Are psychological attitudes towards vaccination an expression of personality? A cross-sectional study on COVID-19 vaccination in France

Abstract

Background
The capacity of the 7C model’s psychological antecedents, which include confidence in vaccines, complacency, convenience, calculation, collective responsibility, confidence in the wider system, and social conformism, to explain variance in COVID-19 vaccine intentions and behaviours has been documented. However, it remains unclear whether the attitudes represented by the 7C psychological antecedents are specific to vaccination or if they are, in fact, an expression of underlying personality traits.

Methods
From February to June 2022, French adults completed self-administered questionnaires assessing COVID-19 vaccination history, the 7C antecedents, and personality traits (“ComCor” and “Cognitiv” studies). Vaccination behaviours were studied through three outcomes: at-least-one-dose vaccination status by 2022 (N = 49,019), up-to-date vaccination status (N = 46,566), and uptake speed of first dose (N = 25,998). Personality traits were evaluated using the French version of the Big Five Inventory (BFI-Fr). Multivariable logistic regressions and Cox models predicting vaccine behaviours were run with the 7C antecedents, both with and without personality traits.

Results
Among the 49,019 participants, 95.0% reported receipt of at least one dose and 89.8% were up to date with recommendations. All 7C antecedents were significantly associated with the outcomes. The inclusion of personality traits did not substantially alter the effect estimates of the association between the 7C antecedents and vaccination behaviours, with differences between effect sizes of models with and without personality traits being < 5%.

Conclusions
Our results suggest that the 7C psychological antecedents of vaccination are not the mere expression of personality and that their impact on vaccine behaviours is independent of personality traits. As such, the 7C antecedents may be modifiable by appropriate information and vaccine promotion.

Trial registration
The “ComCor” study received ethical approval by the Comité de Protection des Personnes Sud Ouest et Outre Mer 1 on 21/09/2020. The addition of the “Cognitiv” questionnaire received ethical approval by the Comité de Protection des Personnes Sud Ouest et Outre Mer 1 on 01/02/2022. The data protection authority Commission Nationale de l’Informatique et des Libertés (CNIL) authorised the processing of data on 21/10/2020. The study is registered with ClinicalTrials.gov under the identifier NCT04607941.

Full text

Lièvreetal. BMC Public Health (2025) 25:209
https://doi.org/10.1186/s12889-025-21364-9
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BMC Public Health
Are psychological attitudes
towardsvaccination anexpression
ofpersonality? Across-sectional study
onCOVID-19 vaccination inFrance
Gaëlle Lièvre1, Jonathan Sicsic2, Simon Galmiche1, Tiffany Charmet1, Arnaud Fontanet1 and Judith Mueller1,3*
Abstract
Background The capacity of the 7C model’s psychological antecedents, which include confidence in vaccines,
complacency, convenience, calculation, collective responsibility, confidence in the wider system, and social conform-
ism, to explain variance in COVID-19 vaccine intentions and behaviours has been documented. However, it remains
unclear whether the attitudes represented by the 7C psychological antecedents are specific to vaccination or if they
are, in fact, an expression of underlying personality traits.
Methods From February to June 2022, French adults completed self-administered questionnaires assessing COVID-
19 vaccination history, the 7C antecedents, and personality traits (“ComCor” and “Cognitiv” studies). Vaccination
behaviours were studied through three outcomes: at-least-one-dose vaccination status by 2022 (N = 49,019), up-to-
date vaccination status (N = 46,566), and uptake speed of first dose (N = 25,998). Personality traits were evaluated using
the French version of the Big Five Inventory (BFI-Fr). Multivariable logistic regressions and Cox models predicting vac-
cine behaviours were run with the 7C antecedents, both with and without personality traits.
Results Among the 49,019 participants, 95.0% reported receipt of at least one dose and 89.8% were up to date
with recommendations. All 7C antecedents were significantly associated with the outcomes. The inclusion of person-
ality traits did not substantially alter the effect estimates of the association between the 7C antecedents and vaccina-
tion behaviours, with differences between effect sizes of models with and without personality traits being < 5%.
Conclusions Our results suggest that the 7C psychological antecedents of vaccination are not the mere expression
of personality and that their impact on vaccine behaviours is independent of personality traits. As such, the 7C ante-
cedents may be modifiable by appropriate information and vaccine promotion.
Trial registration The “ComCor” study received ethical approval by the Comité de Protection des Personnes
Sud Ouest et Outre Mer 1 on 21/09/2020. The addition of the “Cognitiv” questionnaire received ethical approval
by the Comité de Protection des Personnes Sud Ouest et Outre Mer 1 on 01/02/2022. The data protection authority
Commission Nationale de l’Informatique et des Libertés (CNIL) authorised the processing of data on 21/10/2020. The
study is registered with ClinicalTrials.gov under the identifier NCT04607941.
Keywords Vaccination, Health behavior, Personality, Psychological attitudes, 7C antecedents
*Correspondence:
Judith Mueller
judith.mueller@ehesp.fr
Full list of author information is available at the end of the article
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Lièvreetal. BMC Public Health (2025) 25:209
Background
Vaccination is globally recognised as an essential strat-
egy for improving health outcomes [1]. e success and
effectiveness of vaccination campaigns depend not only
on vaccine efficacy and safety, but also on vaccine accept-
ance among the population. Vaccine hesitancy is the
term used to describe refusal, delay, or doubt regarding
the acceptance of recommended and accessible vaccina-
tions [2]. is phenomenon is multifaceted and is associ-
ated with socio-demographic, cultural, and psychological
factors [3, 4]. It is encountered to varying degrees in most
populations, with different vaccines and a variable set of
contributing factors [5]. Despite efforts to produce safe
and effective COVID-19 vaccines and to make them
easily accessible to all population groups, vaccine hesi-
tancy has posed a significant challenge to the rollout of
COVID-19 vaccination campaigns in many countries,
with difficulties for public health systems to understand
the phenomenon and respond with adapted vaccine pro-
motion strategies [6].
