The Perfect Enemy | Deliberation, context, emotion and trust – understanding the …

A total of 33 respondents completed the interview, including males and females across a range of ages and living conditions (see Table 1).

Table 1 Respondent characteristics (N = 33)

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Across all interviews, four major themes emerged regarding COVID-19 vaccination decisions: 1) Deliberation for and against vaccine uptake (benefits versus risks); 2) Social and political context; 3) Emotions towards the COVID-19 pandemic and the associated political and social processes; and 4) Trust in vaccines, science, government-affiliated health institutions and oneself. As respondents weighed whether to get vaccinated, they consistently conveyed, oftentimes via a personal narrative, how they found themselves contending with competing narratives that were shaped by emotional responses to the broader context.

Drawing upon these narratives, we developed the DCET framework (Deliberation, Context, Emotion, Trust) of COVID-19 vaccination decision-making (see Fig. 2). We present our results following the flow of this figure. First, we outline deliberation (see section 3.1) wherein respondents, usually as a first step, weighed benefits and risks of vaccines. Second, we illustrate how these considerations were informed by contextual realities (see section 3.2) including political and interpersonal factors of COVID-19 and vaccines in Germany. Deliberation and context converged to spark a range of emotions (see section 3.3) about vaccines and vaccination, which in turn could lead to further, more personal deliberation (particularly regarding vaccine side effects). Although negative emotions were highly salient in participants’ narratives, they did not necessarily impact vaccination decisions in cases when respondents reported having trust (see section 3.4) in science, doctors, experts, and/or in their own capability to process information.

Deliberation about benefits versus risks

When asked about opinions, experiences and attitudes on COVID-19 vaccines, respondents routinely illustrated how they weighed reasons for and against vaccination, highlighting internal debates about the risks of COVID-19 versus risks associated with vaccines, and navigating these fears to make decisions for or against vaccination uptake:

“The tests before approval were less comprehensive than usual … but I think concerning the risks of getting blood clots compared to the risk of the pandemic … one is significantly smaller than the other. So I have little reservations, I’d be willing to take the risk.” (female, 30 years).

Benefits of vaccines

Respondents generally described the benefits of vaccines as outweighing drawbacks. Vaccines were consistently highlighted as a valuable means to reduce suffering or mortality on a societal level, to end lockdowns and to resume normalcy. When describing the utility of vaccines, respondents often invoked a sense of doing what was in the best interest of society and recalled images of “intensive care units with these completely helpless, profoundly sick, dying people” (female, 61 years). Respondents, particularly younger respondents, perceived their own COVID-19-associated risks as minimal, but viewed vaccines as a means to protect vulnerable individuals within their family or social circle:

“I was never really worried about myself, but more about harming others by unintentionally infecting those around me.” (female, 30 years).

With similar frequency though less intensity, respondents described how vaccines would offer a means to end lockdowns, to meet friends and family, to engage in social and cultural activities, and to travel. As one young man said, “the only relief for me would be to finally have a social life again.” (male, 27 years). Some respondents described how social distancing and a constant fear of catching COVID-19 were detrimental to mental health, and others described the need to re-boot the German economy – in both cases highlighting vaccination as a means to address these issues. With less intensity and frequency, respondents described how a vaccine would mitigate concerns regarding problems associated with a moderate COVID-19 infection including loss of smell and long COVID (see legend of Fig. 2 for a definition). Respondents who had pre-existing conditions (diabetes, multiple sclerosis, lung diseases, etc.) perceived a high personal risk of severe illness from COVID-19 and viewed being vaccinated as “a matter of life or death” (male, 54 years).

Risks of vaccines

While respondents predominantly argued that the benefits of vaccination outweighed the risks, reservations centered on short-term side effects (namely, sinus thrombosis but also a high fever), broad safety concerns (due to a validation process described as unusually fast or “immature” [female, 61 years]) and potential long-term side effects (sterility, DNA-damage, or cancer). As one respondent said: “I’ve heard that it causes blood clots and I don’t … even if they say [the risk is] really minimal that minimal might fall within me.” (male, 37 years). Respondents described concerns such as being treated like a “Versuchskaninchen” [lit.: “trial rabbit”, sem.:“guinea pig”] (female, 57 years) by scientists “experimenting with genetics” (female, 21 years), with one older respondent recalling the thalidomide scandal in the 1960s as a cautionary tale^{Footnote 1} [40].

Vaccine hesitancy regarding deliberation

Despite reservations, most respondents said they would ultimately get the vaccine, but some hesitated and described getting vaccinated as “a basically frightening” (female, 61 years) experience, best undertaken only after “seeing how others respond to it” (male, 27 years), and underscoring that they were concerned about the vaccine not preventing virus spread. Several respondents wondered aloud who would be accountable in the event of negative, vaccine-induced health consequences and whether vaccines might trigger or amplify mutations.

