Background
As of early 2020, the world has been dealing with a global health crisis caused by the COVID-19 pandemic. In the absence of any effective treatments or vaccines for the disease, governments worldwide implemented a wide range of non-pharmaceutical interventions (NPIs), such as social distancing, school closures, remote working, restrictions concerning public gatherings, quarantines, hand-washing and the use of masks to slow transmission of the disease [
1]. Those measures (e.g., school closures and stay-at-home-orders) have been shown to be effective in reducing the number of infections [
2,
3], but that success has been accompanied by substantial economic, social [
4] and psychological costs (for a review, see [
5]). To ease the burden on society, a great effort worldwide has been put into developing and getting access to a vaccine [
6,
7]. A year after the first reported cases of COVID-19, countries around the world have started vaccinations [
8].
What characterizes NPIs and immunization programs is that their success is - to a great degree - dependent on the public’s acceptance and compliance. It is worrying, therefore, that a large number of studies suggest that not all individuals comply with government-implemented NPIs during the COVID-19 pandemic [
9‐
19]. When it comes to a vaccine against COVID-19, recent studies alarmingly show that although most people would take the vaccine, many individuals report that they feel hesitant towards it or would not get vaccinated [
15,
18‐
22]. If the COVID-19 vaccine uptake is insufficient, thus preventing or delaying herd immunity, NPIs will continue to play an important role in managing the spread of the disease [
23].
The willingness of the public to comply with the NPIs and to take the COVID-19 vaccine is essential in how the pandemic plays out, and thus it is of great importance to understand the motives behind non-compliance. The present study focuses on the role of three factors: conspiracy beliefs, a distrust in the institutions providing health information, and an endorsement of complementary and alternative medicine (CAM). Conspiracy beliefs are known to be involved in nearly all forms of science denial (e.g., [
24]; for a summary, see [
25,
26]), and COVID-19 is no exception [
27,
28]. Several studies have shown that conspiracy beliefs are a particularly strong predictor of the rejection of vaccinations [
24,
29], including the rejection of COVID-19 vaccines [
30]. Conspiracy beliefs are also related to the other factors. Individuals with more conspiracy beliefs have lower trust in science or political and medical authorities [
11,
15,
17,
18,
31,
32] and a higher likelihood to turn to CAM [
17,
19,
31,
33], possibly due to a distrust in the biomedical system [
34]. People who endorse CAM have less trust in medical authorities [
35].
What these three factors — conspiracy beliefs, low trust in authorities, and endorsement of CAM— may have in common is that they imply a tendency to question the appropriateness of the recommendations given by governments and health authorities. In the context of COVID-19, this may lead to non-compliance with NPIs and vaccination recommendations. In fact, recent studies suggest that people’s unwillingness to engage in health-protective behavior is associated with more conspiracy beliefs [
11,
14‐
19,
27,
31,
33,
36‐
38], a distrust in the establishment [
10,
17,
22], and an endorsement of CAM [
33].
Conspiracy beliefs
A particular challenge for health authorities in managing the public’s response to NPIs and the vaccine against COVID-19 is countering COVID-19 related misinformation and conspiracy beliefs [
39]. Holding conspiracy beliefs typically implies believing that a secretive group of people with malicious intentions are behind a particular event [
40]. Conspiracy beliefs are common during public health crises and may influence people not to take preventive actions [
41]. The COVID-19 pandemic provides a fertile breeding ground for conspiracy theories, because it is a complex event that causes fear and is difficult to understand [
42]. Indeed, studies show that conspiracy theories about COVID-19 are common [
11,
15,
27] and relate, for example, to the origin and spread of the virus, the reasons behind the NPIs or the development of a vaccine [
43,
44]. Alarmingly, individuals who believe in COVID-19 conspiracy theories are more likely to have negative attitudes to a government’s response to the pandemic [
31,
36], not adhere to NPIs, such as handwashing or social distancing [
11,
14‐
19,
27,
31,
37] and reject a future vaccination against COVID-19 [
15,
18,
19,
30,
33,
37,
38]. These results are in line with previous studies investigating the relationship between conspiracy beliefs and negative attitudes to other vaccines [
24,
45,
46]. However, not all studies find an effect between conspiracy beliefs and people’s compliance with the official guidelines during COVID-19 [
13,
47].