Initially, the three antecedents of vaccine hesitancy—
confidence in vaccines, complacency, and convenience—
formed the 3C model [2]. is model was expanded to
include the calculation of vaccination’s benefit-risk bal-
ance and collective responsibility, resulting in the 5C
model [7].
is 5C model has been found to predict vaccination
intentions for various vaccines, including those against
influenza, pneumococcal disease, shingles, HPV, and
COVID-19 [8, 9].
More recently, a more comprehensive 7C model, which
includes confidence in the wider system (reactance) and
social conformism, has been shown to explain population
variance in COVID-19 and HPV vaccine intention and
status [10, 11] Using data from a large sample of adults
in France, we found that a simple questionnaire on the
7C psychological antecedents explained 58.9% and 23.4%,
respectively, of the variance in at-least-one-dose and up-
to-date vaccination status during the COVID-19 vaccina-
tion campaign in France [12]. is extended 7C model
refers to the framework of vaccine hesitancy [2] or vac-
cine readiness [13]. ese models aim at representing the
various dimensions of psychological factors that are asso-
ciated with and even appear to determine individuals’
intention to get vaccinated and their likelihood of being
vaccinated [13].
Despite this substantial evidence, two weaknesses
surround the concept of psychological antecedents.
First, there is no prospective evaluation available. As
such, the possibility of an inverse association cannot be
excluded, where vaccine intention or decisions would
influence responses to questionnaire items regarding
vaccination. Secondly, it remains unclear whether an
individual’s attitudes captured by the 7C psychologi-
cal antecedents are specific to vaccination or actually
an expression of underlying personality traits. is
distinction is crucial because personality traits are dif-
ficult to influence or consider in individual or official
communications, as discussed by several studies and
reviews on the stability of personality traits in adult-
hood [14, 15]. Personality traits have been associated
with a range of preventive health behaviours, including
vaccination [16]. While both personality traits and the
7C antecedents are important concepts that have been
related to health behaviours and vaccination, no study
to date has explored the how the 7C model may be tied
to personality traits.
On the other hand, knowledge and attitude factors
related to vaccination, rather than personality, may be
easier to influence and more accessible for optimised
health education and vaccine promotion, as suggested by
previous studies [17, 20].
e five-factor model of personality, commonly known
as the Big Five, has been extensively employed in psy-
chological research to assess and compare personality
traits. It categorises an individual’s personality into five
key dimensions: Neuroticism (as opposed to emotional
stability), Extraversion, Openness to experience, Agreea-
bleness, and Conscientiousness. Since its formulation by
American psychologist Donald W. Fiske in 1949 [19] and
empirical work by Lewis Goldberg (1981) [20] and Costa
and McCrae (1985–1992) [21], the “Big Five” frame-
work has been and is still widely used for characterising
individuals’ personalities and studying behaviours. Per-
sonality traits, as measured by the Big Five, tend to be
relatively stable in adulthood [22–24], with little average
changes over time and across different age groups. Evo-
lutions in intraindividual personality are generally unre-
lated to specific experiences or adverse life events, such
as disease [23].
Personality traits, assessed by the Big Five question-
naire, have been associated with a range of health out-
comes and preventative behaviours. In longitudinal
studies, these traits have been identified as predic-
tors of all-cause mortality risk [25] and risk factors of
many diseases, including stroke and coronary heart
disease [26]. Among these traits, low conscientious-
ness appears as the most robust personality correlate
of poor health, linked to several diseases and unhealthy
behaviours [27, 28]. High extraversion and high neu-
roticism are also associated with unhealthy behaviours,
but less so with chronic diseases [29]. Moreover, there
is some evidence that low agreeableness and low open-
ness predict health outcomes in longitudinal studies,
such as reduced physical activity frequency [30] and
increased risk of Alzheimer’s disease [31].
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Lièvreetal. BMC Public Health (2025) 25:209
Despite existing research that has primarily focused on
the relationship between the Big Five personality traits
and health behaviours, there has been relatively limited
investigation into the association between personality
traits and vaccination acceptance and uptake. Existing
studies have yielded mixed results about the connec-
tions between personality traits and vaccination. While
some investigations have suggested negative associations
with vaccine behaviours (e.g., for high extraversion [32]),
others have found positive correlations (e.g., for high
agreeableness [33]), and some have reported no signifi-
cant associations [34]. In the United States, results from a
nationally representative sample indicated that individu-
als with higher levels of agreeableness, conscientiousness,
and emotional stability (i.e., lower neuroticism) were
more likely to agree that vaccination is beneficial [35].
Nonetheless, the field of research on personality and
vaccination has recently been accelerated by public dis-
cussions during the COVID-19 pandemic. A 2024 sys-
tematic review and meta-analysis presented a convincing
picture of notable, although modest, effects of person-
ality traits on vaccination [16]. Individuals with higher
levels of agreeableness [36] and extraversion, and lower
levels of neuroticism were found to have more positive
attitudes towards vaccination. ose high in openness
showed stronger intentions to vaccinate. Additionally,
open and agreeable people had more positive views on
novel COVID-19 vaccines [39]. Another 2024 study sug-
gested that vaccination status, number of vaccine doses,
and vaccination timing may be predicted from personal-
ity traits [37].
