for children between age 5 and 11. In this article, we ask what predicts parents’ intention to vaccinate their children against COVID-19. Methods: We use empirical data from a large-scale survey in Denmark about vaccine intentions. The survey included a subsample of 794 parents to children aged 6-15. For this group of parents, we assess key predictors (including demographics, predispositions, vaccine perceptions, and vaccine barriers) of parents’ acceptance of a vaccine for their child against COVID-19. Results: We propose that the vaccine decision follows a stepwise process: demographic variables shape parents’ predispositions, which again shape their specific perceptions of the safety and effectiveness - both in general and for their children - of the particular vaccine. Moreover, we argue that vaccine barriers will moderate this process. Our results demonstrate that parents’ intention to get their children vaccinated against COVID-19 is not driven by considerations regarding the disease of COVID-19 but by considerations of the safety of vaccines and added benefits of vaccination such as normalizing societal and everyday life. The balance of these considerations shift depending on the child's age, with lower acceptance for younger children. Furthermore, the content of considerations are shaped by trust in the health authorities and factual vaccine knowledge. Conclusion: To increase parents' acceptance of a COVID-19 vaccine for their children, health authorities should focus on establishing and communicating evidence for the safety of vaccines and the impact of vaccination for their everyday lives.

Increased Pressure Lowers Trust Among Unvaccinated: Effects of the Announcement of Re-Introducing Covid-Passports in Denmark (preprint)

On November 8, 2021, the Danish government held a press conference re-introducing COVID-19 passports both to mitigate the recent surge in COVID-19 infections and to put more pressure on still unvaccinated people to take up the vaccine. The press conference was also notable for the Prime Minister, Mette Frederiksen, condemning the unvaccinated in unprecedentedly harsh words. While new vaccinations increased in the weeks following the press conference, we show that the press conference had unintended, negative consequences. We analyze daily, nationally representative survey data (total N = 25K) employing a difference-in-differences design. We demonstrate that the press conference broadened by 25-33% the already large gaps between vaccinated and unvaccinated citizens on four out of five key psychological antecedents of health compliance. Most notably, we find that trust in the strategy of managing the COVID-19 epidemic decreased by 11 percentage points among the unvaccinated but stayed high among the vaccinated. When considering “pressure” as a pandemic management strategy it is important to be aware of these unintended costs and how they may shape the unvaccinated citizens’ compliance with other health advice and their overarching support for the political system.

"Pandemic Fatigue" Fueled Political Discontent: Evidence From 8 Western Democracies Over 11 Months of the COVID-19 Pandemic (preprint)

Health authorities have highlighted "pandemic fatigue" as a psychological consequence of the COVID-19 pandemic and warned that "fatigue" could demotivate compliance with health advice. Yet, "fatigue" from following the advice of authorities may have consequences far beyond the health domain. Theories from the social sciences have raised that real and perceived costs of policies can also drive sentiments of discontent with the entire political establishment. Integrating theories from the health and social sciences, we ask how "pandemic fatigue" (i.e., perceived inability to "keep up" with restrictions) developed over the pandemic and whether it fueled political discontent. Utilizing longitudinal and panel surveys collected from September 2020 to July 2021 in eight Western democracies (N=49,116), we analyze: (1) "fatigue" over time at the country level, (2) associations between "pandemic fatigue" and discontent, and (3) the effect of "pandemic fatigue" on political discontent using panel data. "Pandemic fatigue" significantly increased with time and the severity of interventions but also decreased with COVID-19 deaths. When triggered, fatigue elicited a broad range of discontent, including protest support and conspiratorial thinking. The results demonstrate the significant societal impact of the pandemic beyond the domain of health and raises concerns about the stability of democratic societies, which were already strained by strife prior to the pandemic.

How the Development, Features and Roll-Out of a SARS-COV-2 Vaccine Shape Public Acceptance: A Conjoint Experiment in a Large Representative Sample of Danes (preprint)

While effective vaccines against the SARS-COV-2 virus have been developed and countries around the world have invested heavily to secure vaccine rollout, a fundamental challenge remains. How do policy-makers around the world ensure high vaccine uptake? What is lacking is a comprehensive assessment that captures a total spectrum of features related to the development of a vaccine, the vaccine's characteristics as well as the implementation of the vaccination program. To provide such an assessment, we designed a conjoint experiment embedded in large-scale surveys based on a random sample from the central database of Danish social security numbers (N = 3,099), providing a sample that is representative for the adult Danish population. In the conjoint experiment, we vary features relating to three dimensions: 1) the stage of vaccine development, 2) the specific characteristics of the vaccine, and 3) the implementation of the vaccination strategy. We show that the features relating to characteristics of the specific vaccine have the strongest impact on vaccine acceptance. The features relating to vaccine development were the second most powerful, while the features relating to the implementation of the vaccination strategy were the least.

