“Not Only a Matter of Personal Interest”—Vaccination Narratives and the Model of Moral Motives in China and Germany

Abstract

Understanding vaccination decision-making processes is vital for guiding vaccine promotion within pandemic contexts and for routine immunization efforts. Vaccine-related attitudes influencing individual decision-making can be affected by broader cultural and normative contexts. We conducted 73 qualitative interviews with adults in China (n = 40) and Germany (n = 33) between December 2020 and April 2021 to understand COVID-19 vaccination intentions and preferences, and we analyzed transcripts using a five-step framework approach. During early analysis, we identified moral considerations in line with the tenets of the Model of Moral Motives (MMM) as a recurrent theme in the data. The MMM guided further analysis steps, particularly with its distinction between motives that are proscriptive (focus on avoiding harm by inhibiting “bad” behavior) and prescriptive (focus on actively seeking positive outcomes). Proscriptive vaccination arguments that compelled vaccination in our data included avoiding negative attention, being a law-abiding citizen, preventing harm to others, and protecting one’s country. Prescriptive motives focused on self-efficacious behavior such as protecting the health of oneself and others via widespread but voluntary vaccination, prioritizing elderly and predisposed individuals for vaccination, and favoring a fair and equitable distribution of vaccines at the global level. In the interviews in China, both lines of arguments emerged, with a general tendency toward more proscriptive reasoning; interviews conducted in Germany tended to reflect more prescriptive motives. We encourage research and vaccine promotion practice to reflect moral considerations when aiming to understand public health preventive behavior and when developing tailored health promotion campaigns.

Keywords

China Germany qualitative immunization COVID-19 health behavior ethics moral perspectives Model of Moral Motives

Introduction

The COVID-19 pandemic posed unprecedented challenges for societies and health care systems globally (Baud et al., 2020; Pokhrel & Chhetri, 2021; Xiong et al., 2020). Although vaccination was a key avenue for containing the pandemic (Dagan et al., 2021; Watson et al., 2022), uncertainty about uptake of COVID-19 vaccines has been reported globally (Jain et al., 2021; Solís Arce et al., 2021; J. Wang et al., 2021). Such a “delay in acceptance or refusal of vaccination despite availability of vaccination services” (MacDonald, 2015, p. 4163) is known as vaccine hesitancy (VH), which had been described as a top ten threat to global health even before the onset of the COVID-19 pandemic (World Health Organization, 2019).

With regard to COVID-19 vaccines, existing literature shows that VH frequently stems from fear of adverse events (Kricorian et al., 2022), expected low efficacy of vaccines (J. Wang et al., 2021), and concerns that are often driven by misinformation (Pierri et al., 2022). Previous scholarship has highlighted how socio-demographic factors, psychological states, or trust in government and the health care system can influence VH’ and how these factors can differ across settings (Dasch et al., 2023; Lazarus et al., 2020, 2022, 2024). While higher education levels, for example, led to increased vaccination uptake in France, Germany, or the United States, such levels led to decreased vaccination intent in Canada, Spain, and the United Kingdom (Lazarus et al., 2020). Similarly, higher self-reported anxiety levels were positively correlated with vaccination in Canada but led to increased mistrust in vaccination in the United States (Lazarus et al., 2022). Also, high levels of trust in government led to higher acceptance of COVID-19 vaccines in several countries such as the United States, Canada, India, or Sweden (Lazarus et al., 2022). In China, several studies have outlined the role of trust in the context of vaccination decision-making, with mixed evidence on how various facets of trust affect vaccination uptake (Jiao et al., 2023; Lazarus et al., 2022; C. Wang et al., 2021). For an increased understanding of why people refuse or accept vaccination, several authors in different settings have focused on vaccination intentions and vaccination decision-making, using behavioral theories including the Theory of Planned Behavior (Fan et al., 2021), the Health Belief Model (Zampetakis & Melas, 2021), or the Protection Motivation Theory (Eberhardt & Ling, 2021) to explore public opinions on COVID-19 vaccination.

However, behavioral theories such as the above explain only parts of the behavioral variance and do not necessarily translate into behavior outcomes (Webb & Sheeran, 2006). One proposed solution for this gap is to examine latent constructs, such as morality, to better understand behavior (Godin et al., 2005; Gorsuch & Ortberg, 1983). Defining morality is, however, a complex endeavor, which is reflected in varying perspectives across scientific fields (Haidt & Kesebir, 2010). Fields such as philosophy, sociology, psychology, neurobiology, or law focus on slightly different facets of morality, with methods ranging from theoretical conceptualization of right and wrong (e.g., teleological or deontological), to empirically observing and testing behavior and its motivation (e.g., emotion or social influence), to measuring neurocognitive correlates of morality (e.g., moral cognitions or behavioral intents)—to name a few (Gert & Gert, 2002; Hitlin & Vaisey, 2013; Miller, 2008). The research in this article is guided by discussions in the field of moral psychology (Carnes & Janoff-Bulman, 2012; Godin et al., 2005; Haidt, 2007), which highlights an understanding of morality as personal beliefs of right and wrong that form a regulative framework for personal behavior, social interactions (Janoff-Bulman et al., 2009), and “group living; […] to optimize our existence as social beings” (Janoff-Bulman & Carnes, 2013b, p. 219). We therefore adopt a broader perspective of morality that includes the role of social norms and conventions (FeldmanHall et al., 2018) as well as the role of cultural influences (Janoff-Bulman et al., 2009; Matsuo & Brown, 2022).

Across health-related topics, morality as a concept has been applied to research on pursuing healthy diets (Raats et al., 1995) (e.g., consuming meat (De Backer & Hudders, 2015) or organic food (Dean et al., 2008)), testing for sexually transmittable diseases (Young et al., 2007), or quitting smoking during pregnancy (Holdsworth & Robinson, 2008). Several scholars have also highlighted the influence of moral considerations on vaccination attitudes (Korn et al., 2020). Main recurrent themes related to morality and vaccination include harm prevention and fairness (van den Hoven, 2012), the meaning of risks due to adverse events, and the weighing of benefits for the individual versus the society as a whole (e.g., herd immunity) (Giubilini, 2021). Similarly, people who consider vaccination as a prosocial behavior that helps the community have shown a higher likelihood to get vaccinated (Böhm & Betsch, 2022). At the same time, scholars have described how moral considerations related to vaccination can be pronounced in particular subgroups such as health care workers who take their own and their patients’ health into account (Biswas et al., 2021; van Delden et al., 2008), or parents who have to make decisions for their children (Callaghan et al., 2019).

With regard to the COVID-19 pandemic specifically, moral aspects have been discussed throughout the pandemic (Chan, 2021), especially focusing on aspects such as social-distancing (Zlobina & Dávila, 2022) or mask wearing (Gelfand et al., 2022), the role of “free-riders” (unvaccinated people who profit from herd immunity) (van den Hoven, 2012), or vaccine mandates (Bardosh et al., 2022). While moral considerations have been shown to influence various health behaviors, literature on how these considerations manifest in vaccination decision-making processes amid a viral pandemic across multiple contexts is sparse.

In this study, we contribute to filling gaps in the literature by examining how individuals in Germany and China describe their decisions related to COVID-19 vaccination, focusing on notions of morality and moral framing of vaccination by drawing on the tenets of the Model of Moral Motives (Janoff-Bulman et al., 2009).

Material and Methods

Study Design and Theoretical Background

The overarching aim of our research was to gain an understanding of COVID-19 vaccine preferences and vaccination attitudes in China and Germany. Our approach to data collection and analysis was informed by constructivist grounded theory methodology (Charmaz, 2006) and an inductive–deductive concept, which entails the researcher entering the field with little expectation yet attentiveness to concepts as they emerge from the data (Patton, 2015; Varpio et al., 2020). When originally designing the study, we therefore did not explicitly focus on an investigation of morality, but rather we sought to identify which broader concepts (such as trust, emotion, ethical values, or morality) may play a role in COVID-19 vaccination decision-making, as well as how these concepts are understood and reflect existing socio-cultural theories. To achieve this overarching aim, we chose a qualitative research approach due to its ability to make complex and dynamic social constructs tangible within real-life concepts (Pope & Mays, 1995). Especially considering the broader and unprecedented context of the COVID-19 pandemic, including the novel vaccination options and unforeseeable public reactions, we followed expert recommendations to use inductive, qualitative methods to disentangle vaccination attitudes (Dubé & MacDonald, 2020).

