The Association Between Cultural Tightness and COVID-19 Vaccine Confidence From 28 Countries: Cross-Sectional Study

Social norms provided a framework for understanding a variety of behaviors. Cultural tightness was introduced to measure the level of adherence to social norms and tolerance of deviant behavior.

We aimed to explore the association between cultural tightness and COVID-19 vaccine hesitancy.

A total of 44,339 participants aged 18 years and older were enrolled from 28 different countries between 2020 and 2022. We used the Vaccine Confidence Index (3 items related to evaluation of importance, effectiveness, and safety) with a 5-point Likert scale to collect COVID-19 vaccine confidence. Demographic information at the individual-level was obtained through the survey, while national-level data were sourced from the World Bank and Hofstede insights. Multilevel linear regressions with random effects for country were used to examine the association between cultural tightness and COVID-19 vaccine confidence.

Of the participants, 21,968 (50.2%) were male and 18,957 (43.3%) had an education level of university or above. Vietnam exhibited the highest level of confidence (mean 13.31, SD 1.71) on COVID-19 vaccine and Slovakia had the lowest level (mean 9.52, SD 0.14). The higher levels of cultural tightness were positively linked to greater vaccine confidence (β=1.94, 95% CI 1.72-2.15; P<.001) after controlling individual- and national- level variables. Individuals who were younger in age, female, had lower levels of educational level, or belonged to minority religious groups demonstrated a positive association with lower vaccine confidence. Hofstede's 5 cultural dimensions were not significantly associated with vaccine confidence. The level of vaccine confidence in 2021 (β=-0.54, 95% CI -0.67 to -0.37; P<.001) and 2022 (β=-0.23, 95% CI -0.34 to -0.10; P<.001) was lower than that observed in 2020.

Lower level of cultural tightness might be positively associated with low vaccine confidence. Our findings offered the insight for designing tailor interventions to vaccine hesitancy in different cultural tightness context.