Vaccine uptake and attitudes might predict other
health outcomes (beyond the specific disease the vaccine
prevents) and general health, as health literacy is related
to both vaccination and other health outcomes. Associa-
tions have been found between low health literacy and
more hospitalizations, increased use of emergency care,
lower rates of mammography screening and influenza
vaccination, and poorer ability to correctly take medica-
tions and interpret labels and health messages [38]. In
addition, research has explored the link between person-
ality traits and health outcomes, suggesting that traits
like conscientiousness can influence both vaccination
behaviour and general health [39].
Based on existing research, we expected the following
associations between personality traits and vaccination
behaviours:
1. A positive, albeit small, association between consci-
entiousness, openness, agreeableness, extraversion
and vaccination behaviours.
2. A negative association between neuroticism and vac-
cination behaviours.
We expected conscientiousness to be positively associ-
ated with vaccination behaviours, as it encompasses traits
such as self-discipline, reliability, and diligence [40]. Con-
scientious individuals may also be better at anticipating
and preparing for future adversities and more organised.
ese qualities may make them more likely to decide on
receiving COVID-19 vaccination and to attend their vac-
cine appointment.
Openness to experience refers to cognitive and behav-
ioral flexibility, cultured tendencies, and an awareness of
internal and external events and experiences [41]. ese
factors likely contribute to the prevention of avoidable
health problems and enhance adaptive disclosure of
health concerns, health decision-making, and problem
management [39]. ey may also make individuals more
likely to accept novel vaccinations such as COVID-19
vaccines.
Extraversion includes inclinations towards positive
mood, sociability, and an active lifestyle characterised by
engagement and busyness [42]. As such, individuals with
higher levels of extraversion may be more likely to vac-
cinate to enjoy sociable activities, especially in a period
when movement and leisure restrictions applied to non-
vaccinated individuals.
We expected agreeableness to be positively associated
with vaccination behaviours, as it combines traits that
contribute to fostering interpersonal harmony, includ-
ing trust, honesty, compliance, deference, altruism, and
compassion for others [23]. Given the prosocial nature of
COVID-19 vaccination, individuals with higher agreea-
bleness levels might be more likely to vaccinate.
We expected neuroticism to be negatively associated
with vaccination behaviours, as it refers to instability [43]
and focuses on chronic experiences of negative emotions
like anxiety, depression, and anger [23]. Neuroticism
also relates to vulnerability, with feelings of being unable
to effectively cope with life’s challenges. It is considered
to have broad public health significance due to its asso-
ciation with numerous negative outcomes [44, 45]. How-
ever, some studies have also reported negative findings
[46] or even a positive association between neuroticism
and health outcomes [47]. To resolve these seemingly
conflicting findings, Friedman has proposed a theory
distinguishing between “healthy” and “unhealthy” neu-
roticism [48]. “Healthy” neuroticism includes tendencies
which may encourage engagement in preventive health
behaviours, such as vaccination, to alleviate concerns
about developing chronic health issues. is may be true
of individuals with higher levels of anxiety but without
significant issues of poor self-esteem, vulnerability, or
depressive moods.
In addition, a strong and consistent associations
have been documented between the 7C psychological
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Lièvreetal. BMC Public Health (2025) 25:209
antecedents and vaccination intentions [11] and behav-
iours [14], while associations between personality traits
and vaccination remain small. erefore, we expected the
relationships between the 7C antecedents and COVID-
19 vaccination behaviours to only be modestly explained
by underlying personality traits.
In this article, we evaluate the association between per-
sonality traits and COVID-19 vaccine behaviours among
the adult population in France in 2022. We also investi-
gate whether the association between the 7C psychologi-
cal antecedents and COVID-19 vaccination behaviours is
explained by underlying personality traits.
Our study introduces a hypothetical model in which
personality traits, as evaluated by the Big Five ques-
tionnaire, precede the 7C antecedents of vaccination
readiness. Consequently, personality traits may serve
as confounders in the documented association between
the 7C antecedents and vaccine behaviours [13]. is
constellation is based on the hypothesis that personality
traits impact or are the cause of both vaccine behaviours
and the 7C antecedents (Fig. 1). us, we investigate
the potential association between personality traits and
vaccination behaviours, as well as the hypothetical con-
founding role of personality traits in the association
between the 7C antecedents and vaccine behaviours.
Methods
Study design, participant enrolment anddata collection
We analysed data of the “ComCor” case–control study,
the methods of which have been previously described
[49]. Briefly, between 2020 and 2022, adults with recent
SARS-CoV-2 infection were recruited as cases by the
French national health insurance agency. Controls were
recruited from a national panel as non-infected adults
matched to cases by age, sex, region, population den-
sity, and calendar week. Additional participants were
recruited as cases’ relatives. For all participants, the
“ComCor” questionnaire collected information on soci-
odemographic factors, SARS-CoV-2 infection history,
and detailed self-reported COVID-19 vaccination his-
tory, including vaccination dates and dose numbers.
Between 24 February 2022 to 19 June 2022, upon com-
pletion of the “ComCor” questionnaire, participants
were invited to complete a self-administered “Cognitiv”
questionnaire, which assessed personality traits using the
Big Five questionnaire and current 7C attitudes towards
COVID-19 vaccination (Appendix 1).
e “ComCor” study received ethical approval by the
Comité de Protection des Personnes Sud Ouest et Outre
Mer 1 on 21 September 2020. e addition of the “Cog-
nitiv” questionnaire received ethical approval by the
Comité de Protection des Personnes Sud Ouest et Outre
Mer 1 on 1 February 2022. e data protection authority
Commission Nationale de l’Informatique et des Libertés
(CNIL) authorised the processing of data on 21 Octo-
ber 2020. e study is registered with ClinicalTrials.gov
under the identifier NCT04607941.