Sampling and Data Collection

Team members from Germany, China, and the United States created a semi-structured interview guide that focused on perceptions of COVID-19 vaccines, vaccine preferences, and barriers, as well as on the social dynamics of vaccination decisions, including how to design public vaccination campaigns or to deal with refusals. We collected data between December 2020 and April 2021. At that time, five vaccines were licensed in China (Mallapaty, 2021) and three vaccines (mRNA and vector vaccines) had been launched in Germany (Paul Ehrlich Institut, 2023). In both countries, vaccination had started but was mainly available for either vulnerable or virus-exposed groups such as medical staff (STIKO (Robert-Koch Institut), 2021; Yang et al., 2021).

Respondents were invited via the recruitment platforms Kurun-Data for China and Prolific Academic Ltd (www.prolific.co) for Germany, and selected based on a maximum variation sampling approach (Patton, 2015) to reach a variety of gender (male/female), age (<50 years/>50 years), and living conditions (rural/urban); all of which are indicators for COVID-19 severity and mortality (Chen et al., 2022; Zhou et al., 2020).

In December 2020, three interviewers with backgrounds in public health research and social sciences conducted 40 semi-structured, in-depth interviews via telephone in Mandarin, which lasted 17–56 min. In March and April 2021, one German interviewer with background in medicine and psychology conducted 33 semi-structured, in-depth interviews, which lasted 17–75 min. Interviewers and supervisors in each country met for weekly debriefings (McMahon & Winch, 2018) based on notes taken on self-reflection sheets, and the team collectively discussed options to revise data collection approaches and refine lines of inquiry.

The study received ethical approval from the Ethical Review Board of the Medical Faculty, Heidelberg University, Germany (S-041/2021), and the Institutional Review Board of the Chinese Academy of Medical Sciences and Peking Union Medical College, in China (CAMS&PUMC-IEC-2020-001). Respondents in Germany provided informed consent via an online consent form and in China via written informed consent in digital or printed form. Prior to interviews, interviewers informed all respondents about their role, as well as the overarching goals and objectives of the study, and respondents were invited to ask questions. Compensation for participation was €10 for participation via the Prolific platform and 200 RMB (31 USD at the time of study) via KuRunData.

Analysis

Interviews were audio recorded and transcribed verbatim; Chinese interview transcripts were translated into English. German interviews were coded by bilingual (German and English) coders.

Figure 1.

Data analysis process, informed by the framework approach (Pope et al., 2000). We first applied inductive coding to identify broader social phenomena and subsequently performed deductive coding informed by existing theory, namely, the Model of Moral Motives (Janoff-Bulman & Carnes, 2013b), for final analysis and presentation of results.

Drawing on Pope’s framework approach (Pope et al., 2000), we initially familiarized ourselves with the data, both via the regular debriefing sessions and via an in-depth reading of interview transcripts and via listening to recordings (Figure 1). We then identified five particularly information-rich interviews for open, inductive coding using Dedoose software (Dedoose, 2021). We then clustered related codes to develop a codebook, which the first three authors applied to all 73 interviews, supervised by the senior author. We discussed potential new codes that emerged in the process and, where applicable, integrated these into the codebook. During this step, salient topics and themes were detected that led to further analyses on the role of trust and emotion in vaccination decision-making (findings that are presented elsewhere (Dasch et al., 2023; Jiao et al., 2023)). Over the course of interviews, we repeatedly observed considerations of moral decision-making and discussed their prominence in systematic debriefings (McMahon & Winch, 2018). We inductively identified a dichotomy in moral reasoning: Respondents justified “getting vaccinated” by either emphasizing negative or positive outcomes (e.g., emphasis on danger of viral spread if not vaccinated versus safety for everyone if vaccinated). Additionally, distinctions across respondents in China and Germany emerged from the data. We therefore revisited the literature to identify existing theories or models that could, in a second step, deepen the interpretation of our findings, which drew a link between morality and vaccination decision-making.

Model of Moral Motives

Once morality had been inductively identified as a salient topic in public vaccination discourse, we underpinned our analysis with Janoff-Bulman’s Model of Moral Motives (MMM), which outlines two subtypes of moral reasoning: proscriptive and prescriptive morality (Janoff-Bulman & Carnes, 2013b; Janoff-Bulman et al., 2008, 2009). Proscriptive morality aims to avoid harm by inhibiting what is considered bad behavior, and is guided by avoiding selfishness, adhering to that which is considered an individual’s duty (with a focus on mandatory and precise rules and regulations), and punishing non-adherence (Janoff-Bulman & Carnes, 2013b; Janoff-Bulman et al., 2009). Prescriptive morality, in comparison, emphasizes notions of inherent goodness and positive feelings that can come from an individual choosing of their own volition to actively do good, incentivized by public praise and with less strict consequences for non-adherence (Janoff-Bulman & Carnes, 2013b; Janoff-Bulman et al., 2009). The defining distinction across these types of morality “is not virtues and vices” (Janoff-Bulman & Carnes, 2013b, p. 222) but rather the fundamental compulsion to avoid or enact a particular behavior (Janoff-Bulman et al., 2009). As stressed by Janoff-Bulman, the emphasis when distinguishing between the two morality strains in the MMM is not on doing versus not doing a certain behavior (in our case the decision for or against vaccination) but on motives such as restricting (proscriptive, “should not” harm, “sensitive to negative outcomes” (Janoff-Bulman et al., 2009, p. 522)) versus enabling (prescriptive, “should” help, “sensitive to positive outcomes” (Janoff-Bulman et al., 2009, p. 522)) (Janoff-Bulman & Carnes, 2013a, 2013b; Janoff-Bulman et al., 2009).

Both pro- and prescriptive morality can manifest on three levels: self, interpersonal, and the group/society (including the entire world/out group (Janoff-Bulman & Carnes, 2013b). The MMM theory therefore employs a 2 × 3 framework to describe six different motives of morality (Figure 2): self-restraint/moderation, not harming, and social order/communal solidarity as motives of proscriptive regulation; industriousness, helping/fairness, and social justice/communal responsibility as motives of prescriptive regulation (Janoff-Bulman & Carnes, 2013b).

Figure 2.

Adapted from Model of Moral Motives by Janoff-Bulman (Janoff-Bulman & Carnes, 2013b, p. 221; Janoff-Bulman et al., 2009).

After identifying the MMM as a theory guiding the thematic framework for our analysis, we continued with indexing (step 3 of the framework approach) and coded all 73 interviews a second time, using the six themes from the MMM described above as overarching deductive codes. We then charted (step 4) all coded data from both Chinese and German interviews in one table consisting of rows for each respondent and columns for the six domains of the MMM to facilitate intra- and cross-country comparison (step 5: mapping and interpretation).

Results

In total, we interviewed 73 respondents in China and Germany. We use abbreviations based on respondent characteristics (Table 1) as respondent identifiers. For example, (C, f, >50) represents a respondent from China who is female and older than 50 years.

Table 1.

Respondent Characteristics.

	China, N = 40	Germany, N = 33
Gender	Male, n = 20	Male, n = 14
Gender	Female, n = 20	Female, n = 19
Age (years)	<50, n = 20	<50, n = 13
Age (years)	>50, n = 20	>50, n = 20
	Median = 48.5	Median = 35
Living area	Urban, n = 20	Urban, n = 15
Living area	Rural, n = 20	Rural, n = 18

We identified two overarching response patterns, aligning with the proscriptive–prescriptive differentiation in the MMM. First, the proscriptive pattern was characterized by a motivation to avoid harming others by inadvertently infecting them and a willingness to employ and adhere to strict measures, like mandatory vaccination, to achieve high vaccination rates. Second, the prescriptive pattern of answers frequently featured positive framing and a focus on vaccination as a good deed, which should be rewarded but not punished in case of infringement. In line with the MMM, the first cluster shows attributes of proscriptive morality and the second of prescriptive morality.

This results section is structured along the MMM (Figures 2 and 3). We first describe proscriptive and then prescriptive morality, following the three levels of the model: self, others, and group/society. Each element is described as it applies to insights related to COVID-19 vaccination decisions and views on vaccination policies, underlined by exemplary quotes. We conclude the presentation of our results by drawing parallels and addressing distinctions across our Chinese and German datasets.