Did the European Suspension of the AstraZeneca Vaccine Decrease Vaccine Acceptance During the COVID-19 Pandemic? (preprint)

The decision to temporarily suspend the AstraZeneca vaccine against COVID-19 raised debate about the suspension's potential effects on the levels of acceptance of the overall vaccination program against COVID-19. Here, we trace the impact of first the Danish decision and subsequent national decisions on general COVID-19 vaccine acceptance by comparing levels of acceptance on different specific dates in eight countries. Overall, the findings suggest that the Danish decision to suspend the vaccine may have had (at least, short-term) cross-national ripple effects on acceptance of a vaccine against COVID-19. Importantly, these adverse ripple effects were specific for individuals within countries that are most closely tied to the same informational eco-system as Denmark (i.e., other Western European countries). These countries (in particular, Italy) may furthermore have been negatively affected twice following both the Danish and the national suspension decisions. This raises the possibility that the decision to suspend vaccines following adverse events poses a collective action problem and highlights the importance of coordination between national health authorities.

Communicate Hope to Motivate the Public During the COVID-19 Pandemic (preprint)

How should health authorities communicate to motivate the public to comply with health advice during a prolonged health crisis such as a pandemic? During the SARS-CoV-2 pandemic, for example, people have had to comply with successive restrictions as the world faced multiple races between controlling new waves of the virus and the development and implementation of vaccines. Here, we examine how health authorities and governments most effectively motivate the public by focusing on a specific race: between the Alpha variant and the implementation of the first generation of COVID-19 vaccinations in the winter of 2021. Following prior research on crisis communication, we focus on appeals to fear and hope using communicative aids in the form of visualizations based on epidemiological modelling. Using a population-based experiment conducted in United States (N = 3,022), we demonstrate that a hope-oriented visual communication aid, depicting the competing effects on the epidemic curve of (1) the more infectious variant and (2) vaccinations, motivates public action more effectively than a fear-oriented visual communication, focusing exclusively on the threat of the new variant. The importance of the implementation of such hope-oriented messages is further highlighted by cross-national representative surveys from eight countries (N = 3,995), which demonstrate that feelings of fear towards the Alpha variant alone were insufficient to activate strong compliance in isolation. Overall, these findings provide general insights into the importance of hope as a health communication strategy during the COVID-19 pandemic and beyond.

Moralizing the COVID-19 Pandemic: Self-Interest Predicts Moral Condemnation of Other's Compliance, Distancing and Vaccination (preprint)

The emergence of the novel coronavirus has put societies under tremendous pressure to instigate massive and rapid behavior change. Throughout history, an effective strategy to facilitate novel behaviors has been to morally condemn those who do not behave in an appropriate way. Accordingly, here, we investigate if complying with the advice of health authorities---e.g. to physically distance or vaccinate---has emerged as a moralized issue during the COVID-19 pandemic. In Study 1, we rely on data (N = 94K) from quota-sampled rolling cross-sectional online surveys from eight countries (Denmark, Sweden, Germany, France, Italy, Hungary, the UK, and the US). We find that large majorities find it justified to condemn those who do not keep a distance to others in public and around half of respondents blame ordinary citizens for the severity of the pandemic. Furthermore, we identify the most important predictors of condemnation to be behavior change and personal concern, while institutional trust and social distrust also play large but less consistent roles. Study 2 offers a registered replication of our findings on a representative sample of Britons (N = 1.5K). It shows that both moralization and condemnation of both vaccination and general compliance are best predicted by self-interested considerations.

Transparent Communication About COVID-19 Vaccines Is Not Sufficient for Acceptance but It is Necessary for Trust (preprint)

During the rapid development and rolling-out of vaccines against SARS-CoV-2, researchers have called for an approach of "radical transparency", where vaccine information is transparently disclosed to the public, even if negative information can decrease vaccine uptake. Consistent with theories about the psychology of conspiracy beliefs, these calls predict that a lack of transparency may reduce trust in health authorities and facilitate the spread of conspiracy theories, which may limit the long-term capabilities of health authorities during and after the pandemic. On the basis of pre-registered experiments conducted on large, representative samples of Americans and Danes (N > 13,000), the present study contrasts the effects of vague vaccine communication with transparent communication, which discloses either positive or negative vaccine features. The evidence demonstrates that transparent negative communication may indeed harm vaccine acceptance here and now but that it increases trust in health authorities. Furthermore, the alternative of vague, reassuring communication does not increase vaccine acceptance either and leads to both lower trust and higher endorsements of conspiracy theories.