Questionnaires
Individuals’ attitudes towards COVID-19 vaccination
were assessed using a short form of the 7C questionnaire
previously described by Moirangthem and colleagues
(2022) [11]. is questionnaire was adapted to the gen-
eral adult population and the COVID-19 vaccination
context in 2022, with each antecedent domain reduced to
a single item. Response modalities were mostly coded on
5-point Likert scales (Completely disagree to Completely
agree), with an indecision option as the central modality.
In addition, participants could refuse to respond to indi-
vidual items.
We used the French version of the Big Five Inventory
(BFI-Fr) to evaluate personality traits [19, 50, 51, 23]. e
BFI-Fr is a reliable and effective tool for assessing individ-
ual differences in the five major dimensions of personality
Fig. 1 Associations between the 7C psychological antecedents, personality traits, and COVID-19 vaccination behaviours. Dotted arrows represent
hypothetical associations
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Lièvreetal. BMC Public Health (2025) 25:209
[52], that are neuroticism (mean of 8 items, including
3 reversed), extraversion (mean of 8 items, including 3
reversed), conscientiousness (mean of 9 items, includ-
ing 4 reversed), openness (mean of 10 items, including 2
reversed), and agreeableness (mean of 10 items, includ-
ing 5 reversed). “Following the example of previous stud-
ies [26, 53], personality traits were recoded into three
categories based on terciles to obtain categories of low,
medium, and high levels of these variables” Cronbach’s
alpha coefficients, which measure the internal coherence,
have been described as, respectively, 0.82, 0.75, 0.80, 0.82,
and 0.74 for the five dimensions of extraversion, agreea-
bleness, conscientiousness, neuroticism, and openness
[55].
Socio-demographic factors included age category (18–
28, 29–38, 39–48, 49–58, 59–68, and 69 +), sex (male or
female), diploma category (below Baccalaureate, Bac-
calaureate or equivalent, 2 to 4years of study after Bac-
calaureate, and 5 + years of study after Baccalaureate),
professional category (employee, independent profes-
sion, senior executive, intermediate profession, farmer,
blue-collar worker, pensioner, student, and inactive),
country of birth (France, abroad, and not answered), and
comorbidity (no comorbidity, 1 + comorbidity, and not
answered). e description of participant characteristics
(sociodemographic, comorbidities, the 7C psychological
antecedents, and personality traits), by outcome status is
provided in Supplementary Table3.
Statistical analyses
In our analyses, grounded in epidemiological theory,
we developed three regression models predicting vac-
cine behaviours. Model 0 included the five domains of
the Big Five personality traits as independent variables.
Model 1 comprised the seven domains of the 7C anteced-
ents as independent variables. Model 2 integrated both
the 7C antecedents and the Big Five personality traits.
We examined two aspects: 1) in Model 0, the effect size
of each domain of the Big Five personality traits, and 2)
the comparison between Models 1 and 2 coefficients to
determine if the effect estimates of the 7C antecedents
substantially decreased in Model 2, which would sug-
gest a confounding constellation. ese models were not
adjusted for socio-demographic characteristics or the
presence of comorbidities. However, in sensitivity analy-
ses, we explored potential confounding roles by including
age category, sex, diploma category, professional cate-
gory, country of birth, and comorbidities.
We defined three outcomes based on COVID-19 vac-
cination history: at-least-one-dose vaccination status
was coded as a binary variable with No dose (0) and
One dose or more (1); up-to-date vaccination status was
coded as a binary variable with One or two doses without
infection (0) and Two doses with infection, three doses or
more (1); and “uptake speed” referred to the time to vac-
cination, that is, the delay between the date of age- and
comorbidity-specific vaccine eligibility and the date of
the first dose receipt (if not previously infected). Eligibil-
ity dates varied for different ages and comorbidities (see
Appendix2).
We assessed the determinants of at-least-one-dose and
up-to-date vaccination status using multivariable logistic
regression models, and the determinants of uptake speed
using Cox proportional hazard models. To investigate the
association between personality traits and vaccine behav-
iours, we built Models 0, with personality traits as inde-
pendent variables and vaccine behaviours as dependent
variables. To evaluate whether the associations between
the 7C antecedents and vaccination behaviours were con-
founded by personality traits, we established base models
with the 7C psychological antecedents (Models 1) and
subsequently introduced personality traits (Models 2).
As shown in Lièvre and colleagues (Submitted for
publication) [13], the Odds Ratios (OR) were not signifi-
cantly different between models incorporating only the
7C antecedents and models encompassing both the 7C
antecedents, sociodemographic factors, and comorbidi-
ties. We conducted sensitivity analyses involving soci-
odemographic factors and comorbidities to explore the
differences between models that included or excluded
these variables. Initially, participants recruited as cases,
controls, and relatives were analysed separately. However,
because the determinants of vaccine uptake showed simi-
lar associations across cases, controls, and relatives, we
present results that combine the three groups.
We show exact P-values and use P < 0.05 as the defini-
tion of statistical significance for the narrative presenta-
tion of results. All statistical analyses were performed
using Stata 17.0 (StataCorp, College Station, TX, USA).