Figure 3.

Proscriptive and prescriptive morality on three levels, guided by the MMM (Janoff-Bulman & Carnes, 2013b): the self, others, and society with exemplary quotes. Color intensity reflects preponderance and salience of respondent answers in MMM dimensions. Quote identifiers: country China (C) or Germany (G); gender male (m) or female (f); age younger (<) or older (>) than 50 years.

Part 1: Proscriptive Morality

Personal, Related to the Self

Box 1. Proscriptive personal level in the MMM.

The MMM defines the personal level (self) in proscriptive moralities as: self-control, self-discipline, and moderation (Janoff-Bulman & Carnes, 2013b; Janoff-Bulman et al., 2008, 2009).

Respondents who argued proscriptively on the personal level (Box 1 for a definition in the MMM) focused on not wanting to feel like an exception or a burden by remaining unvaccinated. Aligning with self-controlling motives in the MMM, respondents voiced sentiments of humbleness and modesty and a desire to conform instead of sticking out, as “nobody likes to get into trouble” (C, m, <50). An older woman from China compared vaccination decision-making to wearing face masks in the pandemic context:

When all the people around me have done something, but I have not, I will do it naturally even if I was resistant to it at the beginning. It is the idea of most people. For example, I was reluctant to wear a mask at the beginning. But I later found that people were all wearing a mask. As I didn’t want to be different, I began to wear a mask. (C, f, >50)

Accordingly, when respondents with proscriptive tendencies were asked how they would broach vaccination among those who had refused, they said they would tell them to “follow suit” (C, f, >50), as breaking (implicit or explicit) rules could lead to punishment or potential exclusion from society, resulting in shame for the individual. In some cases, it could not clearly be determined whether such statements were purely morally motivated (valuing self-discipline in a well-ordered society with strict rules) or by rational trade-off of negative consequences (see the Discussion section for more details), as one respondent from China explained: “‘[I'd tell them:] Others have taken [the vaccine], so you cannot be exceptional. People will keep away from you.’ Knowing that, they will go and take the vaccines” (C, m, >50).

Generally, notions of proscriptive self were discussed with less frequency and depth compared to proscriptive statements at other levels (interpersonal or group).

Interpersonal, Related to Others

Box 2. Proscriptive interpersonal level in the MMM.

The MMM defines the interpersonal level (others) in proscriptive moralities as: not harming, unconditional honesty, not cheating, and never hurting or killing people (Janoff-Bulman & Carnes, 2013b; Janoff-Bulman et al., 2008, 2009).

Respondents frequently emphasized that they wanted to avoid harming others by infecting them with the virus and raised concerns about “hav[ing] to live with it, then, so to speak, that we would have them on our conscience” (G, f, <50) if a person they had infected would later die of COVID-19. In all these cases, vaccinations were understood as a means to prevent harming others, while “not taking the vaccines is harming others” (C, f, >50), which would consitute an “immoral, unethical decision” (G, m, >50). Accordingly, the desire to avoid harm on an interpersonal level (Box 2 for a definition in the MMM) led a majority of proscriptively inclined respondents, particularly from rural areas, to call for clear legal guidelines such as compulsory vaccination, as vaccination “is not only a matter of personal interest. In a way, you will bring harm to others. This is not good” (C, f, >50). Some respondents also argued for repercussions for refusing vaccination.

At the same time, a small but impassioned group of respondents voiced moral reflections on potential or anticipated risks of novel vaccines. Despite stressing the beneficial nature of vaccines in general, a young man from China argued that “if the vaccines were poor in quality, I would feel guilty to press people to take them” (C, m, <50), mirroring the sentiments of an older German women: “It’s a pity for the people who are affected, who are dead, that’s … (short laughter) yes, for them it’s tragic” (G, f, >50). One younger man extended his concerns to testing novel vaccines in clinical trials, which he viewed as “improper from a moral standpoint” (C, m, <50).

Societal, Related to One’s Own Group and the Out Group

Box 3. Proscriptive group level in the MMM.

The MMM defines the community level (group) in proscriptive moralities as: Social order, communal solidarity, need for conformity and a resulting tendency to strict rules, focus on protecting one’s own group against transgression and other groups (Janoff-Bulman & Carnes, 2013b; Janoff-Bulman et al., 2008, 2009).

At the societal level (Box 3 for a definition in the MMM), proscriptively aligned respondents placed particular focus on having a functioning system and the protection of one’s fellow citizens. Such notions were identified in almost every interview with a proscriptively inclined respondent.

As a group-based aspect, respondents often discussed who to prioritize for vaccination in case of vaccine shortages. Those arguing proscriptively focused on social order (“maintaining public order” (C, f, >50)) and suggested prioritizing those who face the greatest probability of getting infected and have an elementary position in infrastructure, politics, and health care (“leading cadres” (C, m, >50) and “front-line workers” (C, f, <50), “national heroes/heroines […] protecting our lives and property” (C, m, <50)).

Another approach that respondents described to foster social order and communal solidarity on a group level was the introduction of strict rules such as mandatory vaccination. Some respondents, who generally used proscriptive arguments, including some who were hesitant to take a vaccine if they had the choice, suggested mandatory measures: “I think the importance of the matter should be highlighted and vaccination should be made mandatory. […] It’s not about personal willingness. In the case of one infection, the entire community is in danger” (C, f, <50). Another respondent compared the current discourse to previous mandates: “Chinese people live in a closely bonded society. One person goes against the family planning policy, the whole village will suffer. You can make use of this and restrict their behavior” (C, f, <50).

Moreover, moral conflicts developed over whether the protection of one’s own group, often conveyed as one’s own country, should be prioritized, or whether vaccines should be equally distributed globally. In cases of proscriptive moral arguments, protection of one’s own group was preferred. Respondents suggested that “vaccines are provided to our own people first” (C, m, <50), underlined by sentiments of fear from “the imported [COVID-19] cases” (C, m, >50) and vivid descriptions of the pandemic situation abroad. Respondents described foreign countries as “breeding sites and hatcheries for the, for the variants that then return, ahm, and backfire at us here again” (G, m, >50), underlining the importance of global vaccination but justifying it by the resulting protection of one’s own population:

Well, um, on the one hand, I think it’s logical that a pandemic can only be controlled collectively and globally. If we vaccinate—so to speak, the Western countries—and new mutations form, so to speak, in the emerging countries and in the poor countries […] then the whole thing starts all over again. (G, m, <50)

Part 2: Prescriptive Morality

Personal, Related to the Self

Box 4. Prescriptive personal level in the MMM.

The MMM defines the personal level (self) in prescriptive moralities as: industriousness, meaning providing for yourself and personal success by hard work (Janoff-Bulman & Carnes, 2013b; Janoff-Bulman et al., 2008, 2009).

Prescriptive arguments in favor of COVID-19 vaccination on the personal level (Box 4 for a definition in the MMM) were characterized by a confident self-image as well as a belief in making the right choices for one’s own health. Respondents often underlined how much they had informed themselves about vaccines, such as one young woman describing the need “to read everything again yourself to believe it” (G, f, <50). A smaller group of respondents described trying hard to find out how effective and safe specific vaccine brands were reported to be as to find the best possible solution for their own health. These sentiments were underlined by self-confidence, self-reliance, and pride in their own view and often little understanding for opposing opinions. One young woman in Germany assumed that those against vaccination were “people who don’t like to read long pages of information or are not patient enough to read statistics or to evaluate things for themselves and so on” (G, f, <50).

Interpersonal, Related to Others

Box 5. Prescriptive interpersonal level in the MMM.

The MMM defines the interpersonal level (others) in proscriptive moralities as: helping others, fairness, compassion, and generosity for those in need as admirable traits (Janoff-Bulman & Carnes, 2013b; Janoff-Bulman et al., 2008, 2009).

