Does vaccination elicit risk compensation? Insights from the COVID-19 pandemic in France

Abstract

Vaccination has played a key role in reducing the health burden of COVID-19, however, concern has been raised worldwide regarding risk compensation, a process whereby feelings of security arising from being vaccinated may lead people to reduce their engagement in other protective behaviours.
We investigated whether vaccination led to risk compensation and whether this changed over time by conducting a repeated cross-sectional study at seven intervals over the initial months (February to September 2021) of the vaccine rollout in France. Participants (N = 14,003) completed an online survey measuring vaccination status, vaccination intention and engagement in four preventive behaviours: mask wearing, avoidance of physical contact, hand hygiene, and avoiding social gatherings. Risk compensation was measured indirectly by comparing levels of engagement in protective behaviours according to vaccination status, with those unvaccinated but intending to vaccinate serving as a baseline.
Risk compensation did not occur systematically and was mostly observed towards the end of the vaccine rollout for two of the four protective behaviours: avoiding social gatherings (in July and September for fully-vaccinated participants (Adjusted Odds Ratio (AOR) = .72, p = .045; AOR = .54, p = .022, respectively) and wearing a mask (those vaccinated with one dose, in September: AOR = .48, p = .029)). Our findings suggest that whilst unlikely to impede the overall effectiveness of public health campaigns, risk compensation nonetheless merits attention when designing informed, targeted public health messages and policy.

Full text

Does vaccination elicit risk compensation? Insights from the
COVID-19 pandemic in France
Kathleen McColl
a,b
, Dylan Martin-Lapoirie
a,b
, Giuseppe A. Veltri
c
, Pierre Arwidson
d
and Jocelyn Raude
a,b
a
French School of Public Health, École des Hautes Études en Santé Publique (EHESP), Rennes, France;
b
UMR
ARENES –Équipe de Recherche sur les Services et le Management en Santé, Univ Rennes, EHESP, CNRS 6051,
INSERM 1309, Rennes, France;
c
Dipartimento di Sociologia e Ricerca Sociale, Università di Trento, Trento,
Italy;
d
Direction de la prévention de la santé, Santé Publique France, Saint-Maurice, France
ABSTRACT
Vaccination has played a key role in reducing the health burden of
COVID-19, however, concern has been raised worldwide regarding
risk compensation, a process whereby feelings of security arising
from being vaccinated may lead people to reduce their
engagement in other protective behaviours.
We investigated whether vaccination led to risk compensation
and whether this changed over time by conducting a repeated
cross-sectional study at seven intervals over the initial months
(February to September 2021) of the vaccine rollout in France.
Participants (N = 14,003) completed an online survey measuring
vaccination status, vaccination intention and engagement in four
preventive behaviours: mask wearing, avoidance of physical
contact, hand hygiene, and avoiding social gatherings. Risk
compensation was measured indirectly by comparing levels of
engagement in protective behaviours according to vaccination
status, with those unvaccinated but intending to vaccinate
serving as a baseline.
Risk compensation did not occur systematically and was mostly
observed towards the end of the vaccine rollout for two of the four
protective behaviours: avoiding social gatherings (in July and
September for fully-vaccinated participants (Adjusted Odds Ratio
(AOR) = .72, p= .045; AOR = .54, p= .022, respectively) and wearing
a mask (those vaccinated with one dose, in September: AOR = .48,
p= .029)). Our findings suggest that whilst unlikely to impede the
overall effectiveness of public health campaigns, risk
compensation nonetheless merits attention when designing
informed, targeted public health messages and policy.
ARTICLE HISTORY
Received 14 October 2022
Accepted 15 November 2023
KEYWORDS
Risk compensation; COVID-
19; vaccination; protective
behaviour; France
© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s)
or with their consent.
CONTACT Kathleen McColl kathleen.mccoll@eleve.ehesp.fr French School of Public Health, École des Hautes
Études en Santé Publique (EHESP), 15 Avenue du Professeur Léon Bernard, CS 74312, Rennes 35043, France
Supplemental data for this article can be accessed http://doi.org/10.1080/21642850.2023.2287663.
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE
2024, VOL. 12, NO. 1, 2287663
https://doi.org/10.1080/21642850.2023.2287663

Introduction
Vaccination has been heralded as a major breakthrough in combatting the spread and
health consequences of COVID-19 (World Health Organisation (WHO), 2021,2022).
However, concerns have been raised that the vaccination campaign may instil in
people a sense of security, leading them to reduce or abandon other preventive measures
crucial in fighting the disease (Trogen & Caplan, 2021; WHO, 2020; European Centre for
Disease Control (ECDC), 2021b). This is referred to as risk compensation, whereby
engagement in one protective behaviour generates a perception of reduced risk and
results in compensatory risky behaviour (Brewer et al., 2007). The current research there-
fore sought to investigate whether COVID-19 vaccination resulted in risk compensation,
and whether this changed over time, during the initial stages of the vaccine rollout in
France. Understanding whether vaccination elicits risk compensation is important not
only to the management of future waves of the current pandemic, but also to that of
those to come.
Background
First proposed by Peltzman (1975) in response to increased numbers of road accidents
following the introduction of mandatory seat belt use in the US, risk compensation has
since attracted research attention, with varied findings (Mantzari et al., 2020; Pless,
2016), in various health domains, such as bike (Esmaeilikia et al., 2019; Messiah
et al., 2012)andsnowsporthelmetwearing(Haideretal.,2012), HIV prevention
(Cassell et al., 2006; Eaton & Kalichman, 2007; Underhill, 2013), vaccination
against HPV (Kasting et al., 2016;Mayhewetal.,2014) and Lyme disease (Brewer
et al., 2007). Previous studies of more chronic health issues suggest that although unli-
kely to negate the overall benefit of a public health campaign, risk compensation may
nonetheless lead people to lessen their commitment to other protective behaviours
(eg. Cassell et al., 2006; Kacelnik & Kacelnik, 2022), critical in reducing disease
spread (Bottemanne & Friston, 2021; Kassa & Ouhinou, 2015). This is of particular
relevance when combatting the spread of COVID-19, which involves adherence to
multiple protective measures.
Over the last decades, empirical investigations of risk compensation have presented
contradictory evidence (Mantzari et al., 2020), attributable perhaps in part to varying
definitions. Risk compensation, the Peltzman effect (Peltzman, 1975), risk homeostasis
(Wilde, 1998), ‘risk thermostat’(Kacelnik & Kacelnik, 2022, p. 2), moral licensing,
rebound (Mantzari et al., 2020) and negative spillover effect (Nilsson et al., 2017; Thøger-
sen & Crompton, 2009) are often used interchangeably in the literature, but yet have
different significations. For instance, drawing from the economic and environmental lit-
erature, Jia et al. (2022), refer to the Peltzman Effect as being a negative or compensatory
‘behavioural spillover effect’(Jia et al., 2022, p. 11). Brewer et al. (2007) and Wilde (1998),
on the other hand, view risk compensation as resulting from a need to restore a certain
‘optimal’level of perceived risk. They propose that ‘[. . .] people have stable preferences
for a certain amount of risk and that the feeling of safety created by the initial preventive
activity creates a surplus of risk that will be expended elsewhere by reducing protective
actions’(Brewer et al., 2007, p. 95), whereas other researchers, including ourselves,
2K. MCCOLL ET AL.