Results
A total of 49,200 (30.4%) eligible “ComCor” participants
completed the “Cognitiv” questionnaire, including 44,881
cases, 3,099 controls, and 1,220 relatives. COVID-19 vac-
cine coverage was 95.0% for at-least-one-dose and 87.8%
for up-to-date vaccination status. Supplementary Table3
shows the description of participant characteristics (soci-
odemographic factors, comorbidities, the 7C psycho-
logical antecedents, and personality traits) by outcome
status.
e associations between personality traits and vac-
cination behaviours were initially analysed without
adjustment on sociodemographic factors and comor-
bidities. Neuroticism (high vs. low levels), agreea-
bleness (high and intermediate vs. low levels), and
conscientiousness (high vs. low levels) were significantly
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Lièvreetal. BMC Public Health (2025) 25:209
and moderately associated with at-least-one-dose vac-
cination status (OR = 1.32, OR = 1.20, and OR = 1.22,
respectively; Table1). Openness and extraversion were
not associated with at-least-one-dose vaccination sta-
tus. Openness was the only personality trait to be sig-
nificantly associated with up-to-date vaccination status
(OR = 0.89; Supplementary Table 4). Extraversion and
agreeableness were significantly and weakly associated
with uptake speed (OR = 0.94 and OR = 0.96, respec-
tively; Supplementary Table5).
All 7C antecedent items were significantly associ-
ated with at-least-one-dose vaccination status in Model
1 (Table 2): the strongest effect sizes (most vaccine-
favourable vs. least vaccine-favourable attitude level)
were observed for collective responsibility (percep-
tion of COVID-19 vaccination as a collective action,
OR = 14.44), calculation (perception of more benefits
than risks with COVID-19 vaccination, OR = 10.29),
and confidence in systems (positive perception of
the government’s incitation to get vaccinated against
COVID-19, OR = 8.94; Table1). Weaker effect sizes were
observed for confidence in vaccines (absence of fear of
vaccination side effects, OR = 3.70) and low complacency
(fear of severe forms of COVID-19, OR = 1.87). Two
antecedents showed particular associations with at-least-
one-dose vaccination status: first, indecision regarding
access convenience (perception of no practical difficulties
to get an appointment) was associated with lower vac-
cine uptake (OR = 0.06). Secondly, describing a favora-
ble majority opinion towards COVID-19 vaccination in
one’s close social environment (antecedent item referring
to social conformism) was negatively associated with at-
least-one-dose vaccination status (OR = 0.69).
In Models 2, the inclusion of all five personality traits
did not substantially alter the magnitude of the effect
estimates of the association between the 7C anteced-
ents and vaccination outcomes, with differences between
effect sizes of Models 1 and 2 being < 5% (Table2 for at-
least-one-dose vaccination status, Supplementary Table6
for up-to-date vaccination status, and Supplementary
Table7 for uptake speed). Sensitivity analysis excluding
socio-demographic characteristics and comorbidities
yielded similar results (Supplementary Table 8 for at-
least-one-dose vaccination status, Supplementary Table9
for up-to-date vaccination status, and Supplementary
Table10 for uptake speed). e inclusion of personal-
ity traits individually did not either substantially alter
the effect estimates of the association between the 7C
antecedents and vaccination outcomes (Supplementary
Table 11 for at-least-one dose vaccination status, data
for up-to-date vaccination status and uptake speed not
shown).
In Models 2, two personality traits significantly con-
tributed to the explanation of at-least-one-dose vacci-
nation status (highest vs. lowest category): neuroticism
(OR = 1.68) and openness (OR = 0.77; Table 2). Similar
results were observed for up-to-date vaccination status
(Supplementary Table6), with neuroticism (highest vs.
lowest category, OR = 1.36) and openness (highest vs.
lowest category, OR = 0.68) significantly contributing to
the explanation of up-to-date vaccination status. Agree-
ableness (highest vs. lowest category, HR = 0.92) and
openness (highest vs. lowest category, HR = 0.94) signifi-
cantly contributed to the explanation uptake speed (Sup-
plementary Table7).
Discussion
In this study, conducted in a large sample of adults in
France in early 2022, we found that the strong association
between the 7C antecedents and vaccine behaviours was
not confounded by personality traits. Personality traits
showed a weak-to-moderate and variable association
Table 1 Associations between personality traits and at-least-
one-dose COVID-19 vaccination status among 49,019 adults.
Non-adjusted for sociodemographic factors and comorbidities.