Public Acceptance of COVID-19 Vaccines: Cross-National Evidence on Levels and Individual-Level Predictors Using Observational Data (preprint)

ObjectivesThe management of the COVID-19 pandemic hinges on the approval of safe and effective vaccines but, equally importantly, on high vaccine acceptance among people. To facilitate vaccination acceptance via effective health communication, it is key to understand levels of vaccine skepticism and the demographic, psychological and political predictors. To this end, we examine the levels and predictors of acceptance of an approved COVID-19 vaccine.Design, setting and participantsWe examine the levels and predictors of acceptance of an approved COVID-19 vaccine in large online surveys from eight Western democracies that differ in terms of the severity of the pandemic and their response: Denmark, France, Germany, Hungary, Sweden, Italy, United Kingdom, and United States (total N = 18,231). Survey respondents were quota sampled to match the population margins on age, gender, and geographic location for each country. The study was conducted from September 2020 to February 2021, allowing us to assess changes in acceptance and predictors as COVID-19 vaccine programs were rolled out. Outcome measureThe outcome of the study is self-reported acceptance of a COVID-19 vaccine approved and recommended by health authorities. ResultsThe data reveal large variations in vaccine acceptance that ranges from 82 % in Denmark to 52 % in Hungary. Lack of vaccine acceptance is associated with lack of trust in authorities and scientists, conspiratorial thinking, and a lack of concern about COVID-19. ConclusionMost national levels of vaccine acceptance fall below estimates of the required threshold for herd immunity. The results emphasize the long-term importance of building trust in preparations for health emergencies such as the current pandemic. For health communication, the results emphasize the importance of focusing on personal consequences of infections and debunking of myths to guide communication strategies.

The psychological burden of the COVID-19 pandemic is associated with anti-systemic attitudes and political violence (preprint)

What are the consequences of the COVID-19 pandemic for people's political attitudes and behavior? We tested, specifically, whether the psychological burden of the COVID-19 pandemic relates to anti-systemic attitudes (dissatisfaction with the fundamental social and political order), peaceful political activism, and political violence. Nationally representative two-wave panel data were collected via online surveys of adults in the United States, Denmark, Italy, and Hungary (Ns = 6,131 and 4,568 in Waves 1 and 2 respectively). Overall, levels of anti-systemic attitudes were low and only a small share of interviewees reported behavioral intentions to participate and actual participation in political violence. However, pre-registered analyses indicated that perceived COVID-19 burden was associated with anti-systemic attitudes and intentions to engage in political violence. In the US, COVID-19 burden was also associated with self-reported engagement in violence surrounding the Black Lives Matter protests and counter-protests. We found less robust evidence that perceived COVID-19 burden was associated with peaceful activism.

Support for Border Security During the COVID-19 Pandemic: Evidence on Levels and Predictors from Eight Western Democracies in 2020 (preprint)

One of the unprecedented measures to contain the spread of COVID-19 during the first wave of the pandemic was to close borders across the world. In Europe, the closing of national borders was perceived as particularly controversial because of the emphasis on the free movement of labor and citizens across borders within the European Union. Here, we examine the level of support for border closings among citizens from eight Western democracies, how support developed over time, and how particular COVID-19-related concerns and considerations predict individual differences in support. Specifically, we collected data on support for tightened border security from 9 April 2020 until 19 December 2020 in quota-sampled online surveys in Denmark, Sweden, United States, United Kingdom, France, Germany, Italy and Hungary. Eight Western democracies that differ in their response to and the impact of COVID-19 (N = 67,679). Overall, the data show moderate to high levels of support for tightened border security across all observed countries, with substantial within-country variation. Furthermore, the analyses show that support for border security relates to both usual predictors of anti-immigration views and corona-specific considerations, in particular, personal concerns about the adverse effects of COVID-19 and attributions of blame to international actors such as China and WHO.