Prescriptive aspects regarding others (Box 5 for a definition in the MMM) were frequently mirrored in sentiments of vaccine uptake as a way to actively protect others by preventing viral spread. In many cases, respondents gave detailed accounts of their experiences with or perceptions of their elderly, sick relatives, those people in intensive care units, or those who have great concern about COVID-19 due to pre-existing conditions. Additionally, respondents often underlined how “you can help by getting vaccinated [and by doing so] you could definitely contribute well to your family and friends” (G, f, <50) or “it is good for others” (C, m, >50). The prevailing self-image here, often amplified via body language or intonation, was one of pride in one’s willingness to help others and dedication to people susceptible toward severe COVID-19 disease. In this context, some respondents justified the small probability of harm in cases of adverse events with the much more frequent positive effects of the vaccine, which would then in sum save more lives and provide for the well-being of many (as compared to a more proscriptive view, where respondents focused on how potential vaccine adverse events might cause harm to few individuals).

At the same time, and despite limited understanding for those who refuse vaccination, almost all prescriptively motivated respondents emphasized that they would not force others to get vaccinated, because “if you really want to preserve freedom of expression, then you have to live with the fact that they say no” (G, m, >50). Another respondent described it as “a custom in China that you respect others. You cannot force them into something. If they still refuse, there must be some reasons” (C, f, >50). Respondents emphasized the voluntary nature and importance of incentives for vaccination (rewarding the desired behavior) rather than punishing vaccination refusers.

Societal, Related to One’s Own Group and Out Group

Box 6. Prescriptive group level in the MMM.

The MMM defines the community level (group) in prescriptive moralities as: Social justice, communal responsibility, providing motive, equitable distribution of resources and support for the disadvantaged in one’s own group and out group (Janoff-Bulman & Carnes, 2013b; Janoff-Bulman et al., 2008, 2009).

As compared to the proscriptive positions highlighted above, respondents arguing based on prescriptive morality (Box 6 for a definition in the MMM) voted for a vaccine prioritization of those particularly at risk in case of disease. The “old, the weak, the sick and those living with disabilities” (C, f, <50), and those in frequent contact with these groups, should be protected from a fatal course “because younger people don’t die as much as old people” (G, m, <50). Another aspect was social justice and responsibility for those in need, for example, by supporting financially underprivileged individuals within the group by granting “reduction and exemption [from vaccination costs] for some people. For example, if a family has many members [they might be] unable to afford the vaccines” (C, m, <50).

Fairness and a necessity to support others perceived as less privileged were also extended to other countries. While in proscriptive morality people argued for first protecting one’s own group and vaccinating the rest of the world mostly to prevent mutations that could endanger one’s own country, prescriptive morality became evident in claims for equitable distribution irrespective of financial means, as “no country should be left alone with this” (G, f, <50). As one respondent from Germany argued:

Because it concerns all of us […] and everyone would have the same opportunities. And it would not simply be a question of good luck or bad luck whether one lives and is born in Germany or somewhere in Africa. (G, f, >50)

Part 3: Cross-Country Comparison

Individual respondents from both China and Germany usually argued predominantly along the lines of either a pro- or a prescriptive view throughout all three layers of self, others, and society; in many respondents, both moralities could be found. Respondents who argued proscriptively generally wanted to avoid bringing harm to others and usually argued for strict measures and clear rules for societal stability regardless of what one might personally desire for oneself. Consistent prescriptive lines of arguments focused on taking responsibility for one’s own health as well as providing for the health of those in need (including foreign societies) without forcing people to get vaccinated. At the same time, many respondents with a generally more proscriptive view also shared prescriptive values regarding priority groups and financial subsidies for the less privileged (notions of fairness and helping), with a less clear demarcation of moral motives on the societal level of the MMM in our sample.

When comparing the full country-specific samples, German respondents tended to emphasize more prescriptive views, with, for example, only a small minority arguing in favor of mandatory vaccination. Within the Chinese dataset, both lines of arguments emerged, with a general tendency toward more proscriptive reasoning. This country-specific pattern of argumentative distinctions also emerged with regard to priority populations: Chinese respondents described in more depth a desire to first vaccinate politicians, health care personnel, and those who maintain public infrastructure, followed by individuals with a weaker immune system including children or those with pre-existing medical conditions; German respondents described a preference in the reverse order.

Discussion

This qualitative study explored vaccination decisions and moral views on vaccination policies applying the Model of Moral Motives that distinguishes two types of morality: proscriptive and prescriptive on levels of the self, interpersonal, and societal relations (Janoff-Bulman & Carnes, 2013b; Janoff-Bulman et al., 2008, 2009). In this work, we demonstrated that the MMM is a beneficial model to structure and explain decision-making regarding COVID-19 vaccination. Proscriptive arguments for vaccination from our respondents included getting vaccinated despite ones’ own desires as a means to avoid attracting negative attention, understanding oneself as a citizen who abides by clear laws, preventing harm to others via virus contagion, and protecting the infrastructure of one’s own country. Prescriptive arguments highlighted self-efficacious behavior to provide for one’s own health and for others through mutual immunity; a will to ensure voluntary vaccination; and a responsibility to support disadvantaged groups such as the elderly.

Despite the prominence of moral arguments in our data, morality remains an underexamined topic in vaccination literature. On the one hand, although evidence exists that vaccination was moralized during the COVID-19 pandemic (Bor et al., 2023), the link between morality and behavior is context-dependent and fluctuating (Brandt & Rozin, 2013), which complicates measurement. On the other hand, research has previously highlighted pro- and prescriptive discourses on COVID-19 vaccination (without necessarily using this terminology) including several studies on vaccine mandates (Graeber et al., 2021; Lazarus et al., 2022; Stead et al., 2022), a study in the United States where respondents highlighted trade-offs between protecting one’s own health versus that of others (Moore et al., 2022), and studies in the United Kingdom or China on preferences related to vaccine distribution (Vanderslott et al., 2021; Yu et al., 2022). Our interviews echoed the discourse that mandatory vaccination is an effective means to immunize entire populations and to limit the burden of disease; at the same time, however, it can be viewed as an encroachment on civil liberties (Giubilini, 2021).

Our results underline the relevance of comprehensive research on moral aspects for vaccination attitudes with a link to broader behavioral theories with a focus on morality, social norms, or ethics. While we interpreted our results in the context of the MMM due to the inductively seen dichotomy in moral reasoning (with its focus on negative versus positive outcomes, strict rules to avoid “bad behavior” versus incentives and praise to activate “good behavior”), our findings also align with a broader body of morality literature. The moral foundations theory, for example, describes five dimensions (care/harm, fairness/cheating, loyalty/betrayal, authority/subversion, and purity/degradation) as core aspects of morality (Haidt, 2012). Overlapping with our findings on getting vaccinated to protect others, studies have found positive correlations between pro-vaccination attitudes and notions of care and loyalty (Amin et al., 2017; Nan et al., 2022). Finally, our findings related to prescriptive morality (e.g., being a role-model by getting vaccinated or generously sharing vaccines with other countries) add to discourses on the decision-making role of injunctive norms: This subgroup of norms, described as normative beliefs in what one should do with a focus on getting approval by others, has been shown to positively correlate with COVID-19 vaccination behavior (Baeza-Rivera et al., 2021). Despite potential overlap of these theories, we found the MMM to be particularly suitable to inform interpretation of our findings regarding the observed dichotomy in moral reasoning: either a (proscriptive) focus on avoiding negative outcomes or a (prescriptive) activation of behavior aiming at positive consequences. We would encourage future large-scale quantitative evaluations which could assess the predictive value of different theories.

Our work outlines the potential of the MMM in the public health domain. Originally developed in the field of moral psychology, the model has so far mainly been applied to explain differences between political inclinations, mostly conservative versus liberal positions (Janoff-Bulman et al., 2008) and how they are distinct, for example, in donating behavior (Farmer et al., 2020) or environment protection (Kidwell et al., 2013). More recently, the MMM has been applied at the intersection of political positions and public health when investigating decisions for (not) wearing masks during the COVID-19 pandemic in the United States (Gelfand et al., 2022). With our work, we add to this literature by applying the MMM within public health without a direct linkage to political positions. To our knowledge, we are the first to apply the MMM to COVID-19 vaccination and vaccination in general.