understand risk compensation as occurring when engagement in one protective behav-
iour leads to a reduction in others targeting the same goal (eg. Hedlund, 2000; Jørgensen
et al., 2021).
According to Hedlund (2000), risk compensation occurs when four elements are
present: visibility, efficacy, motivation and control. Firstly, the intervention must be
noticeable- this was true of COVID-19 vaccination at this time, as health passes attesting
to an up-to-date COVID-19 vaccination schedule were constantly required to be shown,
either in paper format or using a ‘phone app, to gain entry to public venues. Secondly,
people must believe in the efficacy of the intervention. With vaccines in France at this
time reported to be between 80-95% effective (Thompson et al., 2021), this criterion is
also met. Thirdly, vaccination motivation was present, particularly due not only to the
perceived health threat, but also to the social benefit induced by the introduction of a
mandatory health pass to gain access to public venues. Finally, with increased vaccine
availability as the rollout progressed, improved access to vaccination afforded people a
high level of control over when and where they could be vaccinated, thereby satisfying
the final criterion. It is therefore clear that the COVID-19 pandemic provides a setting
in which risk compensation might thrive.
Whilst research into risk compensation and COVID-19 to date has focused largely on
the effect of mask wearing on other preventive measures (eg. Aranguren, 2022; Jørgensen
et al., 2021; Luckman et al., 2021), there is a relative lack of studies in Europe investi-
gating whether vaccination elicits risk compensation. From outside Europe, neither a
three-wave, longitudinal investigation in the US (Thorpe et al., 2022) nor a two-wave
repeated cross-sectional Canadian study (Hall et al., 2022) found evidence of risk com-
pensation following vaccination. Instead, vaccinated participants maintained other pro-
tective behaviours. The current research therefore addresses a gap in the literature by
exploring whether, during the initial vaccine rollout in France, vaccination against
COVID-19 led people to reduce their engagement in four protective behaviours: mask
wearing, hand hygiene, avoidance of social gatherings and avoiding physical contact in
social settings. Conducted monthly over the first seven months of the French vaccine
campaign, the current research investigated how risk compensation evolved over time,
providing important insights that may impact future public health messages and
policy during an unfolding epidemic.
Mask wearing and risk compensation
Given the relative dearth of research into COVID-19 vaccination and risk compensation
at the time of writing, investigations of the impact of mask wearing on subsequent pro-
tective measures provide important contextual insights for our research. Despite misgiv-
ings that mask wearing may lead to a reduction in other protective measures (ECDC,
2020; Martin et al., 2020; WHO, 2020), this is not consistently supported in the research
literature. For instance, whereas neither Blanken et al. (2021) nor Liebst et al.’s(2022)
observational study in the Netherlands found evidence risk compensation towards phys-
ical distancing as a result of mask wearing, Seres et al. (2020) and Marchiori (2020) found
it led to increased social distancing in Germany and Italy respectively.
Contrastingly, using a quasi-experimental, online self-report survey, Jørgensen et al.
(2021) observed limited risk compensation towards physical distancing, but not
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE 3

towards hand hygiene or number of physical contacts, following the introduction of
mandated mask wearing in Denmark. Similar findings were reported by Luckman
et al. (2021) in their online simulation in the UK, when either participant or stranger,
or both, wore a mask. A further online simulation in France also found reduced physical
distancing among virtual mask wearers, particularly those in low-risk areas and alar-
mingly, those testing positive to COVID-19 (Cartaud et al., 2020). Comparable results
were obtained among German participants in a virtual supermarket simulation in
which physical distancing was not respected among mask-wearers, particularly when
effortful (Kroczek et al., 2022). In an observational field experiment in France, Aranguren
(2022) also found support for risk compensation towards physical distancing among
mask-wearers, particularly men. Finally, risk compensation was observed towards stay-
at-home orders, as measured by mobile location data, following mask mandates in the
US (Yan et al., 2021).
Risk compensation & vaccination
Such evidence in support of risk compensation highlights the need to understand
whether it is also elicited by vaccination, and how this may change over time,
however research in this area at the time of writing remains scant. Buckell et al.
(2021), using a repeated, cross-sectional design in the UK, found that overall, phys-
ical distancing, public transport usage, avoidance of social gatherings, working at
home and avoiding physical contact were unaffected by vaccination. However,
when adjusted for mandated policies, protective behaviours changed according to
general population vaccination rates, providing support for limited risk compen-
sation at the population, rather than individual level, across all four countries:
England, Scotland, Wales and Northern Ireland, despite different mandate timing
in each country. In a national, three-stage study of the US vaccine rollout, Jia
et al. (2022) also found evidence of risk compensation over time towards all
forms of preventive behaviours, particularly social distancing, following the first
vaccine dose. Contrastingly, Sun et al. (2022) found no evidence of risk compen-
sation in an online study of healthcare workers in China, except for the type of
gloves used. Rather, the frequency and duration of hand washing and wearing
gloves and masks increased among vaccinated healthcare workers, especially
those vaccinated early in the campaign. Similarly,intwoseparate,longitudinal
studies in the UK, Desrichard et al. (2022)andWrightetal.(2022)observedno
risk compensatory behaviour following vaccination, finding instead that partici-
pantsweremoreinclinedtoincreasepreventivemeasures,withtheexceptionof
social distancing (although not systematically, Wright et al., 2022) and avoidance
of crowded spaces (Desrichard et al., 2022). Desrichard and his colleagues observed
this after both first and second vaccine doses.
Whilst not specifically measuring risk compensation, researchers concluded that
reduced vaccine efficacy alone could not account for the resurgence of COVID-19
cases in Qatar (Tang et al., 2021) and India (eg. Iyengar et al., 2021; Jain et al., 2021;
Juyal et al., 2021; Kamath & Nivea, 2021; Parikh et al., 2021; Thankappan & Nedumpillil,
2021), and that despite a successful vaccination campaign, human behaviour, through
risk compensation, must have been partly to blame.
4K. MCCOLL ET AL.

Implications for management
Given that several studies suggest that mask wearing may lead to a reduction in other
COVID-19 preventive behaviours, also instrumental in reducing disease spread and
overall health burden, it is somewhat surprising that few empirical studies to date
have sought to investigate whether COVID-19 vaccination also elicits risk compensation,
and whether this changes over time. The hitherto contrasting findings suggest that more
is to be gleaned in the area of risk compensation, and it is hoped that the current study
will not only shed light on this topic, but also that the insights gained will help target
health messages and inform public policy during the unfolding epidemic, as well as
prepare for those to come.
Methods
Data
Cross-sectional data were collected via seven online surveys conducted monthly, from
February through to September 2021, during the initial vaccine rollout in France. Partici-
pants (N = 14,003) were French residents aged between 18 and 99 years of age. A stra-
tified sampling method was used so that the sample was representative of the French
population on age, sex, education, socio-economic status, occupation and region of resi-
dence, according to the 2016 National Institute of Statistics and Economic Studies census
(INSEE, 2017). The sample size for each survey wave was approximately 2,000. This
sample size was chosen in order to obtain a maximum margin of error plus or minus
two percentage points, with a 95% confidence interval for the behavioural measures.
The study was conducted in compliance with the French national guidelines for
ethical research in the social and human sciences. The research was declared to the
EHESP School of Public Health Office for Personal Data Protection (Rennes, France)
[Reference: MR 2510110520], and approved by the ethics committee of the University
Hospital Institute, Méditerranée Infection (Marseille France) [Decision No. 2020-022].
Informed consent was obtained from participants.
The first data collection wave took place following the introduction of a national
curfew, regional weekend lockdowns, and first dose vaccination for people who
were immunocompromised or over 75 years of age. During the second wave of
data collection in March 2021, nineteen departments went into their third lockdown
and by 3 April, this extended to all metropolitan France. Phases 1 and 2 of deconfine-
ment began in early May, as Wave 4 of the surveys was conducted, and as vaccination
opened up for people 50 + years and those aged 18–50 with comorbidities. The final
stage (Phase 3) of deconfinement occurred in June, as participants responded to
Wave 5 surveys, and first dose vaccination was extended to everyone over 18 years.
Following the introduction in July of a mandatory health pass to gain access to cul-
tural and leisure facilities, and its extension in August to public venues such as restau-
rants, cinemas, bars, gyms and swimming pools, as well as to their employees, the
final wave of surveys (Wave 7) was undertaken. This September survey coincided
with 80% of the population aged 12 and above’s having received their first dose of
the vaccine (INSEE, 2021; Statsista, 2022). For an outline of vaccination rollout and
mandatory measures, see Figure 1.
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE 5