Cognitiv study. France, 24 February 2022—19 June 2022
(N = 49,019 adults)
Reading grid: The OR of the association between neuroticism and at-least-one-
dose vaccination status was 1.08 (n.s.) for individuals with intermediate levels of
neuroticism
At-least-one-dose vaccination status
NOR 95%
Condence
Interval
p-value
Neuroticism
Low neuroticism 15,497 1.00 - -
Intermediate neuroticism 18,430 1.08 0.98–1.19 0.138
High neuroticism 15,092 1.32 1.18–1.47 < 0.001
Agreeableness
Low agreeableness 15,133 1.00 - -
Intermediate agreeableness 13,750 1.24 1.11–1.37 < 0.001
High agreeableness 20,136 1.20 1.09–1.33 < 0.001
Openness
Low openness 17,555 1.00 - -
Intermediate openness 14,523 1.08 0.97–1.19 0.147
High openness 16,941 1.04 0.94–1.14 0.489
Extraversion
Low extraversion 15,430 1.00 - -
Intermediate extraversion 19,610 0.94 0.85–1.04 0.226
High extraversion 13,979 0.90 0.80–1.00 0.060
Conscientiousness
Low conscientiousness 18,944 1.00 - -
Intermediate conscientious-
ness 12,223 1.09 0.99–1.21 0.088
High conscientiousness 17,852 1.22 1.10–1.34 < 0.001
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Table 2 Associations between the 7C antecedents and at-least-one-dose COVID-19 vaccination status among 49,019 adults without (Model 1) and with (Model 2) adjustment on
personality traits. Both models are adjusted for sociodemographic factors and comorbidities. Cognitiv study. France, 24 February 2022—19 June 2022 (N = 49,019 adults)
At-least-one-dose vaccination status
NModel 1 without adjustment Model 2 adjusting for personality traits
OR 95% Condence
Interval
p-value OR 95% Condence Interval p-value
Completely
disagree
3,070 1.00 - - 1.00 - -
Rather disagree 2,509 2.14 1.81–2.53 < 0.001 2.15 1.86–2.62 < 0.001
Does not know 6,328 4.53 3.81–5.38 < 0.001 4.45 3.80–5.40 < 0.001
Rather agree 10,598 14.88 11.06–20.01 < 0.001 14.66 11.14–20.27 < 0.001
Completely agree 25,712 10.29 7.53–14.05 < 0.001 10.32 7.75–14.53 < 0.001
Not answered 802 3.37 2.25–5.05 < 0.001 3.50 2.31–5.24 < 0.001
Completely
disagree
2,778 1.00 - - 1.00 - -
Rather disagree 2,153 1.27 1.07–1.50 0.006 1.26 1.10–1.55 0.003
Does not know 2,858 2.08 1.74–2.49 < 0.001 2.09 1.83–2.65 < 0.001
Rather agree 8,875 4.25 3.47–5.21 < 0.001 4.31 3.73–5.67 < 0.001
Completely agree 31,427 14.44 10.72–19.45 < 0.001 14.58 11.59–21.28 < 0.001
Not answered 928 2.66 1.82–3.87 < 0.001 2.66 2.00–4.32 < 0.001
Condence in systems (positive perception of the government’s incitation to get vaccinated against COVID-19)
Deters
from vaccination
3,026 1.00 - - 1.00 - -
No effect 21,029 1.35 1.19–1.54 < 0.001 1.37 1.20–1.57 < 0.001
Encourage vac-
cination
24,964 8.94 6.51–12.27 < 0.001 8.89 6.23–11.95 < 0.001
Condence in vaccines (absence of fear of COVID-19 vaccination side eects)
Completely
disagree
4,895 1.00 - - 1.00 - -
Rather disagree 7,390 1.72 1.48–2.00 < 0.001 1.75 1.51-2.04 < 0.001
Does not know 7,960 2.65 2.18–3.21 < 0.001 2.73 2.25–3.32 < 0.001
Rather agree 12,657 3.77 2.96–4.80 < 0.001 3.95 3.09–5.04 < 0.001
Completely
agree
15,803 3.70 2.95–4.64 < 0.001 3.87 3.08–4.85 < 0.001
Not answered 314 1.49 1.01–2.21 0.046 1.50 1.00–2.23 0.048
Social conformism (majority opinion towards COVID-19 vaccination in one’s close social environment)
Very skeptical 1,815 1.00 - - 1.00 - -
Rather skeptical 3,379 0.84 0.69–1.02 0.075 0.83 0.71–1.05 0.152
Equal share
of skeptical
and favourable
9,331 0.69 0.57–0.82 < 0.001 0.69 0.61–0.87 < 0.001
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Lièvreetal. BMC Public Health (2025) 25:209
Table 2 (continued)
At-least-one-dose vaccination status
NModel 1 without adjustment Model 2 adjusting for personality traits
OR 95% Condence
Interval
p-value OR 95% Condence Interval p-value
Rather favourable 20,073 0.72 0.59–0.88 0.001 0.71 0.61–0.92 0.005
Very favourable 14,421 0.69 0.52–0.93 0.013 0.69 0.54–0.98 0.036
Convenience (perception of no practical diculties to get an appointment for COVID-19 vaccination)
Completely
disagree
1,098 1.00 - - 1.00 - -
Rather disagree 3,506 1.90 1.03–3.50 0.041 1.88 1.02–3.49 0.044
Does not know 2,383 0.06 0.04–0.10 < 0.001 0.06 0.04–0.10 < 0.001
Rather agree 11,049 0.60 0.37–0.98 0.040 0.60 0.36–0.98 0.040
Completely
agree
30,318 0.40 0.25–0.64 < 0.001 0.40 0.25–0.65 < 0.001
Not answered 665 0.05 0.03–0.08 < 0.001 0.05 0.03–0.08 < 0.001
Completely
disagree
9,051 1.00 - - 1.00 - -
Rather disagree 11,966 0.98 0.83–1.16 0.836 0.97 0.85–1.19 0.907
Does not know 7,511 1.30 1.08–1.56 0.005 1.26 1.05–1.52 0.015
Rather agree 11,620 1.60 1.32–1.94 < 0.001 1.51 1.29–1.91 < 0.001
Completely
agree
8,470 1.87 1.49–2.34 < 0.001 1.72 1.40–2.21 < 0.001
Not answered 401 1.17 0.75–1.82 0.501 1.13 0.73–1.79 0.570
Personality traits
Neuroticism
Low neuroti-
cism
15,497 - - - 1.00 - -
Intermediate
neuroticism
18,430 - - - 1.17 1.02–1.35 0.028
High neuroti-
cism
15,092 - - - 1.68 1.43–1.98 < 0.001
Agreeableness
Low agreeable-
ness
15,133 - - - 1.00 - -
Intermediate
agreeableness
13,750 - - - 0.94 0.81–1.10 0.439
High agreeable-
ness
20,136 - - - 0.88 0.76–1.02 0.091
Openness
Low openness 17,555 - - - 1.00 - -
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Lièvreetal. BMC Public Health (2025) 25:209
Table 2 (continued)
At-least-one-dose vaccination status
NModel 1 without adjustment Model 2 adjusting for personality traits
OR 95% Condence
Interval
p-value OR 95% Condence Interval p-value
Intermediate
openness
14,523 - - - 0.81 0.70–0.94 0.004
High openness 16,941 - - - 0.77 0.66–0.89 < 0.001
Extraversion
Low extraver-
sion
15,430 - - - 1.00 - -
Intermediate
extraversion
19,610 - - - 1.11 0.96–1.28 0.154
High extraver-
sion
13,979 - - - 1.21 1.03–1.42 0.020
Conscientiousness
Low conscien-
tiousness
18,944 - - - 1.00 - -
Intermediate
conscientiousness
12,223 - - - 1.09 0.94–1.26 0.275
High conscien-
tiousness
17,852 - - - 1.16 1.01–1.34 0.041
Reading grid: The OR of the association between calculation and at-least-one-dose vaccination status was 2.14 for individuals who rather disagreed with the proposal “vaccination has more benets than risks for me”
in a simple model with only the 7C antecedents, sociodemographic factors, and comorbidities. This OR did not substantially change in a model with the 7C antecedents, sociodemographic factors, comorbidities, and
personality traits (OR = 2.15)
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Lièvreetal. BMC Public Health (2025) 25:209
with COVID-19 vaccination behaviours. Our results sug-
gest that the influence of the 7C antecedents on vaccine
behaviours is independent of personality traits (Fig.2).