Trust
The COVID-19 pandemic is a “rapidly evolving event characterized by scientific uncertainty” [
48]. This uncertainty and constantly evolving science on COVID-19, has made health communication during the pandemic difficult [
49], as it has resulted not only in a massive flow of health information, but also in rapidly changing information, mixed messages and inconsistencies in recommendations. The possible consequences of this on the public’s trust in health communicators and policy makers is a matter of concern [
48] because low trust has been related to a smaller likelihood of following recommendations given by health authorities during previous outbreaks of infectious diseases [
50,
51]. The importance of trust has also been emphasized in studies on COVID-19, as stronger public trust has been related to lower COVID-19 mortality [
52], a greater reduction in human mobility during lockdown [
53], a higher likelihood of individuals complying with the NPIs [
10,
17,
18], and more willingness to take a COVID-19 vaccine [
18,
22]. A lack of trust in medical authorities is an important antecedent of antivaccination attitudes [
35,
54‐
58] and antivaccination behavior [
35] also when it comes to other vaccines.
CAM endorsement
CAM is an umbrella term for a wide range of treatments and substances that fall outside the conventional care recommended in a country. By definition, CAM can be used either in addition to, or instead of, conventional treatments [
59]. Approximately 30% of adults living in the U.S. [
60] and 10–40% in Europe [
61] use CAM. Studies show that individuals who use CAM, or have positive attitudes to CAM, have a lower likelihood of complying with conventional treatments, such as vaccinations [
35,
62‐
67]. It has been suggested that the relationship between positive attitudes to CAM and negative attitudes to vaccines is due to an underlying view on health that is not evidence-based and an unwillingness to adhere to conventional medicine [
62‐
64]. Among those who endorse CAM, CAM is also considered a natural, non-toxic way to strengthen the immune system, while vaccines are perceived as harmful [
63]. Furthermore, both CAM use and antivaccination attitudes have been shown to be related to lower trust in medical authorities [
35]. As regards COVID-19, recent studies suggest that people with more positive attitudes to CAM are more unwilling to accept a COVID-19 vaccine [
33] and to follow the official COVID-19 guidelines [
17].
The present study
To shed light on the reasons behind people’s unwillingness to adhere to official recommendations during the COVID-19 pandemic, we tested hypotheses derived from previous research suggesting that stronger COVID-19 related conspiracy beliefs, more endorsement of CAM, and a lower trust in the sources providing information on COVID-19, are related to more negative responses (compliance with the NPIs and emotional response to the NPIs) towards the NPIs implemented by the government during the pandemic. We also tested the hypotheses that COVID-19 conspiracy beliefs, a lack of trust in information sources and more positive attitudes to CAM are related to an unwillingness to take a vaccine against COVID-19. Finally, we explored whether people’s responses to the NPIs are related to their willingness to take the COVID-19 vaccine, and whether this association can be explained by conspiracy beliefs, a lower trust in the information sources, and more endorsement of CAM.
Discussion
How the COVID-19 pandemic develops is - to a great degree - dependent on the public’s compliance with government measures taken to manage the spread of the disease. Alarmingly, recent reports suggest that even though a majority of the public adheres to the official recommendations, non-compliance does exist as well [
9‐
19]. Additionally, some individuals are unwilling to take a vaccine against COVID-19 [
15,
18‐
22]. The results from the present study conducted during the first peak of COVID-19, support those findings. They show that on average, 93% of the respondents had been completely or somewhat willing (78 and 15% respectively) to comply with the NPIs implemented during the COVID-19 pandemic, and on average, 10% felt frustrated, annoyed, or upset because of the NPIs. Furthermore, 73% considered it very or somewhat likely (51 and 22% respectively) that they would take a vaccine against COVID-19, if the authorities recommended it and if it were free of charge. These percentages roughly correspond to the results from previous studies conducted in other countries [
15,
18,
20,
22].