Measures
Self-report measures were used to ascertain engagement in protective behaviour, vac-
cination status and intention, as well as health, sociocultural and demographic charac-
teristics. The latter included questions regarding sex (male/female), age, secondary
school completion (yes/no), socioeconomic status (high/low), financial situation
(good/bad), housing overcrowding (yes/no), as well as whether they suffered from
chronic illness (yes/no) or had experienced COVID-like symptoms (yes/no). Partici-
pants also reported whether they had been vaccinated, how many doses they had
received and, for the unvaccinated, whether they intended to be vaccinated. In
addition, they were asked whether they engaged in four protective behaviours:
wearing a mask, observing hand hygiene, avoiding physical contact and avoiding
social gatherings. For a complete list of questions regarding behaviour and possible
responses, see Table 1. Behavioural frequency responses were dichotomised, with
‘Yes, systematically’coded as 1 and ‘Yes, often’,‘Yes, sometimes’and ‘No, never’as
0. This coding was adopted, grouping together the last three conditions, due there
being a ceiling effect (Raude et al., 2020), as illustrated in Figure 2. Risk compensation
was measured indirectly by comparing levels of engagement in protective behaviours
Figure 1. Vaccine rollout and mandated measures in France.
6K. MCCOLL ET AL.

Table 1. Behaviour survey questions and responses.
Behaviour Question Response
Over the past few days have you adopted the
following protective measures?
Wear a mask - Wearing a mask in public Yes, systematically Yes, often Yes, sometimes No, never
Avoid social gatherings - Avoiding face-to-face gatherings and meetings with
people who don’t live with you/ in the same
household as you (family or social gatherings, drinks
or discussions with neighbours)
Yes, systematically Yes, often Yes, sometimes No, never
Avoid physical contact - Greeting people without shaking hands and avoiding
hugging and kissing people not from your
household
Yes, systematically Yes, often Yes, sometimes No, never
Hand hygiene - Washing your hands very regularly with soap or
using hand sanitiser
Yes, systematically Yes, often Yes, sometimes No, never
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE 7

according to vaccination status. The behaviour of unvaccinated participants who
intended to be vaccinated served as the baseline. Risk compensation was considered
to be present when there was a reduction in behaviours in those vaccinated, as com-
pared with those unvaccinated but intending to vaccinate.
Data analysis
A series of binary logistic analyses was performed to analyse the data, with preventive
behaviour as the dependent variable. Odds ratios by vaccination status were calculated
and then adjusted, controlling for age, sex and chronic health conditions, variables pre-
viously and consistently found to affect behavioural response (eg. Alleaume et al., 2021;
Papageorge et al., 2021; Tang et al., 2021), to produce adjusted scores. Significant
weighted odds ratio scores less than one were considered to be evidence of risk compen-
sation in those who had received one or two vaccine doses.
Results
As illustrated in Figure 3, the curve representing people having received one or two doses
of the vaccine progresses in inverse proportion to those intending to be vaccinated. Infor-
mation regarding vaccination status, age group, risk factors (chronic illness) and socio-
demographic characteristics of participants at each of the seven survey waves is presented
in Table 2. As explained earlier, risk compensation was measured indirectly by compar-
ing protective behavioural engagement among vaccinated participants (1 or 2 doses) with
those unvaccinated but intending to do so. It was hypothesised that there was evidence of
risk compensation when vaccinated participants demonstrated a significant reduction in
behavioural engagement, as compared with the unvaccinated-but-intending-to-vaccinate
Figure 2. Distribution of protective behaviours according to initial coding.
8K. MCCOLL ET AL.

group (Hedlund, 2000; Jørgensen et al., 2021). Levels of engagement in the four different
protective behaviours over time according to vaccination status were therefore measured
and are presented in Figure 4. As can be seen in the graphs of behavioural engagement in
each of the four protective behaviours according to vaccination status at different stages
over the seven-month period, following an initial rise in behavioural protection, frequen-
cies thereof decreased towards the end of the measurement period. Although vaccinated
participants appear to reduce their engagement in preventive behaviours, we are unable
to tell whether this reduction is due to vaccination status. Logistic odds ratios and
adjusted odds ratios (AOR) were therefore calculated and are presented in Table 3.
Overall, reduced engagement in protective behaviours among those fully vacci-
nated, as compared with those intending to do so, occurred neither systematically
nor consistently but was nonetheless observed occasionally, particularly towards the
end of the survey period, in Wave Six and Wave Seven (See Table 3). Interestingly,
comparatively reduced behavioural engagement was observed in February, among
those who had received two vaccine doses (and were considered fully vaccinated at
this time (ECDC, 2021a)), for two behaviours: wearing a mask in public (AOR
= .22 (95% CI[.10,.50], p< .001)) and avoiding physical contact (shaking hands,
hugging etc.) (AOR = .23 (95% CI[.10,.50], p. < 001)). It should be noted that partici-
pants having received a single Janssen dose were considered fully vaccinated (Centres
for Disease Control and Prevention (CDC), 2022) and were therefore included in the
fully-vaccinated (2-dose) group. To the extent that the Johnson & Johnson Janssen
vaccine represented less than 1% of the national vaccination figures to the end of
June, 2021 (Santé Publique, 2022), this concerned very few of the survey respondents.
Curiously, an increase in protective behaviours among fully-vaccinated participants
occurred in March towards avoiding social gatherings (AOR = 1.70 (95% CI
[1.06,2.73], p= .029)) and in May towards hand hygiene (AOR = 1.47 (95% CI
[1.07,2.00], p= .016)). As compared with the unvaccinated-but-intending-to vaccinate
Figure 3. Vaccination status during the vaccine rollout in France, February –September, 2021.
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE 9

