The COVID-19 pandemic underscored the critical need for effective vaccination strategies. While vaccine availability is crucial, its uptake is influenced by a complex interplay of factors beyond mere access and knowledge. Existing models of health behavior, such as the health belief model, the information-motivation-behavioral skills model, and theories of reasoned action and planned behavior, emphasize the role of individual perceptions, motivations, and skills. However, these models often overlook the influence of deeper, more ingrained factors like moral values and social norms. Social value orientations, defined as the guiding moral principles influencing individual behavior, are particularly important during crises. Schwartz's theory of basic human values categorizes them along two dimensions: self-transcendence versus self-enhancement and openness-to-change versus conservation. Studies suggest that prosocial value orientations, focusing on social outcomes and cooperation, are associated with higher compliance with public health measures. Trust in institutions, another key factor, significantly influences behavior during pandemics. Mistrust in government or health authorities can lead to vaccine hesitancy, especially when economic hardship is involved. Trust in vaccine safety, manufacturers, and health experts is also crucial, particularly for new vaccines developed rapidly. This study focuses on the Maldives, a small island nation that implemented an intensive risk communication campaign to promote COVID-19 vaccination. Despite a relatively high initial receptiveness to vaccination, there was a limited understanding of the social drivers behind uptake, particularly given moderate levels of trust in government and adherence to public health measures observed earlier in the pandemic. This study aims to explore the role of social value orientations as independent determinants of vaccination behavior, in addition to trust in institutions and demographic factors.

Existing literature highlights the multifaceted nature of vaccine uptake. While access and information are essential, psychological and social factors significantly influence individual decisions. Models like the Health Belief Model and the Theory of Planned Behavior highlight individual beliefs, attitudes, and perceived control as key determinants. However, emerging research points towards the importance of social and cultural contexts, encompassing social norms, trust in institutions, and underlying value systems. Studies have explored the influence of political ideologies and trust in government on vaccination behaviors, highlighting the role of misinformation and its impact on confidence. Other research emphasizes the role of value-expressive messaging, demonstrating that aligning communication strategies with individuals' values can improve vaccine uptake. However, the interaction between social value orientations and vaccine behavior, especially during crises, requires further investigation. This study builds upon existing work by examining the interplay of social value orientations, trust in institutions, and demographic factors in predicting COVID-19 vaccine uptake in a specific context.

This cross-sectional study utilizes data from the Values in Crisis Survey – Wave Two, conducted in the Maldives from October to December 2021. The survey employed a multi-cluster population proportionate random sample, stratified by gender and age, encompassing both urban and rural communities. After data cleaning, the final sample included 497 respondents. Social value orientations were measured using items from the Personal Values Questionnaire (PVQ-21), based on Schwartz's value framework. Respondents rated their agreement with each item on a six-point Likert scale. Higher-order values (openness-to-change, conservation, self-enhancement, and self-transcendence) were computed by averaging responses to constituent items. Data cleaning involved removing participants exhibiting pattern responding, resulting in a final sample of 497 participants. Internal reliability of the higher-order values was assessed, with acceptable reliability (α > 0.6) observed for all. Corrected centred values were generated to account for response biases. Public confidence in government, health sector, scientific experts, and public broadcasters was measured using single-item Likert scale questions. Vaccine uptake was assessed using an ordinal scale, recoding responses to reflect a continuum of vaccination behavior. Descriptive statistics were used to present demographic characteristics and vaccine uptake rates. Spearman's correlations were employed to examine relationships between vaccine uptake, public confidence, and social value orientations. Finally, multivariate linear regression was used to identify predictors of vaccine uptake, controlling for demographic factors.

The study revealed a high COVID-19 vaccine coverage rate of 97.8% in the sample, with only 2.2% of respondents indicating they would not get vaccinated. No significant differences in vaccine uptake were observed across demographic factors (age, gender, income, education, residential area). Public confidence in institutions was generally moderate to low, with over half of respondents expressing little or no confidence in government, the health sector, and public broadcasters. However, confidence in health experts was higher (65%). Correlation analysis showed no significant association between vaccine uptake and public confidence in institutions. However, positive correlations were found between vaccine uptake and several basic values (benevolence, conformity, security) and higher-order values (conservation, self-transcendence). Multivariate linear regression revealed that only conservation was a significant predictor of vaccine uptake, even after controlling for demographic factors (B = 0.158, p = 0.004). This suggests that the prosocial value of conservation played a crucial role in driving high vaccine uptake in the Maldivian context.

The findings diverge from some previous studies showing demographic factors influencing vaccine uptake. The lack of significant association with demographics in this study may be attributed to the Maldives' policy of providing free vaccination to all residents, irrespective of socioeconomic status. While previous research emphasized the importance of confidence in institutions as a driver of vaccine uptake, this study's results did not support this, possibly due to pre-existing moderate levels of public trust in institutions. The high vaccine coverage observed suggests the prominence of other social drivers, such as social norms and values. The strong association between conservation value orientation and vaccine uptake aligns with the notion that prosocial societies exhibit higher compliance with public health measures. The Maldivian society's pre-existing inclination towards conservation, coupled with the government's effective implementation of vaccination campaigns, likely contributed to the high uptake. However, this association may be context-specific and potentially temporary, requiring further investigation in non-crisis situations. The study also acknowledges potential limitations, such as the focus on local residents and the exclusion of migrant populations, affecting the generalizability of the findings.

This study demonstrates a significant association between social value orientation, particularly conservation, and COVID-19 vaccine uptake in the Maldives. While the high vaccination rate highlights the success of the vaccination campaign, further research is needed to validate these findings in non-crisis situations and explore the long-term effects of the pandemic on vaccination attitudes and behaviors. Future studies should consider the evolving nature of the pandemic and the impact of vaccine mandates on equity and access. Expanding the scope to include cyber communities and adopting advanced data science methodologies will enhance understanding of these complex dynamics.

This study's cross-sectional design limits causal inferences. The reliance on self-reported data may introduce bias. The sample is limited to local residents, excluding migrant populations, which may affect the generalizability of findings. The study focuses primarily on social value orientations, and other relevant factors such as health beliefs, perceived risks, and exposure to misinformation were not fully explored. Finally, the study's findings might be specific to the Maldivian context and may not be generalizable to other populations with different cultural values and social norms.