The 7C antecedents, more thananexpression
ofpersonality
All 7C antecedent items were significantly associated
with at-least-one-dose vaccination status. Previous stud-
ies have also documented a strong association of the 7C
psychological antecedents, all of which significantly con-
tribute to the intention and uptake of various vaccines
[11, 13]. In particular, we found an outstanding role of
confidence in system, collective responsibility, and cal-
culation in vaccine decisions, for all three outcomes [12].
While it is intuitive that the fear of side effects impacts
vaccine acceptance, the finding that seven different
dimensions play a role is surprising, underscoring the
complexity of vaccine decision-making. erefore, the
development and evaluation of interventions to enhance
vaccine promotion must be based on a comprehen-
sive model that incorporates, at a minimum, the seven
domains of the 7C antecedents.
e primary result of this study is that personality traits
are not involved in the strong association between the
7C antecedents and COVID-19 vaccination behaviours.
is implies that attitudes related to the 7C antecedents
exert a direct and independent effect on COVID-19 vac-
cination behaviours, regardless of individuals’ personal-
ity traits. Personality traits are considered to be relatively
stable within individuals over time [18, 54] and are resist-
ant to change through interventions [55]. e fact that
they exhibit little association with vaccine behaviours is,
therefore, an encouraging finding, as it suggests poten-
tial opportunities for interventions. Conversely, the 7C
antecedents may exhibit more variability over time,
although no longitudinal observations are currently avail-
able to confirm how they evolve over time, and whether
increased knowledge translates into improved attitudes.
Nonetheless, attitudes and knowledge related to the 7C
antecedents could potentially be influenced by appro-
priate interventions. Further psychometric analyses of
data on personality traits, the 7C antecedents, and vac-
cine intention or behavior should delve into the intri-
cate mechanisms at play. is exploration could offer
valuable insights to guide the development of effective
interventions.
Personality traits andvaccination
Our findings, which reveal weak-to-moderate associa-
tions between personality traits and vaccine behaviours,
indicate that personality traits play a more distal role in
vaccination behaviours compared to the 7C antecedents.
is is consistent with two recent studies that reported
weak associations between higher levels of neuroticism
and increased COVID-19 vaccination rates (ecologi-
cal level) or vaccine intention (individual level) [56, 57].
Interestingly, we observed the association between neu-
roticism and vaccination behaviours even after adjust-
ing for the 7C antecedents. For individuals with neurotic
tendencies, characterised by a relatively stable inclination
towards experiencing negative emotions, anxiety, and
low stress tolerance [58], the fear of contracting COVID-
19 may outweigh concerns about potential vaccine side
effects.
e association between agreeableness and conscien-
tiousness and being up to date with vaccinations aligns
with a 2016 nationally representative survey on individ-
ual perceptions of vaccination among school-age chil-
dren in the US. is survey found that higher levels of
conscientiousness and agreeableness were significantly
correlated with positive attitudes towards vaccination,
even after controlling for demographic factors [35]. Lee
and colleagues (2017) also reported that individuals with
higher levels of conscientiousness and agreeableness,
but lower levels of openness, displayed stronger confi-
dence in vaccines [59]. In the Big Five model, low con-
scientiousness appears as the most robust personality
correlate of poor health [24]. Regarding the specific case
of SARS-CoV-2, higher agreeableness scores were associ-
ated with a higher probability of adhering to the COVID-
19 vaccination program [60]. Recent studies have also
documented associations between lower levels of con-
scientiousness and COVID-19 vaccine hesitancy [61], as
well as conscientiousness-related traits and attitudes and
behaviours related to COVID-19 vaccination [62].
Public health implications
e results of our study have notable implications for
public health. ey show that the 7C psychological ante-
cedents are independently associated with various vac-
cine behaviors, including the speed of vaccine uptake
during an epidemic-response vaccine campaign. is
finding holds particular relevance for epidemic prepar-
edness plans, in situations where rapid vaccine uptake
is essential. As the impact of the 7C psychological ante-
cedents on vaccine behaviours is not the expression of
personality traits, these antecedents may be amenable
to modification through appropriate information and
vaccine promotion efforts. Specifically, efforts aimed at
improving knowledge and attitudes related to collective
responsibility, calculation, and confidence in systems may
yield valuable results. Previous research suggested that
interventions could indeed be effective for individuals
who engage in calculated decision-making [63]. Explain-
ing the concept of herd immunity can also increase
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Page 11 of 13
Lièvreetal. BMC Public Health (2025) 25:209
people’s willingness to vaccinate by emphasizing collec-
tive responsibility [64].