Two respondents conveyed outright rejection of COVID-19 vaccines. They described the risk of severe COVID-19 infection as minimal for younger people and lamented that information about the virus appeared “fear-focused and detached from reality” (male, 31 years). In their view, vaccines were generally dangerous (“I don’t trust the procedures.” female, 21 years) and there appeared to be no institutional recourse in the event of vaccine-related injury. Both respondents highlighted how they had grown up in a non-German context, and how they today partially relied on information they received from contexts outside of Germany, particularly regarding the potential harm of vaccines and how one’s own immune system was naturally capable of overcoming disease.

Social and political context

Although not explicitly asked in interview guides, each respondent lamented some facet of the current social and political context in which COVID-19 vaccines were discussed, debated, promoted, and presented by politicians, journalists, or members of society.

Political shortcomings

Respondents described how, despite “many well-performing public bodies” (female, 51 years) in Germany, vaccine-related mismanagement (e.g. incomprehensible online registration portals, complex admission procedures within vaccination centers, or an inability to receive vaccines within family doctors’ offices) was “rather problematic” (female, 30 years) and served as one more example of political incompetence, thereby “trying the limits of people’s patience” (female, 51 years). Respondents decried the government’s vaccine purchase and supply chain process as “abysmal” (male, 57 years), “wandering” (male, 61 years), and “amateurish” (male, 57 years), leading to sentiments “that [vaccination roll-out] is faster everywhere in the world, compared to us” (male, 31 years). Respondents described how vaccines became a topic that seemed to serve political self-interest or a desire to expand personal clout in an election year:

“How [vaccines] are being communicated to the public is fatal. And even beyond vaccines, there’s the lockdown measures, with politicians making promises they cannot keep. They have self-serving interests, probably because of the upcoming elections.” (female, 30 years).

Media communication

Respondents also uttered dissatisfaction with how information was presented in news media. Divergent news on vaccines lead to a sense that journalists were intent on “emotionally arousing” (female, 37 years) reporting, “ripping facts out of context” (female, 58 years), “showboating” (“Effekthascherei”, female, 58 years), sowing stories that foment panic (“Panikmache”, female, 30 years), creating “mass hysteria” (female, 61 years), or encouraging broader social division related to COVID-19 vaccines. One woman explained that her negative opinion about one specific vaccine was “triggered by the media, because you hear a lot more negative things about AstraZeneca than about the other vaccines. And you have to build your opinion based on what you hear, there is no other option.” (female, 52 years). Respondents wished for more clarity and a greater sense of responsibility on behalf of the media concerning vaccination news, comparing the task to a mother who “has a responsibility, and [I] must choose my words when I want to deliver a message.” (female, 58 years).

Social divisiveness

Along with the political and media climate, respondents lamented the manner in which extended lockdowns and social distancing measures in Germany underpinned societal divisiveness and seemed to widen tensions between those in favor of and those opposed to COVID-19 vaccines. Respondents shared firsthand experiences of public conflict as those holding differing views on masks, vaccines, or social distancing engaged in arguments in public transportation, on the street, or online. Respondents who favored vaccines described a desire for expanded freedom for the vaccinated, and outlined frustration toward those who were unvaccinated, for whom they had “very little understanding” (female, 51 years). Unvaccinated people were further described as “egotistical” (female, 55 years) and “careless” (female, 51 years), and as inclined to “demonize everything” (male, 61 years), while society should instead focus on “what it is actually about – that this vaccine is our hope” (male, 31 years). Respondents who expressed outright objection to vaccination feared mandatory vaccines and indicated that they “would be more open towards” (male, 31 years) vaccination if it was voluntary.

Emotions

Emotions emerged as a layer through which deliberation (benefits versus risks) and contextual factors (political, medial, and social) were filtered when making a decision about vaccines. Some participants voiced their desire to make a purely rational decision, without letting emotions influence their vaccination intention (see direct arrow from Deliberation to Trust in Fig. 2). In most of such cases, however, emotions were nevertheless verbally or non-verbally expressed. The dominant emotion associated with COVID-19 vaccines or vaccination in general across interviews, regardless of age or gender, was anger coupled with impatience, frustration, insecurity, or exasperation primarily directed at the slow roll-out of vaccines and other contextual factors, voicing concerns that “it will take a hundred years until it’s my turn to get vaccinated” (male, 20 years) and that “that’s the biggest misstep I accuse our government of” (male, 61 years). A young woman, who had been very hopeful about the vaccines, felt “helplessness, fury, because you are forced to spend many more months of your life indoors without leisure time activities” (female, 30 years). Respondents also fumed about how vaccines were presented in the media (particularly with regards to a perceived exaggeration of side effects such as sinus thrombosis caused by the AstraZeneca vaccine), and how vaccines were becoming another topic that was tearing society apart. Some respondents anticipated that provocative headlines and divisive news might lead to feeling “insecure” (female, 29 years) or “confused” (female, 21 years) about which vaccination information to believe, with one respondent conveying the feeling of being “beaten to death by information” (female, 51 years). Some respondents described feeling primed by the media to take a negative view (“it sows in your mind some doubts towards it”, male, 37 years), with one respondent stating:

“If there is so much squabbling [German: “Hick Hack”] about a vaccine, you just can’t have a positive feeling. And there might be many who tell me: ‘Well, a few have died but it [the vaccine] has many positive aspects.’ Nevertheless, it remains an uneasy feeling.” (female, 57 years).