Table 2. Participant vaccination status according to age, risk factors (chronic illness), socio-demographic characteristics and survey wave (February –September,
2021).
Survey date 16 February (N = 2,000) 17 March (N = 2,001) 23 April (N = 2,001) 19 May (N = 2,000)
Vaccination
status 1 dose 2 doses Intention
No
intention 1 dose 2 doses Intention
No
intention 1 dose 2 doses Intention
No
intention 1 dose 2 doses Intention
No
intention
Sex
Female 1.5% (16) 1.8% (19) 51.9% (551) 44.8% (476) 3.3% (35) 6.6% (71) 47.5% (510) 42.6% (457) 7.5% (81) 17.4% (189) 39.0% (423) 36.1% (392) 18.4% (202) 22.8% (250) 30.6% (336) 28.2% (309)
Male 1.5% (14) 2.7% (25) 60.1% (564) 35.7% (335) 5.2% (48) 7.8% (72) 52.9% (491) 34.2% (317) 12.5% (114) 21.9% (201) 40.4% (370) 25.2% (231) 24.3% (219) 32.9% (297) 24.8% (224) 18.1% (163)
Age
18-24 2.4% (4) .6% (1) 34.1% (56) 62.8% (103) 2.9% (5) .6% (1) 35.9% (61) 60.6% (103) 2.6% (4) 3.2% (5) 53.2% (82) 40.9% (63) 2.6% (4) 13.1% (20) 49% (75) 35.3% (54)
25-34 .7% (2) 1.4% (4) 38.9% (112) 59% (170) 1.4% (4) 1.4% (4) 37.7% (104) 59.4% (164) 5.5% (17) 6.5% (20) 37.4% (116) 50.6% (157) 8.2% (22) 13.4% (36) 43.7% (117) 34.7% (93)
35-49 .8%(4) 1.1% (6) 52.6% (279) 45.5% (241) 1.1% (6) 2.7% (14) 52.5% (276) 43.7% (230) 4% (21) 6.6% (35) 51% (270) 38.4% (203) 11.8% (64) 21.3% (116) 35.8% (195) 31.1% (169)
50-64 2.3% (12) 1.3% (7) 59.7% (312) 36.7% (192) 5.3% (28) 8.5% (45) 49.4% (262) 36.8% (195) 6.8% (35) 22.7% (117) 43.6% (225) 26.9% (139) 17.9% (98) 35.7% (196) 24.2% (133) 22.2% (122)
65+ 1.6% (8) 5.3% (26) 72% (356) 21.2% (105) 8.0% (40) 15.8% (79) 59.7% (298) 16.4% (82) 24% (118) 43.3% (213) 20.3% (100) 12.4% (61) 47.9% (233) 36.8% (179) 8.2% (40) 7% (34)
Chronic disease
No 1.2% (15) 1.6% (19) 52.3% (632) 44.9% (543) 3.4% (43) 4.3% (54) 48.7% (615) 43.6% (551) 6% (73) 15.5% (187) 43.1% (521) 35.4% (428) 15% (186) 26.5% (328) 32.5% (403) 26% (323)
Yes 1.9% (15) 3.2% (25) 61% (483) 33.9% (268) 5.4% (40) 12.1% (89) 52.3% (386) 30.2% (223) 15.4% (122) 25.6% (203) 34.3% (272) 24.6% (195) 30.9% (235) 28.8% (219) 20.7% (157) 19.6% (149)
History of COVID-like symptoms
Yes 2.2% (8) 1.3% (5) 56.6% (210) 39.9% (148) 2.2% (8) 5.0% (18) 47.5% (170) 45.3% (162) 4.7% (19) 14.8% (60) 44.0% (178) 36.5% (148) 15.9% (65) 22.1% (90) 36.8% (150) 25.3% (103)
No 1.4% (22) 2.4% (39) 55.6% (905) 40.7% (663) 4.6% (75) 7.6% (125) 50.6% (831) 37.3% (612) 11.0% (176) 20.7% (330) 38.5% (615) 29.8% (475) 22.4% (356) 28.7% (457) 25.8% (410) 23.2% (369)
Completed secondary school
Yes 1.6% (22) 2.6% (36) 57.1% (806) 38.8% (547) 4.6% (65) 6.9% (97) 51.6% (728) 37.0% (522) 10.6% (150) 19.3% (275) 41.2% (586) 28.9% (411) 21.1% (304) 27.3% (393) 29.1% (419) 22.5% (324)
No 1.4% (8) 1.4% (8) 52.5% (309) 44.8% (264) 3.1% (18) 7.8% (46) 46.35% (273) 42.8% (252) 7.8% (45) 19.9% (115) 35.8% (207) 36.6% (212) 20.9% (117) 27.5% (154) 25.2% (141) 26.4% (148)
Socioeconomic status
High 1.2% (3) .4% (1) 43.7% (108) 54.7% (135) 2.6% (6) 1.8% (4) 45.2% (103) 50.4% (115) 2.0% (5) 5.3% (13) 46.7% (114) 45.9% (112) 9.9% (25) 16.3% (41) 38.9% (98) 34.9% (88)
Low .7% (6) 1.2% (10) 49.2% (409) 48.9% (407) 2.5% (21) 6.3% (53) 45.3% (380) 45.8% (384) 5.1% (40) 15.5% (122) 40.0% (315) 39.5% (311) 15.6% (119) 24.5% (187) 30.2% (230) 29.7% (226)
Inactive 2.3% (21) 3.6% (33) 64.9% (598) 29.2% (269) 6.0% (56) 9.2% (86) 55.4% (518) 29.4% (275) 15.5% (150) 26.3% (255) 37.6% (364) 20.6% (200) 28.1% (277) 32.4% (319) 23.5% (232) 16.0% (158)
Survey date 28 June (N = 2,000) 21 July (N = 2,000) 7 September (N = 2,001)
Vaccination
status 1 dose 2 doses Intention
No
intention 1 dose 2 doses Intention
No
intention 1 dose 2 doses Intention
No
intention
Sex
Female 36.6% (398) 23.7% (258) 14.2% (154) 25.6% (278) 57.7% (634) 13.8% (152) 11.6% (127) 16.9% (185) 75.0% (817) 6.1% (66) 3.7% (40) 15.2% (166)
Male 42.3% (386) 26.2% (239) 12.5% (114) 19.0% (173) 64.2% (579) 11.5% (104) 9.5% (86) 14.8% (133) 80.3% (732) 7.4% (67) 2.5% (23) 9.9% (90)
Age
18-24 10.1% (17) 33.7% (57) 23.7% (40) 32.5% (55) 37.4% (55) 22.4% (33) 16.3% (24) 23.8% (35) 67.8% (141) 11.1% (23) 8.7% (18) 12.5% (26)
25-34 15.5% (51) 27.1% (89) 18.3% (60) 39% (128) 40.7% (121) 18.9% (56) 16.5% (49) 23.9% (71) 61.5% (163) 13.2% (35) 4.2% (11) 21.1% (56)
35-49 25.3% (137) 29.9% (162) 18.9% (102) 25.9% (140) 49.5% (278) 18.7% (105) 12.6% (71) 19.2% (108) 74.3% (401) 8.7% (47) 3.1% (17) 13.9% (75)
50-64 49.4% (266) 24.1% (130) 9.3% (50) 17.1% (92) 72.4% (402) 7.2% (40) 8.1% (45) 12.3% (68) 83% (433) 4% (21) 2.1% (11) 10.9% (57)
65+ 73.8% (313) 13.9% (59) 3.8% (16) 8.5% (36) 81.3% (357) 5% (22) 5.5% (24) 8.2% (36) 88.2% (411) 1.5% (7) 1.3% (6) 9% (42)
10 K. MCCOLL ET AL.

Chronic disease
No 30.2% (342) 28.6% (324) 15.6% (177) 25.6% (290) 56.6% (633) 14.2% (159) 12.4% (139) 16.8% (188) 74.6% (851) 6.9% (79) 4.3% (49) 14.2% (162)
Yes 51% (442) 20% (173) 10.5% (91) 18.6% (161) 65.8% (580) 11% (97) 8.4% (74) 14.8% (130) 81.2% (698) 6.3% (54) 1.6% (14) 10.9% (94)
History of COVID-like symptoms
Yes 34.5% (140) 20.4% (83) 21.9% (89) 23.2% (94) 52.5% (232) 15.4% (68) 13.6% (60) 18.6% (82) 75.6% (303) 9.0% (36) 5.2% (21) 10.2% (41)
No 40.4% (644) 26.0% (414) 11.2% (179) 22.4% (357) 63.0% (981) 12.1% (188) 9.8% (153) 15.2% (236) 77.9% (1,246) 6.1% (97) 2.6% (42) 13.4% (215)
Completed secondary school
Yes 40.3% (568) 25.0% (353) 13.0% (183) 21.7% (306) 61.8% (885) 13.3% (191) 9.8% (141) 15.1% (216) 79.4% (1,099) 5.9% (82) 3.4% (47) 11.3% (157)
No 36.6% (216) 24.4% (144) 14.4% (85) 24.6% (145) 57.9% (328) 11.5% (65) 12.7% (72) 18.0% (102) 73.1% (450) 8.3% (51) 2.6% (16) 16.1% (99)
Socioeconomic status
High 18.5% (46) 27.7% (69) 20.5% (51) 33.3% (83) 38.8% (92) 21.5% (51) 13.9% (33) 25.7% (61) 69.3% (169) 9.4% (23) 6.1% (15) 15.2% (37)
Low 32.7% (265) 25.9% (210) 14.8% (120) 26.6% (216) 52.7% (433) 14.5% (119) 13.7% (113) 19.1% (157) 72.4% (585) 7.7% (62) 3.1% (25) 16.8% (136)
Inactive 50.3% (473) 23.2% (218) 10.3% (97) 16.2% (152) 73.1% (688) 9.1% (86) 7.1% (67) 10.6% (100) 83.8% (795) 5.1% (48) 2.4% (23) 8.7% (83)
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE 11