As outlined in the Introduction section, defining morality can be challenging and differs across scientific fields. The MMM views moral actions in constant tension between inhibiting bad behavior and doing good, according to one’s pro- or prescriptive attitudes (Janoff-Bulman et al., 2009). Thereby, the MMM focuses on how personal behavior and values, regarding the self, others, and society as a whole, all serve group functioning (directly or indirectly) (Janoff-Bulman & Carnes, 2013b). While morality scholarship does not necessarily consider abiding by rules to avoid punishment as morally motivated but rather as a rational benefit–risk assessment borne of self-interest (Badhwar, 1993), the MMM argues that avoiding punishment can be motivated by one’s desire to be self-disciplined, to avoid temptations, and, as a more distant motive, to live in a well-ordered society with strict rules (Janoff-Bulman & Carnes, 2016). Other scholars have similarly described this conforming behavior as a form of morally motivated self-control due to its group focus (Hofmann et al., 2018). In our study, respondents in favor of a well-organized society were often in favor of punishment for what they considered “bad behavior.” Wanting to avoid punishment or social exclusion can thus be considered morally motivated in the MMM, provided that the focus is on “resisting the temptation to advantage ourselves” (Janoff-Bulman, 2023, p. 17), with the aim to avoid shame and preserve self-discipline, and with less emphasis on avoiding discomfort through negative consequences or repercussions per se (Janoff-Bulman, 2023). We therefore encourage others to consider the MMM as a framework to explain public health topics, with the aim to predict and influence preventive behavior, guided by an approach that values moral motives.

Our results also align with findings regarding inter-cultural differences in vaccination opinions (Larson et al., 2014). Similar to the patterns observed in our data, a population representative study found that while the vast majority of individuals supported mandatory vaccination in China, less than half of respondents supported the same in Germany (Lazarus et al., 2022). Furthermore, a quantitative survey in Germany revealed that about half of those willing to get vaccinated would nevertheless disapprove a mandatory vaccination (Graeber et al., 2021).

In general, while there was no strict separation between the themes discussed in our two samples, a proscriptive cluster emerged more strongly from the Chinese interviews and a prescriptive cluster emerged more strongly from the German interviews. In a simplistic sense, one could say that several aspects such as socio-political, cultural, and historical backgrounds might account for the aforementioned differences between our Chinese and German datasets due to potential influence on respondents’ type of morality. China, which is often described as a more collectivistic society (for a definition, see Oyserman et al. (2002)), is distinct from Germany, which is commonly described as a more individualistic society (for a definition, see Oyserman et al. (2002)). However, we concur with several other scholars cautioning against direct applications of Western morality theories (Kohlberg & Hersh, 1977) to other settings due to nuanced differences in how the individual is perceived in individualistic versus collectivistic contexts (Dien, 1982). The authors of the MMM themselves emphasize that the model does not explain cultural differences between pro- and prescriptive morality but how moral motives can move on a continuum influenced by cultural particularities (Janoff-Bulman & Carnes, 2018). While we saw varying degrees of pro- and prescriptive moral motives within the German and Chinese samples, more representative data that explicitly examines cultural distinctions and attendant links to moral constructs would be necessary to comprehensively compare pro- and prescriptive motives.

Emphasizing moral values in campaigns, also known as moral framing, can compel behavior (Maio et al., 2009). Hence, deeper understanding of moral motives on vaccination, gained through this study, might guide development of future information campaigns to increase vaccination rates (Feinberg & Willer, 2013; Schmidtke et al., 2022). Indeed, emphasizing collectivistic values can increase vaccine acceptance (Leonhardt & Pezzuti, 2022), and scholars assume that tailoring vaccination messages to moral values has similar effects (Amin et al., 2017). Especially in prescriptive contexts, creating an environment where people feel pressured to “do the right thing,” in this case to get vaccinated, holds danger of perceived accusations from vaccinated people toward unvaccinated ones (Sprengholz et al., 2023) and thus could reinforce disengagement in the desired behavior from the latter (Rosenfeld & Tomiyama, 2022). When the obligation to do something is congruent with personal preferences, more pointedly when “shoulds are perceived as wants” (Janoff-Bulman & Leggatt, 2002, p. 260), people are more satisfied with their behavior (Janoff-Bulman & Leggatt, 2002). A possible approach for rapid pandemic response in the future would be a hybrid strategy of research and application: Building on our qualitative results, a quantitative questionnaire based on the MMM could be used to determine whether a society (or a sub-set of focus) is more pro- or prescriptive in its moral views toward vaccination. Subsequently, promotional materials could then leverage pro- or prescriptive messaging styles.

This study has limitations. Despite efforts to ensure comparability within and across the German and Chinese datasets, factors like interview mode (phone calls in China versus video calls in Germany), as well as a different socio-political surrounding, might have hampered comparability. For instance, respondents’ preferences on who to prioritize for vaccination might have mirrored how prioritization was actually carried out in a given country (STIKO (Robert-Koch Institut), 2021; Yang et al., 2021) rather than reflecting morality-infused inclinations. At the same time, elderly persons in China more frequently live at home within the care of their families (Zhang, 2006), which limits their possibility of infection, while in Germany, COVID-19 outbreaks in nursing homes gained public attention (Schilling et al., 2021), contributing to differences in priority assessments. The extent to which these aspects influenced respondents’ answers cannot be conclusively explained based on our data and would need further research. Additionally, we cannot exclude that our data are partly subject to a social desirability bias despite active attempts to avoid it in interviews (Bergen & Labonté, 2020). Furthermore, our data were collected at a time when it was unclear to what extent different vaccinations protect against transmission of SARS-CoV-2 (Ledford et al., 2020).

Conclusion

This study applied the MMM to understand discourse around COVID-19 vaccination. Our results indicate that threatening people with restrictions in case of non-vaccination might not work in prescriptive contexts, but instead persuading people to want to get vaccinated could prove more powerful. Strongly framing individuals not engaging in a certain behavior as immoral could spark further resistance and should therefore be avoided (Täuber et al., 2015). Instead, a tailored approach to vaccination promotion campaigns guided by moral motives of the respective target group might be helpful to approach vaccine-hesitant individuals and to increase willingness to vaccinate.

Footnotes

Acknowledgments

The authors would like to thank Viola von Neumann-Cosel for her inspiration and support as well as all participants for their time.

Author Contributions

S.M. recruited and interviewed respondents, analyzed and interpreted the data, and drafted the manuscript. J.W. contributed to the design of the project and the interview guide and the analysis and interpretation of the interviews and substantially revised the manuscript. L.J. recruited and interviewed respondents, contributed substantially to the design of the interview guide and to data-analysis and revised the manuscript. T.B. contributed substantially to the conception and design of the project and has revised the manuscript. S.C. conceptualized and designed the project and has substantially revised the manuscript. S.A.M. made substantial contribution to the design of the project, supervised the analysis of the interviews, interpreted the data, and substantially revised the manuscript. All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the Sino-German Center for Research Promotion (Project C-0048), which is funded by the German Research Foundation (DFG) and the National Natural Science Foundation of China (NSFC).

Ethical Statement

ORCID iDs

Selina Müller

Jonas Wachinger

Simiao Chen

Shannon A. McMahon

References

Amin

A. B.

Bednarczyk

R. A.

Ray

C. E.

Melchiori

K. J.

Graham

Huntsinger

J. R.

Omer

S. B.

(2017). Association of moral values with vaccine hesitancy. Nature Human Behaviour, 1(12), 873–880. https://doi.org/10.1038/s41562-017-0256-5

Badhwar

N. K.

(1993). Altruism versus self-interest: Sometimes a false dichotomy. Social Philosophy and Policy, 10(1), 90–117. https://doi.org/10.1017/S0265052500004039

Baeza-Rivera

M. J.

Salazar-Fernández

Araneda-Leal

Manríquez-Robles

(2021). To get vaccinated or not? Social psychological factors associated with vaccination intent for COVID-19. Journal of Pacific Rim Psychology, 15. https://doi.org/10.1177/18344909211051799

Bardosh

de Figueiredo

Gur-Arie

Jamrozik

Doidge

Lemmens

Keshavjee

Graham

J. E.

Baral

(2022). The unintended consequences of COVID-19 vaccine policy: Why mandates, passports and restrictions may cause more harm than good. BMJ Global Health, 7(5), Article e008684. https://doi.org/10.1136/bmjgh-2022-008684

Baud

Nielsen-Saines

Musso

Pomar

Favre

(2020). Real estimates of mortality following COVID-19 infection. The Lancet Infectious Diseases, 20(7), Article 773. https://doi.org/10.1016/S1473-3099(20)30195-X

Bergen

Labonté

(2020). “Everything is perfect, and we have no problems”: Detecting and limiting social desirability bias in qualitative research. Qualitative Health Research, 30(5), 783–792. https://doi.org/10.1177/1049732319889354

Biswas

Mustapha

Khubchandani

Price

J. H.

(2021). The nature and extent of COVID-19 vaccination hesitancy in healthcare workers. Journal of Community Health, 46(6), 1244–1251. https://doi.org/10.1007/s10900-021-00984-3

Böhm

Betsch

(2022). Prosocial vaccination. Current Opinion in Psychology, 43, 307–311. https://doi.org/10.1016/j.copsyc.2021.08.010

Bor

Jørgensen

Lindholt

M. F.

Petersen

M. B.

(2023). Moralizing the COVID-19 pandemic: Self-interest predicts moral condemnation of other’s compliance, distancing, and vaccination. Political Psychology, 44(2), 257–279. https://doi.org/10.1111/pops.12835

10.

