The role of social value orientation in modulating vaccine uptake in the COVID-19 pandemic: A cross-sectional study

The study examines whether social value orientations (SVOs) influenced COVID-19 vaccination behaviour in the Maldives during the pandemic. While vaccines were prioritized globally, uptake does not automatically follow availability or knowledge. Behavioural theories (e.g., health belief model, theory of reasoned action/planned behaviour, social cognitive theory) suggest internal (beliefs, values, identity) and external (media, norms) factors shape adoption of protective behaviours. Schwartz’s values framework posits higher-order bipolar dimensions: self-transcendence vs self-enhancement and openness-to-change vs conservation; prosocial orientations (self-transcendence, conservation) have been linked to greater compliance with public health measures. Trust in institutions and experts is also theorized to predict adherence in crises. In the Maldives, previous work documented moderate institutional trust and prosocial value leanings. This study tests the hypothesis that SVOs, alongside demographic factors and trust in institutions/experts, are determinants of vaccination behaviour in a pandemic context.

Prior research demonstrates that vaccine uptake is shaped by psychological and social determinants beyond access, including beliefs, norms, and values. Behavioural models (health belief model; theories of reasoned action and planned behaviour; social cognitive theory) highlight perceived susceptibility/severity, attitudes, and self-efficacy. Schwartz’s value theory organizes ten basic values into higher-order dimensions, with self-transcendence and conservation associated with prosocial, cooperative outcomes; such orientations have been linked to greater compliance with public health measures during COVID-19. Trust in government, health institutions, vaccine manufacturers, and experts has been associated with vaccine confidence and adherence, though findings vary by context. Emerging studies have examined political ideology, messaging, and social norms (including herding effects) on vaccination intentions; fewer have focused directly on SVOs. Evidence from messaging studies suggests value-expressive approaches and societal prosocial orientations can enhance preventive behaviours, but the specific role of SVOs relative to institutional trust and demographics remains underexplored, particularly in small island contexts like the Maldives.

Design and setting: Cross-sectional analysis using Values in Crisis Survey – Wave Two conducted in the Maldives (October–December 2021) among adults previously sampled in Wave One (May 2020). Sampling: Multi-cluster, population-proportionate random sample from urban and rural communities, stratified by gender and age. Sample: After data cleaning, n=497 (185 urban; 312 rural); 46% male, 54% female; age 18–34: 45.7%, 35–64: 50.7%, 65+: 3.6%. Measures: Social value orientations measured via Schwartz PVQ-21 (6-point scale; all items reverse-scored so higher scores reflect greater agreement). Ten basic values aggregated into higher-order dimensions: openness-to-change (items 1,10,11,6,15,21), conservation (5,9,14,7,16,20), self-enhancement (2,4,17,13), self-transcendence (3,8,12,18,19). Scores computed as averages per value; corrected centered values generated by centering each respondent’s item scores to their overall mean to reduce scale-use bias and capture relative importance. Other measures: Trust in government, health sector, scientific experts, and public service broadcasters assessed by single items on a 1–4 Likert scale (1=a great deal to 4=none at all), reverse-scored. Vaccination behaviour/attitudes coded on a 1–6 scale (1=definitely not to 6=want to but cannot due to health issues); response 6 recoded to 2 for analysis to reflect higher motivation to uptake. Data cleaning and reliability: Participants with patterned responding on PVQ-21 (same response on >16 items) were removed (n=119). Higher-order values showed acceptable internal reliability (α>0.6); basic values had lower reliability for some (e.g., self-direction, power), consistent with brevity and conceptual breadth of PVQ-21. Analysis: Descriptive statistics for vaccine uptake, trust, and SVOs by demographics; Spearman correlations between vaccine uptake, trust, and SVOs; multivariate linear regression testing higher-order values as predictors of vaccine uptake while controlling for demographics.

- Vaccine uptake was very high: 97.8% reported already vaccinated or intending to vaccinate; 2.2% indicated they would not vaccinate. The abstract reports overall coverage of 94% with 2.2% unwilling to vaccinate. - No significant associations were found between vaccination behaviour and demographic variables (age, gender, education, income, or urban/rural residence). - Public confidence was moderate to low for institutions: government (57.9% none/not very much), health sector (55.1%), and public service broadcasters (61.6%); confidence in health experts was higher (65% quite a lot/great deal). - Mean higher-order values: conservation M=5.16 (SD=0.694) higher than openness-to-change M=4.48 (SD=0.802); self-transcendence M=5.25 (SD=0.679) higher than self-enhancement M=3.96 (SD=0.922). - Correlations with vaccination behaviour: • No significant associations with trust in government, health sector, public broadcasters, or scientific experts. • Significant positive associations with basic values security (r=0.118, p=0.009), conformity (r=0.117, p=0.009), and benevolence (r=0.095, p=0.035); negative association with power (r=-0.097, p=0.031). • Significant positive associations with higher-order values conservation (r=0.180, p<0.01) and self-transcendence (r=0.136, p=0.002); no significant associations for openness-to-change or self-enhancement. - Multivariate regression: Model significantly predicted vaccine uptake (F(?,?)=3.184, p=0.001; R=0.236; R^2=0.056). Only conservation was a significant predictor (B=0.158, p=0.004; 95% CI 0.050–0.267) after controlling for demographics.

Findings indicate that in the Maldivian context, extremely high vaccine uptake occurred without significant demographic disparities and despite moderate-to-low confidence in several public institutions. This challenges assumptions that demographics and institutional trust are primary drivers and instead highlights the role of prosocial value orientations. Higher conservation and self-transcendence values correlated with more positive vaccination behaviour, with conservation uniquely predicting uptake in multivariate analysis. The conservation orientation (tradition, conformity, security) may facilitate compliance with government-led public health initiatives in crisis, supporting high coverage even when institutional confidence is modest. The results align with literature linking prosocial orientations to greater adherence to public health measures and suggest that social norms and values may mediate behaviour during pandemics. However, the pandemic context includes additional situational influences (e.g., policy incentives/restrictions, perceived disease risk) that may confound these relationships. The stability of value–behaviour links may vary over time as crises evolve; motivation for social outcomes may wane with pandemic protraction, potentially altering uptake dynamics. Further, mixed evidence on the influence of communicated social norms and complex online network effects underscores the multifactorial nature of vaccine behaviour.

Social value orientations, particularly conservation, were associated with and helped explain the high COVID-19 vaccine uptake observed in the Maldives. While trust in institutions did not significantly relate to uptake, prosocial value orientations appear instrumental during crisis contexts. Future research should test these relationships in non-crisis conditions, account for evolving vaccination regimes and disinformation, and extend to cyber communities using emerging data science methods. Vaccination rollout and behaviour-change strategies should consider social value orientations to achieve and sustain high coverage post-pandemic.

- Cross-sectional design limits causal inference; findings establish associations, not causality. - Measures of institutional trust were single-item and overall confidence levels were moderate, which may affect detection of associations. - Limited examination of other situational factors (e.g., vaccine mandates, movement/travel restrictions, differential service access) that could influence uptake irrespective of values or trust. - Sample included only local Maldivian residents; foreign migrant populations were not captured, limiting generalizability. - Some basic value scales (e.g., self-direction, power) exhibited low internal reliability in PVQ-21 due to few items and conceptual breadth. - Potential temporal specificity: value orientations and their effects may shift in crisis versus peacetime, and effects may change as the pandemic evolves.