group, a decrease in frequency of adoption of protective measures was found towards
the end of the vaccine rollout for two of the four protective behaviours: avoiding
social gatherings in July (AOR = .72 (95% CI[.53,.99], p= .045)) and September
(AOR = .54 (95% CI[.32,.91], p= .022)) among fully-vaccinated participants, and
wearing a mask in September (AOR = .48 (95% CI[.25,.93], p= .029)) for those vacci-
nated with one dose.
From these results, it appears that fully-vaccinated participants reported being less
likely to avoid social gatherings in July than the intending-to-vaccinate group. This
trend was observed again in September. Similarly, in September, participants vaccinated
with one dose reported wearing masks less frequently than the intending-to-vaccinate
group. No such significant differential engagement in protective behaviour between
the vaccinated and intending-to-vaccinate groups was observed towards hand hygiene
or avoidance of physical contact at this stage.
Discussion
Overview
Consistent with an indirect measurement of risk compensation, through a comparison of
behavioural engagement according to vaccination status, our results were suggestive of
risk compensation when vaccinated participants demonstrated a reduction in protective
measures, as compared with the baseline behaviour of those who were unvaccinated but
intended to do so (Hedlund, 2000; Jørgensen et al., 2021). Overall, it would appear from
our findings that from time to time, vaccinated participants adhered less frequently to
protective behaviours than the baseline group, towards specific behaviours and with
greater frequency towards the end of the survey period, which coincided with the final
stages of the vaccination campaign in France.
Figure 4. Engagement in protective behaviours according to vaccination status.
12 K. MCCOLL ET AL.

Table 3. Odds ratios of protective behaviour according to vaccination status.
Survey date Vaccination status
Wear a mask in public Avoid social gatherings Hand Hygiene Avoid physical contact
Non-adjusted Adjusted Non-adjusted Adjusted Non-adjusted Adjusted Non-adjusted Adjusted
16 Feb (N = 2,000) Vaccinated with 2 doses .26*** [.12,.58] .22*** [.10,.50] .67 [.32,1.39] .68 [.32,1.44] .57 [.27,1.18] .53 [.25,1.14] .23*** [.11,.50] .23*** [.10,.50]
Vaccinated with 1 dose .58 [.25,1.34] .56 [.24,1.32] 1.88* [.99,3.58] 1.76* [.91,3.40] .93 [.49,1.77] .97 [.50,1.89] .70 [.32,1.55] .60 [.26,1.36]
No intention to vaccinate .35*** [.27,.45] .34*** [.26,.45] .55*** [.45,.66] .63*** [.52,.77] .62*** [.51,.74] .62*** [.51,.76] .32*** [.25,.40] .36*** [.29,.46]
17 March (N =2,001) Vaccinated with 2 doses .69 [.35,1.39] .66 [.33,1.34] 1.86*** [1.18,2.96] 1.70** [1.06,2.73] 1.02 [.63,1.65] 1.02 [.62,1.68] .87 [.48,1.56] .78 [.43,1.42]
Vaccinated with 1 dose .71 [.41,1.23] .62 [.35,1.10] 1.19 [.84,1.69] .96 [.67,1.37] 1.24 [.84,1.83] 1.13 [.75,1.69] 1.05 [.65,1.71] .86 [.52,1.41]
No intention to vaccinate .26*** [.20,.34] .26*** [.20,.35] .62*** [.51,.75] .73*** [.60,.90] .69*** [.57,.84] .73*** [.59,.89] .32*** [.26,.40] .37*** [.29,.47]
23 April (N = 2,001) Vaccinated with 2 doses .90 [.56,1.42] .75 [.46,1.24] 1.26 [.92,1.74] 1.07 [.76,1.51] 1.31 [.92,1.85] 1.20 [.83,1.75] 1.64* [.99,2.70] 1.13 [.67,1.93]
Vaccinated with 1 dose 1.06 [.72,1.54] .84 [.56,1.27] 1.03 [.81,1.32] .82 [.63,1.08] 1.08 [.84,1.41] .94 [.70,1.25] 1.09 [.78,1.54] .69* [.48,1.01]
No intention to vaccinate .37*** [.28,.49] .36*** [.27,.47] .54*** [.43,.66] .57*** [.46,.71] .71*** [.57,.89] .71*** [.57,.89] .33*** [.26,.43] .34*** [.26,.44]
19 May (N = 2,000) Vaccinated with 2 doses 1.86*** [1.23,2.80] 1.54* [.99,2.41] 1.43*** [1.11,1.84] 1.03 [.77,1.37] 1.54*** [1.17,2.03] 1.47** [1.07,2.00] 2.01*** [1.47,2.74] 1.28 [.90,1.81]
Vaccinated with 1 dose 1 [.72,1.39] .92 [.65,1.31] 1. [.98,1.58] .97 [.75,1.25] 1.09 [.85,1.39] 1.06 [.81,1.38] 1.79*** [1.36,2.37] 1.32* [.98,1.79]
No intention to vaccinate .40*** [.30,.55] .37*** [.27,.51] .72** [.56,.93] .69*** [.53,.89] .62*** [.49,.80] .58*** [.45,.75] .62*** [.48,.80] .57*** [.44,.75]
28 June (N = 2,000) Vaccinated with 2 doses 1.57*** [1.15,2.14] 1.38* [.99,1.94] 1.23 [.92,1.64] .94 [.69,1.28] 1.10 [.82,1.46] 1.07 [.78,1.47] 1.58*** [1.17,2.12] 1.17 [.85,1.62]
Vaccinated with 1 dose 1.19 [.86,1.66] 1.18 [.84,1.64] 1.07 [.79,1.46] 1.01 [.73,1.38] .95 [.70,1.30] .96 [.70,1.31] 1.33* [.97,1.83] 1.27 [.92,1.75]
No intention to vaccinate .62*** [.45,.86] .59*** [.43,.82] .73* [.53,1] .72** [.52,1] .70** [.52,.96] .67** [.49,.93] .70** [.51,.95] .67** [.49,.92]
21 July (N = 2,000) Vaccinated with 2 doses 1.11 [.81,1.53] .97 [.70,1.35] .89 [.65,1.21] .72** [.53,.99] 1.11 [.82,1.50] 1.03 [.75,1.40] 1.49*** [1.11,2.01] 1.23 [.91,1.68]
Vaccinated with 1 dose 1.13 [.76,1.68] 1.17 [.78,1.75] 1.01 [.69,1.48] 1.05 [.71,1.54] 1.14 [.79,1.66] 1.18 [.80,1.73] .98 [.68,1.42] 1.02 [.70,1.48]
No intention to vaccinate .74 [.51,1.06] .74 [.51,1.07] .78 [.54,1.13] .78 [.54,1.13] .78 [.55,1.11] .79 [.55,1.13] .87 [.61,1.23] .86 [.60,1.23]
7 Sept (N = 2,001) Vaccinated with 2 doses 1.03 [.60,1.79] .85 [.48,1.50] .65 [.39,1.09] .54** [.32,.91] 1.07 [.64,1.79] .91 [.54,1.55] 1.17 [.70,1.95] .91 [.53,1.54]
Vaccinated with 1 dose .48** [.25,.91] .48** [.25,.93] .55* [.30,1.03] .54* [.29,1.02] .63 [.34,1.16] .65 [.35,1.22] .64 [.35,1.16] .65 [.35,1.21]
No intention to vaccinate .65 [.36,1.18] .54** [.29,.99] .62* [.35,1.08] .54** [.30,.95] .80 [.46,1.39] .66 [.37,1.17] .84 [.48,1.46] .68 [.38,1.21]
Note: Odds ratio [95% confidence interval] in binary logistic regressions. Intention to be vaccinated served as reference. Adjusted regressions included control variables: age categories (18-24 as reference)
25–34 (yes = 1; no = 0), 35–49 (yes = 1; no = 0), 50–64 (yes = 1; no = 0), 65+ (yes = 1; no = 0); gender (female = 1; male = 0); and suffering from a chronic disease (yes = 1; no = 0). ***p< .01,**p< .05,
*p< .1.
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE 13