Brandt

A. M.

Rozin

(2013). Morality and health. Routledge.

11.

Callaghan

Motta

Sylvester

Lunz Trujillo

Blackburn

C. C.

(2019). Parent psychology and the decision to delay childhood vaccination. Social Science & Medicine, 238, Article 112407. https://doi.org/10.1016/j.socscimed.2019.112407

12.

Carnes

Janoff-Bulman

(2012). Harm, help, and the nature of (Im)moral (In)action. Psychological Inquiry, 23(2), 137–142. https://doi.org/10.1080/1047840X.2012.667768

13.

Chan

E. Y.

(2021). Moral foundations underlying behavioral compliance during the COVID-19 pandemic. Personality and Individual Differences, 171, Article 110463. https://doi.org/10.1016/j.paid.2020.110463

14.

Charmaz

(2006). Constructing grounded theory: A practical guide through qualitative analysis. Sage.

15.

Chen

Sun

Heng

Tong

Geldsetzer

Wang

Yang

Wang

Bärnighausen

(2022). Factors predicting progression to severe COVID-19: A competing risk survival analysis of 1753 patients in community isolation in Wuhan, China. Engineering, 13, 99–106. https://doi.org/10.1016/j.eng.2021.07.021

16.

Dagan

Barda

Kepten

Miron

Perchik

Katz

M. A.

Hernán

M. A.

Lipsitch

Reis

Balicer

R. D.

(2021). BNT162b2 mRNA Covid-19 vaccine in a nationwide mass vaccination setting. New England Journal of Medicine, 384(15), 1412–1423. https://doi.org/10.1056/NEJMoa2101765

17.

Dasch

Wachinger

Bärnighausen

Chen

McMahon

S. A.

(2023). Deliberation, context, emotion and trust – understanding the dynamics of adults’ COVID-19 vaccination decisions in Germany. BMC Public Health, 23(1), Article 136. https://doi.org/10.1186/s12889-022-14587-7

18.

Dean

Raats

M. M.

Shepherd

(2008). Moral concerns and consumer choice of fresh and processed organic foods. Journal of Applied Social Psychology, 38(8), 2088–2107. https://doi.org/10.1111/j.1559-1816.2008.00382.x

19.

De Backer

C. J. S.

Hudders

(2015). Meat morals: Relationship between meat consumption consumer attitudes towards human and animal welfare and moral behavior. Meat Science, 99, 68–74. https://doi.org/10.1016/j.meatsci.2014.08.011

20.

Dedoose . (2021). Version 9.2.12, web application for managing, analyzing, and presenting qualitative and mixed method research data (2021). SocioCultural research Consultants LLC. www.dedoose.com

21.

Dien

D. S.-f.

(1982). A Chinese perspective on Kohlberg’s theory of moral development. Developmental Review, 2(4), 331–341. https://doi.org/10.1016/0273-2297(82)90017-x

22.

Dubé

MacDonald

N. E.

(2020). How can a global pandemic affect vaccine hesitancy? Expert Review of Vaccines, 19(10), 899–901. https://doi.org/10.1080/14760584.2020.1825944

23.

Eberhardt

Ling

(2021). Predicting COVID-19 vaccination intention using protection motivation theory and conspiracy beliefs. Vaccine, 39(42), 6269–6275. https://doi.org/10.1016/j.vaccine.2021.09.010

24.

Fan

C.-W.

Chen

I. H.

N.-Y.

Yen

C.-F.

Lin

C.-Y.

Griffiths

M. D.

Pakpour

A. H.

(2021). Extended theory of planned behavior in explaining the intention to COVID-19 vaccination uptake among mainland Chinese university students: An online survey study. Human Vaccines & Immunotherapeutics, 17(10), 3413–3420. https://doi.org/10.1080/21645515.2021.1933687

25.

Farmer

Kidwell

Hardesty

D. M.

(2020). Helping a few a lot or many a little: Political ideology and charitable giving. Journal of Consumer Psychology, 30(4), 614–630. https://doi.org/10.1002/jcpy.1164

26.

Feinberg

Willer

(2013). The moral roots of environmental attitudes. Psychological Science, 24(1), 56–62. https://doi.org/10.1177/0956797612449177

27.

FeldmanHall

Son

J. Y.

Heffner

(2018). Norms and the flexibility of moral action. Personality Neuroscience, 1, Article e15. https://doi.org/10.1017/pen.2018.13

28.

Gelfand

Stamkou

Pieper

Denison

Fernandez

Choi

Chatman

Jackson

Dimant

(2022). Persuading republicans and democrats to comply with mask wearing: An intervention tournament. Journal of Experimental Social Psychology, 101, Article 104299. https://doi.org/10.1016/j.jesp.2022.104299

29.

Gert

(2002). The definition of morality. In Zalta

(Ed.), The Stanford Encyclopedia of Philosophy. Metaphysics Research Lab, Stanford University.

30.

Giubilini

(2021). Vaccination ethics. British Medical Bulletin, 137(1), 4–12. https://doi.org/10.1093/bmb/ldaa036

31.

Godin

Conner

Sheeran

(2005). Bridging the intention–behaviour gap: The role of moral norm. British Journal of Social Psychology, 44(4), 497–512. https://doi.org/10.1348/014466604X17452

32.

Gorsuch

R. L.

Ortberg

(1983). Moral obligation and attitudes: Their relation to behavioral intentions. Journal of Personality and Social Psychology, 44(5), 1025–1028. https://doi.org/10.1037/0022-3514.44.5.1025

33.

Graeber

Schmidt-Petri

Schröder

(2021). Attitudes on voluntary and mandatory vaccination against COVID-19: Evidence from Germany. PLoS One, 16(5), Article e0248372. https://doi.org/10.1371/journal.pone.0248372

34.

Haidt

(2007). The new synthesis in moral psychology. Science, 316(5827), 998–1002. https://doi.org/10.1126/science.1137651

35.

Haidt

(2012). The righteous mind: Why good people are divided by politics and religion. Vintage.

36.

Haidt

Kesebir

(2010). Morality. In Fiske

Gilbert

Lindzey

, (Eds.), Handbook of social psychology (pp. 778–867). Wiley.

37.

Hitlin

Vaisey

(2013). The new sociology of morality. Annual Review of Sociology, 39(1), 51–68. https://doi.org/10.1146/annurev-soc-071312-145628

38.

Hofmann

Meindl

Mooijman

Graham

(2018). Morality and self-control: How they are intertwined and where they differ. Current Directions in Psychological Science, 27(4), 286–291. https://doi.org/10.1177/0963721418759317

39.

Holdsworth

Robinson

J. E.

(2008). ‘I’ve never ever let anyone hold the kids while they’ve got ciggies’: Moral tales of maternal smoking practices. Sociology of Health & Illness, 30(7), 1086–1100. https://doi.org/10.1111/j.1467-9566.2008.01102.x

40.

Jain

Saurabh

Kumar

Verma

M. K.

Goel

A. D.

Gupta

M. K.

Bhardwaj

Raghav

P. R.

(2021). COVID-19 vaccine hesitancy among medical students in India. Epidemiology & Infection, 149, Article e132.https://doi.org/10.1017/S0950268821001205

41.

Janoff-Bulman

(2023). The two moralities: Conservatives, liberals, and the roots of our political divide. Yale University Press.