Vaccine hesitancy regarding emotions

As highlighted earlier, the vast majority of respondents described their intention to get vaccinated (once a vaccine was available), and expressed a range of positive emotions and phrases to describe vaccines, such as “ray of hope” [German: “Lichtblick”] (male, 31 years), feeling “happy to get vaccinated” (male, 37 years) or “relieved” (female, 58 years) and able to feel safe again: “What would it mean to catch COVID-19? Would I get severely ill? Would I die? Well, I’ll put it like this: I hope that this fear will decrease substantially when many people get vaccinated.” (female, 51 years). Those respondents for whom risks of vaccines outweighed benefits described feeling “ambivalent” (female, 51 years), “an inner apprehension” (female, 21 years), or “skepticism” (female, 52 years) toward vaccination, and they wondered aloud: “What are we exposing ourselves to, as world-population? […] Well, that’s my gut feeling.” (female, 51 years).

Trust

Almost all respondents outlined frustration with the COVID-19 response, concerns about the rapid pace of vaccine development, or exasperation with the government’s approach to vaccine distribution. Yet, when asked how these factors influenced decisions to vaccinate, respondents answered with phrases such as “not at all” (female, 55 years) or “it is independent” (female, 57 years). Upon further probing, respondents described how trust – in science and the scientific process, in doctors, institutions, media, or oneself (see Table 2 for key quotes with regards to the different trusted entities as emerging from respondents’ accounts) – safeguarded their vaccination intention or tipped the balance in favor of vaccination even in light of disheartening or unsettling contextual factors:

“I had some reservations against the mRNA vaccine, as it hasn’t been used before. But well, I think the trust in the EMA [European Medicines Agency] regarding this … yes, is stronger. What other than trust could it be? I think nobody knows what is going to happen in 20 years, whether we will light up green or something. Nobody can know that, I’m aware of this.” (female, 58 years).

Table 2 Representative quotes on trusted entities related to vaccines and science

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The most trusted authorities indicated by respondents were scientific and medical institutions responsible for reviewing and validating vaccines in Germany. Even respondents who were skeptical about foreign vaccines (such as Russia’s Sputnik V) expressed that they would have confidence in them if German supervisory authorities decided to approve them. These trusted institutions included government-affiliated scientific institutions such as the European Medical Agency (EMA), the Robert Koch Institute (RKI, Germany’s main public health agency), and the Paul Ehrlich Institute (PEI, Germany’s Federal Institute for Vaccines and Biomedicines), while political actors such as elected government officials were much less trusted:

“All that happens on a scientific level, like the EMA on the EU-level, the PEI in Germany – I trust completely. On a scale from 1-10, that’s a 10. But this goes into a minus range for federal- or state-level politics. So, I see vaccines very positively, but the way we handle them is evidence of incapacity [German: “Armutszeugnis”].” (male, 37 years).

In general, respondents described feeling “very inclined toward science” (female, 55 years), scientists, and family physicians. The latter were particularly emphasized by several respondents because they expected family physicians to be beholden to their patients, to have a longstanding relationship with their patients, and to better understand patients’ medical histories and unique concerns or priorities in relation to medical information. Respondents also mentioned scientists as role models, naming prominent figures such as Dr. Mai Thi Nguyen Kim (a German chemist who focuses on science education via YouTube) or Prof. Dr. Christian Drosten (a German virologist and expert consultant of the government, who hosted an educational podcast over large parts of the pandemic), as well as scientists or experts with whom they personally interacted in their everyday environment. One student, for example, recounted how her professor helped her feel less insecure about vaccines by explaining how to interpret numbers about risks.

Finally, several respondents expressed trust in their own ability to sift through divisive or misleading media reports, and to better identify trustworthy information by reading scientific evidence themselves, particularly as a means to gauge risk:

“I am a science student and, well, I know, to some extent at least, how to make sense of things that were reported in a misleading way. But I guess that most people are not familiar with this field and do not know where to find which information or which information to believe.” (female, 37 years).

Vaccine hesitancy or refusal regarding deficits in trust

While the above examples highlight how high trust has protective qualities for vaccine uptake when facing negative emotions, some respondents also described how trust deficits facilitate the opposite consequence. Some respondents raised doubts regarding the general honesty of governmental stakeholders and media or explained how they could not find vaccine related information they were searching for online, suggesting that relevant facts about vaccines have been “hidden” or “covered up” (female, 21 years). The resulting insecurities prepared the ground to vaccine hesitancy: “This creates extreme mistrust […] and then it’s not a long way towards becoming vaccine hesitant, anti-vaccinator, conspiracy theorist.” (male, 54 years).