According to the afore-mentioned definition, it would therefore seem that there was
somewhat limited evidence of risk compensation during the 2021 COVID-19 vaccination
campaign in France, particularly towards the end of the vaccine rollout towards two pro-
tective behaviours: avoiding social gatherings (in July and September for fully-vaccinated
participants) and wearing a face mask (in September for people vaccinated with
one dose). Indeed, of relevance from a public health perspective, it appears that fully-vac-
cinated participants avoided social gatherings less often in July than those intending to
vaccinate, and this trend in lack of social gathering avoidance was repeated again in Sep-
tember. A similar trend was observed in September among participants vaccinated with
one dose who reported wearing a mask less often than their intending-to-vaccinate
counterparts. Whilst perhaps not representing a threat to the expected efficacy of the vac-
cination campaign (Buckell et al., 2021), such evidence of risk compensation, and indeed,
decreasing levels of adherence to a particular protective behaviour among a specific
group, during the late stages of the vaccine rollout nevertheless merits attention, as
any reduction in behavioural preventive vigilance may result in subsequent propagation
of the virus (Youssef et al., 2022).
Observed episodic behaviours
Although reduced levels of protective engagement indicative of risk compensation were
observed in fully-vaccinated participants towards mask wearing and avoiding physical
contact at the outset of the vaccine rollout, this concerned very few participants (n =
21/30), due in part to limited vaccine availability and at the time, vaccination’s being
restricted to people who were immunocompromised or over the age of 85. The increased
engagement in avoiding social gatherings in March among fully-vaccinated participants,
as compared with those intending to be vaccinated, coincided with the introduction of
regional lockdowns and curfews. At this stage, in March, vaccination was open to
people over 75 and those 50–74 with a pre-existing medical condition. It is possible
that this vulnerable population, in the context of regional lockdowns and curfews, may
have preferred to avoid social gatherings so as not to come into contact with the
rather large unvaccinated population. This increased avoidance of social gatherings
may perhaps also be explained by differential risk reappraisal by these two groups.
According to the theory of risk reappraisal, when faced with a health risk, an individual
may adopt protective measures and, as a result of these protective actions, perceptions of
risk are reduced which may, in turn, lead to a subsequent reduction in behavioural
engagement (Brewer et al., 2004). Applied to the situation under investigation, the epi-
demic context and government-mandated measures may have led to different re-apprai-
sals among the people who were fully vaccinated, as compared with those intending to do
so. For instance, whereas in March, nineteen French departments were in lockdown and
by early April, this had extended to the entire metropolitan population, May marked the
beginning of Phase 1 deconfinement, during which only limited social gatherings were
possible. Fully-vaccinated participants’increased frequency of engagement in hand
hygiene, as compared with the unvaccinated-but-intending-to-vaccinate group in May
might perhaps reflect a more delayed time frame regarding risk re-appraisal and sub-
sequent behaviour. Having being fully vaccinated earlier, it is possible that this group
of people may have been initially more risk-averse and therefore maintained
14 K. MCCOLL ET AL.

comparatively greater hand hygiene precautions, as they perhaps took longer than the
intending-to-vaccinate group to re-appraise their risk and behaviour in response to
deconfinement and an increasingly vaccinated general public. Interestingly, in June,
the number of unvaccinated individuals who intended to be vaccinated may also be
explained by a slowing down in vaccine distribution that occurred at around this time
in France, which was the subject of media attention (Boisselier, 2021).
Risk compensation and vaccine rollout
Of relevance to risk management, through public health messages and campaigns target-
ing the mitigation of disease spread, is the reduction in levels of behavioural engagement,
suggestive of risk compensation, observed towards the end of the vaccine rollout among
the fully-vaccinated. Risk compensation at this stage, particularly with the appearance of
new COVID-19 variants and possible reduced vaccine efficacy, may indeed pose a threat
to combatting the disease, the battle against which is heavily reliant upon continued and
prolonged maintenance of barrier measures. Although increasing vaccine uptake among
the unvaccinated-but-not-intending-to-vaccinate group would also represent a means of
disease mitigation, this was not the focus of our study. Moreover, people not intending to
vaccinate have been observed to be less likely to respond to public health messages pro-
moting behavioural protective measures, and in some cases, such messages have even
been found to be counterproductive among those not intending to vaccinate (Nyhan
et al., 2014). As this extends beyond the remit of the current study, our discussion there-
fore concentrates upon those unvaccinated-but-intending-to-vaccinate.
It should be noted that risk compensation, or comparatively reduced behavioural
engagement, observed towards the end of the rollout coincided with 73.2% and 87.7%
of the French adult population’s having received their first dose of the vaccine and
56.7% and 75.5% their full primary course in July and September respectively (ECDC,
2021a). In addition to being the French summer vacation period, July and August also
marked the introduction of a mandatory health pass attesting to full primary course vac-
cination, or a negative polymerase chain reaction (PCR) test, to gain access firstly, to cul-
tural and leisure facilities, and then to public venues such as restaurants, cinemas,
swimming pools, amusement parks and gyms. Avoiding or foregoing such activities
may have proven effortful and extremely costly socially, particularly following the
extended period of lockdowns and reduced social interaction. This may account for
the observed reduced behavioural adherence thought to represent risk compensation
in July towards avoiding social gatherings. The sense of security afforded by being
fully vaccinated, and frequenting venues along with others who also held a mandatory
health pass, perhaps allowed people to participate in long-awaited social activities once
again.This was perhaps not the case for those unvaccinated or partially vaccinated,
who faced more barriers to access venues where social gatherings took place, and
could also explain the differential avoidance of social gatherings among the fully and par-
tially- or unvaccinated participants at this stage.
Whereas the July data collection period coincided with summer holidays, the Septem-
ber phase of data collection marked the return to work and beginning of the school year.
It is curious that risk compensation, or relaxing of protective behavioural adherence,
towards avoidance of social gatherings continued at these contextually different stages.
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE 15

Social gatherings were perhaps unavoidable in the context of returning to work and
school. It is also possible that the extension of the mandated health pass in August to
employees working in the aforementioned public venues and services, heightened the
sense of security afforded by vaccination, not only due to one’s own vaccination, but
also to that of others, as suggested by Buckell et al. (2021). It is conceivable that partici-
pants who had not been vaccinated until this late stage were laggards and had perhaps
been reticent to do so up until this point and therefore also less likely to engage in or
maintain other protective behaviours (Sutton, 1994), particularly a costly one (Kroczek
et al., 2022), such as avoiding social gatherings. As working-age French residents were
eligible for vaccination from May 2021 onwards, possible motivating factors for being
vaccinated may have emanated from a desire to protect oneself and others, or may
have been unrelated to health reasons. If the underlying incentive to be vaccinated
were driven by non-health-related reasons, such as the freedom and benefits accorded
to those holding a health pass, then individuals in this category at this late stage of the
vaccination campaign, for whom health grounds were not the main concern, may also
have been less likely to engage in other means of protection. Another possibility is
that this group believed that they had contributed adequately to herd immunity and
therefore could relax other, non-pharmaceutical protective behaviours.
Interestingly, the quasi absence of lessened behavioural adherence, possibly indicative
of risk compensation, during the first five months of the vaccination campaign, and
towards the other protective behaviours throughout, would suggest that whether a par-
ticular behaviour is maintained may depend largely on the nature of the behaviour,
whether it is easily achieved, as well as the social and professional context. For instance,
it is easier to engage in all forms of preventive behaviour during phases of confinement
than during deconfinement. Moreover, during deconfinement, it was perhaps easier to
use hand sanitiser, wear a mask or avoid physical contact during social interactions
than it was to avoid social gatherings altogether, particularly as confinement restrictions
had just been lifted in July, allowing friends and family to reunite during the summer
holidays, and September marked a physical return to the workplace and post-holiday
work gatherings.
That risk compensation was also observed towards mask wearing in September
among people vaccinated with one dose is interesting. By this stage in France, Pfizer
and Moderna vaccines were administered predominantly, with an efficacy at the time
estimated at 80% following a single dose (eg. Thompson et al., 2021). This was
perhaps sufficient to elicit a sense of security and resultant risk compensation
towards mask wearing among this group, and towards social gatherings among the
fully-vaccinated participants. In addition, wearing a mask during the return to the
workplace, and in hot weather, may have proven uncomfortable both physically and
socially and therefore also been a costly behaviour in which to engage, however this
does not explain why those who were fully vaccinated were nonetheless prepared to
put up with this inconvenience.
A further possibility is that other contextual factors, combined with vaccination, may
have contributed to a decrease in protective behaviours. For instance, decreased severity
associated with the Delta variant (Miyashita et al., 2023), and for those vaccinated, a
decrease in the number of COVID-19-related fatalities (Santé Publique, 2021), as well
as the progressive relaxation of mandated restrictive measures and increased numbers
16 K. MCCOLL ET AL.