National identity predicts public health support during a global pandemic (preprint)

Changing collective behaviour and supporting non-pharmaceutical interventions is an important component in mitigating virus transmission during a pandemic. In a large international collaboration (Study 1, N = 49,968 across 67 countries), we investigated self-reported factors that associated with people reported adopting public health behaviours (e.g., spatial distancing and stricter hygiene) and endorsed public policy interventions (e.g., closing bars and restaurants) during the early stage of the pandemic (April-May 2020). Respondents who reported identifying more strongly with their nation consistently reported greater engagement in public health behaviours and support for public health policies. Results were similar for representative and non-representative national samples. Study 2 (N = 42 countries) conceptually replicated the central finding using aggregate indices of national identity (obtained using the World Values Survey) and a measure of actual behaviour change during the pandemic (obtained from Google mobility reports). Higher levels of national identification prior to the pandemic predicted lower mobility during the early stage of the pandemic (r = -.40). We discuss the potential implications of links between national identity, leadership, and public health for managing COVID-19 and future pandemics.

Public Support for Government Responses Against COVID-19: Assessing Levels and Predictors in Eight Western Democracies During 2020 (preprint)

To halt the spread of COVID-19 governments have engaged in policies that are both economically costly and involve infringements of individual rights. In democratic countries, these policy responses have elicited significant debate but we know little about the extent to which the responses are supported or opposed by the broader public. This manuscript investigates how citizens across eight Western democracies evaluate the specific policies imposed by their governments to contain the COVID-19 pandemic. We rely on large-scale, longitudinal surveys that are reflective of the national populations (total N = 124,062). On this basis, we investigate how pandemic-specific and broader political attitudes correlate with support for government responses during a significant part of 2020, a period marked by pandemic restrictions in all the countries. We find medium to high levels of support for the government's responses in all eight countries. Beyond the regular voters of the government, support is driven by individuals high in interpersonal trust and self-assessed knowledge about COVID-19. This suggests that halting the spread of COVID-19 is viewed as a collective action problem and mobilizes support from those knowing how to act and trusting others to act similarly.

Does face mask use elicit risk-compensation? Quasi-experimental evidence from Denmark during the SARS-CoV-2 pandemic (preprint)

Background: Public use of face masks has been widely adopted to halter the SARS-CoV-2 pandemic but a key concern has been whether the effectiveness of face mask use is limited due to the elicitation of false feelings of security that decrease the observance of other protective behaviors, so-called risk-compensation. Methods: We exploit quasi-experimental variation, prompted by three major changes in policy, to assess whether public use of face masks elicit risk-compensation by increasing the number of close contacts or decreasing attention to distancing and hygiene measured in daily nationally representative surveys (N = 106,880). Results: Number of close contacts: Face mask use prompted by the policy changes decrease the number of contacts in two of the three interventions. In the remaining intervention, it has no effect. Attention to hygiene: Across the changes face masks use does not affect people's attention to hygiene. Attention to distancing: In two of three interventions, face mask use increase attention to distancing. In the remaining intervention, we see a decrease in attention. Conclusions: Overall, face mask may occasionally elicit a narrow form of risk-compensation; specifically, reducing engagement in physical distancing. However, such narrow forms of risk-compensation are limited: The results do not reveal any effects on the actual number of physical contacts, only on the psychological attention to distancing advice. Moreover, the negative effect only appears for one of three interventions. The other two interventions suggest that face mask use increases attention to physical distancing.

Compliance Without Fear: Individual-Level Predictors of Protective Behavior During the First Wave of the COVID-19 Pandemic (preprint)

Objectives: The outbreak of the COVID-19 pandemic required rapid public compliance with advice from health authorities. Here, we ask who was most likely to do so during the first wave of the pandemic. Design: Quota-sampled cross-sectional and panel data from eight Western democracies (Denmark, France, Germany, Hungary, Italy, Sweden, UK and USA). Methods: We fielded online public opinion surveys to 26,508 citizens between March 19 and May 16. The surveys included questions about protective behavior, perceptions of the pandemic (threat and self-efficacy), as well as broader attitudes towards society (institutional and interpersonal trust). We employ multilevel and fixed-effects regression models to analyse the relationship between these variables. Results: Consistent with prior research on epidemics, perceptions of threat culturally uniform determinants of both avoidant and preventive forms of protective behavior. On this basis, authorities could foster compliance by appealing to fear of COVID-19, but there may be normative and practical limits to such a strategy. Instead, we find that another major source of compliance is a sense of self-efficacy. Using individual-level panel data, we find evidence that self-efficacy is amendable to change and exerts an effect on protective behavior. Furthermore, the effects of fear are small among those who feel efficacious, creating a path to compliance without fear. In contrast, two other major candidates for facilitating compliance from the social sciences, interpersonal trust and institutional trust, have surprisingly little motivational power during the first wave of the COVID-19 pandemic. Conclusions: To address future waves of the pandemic, health authorities should thus focus on facilitating self-efficacy in the public.