However, changing such attitudes can be challenging,
especially in emergency situations, and may necessi-
tate broader, long-term approaches to enhance vaccine-
related literacy, attitudes, and trust within society before
epidemics emerge. Our study focuses on vaccine uptake
within the context of strong incentives imposed by the
COVID-19 health pass requirement in France, and future
research should also investigate the long-term effects of
such incentive policies on vaccine antecedents.
Limitations
is study has several limitations. Firstly, the sample is
not representative of the adult population in France in
2022, despite the large sample size of the study. Infected
participants were recruited nationwide among all persons
with social security undergoing testing, and non-infected
participants were selected from a panel by a market and
public opinion research company, matched to infected
participants on age, sex, region, population size of area
of residence, and calendar week. In consequence, partici-
pants characteristics such as willingness to participate in
a study, computer literacy, and access to a computer dif-
fered between our study population and the source popu-
lation. Previous analyses of the study population have
shown that both infected and non-infected respondents
tended to be younger, included a higher proportion of
women, and were wealthier compared to the source pop-
ulation [65]. In addition, 95% of our sample had received
at least one dose of COVID-19 vaccine, which is higher
than vaccine coverage in the general French adult popu-
lation (92.4%). In consequence, prevalence estimates (e.g.,
vaccination rates) are prone to selection bias and should
be interpreted with caution. Associations between deter-
minants and vaccine behaviour are usually less biased
by such selection, but their extrapolation to the entire
population should recognise a limited generalisability.
Secondly, the data collection was cross-sectional, and we
cannot exclude that individuals’ vaccine experience influ-
enced their responses to the 7C attitude items. irdly,
the Big Five personality assessment is self-reported. As
such, responses might be influenced by the respondents’
social desirability biases. In addition, the Big Five person-
ality assessment may capture pathological conditions, as
neuroticism has frequently been associated with pathol-
ogy and mental health conditions, including depression
and anxiety disorders [66]. Lastly, the large sample size of
this study can lead to statistically significant results even
when the practical significance of the effects is limited.
Conclusions
e current research indicates that the 7C psychologi-
cal antecedents of vaccination impact vaccine behaviours
independently from personality traits, and therefore, they
may be amenable to appropriate interventions. Further
research should explore how psychological antecedents
– or their association with vaccine behaviours – can be
positively influenced to increase and accelerate vaccine
uptake during epidemics.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12889- 025- 21364-9.
Supplementary Material 1.
Acknowledgements
We thank all participants who participated in the study.
Authors’ contributions
GL, JEM, AF, SG, TC, and JS designed the study. SG, TC, and AF developed the
“ComCor” questionnaire on vaccination history and sociodemographic factors.
GL, JEM, and JS developed the “Cognitiv” questionnaire including psycho-
logical antecedents of vaccination. GL performed the statistical analyses. GL
drafted the first version of the manuscript. All authors read and approved the
final manuscript.
Funding
The study was funded by Institut Pasteur, REACTing (Research, Action
Emerging Infectious Diseases), and the French agency Agence nationale
de recherches sur le sida et les hépatites virales—Maladies Infectieuses
Fig. 2 Associations between the 7C psychological antecedents, personality traits, and COVID-19 vaccination behaviour
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Page 12 of 13
Lièvreetal. BMC Public Health (2025) 25:209
Emergentes (ComCor project). Professor Fontanet’s laboratory receives
support from the LabEx Integrative Biology of Emerging Infectious Diseases
(IBEID) (grant No. ANR-10-LABX-62-IBEID) and the INCEPTION project (grant
No. PIA/ANR-16-CONV-0005) for studies on emerging viruses. Ms. Lièvre is
funded by the Institut Pasteur. Dr Galmiche is funded by the INCEPTION
program (Investissement d’Avenir grant No. ANR-16-CONV-0005). Ms. Charmet
was funded by the Fondation de France (Tous unis contre le virus alliance).
The funders had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review,
or approval of the manuscript; and decision to submit the manuscript for
publication.
Data availability
The data that support the findings of this study are available from Institut
Pasteur. Restrictions apply to the availability of these data, which were used
under authorised agreement for this study from the data protection authority,
the Commission Nationale de l’Informatique et des Libertés (CNIL). Access to
these pseudonymized data would therefore require prior authorisation by the
CNIL.
Declarations
Ethics approval and consent to participate
All protocols were approved. The “ComCor” study received ethical approval
by the Comité de Protection des Personnes Sud Ouest et Outre Mer 1 on
21/09/2020. The addition of the “Cognitiv” questionnaire received ethical
approval by the Comité de Protection des Personnes Sud Ouest et Outre
Mer 1 on 01/02/2022. The data protection authority Commission Nationale
de l’Informatique et des Libertés (CNIL) authorised the processing of data on
21/10/2020. The study is registered with ClinicalTrials.gov under the identifier
NCT04607941. Informed consent was obtained from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1 Emerging Diseases Epidemiology Unit, Institut Pasteur, 25-28 Rue du Docteur
Roux, Bâtiment Laveran, Paris 75015, France. 2 Université de Paris, IUT de Paris,
Rives de Seine, 143 Avenue de Versailles, Paris 75016, France. 3 EHESP School
of Public Health, Rennes 35043, France.
Received: 19 January 2024 Accepted: 7 January 2025
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