Understanding parental vaccine refusal: Implicit and explicit associations about vaccines as potential building blocks of vaccine beliefs and behavior.

Objective: A movement of parents refusing vaccines for their children has contributed to increasingly large outbreaks of diseases that are preventable by vaccines. Research has identified multiple factors that relate to parents' vaccination behaviors (i.e., whether not they vaccinate their children), including their beliefs about vaccines' safety and utility and their trust in those who recommend vaccines. Here we examine the role of more fundamental psychological processes that may contribute to multiple vaccine-related beliefs and behaviors: cognitive associations.

Methods: Using a large sample of U.S. parents (pre-COVID-19), we investigated parents' associations between vaccines and helpfulness/harmfulness, as well as between the self and vaccines (vaccine identity), and their relation to parents' beliefs about vaccine safety and utility, trust in authorities' vaccine recommendations, and prior vaccination refusal for their children. To capture a more complete understanding of people's associations, we examined both explicit associations (measured via self-report) and implicit associations (measured by the Implicit Association Test).

Results: Both implicit and explicit associations correlated with beliefs, trust, and vaccination refusal. Results from structural equation models indicated that explicit vaccine-identity and vaccine-helpfulness associations and implicit vaccine helpfulness associations were indirectly related to vaccination refusal via their relation with vaccine beliefs.

Conclusions: Collectively, study findings suggest that vaccine associations-especially those related to helpfulness/harmfulness-may serve as psychological building blocks for parental vaccine beliefs and behaviors.