of vaccinated people, may have contributed to a reduced perception of risk and sub-
sequent adherence to protective measures.
Denoting a comparative reduction in protective behavioural engagement, it could be
argued that risk compensation does not take into consideration people’s motivation to
reduce protection and as such, does not distinguish between people who might justifiably
reduce their level of protection and those who do so recklessly. Whilst vaccination
did indeed protect against severe forms of the disease, breakthrough cases were nonethe-
less commonly reported and health authorities continued to advise maintenance of non--
pharmaceutical protective measures (Covid et al., 2021). The fact that cases were less
severe among those vaccinated may have led them to perceive a reduced threat to
both themselves and others, allowing them to reduce other non-pharmaceutical
measures that, themselves, were not without harms. For instance, social isolation, due
to avoidance of social gatherings, was associated with mental health issues (Pancani
et al., 2021; Pietrabissa & Simpson, 2020; Santé Publique, 2021) and mask wearing was
associated with both physiological and psychological problems (Park et al., 2021;
Rosner, 2020; Scheid et al., 2020). Such a reduction in non-pharmaceutical measures
should in no way be interpreted as risky behaviour associated with wilful endangerment
or compromising the health of oneself or others, that is certainly not the intention of this
paper. What we seek to explore are differences in frequencies of engagement in protective
behaviour between vaccinated and intending-to-vaccinate groups at different times
throughout the pandemic, because a comparative reduction in protection by vaccinated
people may be indicative of risk compensation, which certain researchers warn could
ultimately lead to disease spread (Trogen & Caplan, 2021). Through our investigation,
we hope to glean insight into the temporal variations in protective engagement, which
may serve to inform targeted, strategic epidemic management.
A further result of note, from a public health perspective, is that with the exception of
July, when all groups appeared to reduce their engagement in protective behaviours, a
group of people who had no intention of being vaccinated was present at each study
wave. Indeed, despite the introduction of the mandatory health pass, this group rep-
resented more than 10% of the sample (ie. over 200 participants) in the final survey
wave in September. Previous research has found that for individuals in this category,
for whom vaccination may have been less of a choice than an un-health-related, utilitar-
ian necessity, engagement in other health protective behaviours would be an unlikely
outcome of conscious decision-making on their behalf (Ouellette & Wood, 1998;
Sutton, 1994). This is of concern as the behavioural reticence of this group, not only
towards vaccination, but also towards non-pharmaceutical interventions, could ulti-
mately have an impact on the spread of the epidemic.
Our findings and prior research
In light of the existing research into risk compensation following COVID-19 vaccination
in Europe, our findings provide interesting insights. Indeed, they contrast those of Sun
et al. (2022) who, focusing on health care workers in China, targeted a population that
was perhaps acutely aware of and educated about the importance of protective measures.
In addition, due to their often constant and prolonged exposure to patients suffering
from the virus, health care workers’personal health risk was higher than that of the
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE 17

general population. This may explain their increased engagement in protective measures
following vaccination. In contrast, our findings, based upon a large representative sample
of the general population, provide ecologically relevant insights into the behaviour of the
public at large, and may help inform policy makers’decisions to target public health
messages at particular epidemic stages and among particular populations in order to
combat risk compensation and ultimately, disease spread.
The results of the current investigation partially diverge from those of two studies
in the US and Canada that found protective behaviours of vaccinated participants
were maintained over time, despite vaccination (Hall et al., 2022;Thorpeetal.,
2022). Thorpe et al.’s(2022) three-wave, longitudinal US investigation took place
over the initial three and a half months of the vaccination campaign and may not
reflect changes that occur as the vaccination campaign and the epidemic wore on.
In their two-wave, longitudinal study in Canada, Hall et al. (2022)comparedbehav-
ioural engagement between fully-vaccinated and vaccine-hesitant participants at two
different epidemic peaks. Whilst decreasing among all groups, levels of protection
were significantly reduced among the unvaccinated, leading the authors to conclude
that vaccinated participants were more likelytoadheretopreventivebehaviours
than those who were unvaccinated. Targeting participants aged 18 - 55 years, who
areperhapslessatriskofseverformsofthedisease(INSEE,2021), the protective
behaviour of the over 55 age group, more susceptible to severe forms of the disease
and a poorer health outcome (Miyashita et al., 2023), remains unknown. Additionally,
comparing behaviour of fully-vaccinated with that of vaccine-hesitant groups, may
provide more starkly contrasted results, in terms of beliefs, motivation and behaviour,
than would the comparison between the vaccinated and intending-to-vaccinate
groups in our study. Moreover, measuring behavioural response at the peak of two
epidemic waves does not capture levels of protective engagement between waves
which, from a public health perspective, could provide valuable insights, allowing
researchers and public health authorities to develop targeted and timely management
strategies which could contribute to reducing the spread and health impact of succes-
sive epidemic waves.
Our findings also differ from those of Desrichard et al. (2022) and Wright et al. (2022),
who observed no evidence of risk compensatory behaviour, and even a slight increase in
most protective behaviours following vaccination among their UK participants. This
difference may be explained in part by national variations in health advice and the epi-
demic context, as well as by the stage and duration of the time frame investigated. In the
case of Wright et al. (2022), in addition to their non-representative sample’s being volun-
tary and older, and therefore more aware of and likely to adopt protective measures, their
investigation coincided with lockdown, during which compliance with protective
measures was easier, as well as the initial phase of limited vaccine rollout. Although admi-
nistered later, Desrichard et al.’s(2022)final survey wave was also conducted during the
early stages of the UK vaccination campaign, whereas those in our investigation spanned
all seven months of the vaccine rollout and therefore were perhaps able to capture
changes in behaviour that appeared over a longer period of time –weeks and in some
cases, months, following vaccination. An interesting parallel exists between the
authors’documentation of a decrease in avoidance of crowded areas (Desrichard et al.,
2022) and in some groups, social distancing (Wright et al., 2022) and our finding of
18 K. MCCOLL ET AL.