The main aim of the present study was to investigate why some individuals have a negative response to official recommendations (NPIs and vaccine) during the COVID-19 pandemic. The results showed that those people who are unwilling to comply with the NPIs, or who react with negative emotions towards the NPIs, have more conspiracy beliefs and a lower trust in the sources providing information on COVID-19. Trust was important also in people’s willingness to take the COVID-19 vaccine, as individuals who are reluctant to get vaccinated, have a lower trust in the COVID-19 information sources. They also have a more positive attitude to CAM.
The results supported previous studies showing that lower trust is related to less compliance with the NPIs [
10,
17] and a lower likelihood of wanting to take the COVID-19 vaccine [
18,
22]. Trust in the sources providing information on COVID-19 was the strongest predictor of all three outcomes, explaining approximately 12–14% of the variance in people’s response to the NPIs and 20% in people’s willingness to take the vaccine. Of the four listed sources of information (i.e., medical doctors, scientists, news media, authorities), only approximately half of the respondents completely or somewhat trusted the authorities and the media in providing accurate information on COVID-19. Medical doctors and scientists were perceived as being more trustworthy, as 65% of the respondents completely or somewhat trusted doctors, and 71% completely or somewhat trusted scientists.
In line with previous research [
11,
14‐
19,
27,
31,
36,
37], the results indicated that people who have stronger COVID-19 conspiracy beliefs have a more negative response towards the NPIs. However, the hypothesis that people who have stronger COVID-19 conspiracy beliefs are less willing to take a vaccine against COVID-19 [
15,
18,
19,
33,
37,
38], was not supported. The zero-order correlation between conspiracy beliefs and COVID-19 vaccination intentions was medium strong (
r = −.45), indicating that more conspiracy beliefs are related to more unwillingness to take a COVID-19 vaccine. When controlling for the other predictors in the model, however, the unique effect of conspiracy beliefs did not reach statistical significance. On average 8% believed that the conspiracy theories are completely or somewhat true (3 and 5%, respectively). Of the four listed conspiracy theories, beliefs that a hidden organization or financial interests lie behind the spread of COVID-19, received the most support. The average proportion of people who - to some degree - believe in the conspiracy theories, is lower than in previous studies. For example, in two studies investigating COVID-19 related conspiracy beliefs in the UK [
15,
27], the average percentage of people believing in the COVID-19 related conspiracy theories was almost twice as high as in the present study. One possible reason for this discrepancy relates to which conspiracy beliefs were included in the questionnaires. However, for the same conspiracy theories, endorsement was also higher in the two studies conducted in the UK [
15,
27]. For example, the statement that the COVID-19 pandemic was a hoax was supported by approximately 7% in the Allington et al. [
27] study, compared to 4% in the present study, and items stating that financial gains are behind the spread of the virus were supported by approximately 12–14% in the study by Freeman et al. [
15] and 10% in the present study.
The finding that people with more positive attitudes to CAM were less willing to take a COVID-19 vaccine was in accordance with previous research [
33], supporting the notion that for some people negative attitudes to vaccines may be due to an unwillingness to adhere to conventional medicine [
62‐
64]. The correlations between endorsement of CAM and the two outcomes measuring people’s response to the NPIs were statistically significant and moderate, indicating that more endorsement of CAM was related to a more negative response to the NPIs. There was, however no statistically significant unique effect of CAM endorsement when controlling for the other predictors in the model. Similar findings were reported in the previous study investigating the role of conspiracy beliefs, trust, and CAM beliefs in people’s compliance with NPIs [
17]. That study demonstrated a statistically significant correlation between CAM beliefs and NPI compliance, but no mediating effect of CAM beliefs when studying the effects of conspiracy beliefs on NPI compliance. Of the participants in the present study, approximately 47% completely or somewhat endorsed CAM (26 and 21%, respectively). These numbers are higher than in the previous study [
67] where the same set of statements were used to measure CAM attitudes in the UK. In that study, approximately 35% had positive attitudes to CAM to some degree.