42.

Janoff-Bulman

Carnes

N. C.

(2013a). Moral context matters: A reply to Graham. Personality and Social Psychology Review, 17(3), 242–247. https://doi.org/10.1177/1088868313492021

43.

Janoff-Bulman

Carnes

N. C.

(2013b). Surveying the moral landscape: Moral motives and group-based moralities. Personality and Social Psychology Review, 17(3), 219–236. https://doi.org/10.1177/1088868313480274

44.

Janoff-Bulman

Carnes

N. C.

(2016). Social justice and social order: Binding moralities across the political spectrum. PLoS One, 11(3), Article e0152479. https://doi.org/10.1371/journal.pone.0152479

45.

Janoff-Bulman

Carnes

N. C.

(2018). The model of moral motives: A map of the moral domain. In Gray

Graham

(Eds.), Atlas of moral psychology (pp. 223–230). The Guilford Press.

46.

Janoff-Bulman

Leggatt

H. K.

(2002). Culture and social obligation: When “shoulds” are perceived as “wants”. Journal of Research in Personality, 36(3), 260–270. https://doi.org/10.1006/jrpe.2001.2345

47.

Janoff-Bulman

Sheikh

Baldacci

K. G.

(2008). Mapping moral motives: Approach, avoidance, and political orientation. Journal of Experimental Social Psychology, 44(4), 1091–1099. https://doi.org/10.1016/j.jesp.2007.11.003

48.

Janoff-Bulman

Sheikh

Hepp

(2009). Proscriptive versus prescriptive morality: Two faces of moral regulation. Journal of Personality and Social Psychology, 96(3), 521–537. https://doi.org/10.1037/a0013779

49.

Jiao

Wachinger

Dasch

Bärnighausen

McMahon

S. A.

Chen

(2023). Calculation, knowledge, and identity: Dimensions of trust when making COVID-19 vaccination choices in China. SSM - Qualitative Research in Health, 4, Article 100288. https://doi.org/10.1016/j.ssmqr.2023.100288

50.

Kidwell

Farmer

Hardesty

D. M.

(2013). Getting liberals and conservatives to go green: Political ideology and congruent appeals. Journal of Consumer Research, 40(2), 350–367. https://doi.org/10.1086/670610

51.

Kohlberg

Hersh

R. H.

(1977). Moral development: A review of the theory. Theory Into Practice, 16(2), 53–59. https://doi.org/10.1080/00405847709542675

52.

Korn

Böhm

Meier

N. W.

Betsch

(2020). Vaccination as a social contract. Proceedings of the National Academy of Sciences, 117(26), 14890–14899. https://doi.org/10.1073/pnas.1919666117

53.

Kricorian

Civen

Equils

(2022). COVID-19 vaccine hesitancy: Misinformation and perceptions of vaccine safety. Human Vaccines & Immunotherapeutics, 18(1), Article 1950504. https://doi.org/10.1080/21645515.2021.1950504

54.

Larson

H. J.

Jarrett

Eckersberger

Smith

D. M.

Paterson

(2014). Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007-2012. Vaccine, 32(19), 2150–2159. https://doi.org/10.1016/j.vaccine.2014.01.081

55.

Lazarus

J. V.

White

T. M.

Wyka

Ratzan

S. C.

Rabin

Larson

H. J.

Martinon-Torres

Kuchar

Abdool Karim

S. S.

Giles-Vernick

Müller

Batista

Myburgh

Kampmann

El-Mohandes

(2024). Influence of COVID-19 on trust in routine immunization, health information sources and pandemic preparedness in 23 countries in 2023. Nature Medicine, 30(6), 1559–1563. https://doi.org/10.1038/s41591-024-02939-2

56.

Lazarus

J. V.

Wyka

Rauh

Rabin

Ratzan

Gostin

L. O.

Larson

H. J.

El-Mohandes

(2020). Hesitant or not? The association of age, gender, and education with potential acceptance of a COVID-19 vaccine: A country-level analysis. Journal of Health Communication, 25(10), 799–807. https://doi.org/10.1080/10810730.2020.1868630

57.

Lazarus

J. V.

Wyka

White

T. M.

Picchio

C. A.

Rabin

Ratzan

S. C.

Parsons Leigh

El-Mohandes

(2022). Revisiting COVID-19 vaccine hesitancy around the world using data from 23 countries in 2021. Nature Communications, 13(1), Article 3801. https://doi.org/10.1038/s41467-022-31441-x

58.

Ledford

Cyranoski

Van Noorden

(2020). The UK has approved a COVID vaccine - here’s what scientists now want to know. Nature, 588(7837), 205–206. https://doi.org/10.1038/d41586-020-03441-8

59.

Leonhardt

J. M.

Pezzuti

(2022). Vaccination acceptance across cultures: The roles of collectivism, empathy, and homophily. Journal of International Marketing, 30(2), 13–27. https://doi.org/10.1177/1069031x211073179

60.

MacDonald

(2015). Vaccine hesitancy: Definition, scope and determinants. Vaccine, 33(34), 4161–4164. https://doi.org/10.1016/j.vaccine.2015.04.036

61.

Maio

G. R.

Pakizeh

Cheung

W.-Y.

Rees

K. J.

(2009). Changing, priming, and acting on values: Effects via motivational relations in a circular model. Journal of Personality and Social Psychology, 97(4), 699–715. https://doi.org/10.1037/a0016420

62.

Mallapaty

(2021). China’s COVID vaccines are going global—but questions remain. Nature, 593(7858), 178–179. https://doi.org/10.1038/d41586-021-01146-0

63.

Matsuo

Brown

C. M.

(2022). Culture points the moral compass: Shared basis of culture and morality. Culture and Brain, 10(2), 113–139. https://doi.org/10.1007/s40167-022-00106-3

64.

McMahon

S. A.

Winch

P. J.

(2018). Systematic debriefing after qualitative encounters: An essential analysis step in applied qualitative research. BMJ Global Health, 3(5), Article e000837. https://doi.org/10.1136/bmjgh-2018-000837

65.

Miller

(2008). Neurobiology. The roots of morality. Science, 320(5877), 734–737. https://doi.org/10.1126/science.320.5877.734

66.

Moore

Purvis

R. S.

Hallgren

Willis

D. E.

Hall

Reece

CarlLee

Judkins

McElfish

P. A.

(2022). Motivations to vaccinate among hesitant adopters of the COVID-19 vaccine. Journal of Community Health, 47(2), 237–245. https://doi.org/10.1007/s10900-021-01037-5

67.

Nan

Wang

Thier

Adebamowo

Quinn

Ntiri

(2022). Moral foundations predict COVID-19 vaccine hesitancy: Evidence from a national survey of Black Americans. Journal of Health Communication, 27(11–12), 801–811. https://doi.org/10.1080/10810730.2022.2160526

68.

Oyserman

Coon

H. M.

Kemmelmeier

(2002). Rethinking individualism and collectivism: Evaluation of theoretical assumptions and meta-analyses. Psychological Bulletin, 128(1), 3–72. https://doi.org/10.1037/0033-2909.128.1.3

69.

Patton

M. Q.

(2015). Qualitative research & evaluation methods: Integrating theory and practice (4th ed.). Sage.

70.

Paul Ehrlich Institut . (2023). COVID-19-Impfstoffe. https://www.pei.de/DE/arzneimittel/impfstoffe/covid-19/covid-19-node.html

71.

Pierri

Perry

B. L.

DeVerna

M. R.

Yang

K.-C.

Flammini

Menczer

Bryden

(2022). Online misinformation is linked to early COVID-19 vaccination hesitancy and refusal. Scientific Reports, 12(1), Aricle 5966. https://doi.org/10.1038/s41598-022-10070-w

72.

Pokhrel

Chhetri

(2021). A literature review on impact of COVID-19 pandemic on teaching and learning. Higher Education for the Future, 8(1), 133–141. https://doi.org/10.1177/2347631120983481

73.

Pope

Mays

(1995). Reaching the parts other methods cannot reach: An introduction to qualitative methods in health and health services research. BMJ, 311(6996), 42–45. https://doi.org/10.1136/bmj.311.6996.42

74.