decreased avoidance of social gatherings. It is perhaps a need for social contact, particu-
larly following repeated lockdowns and restrictions, that prevails over time, manifesting
itself in reduced avoidance of social gatherings and settings.
There is a small degree of concordance between our findings and those of Jia et al.
(2022) who observed risk compensation towards avoiding social gatherings. However,
whereas risk compensation occurred towards the end of the vaccine rollout and as
people returned to work in our investigation, it was present in the US study immediately
following partial vaccination. Unlike our American counterparts, who found that
engagement in protective behaviours decreased over time, we found no such disengage-
ment towards the other protective behaviours measured. Such differences may perhaps
be attributed to national variations in health advice and government mandates in the
two countries.
Like Buckell et al. (2021), we also found limited evidence of risk compensation
towards the avoidance of social gatherings. However, whilst risk compensation in
ourstudywasobservedtowardstheendofthe vaccine rollout for two behaviours
among vaccinated participants, our British counterparts found no such association
between personal vaccination and non-pharmaceutical protective behaviours. Rather,
participants in England, Scotland, Wales and Northern Ireland demonstrated risk com-
pensation as national vaccination uptake rates increased in the general population.
These contrasting findings would, at firstglance,suggestthatdifferent factors must
be operating. However, whereas we investigated a range of behavioural measures
(mask wearing, hand hygiene, avoiding physical contact, avoiding social gatherings),
the UK study predominantly investigated variations of physical distancing measures.
The level of choice, and therefore locus of control, involved these behaviours varies
considerably. For instance, whilst an individual may be able to choose whether to
avoid physical contact with different populations, this degree of choice may have
been reduced for physical distancing due to the nature of people’s work, and negligible
for those unable to work from home and for whom it was necessary to take public
transport, or for those caring for others. In contrast, a greater degree of personal
control and choice was associated with the behavioural measures investigated in our
study. Individuals could choose whether they adhered to the mask mandate, avoided
physical contact and / or observed hand hygiene and even to a certain extent,
avoided social gatherings over the summer vacation period. The greater control
afforded by personal choice to adhere to protective behaviours, reinforced by public
health messages, may have focused vaccinated participants’attention on their individ-
ual contribution to fighting the disease. This continued individual focus, the same one
that initially motivated their engagement in protective measures and vaccination, may
have elicited feelings of relative security, which subsequently resulted in risk compen-
sation towards the end of the rollout.
Interestingly, it would appear that our findings echo those of our predecessors, who
also found limited evidence of risk compensation towards COVID-19 protective
measures as a result of mask wearing, (Aranguren, 2022; Cartaud et al., 2020;
Jørgensen et al., 2021;Kroczeketal.,2022; Luckman et al., 2021; Yan et al., 2021).
We therefore concur in concluding that whilst risk compensation may reduce the
efficacy of the COVID-19 vaccination campaign, it would in no way negate the
overall benefits.
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE 19

Implications for management
Our findings, although suggesting that risk compensation would not detract from the
overall efficacy of a public health campaign combining behavioural and pharmaceutical
interventions, nonetheless have direct implications for the management of public health
policies during an evolving pandemic or epidemic. Strategic timing of public health
messages at particular stages of the pandemic, in response to government mandates or
the relaxing thereof, whilst taking into account seasonality and the calendar of festivities
and public events, would appear to be fundamental in combatting the disease. In
addition, strategically targeting certain populations, notably those who are vaccinated
or intend to be vaccinated, may also be advantageous. Given their acceptance of this pro-
tective measure, they are perhaps a motivated, receptive audience and with strategically-
timed public health reminders and encouragement, may be more likely to maintain all
protective behaviours. Educating and informing these populations, as well as health
care professionals and policy makers, about risk compensation could also be effective
in combatting the disease. Moreover, in order to orientate public health and government
decision-making during an epidemic in real-time, it would be both advantageous and
beneficial to prepare and establish in advance a partnership between health authorities
and competent research teams so as to ensure that human and financial resources are
available to be mobilised when, and as required.
Limitations
Targeting risk compensation arising from COVID-19 vaccination, our study provides an
insight into changes in behaviour over time as the vaccine rollout and pandemic
unfolded. Despite its advantages, our study nonetheless has some limitations. Being
repeated and cross-sectional, it provides information over time at the population level.
Future longitudinal research would provide interesting, complementary information as
to patterns of individual behaviour change. Though our data were highly consistent
with the actual vaccine coverage recorded by the French health authorities, as our
surveys relied upon self-reports of protective behaviour, we have no way of knowing
whether participants actually engaged in the reported behaviours, or if answers were
subject to a social desirability bias (Crane et al., 2021; Sapsford, 2006). However, as it
was not possible to measure participant behaviour directly, this online means of
measurement served as a proxy that has been validated empirically, used widely in the
research literature, and has been found to be less subject to social desirability biases
than face-to-face surveys (Weinstein et al., 2005).
A methodological limitation of our exploratory study lies in the fact that whilst a
reduction in behavioural protection was observed and satisfied the definition of risk com-
pensation (Hedlund, 2000; Jørgensen et al., 2021), the underlying social psychological
factors responsible remain unknown. It is possible that the reduced adherence to protec-
tive measures may have resulted from a number of other factors, such as those involved
in the risk reappraisal process. From an ecological perspective, changes in the epidemio-
logical trajectory, mandated measures, health authority guidelines, death incidence rates,
perceived security due others’being vaccinated or an economic need to return work and
workplace gatherings, may also explain a general reduction in socially costly distancing
20 K. MCCOLL ET AL.

behaviours over time (Crane et al., 2021; Petherick et al., 2021). However, the analysis of
individual behavioural data in a series of seven cross-sectional studies enables us to at
least partly control the influence of the epidemiological and regulatory context, as an
absence of risk compensation effects was repeatedly found during the vaccination cam-
paign at different points of time. Further research incorporating social cognitive vari-
ables, such as perceived risk, may provide valuable insights into factors contributing to
and detracting from behavioural engagement, thereby shedding further light on risk
compensation and allowing public health advisers to develop a targeted, strategic
response.
Future research
As mentioned in the previous section, investigating changes in risk perception and
behavioural response over time would enable researchers to develop a better understand-
ing of the underlying factors and mechanisms involved in risk compensation. In addition
to longitudinal research, further investigation of risk compensation, as well as the evol-
ution of participant behaviour at an individual level, and in the period following the
vaccine campaign, would allow us to ascertain as to whether risk compensation were
increasingly present as time wore on, or whether it fluctuated, important elements to
consider in pandemic management. Another interesting area of research would be to
investigate motivation and behavioural response among the unvaccinated-but-not-
intending-to-vaccinate group.
Conclusion
As one of the first investigations of risk compensation over time following COVID-19
vaccination among a large representative sample of the general French population, our
findings of limited evidence of risk compensation, observed at the end of the vaccine
rollout towards two protective behaviours, provide insights into the evolutive nature
of people’s preventive behaviours in response to pandemic and epidemiological
changes. Future longitudinal research in this area at an individual level may complement
and refine our understanding of risk compensation and its behavioural implications.
Congruent with the literature on risk compensation and mask wearing, we also conclude
that whilst not negating the overall efficacy of the vaccination campaign, risk compen-
sation can nonetheless detract from the achievement of optimal health benefits associated
with vaccination (Iyengar et al., 2021). This has implications for the effective manage-
ment of public health messages, campaigns and policy. Understanding when, among
whom and towards which category of protective measures risk compensation may
occur provides public health authorities with valuable tools with which to manage
future campaigns. Strategically planned, well-timed public health interventions, delivered
at contextually advantageous phases and stages, focusing on specific behaviours and tar-
geting relevant groups most likely to respond with the desired behaviour, in addition to
educating people about risk compensation, may prove to be an effective way forward in
managing and combatting not only the spread of new variants of COVID-19, but also
that of epidemics and pandemics to come.
HEALTH PSYCHOLOGY AND BEHAVIORAL MEDICINE 21

Acknowledgements
The authors are grateful to Dr Pierre Arwidson and the COVIPREV group (Enguerrand du
Roscoät, Jean-Michel Lecrique, Linda Lasbeur, Christophe Léon, Pierre Arwidson, Isabelle Bon-
marin, and Oriane Nassany) from the Department of Health Promotion and Prevention (Santé
Publique France) for their valuable support.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This work was supported by Santé Publique France (Public Health France) under Grant [number
21DPPA046-0]; the European Union’s Horizon 2020 research and innovation programme, ‘PERI-
SCOPE: Pan European Response to the ImpactS of COvid-19 and future Pandemics and Epi-
demics’, under Grant [number 101016233, H2020-SC1-PHE_CORONAVIRUS-2020-2-RTD].
Ethics statement
This study was conducted in compliance with the French national guidelines for ethical research in
the social and human sciences. The research was declared to the EHESP School of Public Health
Office for Personal Data Protection (Rennes, France) [Reference: MR 2510110520], and approved
by the ethics committee of the University Hospital Institute, Méditerranée Infection (Marseille
France) [Decision No. 2020-022]. Informed consent was obtained from participants.
Institutional review board statement
The study was conducted in accordance with the Declaration of Helsinki and was approved by an
Institutional Review Board/Ethics committee. See details above and under Methods.
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