The results from the present study also showed that COVID-19 related conspiracy beliefs, distrust in the sources of COVID-19 information, and endorsement of CAM, are moderately to strongly correlated, supporting previous studies [
18,
19,
31,
33,
35]. People with lower trust in the establishment giving accurate information had stronger conspiracy beliefs, and a more positive attitude to CAM. The three predictors together explained approximately 36% of how willing people were to comply with the NPIs, 27% of how frustrated, annoyed or upset people felt about the NPIs, and 40% of how willing they were to take a COVID-19 vaccine. Furthermore, the results indicated that some of the people who respond negatively to the NPIs also have more unwillingness to take the vaccine. This association was related to the predictors in the model, in particular to a lower trust in the establishment providing accurate information.
The present results thus show that the level of trust people feel towards political authorities, health authorities, scientists, and the media, is consistently related to what degree they are willing to adhere to the official guidelines during COVID-19. This underlines the importance of taking action towards building public trust in order to ensure acceptance and compliance with the NPIs and the vaccine. A key factor in building trust during a pandemic is transparent communication [
48,
71]. Correcting conspiracy theories is challenging, particularly among strong believers of conspiracy theories [
72]. One explanation is that evidence
against a theory may be interpreted as evidence
supporting the theory, because the people who are providing the evidence are seen as part of the conspiracy [
73]. However, some suggestions on how to tackle conspiracy theories do exist, such as providing anti-conspiracy (i.e., accurate scientific information) information prior to the conspiracy theories becoming established [
74], or approaching the issue by treating the possible underlying motives, such as feelings of powerlessness [
42,
72], distrust, and alienation [
42].
Limitations
In the present study, we assumed that compliance with the official recommendations (NPIs and vaccine) are underpinned by conspiracy beliefs, CAM endorsement, and trust in information sources. The cross-sectional design does not allow us to draw causal inferences. Based on previous literature, however, it seems plausible to assume that conspiracy beliefs, CAM endorsement, and trust explains compliance with the NPIs and not the other way around. Additionally, as a COVID-19 vaccine was not yet available at the time of data collection, it seems unlikely that the intentions to take the vaccine would influence people’s beliefs in conspiracy theories, attitudes to CAM, or trust in the information sources.
The fact that the data collection was conducted over Facebook may have influenced the generalizability of the results. This is because it may have led to sampling bias due to self-selection. It is possible that individuals with certain characteristics, for example very negative or very positive attitudes to the COVID-19 official guidelines or a COVID-19 vaccine, may have been more interested in participating in the study. The histograms in Fig.
1, however, reveal that for both NPI compliance and vaccination intentions, our results are approximately in line with previous studies, suggesting that in this regard, the sample in the present study did not clearly deviate from other samples. Important to note, however, is that the gender distribution in the present study was very uneven, with men constituting only 1/5 of the total sample. Furthermore, the age distribution indicates that most respondents were between 40 and 60 years of age. These asymmetries are important to keep in mind when generalizing the results.
A general issue with self-reported survey data, is the risk of response bias, caused for example by respondents answering the questions in a socially desirable way. This may affect the validity of the results. However, a recent study suggests that self-reports of NPI compliance during COVID-19 do not seem to suffer from social desirability bias [
75]. To decrease the risk of social desirability bias in the present study, the respondents were informed that participation in the study was completely anonymous. To work against response bias further, the survey included an attention check, where the participants were asked to select a specific number on a scale. Only those participants answering the attention check correctly were included in the study. Furthermore, NPI compliance and CAM endorsement included reverse-scored items.
The questionnaires assessing conspiracy beliefs, trust in information sources, NPI compliance, and vaccination intentions have not been validated in other samples. For all constructs other than vaccination intentions, however, factor analysis was used to assess the factor loadings of the questions on the constructs and to handle measurement error. Factor analysis was not performed on vaccination intentions because the survey included only one question about people’s intentions to take a COVID-19 vaccine. The reason for this was that we wanted to obtain information specifically on people’s willingness to take a vaccine in a situation where the vaccine is recommended by the authorities and free of charge.
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