Pope

Ziebland

Mays

(2000). Qualitative research in health care. Analysing qualitative data. BMJ, 320(7227), 114–116. https://doi.org/10.1136/bmj.320.7227.114

75.

Raats

M. M.

Shepherd

Sparks

(1995). Including moral dimensions of choice within the structure of the theory of planned Behavior. Journal of Applied Social Psychology, 25(6), 484–494. https://doi.org/10.1111/j.1559-1816.1995.tb01763.x

76.

Rosenfeld

D. L.

Tomiyama

A. J.

(2022). Jab my arm, not my morality: Perceived moral reproach as a barrier to COVID-19 vaccine uptake. Social Science & Medicine, 294, Article 114699. https://doi.org/10.1016/j.socscimed.2022.114699

77.

Schilling

Tolksdorf

Marquis

Faber

Pfoch

Buda

Haas

Schuler

Altmann

Grote

Diercke

& RKI COVID-19 Study Group . (2021). Die verschiedenen Phasen der COVID-19-Pandemie in Deutschland: Eine deskriptive Analyse von Januar 2020 bis Februar 2021 [The different periods of COVID-19 in Germany: a descriptive analysis from January 2020 to February 2021]. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz, 64(9), 1093–1106. https://doi.org/10.1007/s00103-021-03394-x

78.

Schmidtke

K. A.

Kudrna

Noufaily

Stallard

Skrybant

Russell

Clarke

(2022). Evaluating the relationship between moral values and vaccine hesitancy in Great Britain during the COVID-19 pandemic: A cross-sectional survey. Social Science & Medicine, 308, Article 115218. https://doi.org/10.1016/j.socscimed.2022.115218

79.

Solís Arce

J. S.

Warren

S. S.

Meriggi

N. F.

Scacco

McMurry

Voors

Syunyaev

Malik

A. A.

Aboutajdine

Adeojo

Anigo

Armand

Asad

Atyera

Augsburg

Awasthi

Ayesiga

G. E.

Bancalari

Björkman Nyqvist

… Omer

S. B.

, (2021). COVID-19 vaccine acceptance and hesitancy in low- and middle-income countries. Nature Medicine, 27(8), 1385–1394. https://doi.org/10.1038/s41591-021-01454-y

80.

Sprengholz

Korn

Felgendreff

Eitze

Betsch

(2023). A lay perspective on prioritization for intensive care in pandemic times: Vaccination status matters. Clinical Ethics, 18(4), 434–441. https://doi.org/10.1177/14777509221094474

81.

Stead

Ford

Eadie

Biggs

Elliott

Ussher

Bedford

Angus

Hunt

MacKintosh

A. M.

Jessop

MacGregor

(2022). A “step too far” or “perfect sense”? A qualitative study of British adults’ views on mandating COVID-19 vaccination and vaccine passports. Vaccine, 40(51), 7389–7396. https://doi.org/10.1016/j.vaccine.2022.05.072

82.

STIKO (Robert-Koch Institut) . (2021). Stufenplan der STIKO zur Priorisierung der COVID-19-Impfung [Step-by-step COVID-19 vaccine prioritisation plan of STIKO]. https://www.rki.de/DE/Content/Infekt/Impfen/ImpfungenAZ/COVID-19/Stufenplan.pdf?__blob=publicationFile

83.

Täuber

van Zomeren

Kutlaca

(2015). Should the moral core of climate issues be emphasized or downplayed in public discourse? Three ways to successfully manage the double-edged sword of moral communication. Climatic Change, 130(3), 453–464. https://doi.org/10.1007/s10584-014-1200-6

84.

van Delden

J. J. M.

Ashcroft

Dawson

Marckmann

Upshur

Verweij

M. F.

(2008). The ethics of mandatory vaccination against influenza for health care workers. Vaccine, 26(44), 5562–5566. https://doi.org/10.1016/j.vaccine.2008.08.002

85.

van den Hoven

(2012). Why one should do one’s bit: Thinking about free riding in the context of public health ethics. Public Health Ethics, 5(2), 154–160. https://doi.org/10.1093/phe/phs023

86.

Vanderslott

Emary

te Water Naude

English

Thomas

Patrick-Smith

Henry

Douglas

Moore

Stuart

Hodgson

S. H.

Pollard

A. J.

(2021). Vaccine nationalism and internationalism: Perspectives of COVID-19 vaccine trial participants in the United Kingdom. BMJ Global Health, 6(10), Article e006305. https://doi.org/10.1136/bmjgh-2021-006305

87.

Varpio

Paradis

Uijtdehaage

Young

(2020). The distinctions between theory, theoretical framework, and conceptual framework. Academic Medicine, 95(7), 989–994. https://doi.org/10.1097/ACM.0000000000003075

88.

Wang

Han

Zhao

Liu

Chen

Xie

Liu

Zheng

Zhang

Wang

Huang

Liu

Y.-Q.

Q.-B.

Cui

(2021). Vaccination willingness, vaccine hesitancy, and estimated coverage at the first round of COVID-19 vaccination in China: A national cross-sectional study. Vaccine, 39(21), 2833–2842. https://doi.org/10.1016/j.vaccine.2021.04.020

89.

Wang

Yuan

Liu

Geng

Zhang

Lai

Lyu

Feng

Jing

Guo

Huang

Liang

Fang

(2021). Willingness to accept COVID-19 vaccine among the elderly and the chronic disease population in China. Human Vaccines & Immunotherapeutics, 17(12), 4873–4888. https://doi.org/10.1080/21645515.2021.2009290

90.

Watson

O. J.

Barnsley

Toor

Hogan

A. B.

Winskill

Ghani

A. C.

(2022). Global impact of the first year of COVID-19 vaccination: A mathematical modelling study. The Lancet Infectious Diseases, 22(9), 1293–1302. https://doi.org/10.1016/S1473-3099(22)00320-6

91.

Webb

T. L.

Sheeran

(2006). Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence. Psychological Bulletin, 132(2), 249–268. https://doi.org/10.1037/0033-2909.132.2.249

92.

World Health Organization . (2019). Ten threats to global health in 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

93.

Xiong

Lipsitz

Nasri

Lui

L. M. W.

Gill

Phan

Chen-Li

Iacobucci

Majeed

McIntyre

R. S.

(2020). Impact of COVID-19 pandemic on mental health in the general population: A systematic review. Journal of Affective Disorders, 277, 55–64. https://doi.org/10.1016/j.jad.2020.08.001

94.

Yang

Zheng

Shi

Yan

Dong

You

Zhong

Gong

Chen

Jit

Viboud

Ajelli

(2021). Who should be prioritized for COVID-19 vaccination in China? A descriptive study. BMC Medicine, 19(1), Article 45. https://doi.org/10.1186/s12916-021-01923-8

95.

Young

S. D.

Nussbaum

A. D.

Monin

(2007). Potential moral stigma and reactions to sexually transmitted diseases: Evidence for a disjunction fallacy. Personality and Social Psychology Bulletin, 33(6), 789–799. https://doi.org/10.1177/0146167207301027

96.

Wang

Yang

Jiao

Wang

Liu

Bärnighausen

Xue

Wang

McMahon

Geldsetzer

Chen

(2022). Attitudes toward the global allocation of Chinese COVID-19 vaccines: Cross-sectional online survey of adults living in China. JMIR Public Health and Surveillance, 8(6), Article e33484. https://doi.org/10.2196/33484

97.

Zampetakis

L. A.

Melas

(2021). The health belief model predicts vaccination intentions against COVID‐19: A survey experiment approach. Applied Psychology: Health and Well‐Being, 13(2), 469–484. https://doi.org/10.1111/aphw.12262

98.

Zhang

(2006). Family care or residential care? The moral and practical dilemmas facing the elderly in urban China. Asian Anthropology, 5(1), 57–83. https://doi.org/10.1080/1683478X.2006.10552560

99.

Zhou

Fan

Liu

Xiang

Wang

Song

Guan

Wei

Zhang

Chen

Cao

(2020). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. The Lancet, 395(10229), 1054–1062. https://doi.org/10.1016/S0140-6736(20)30566-3

100.

Zlobina

Dávila

M. C.

(2022). Preventive behaviours during the pandemic: The role of collective rituals, emotional synchrony, social norms and moral obligation. British Journal of Social Psychology, 61(4), 1332–1350. https://doi.org/10.1111/bjso.12539