Do Vaccination Attitudes Mediate the Link between Critical Consciousness and COVID-19 Vaccination Behaviour? A Cross-Sectional Study

Abstract

Critical consciousness development represents a building block in the formation of health-related attitudes and behaviours. One of the most studied health-related behaviours in the previous year is COVID-19 vaccination behaviour. The present study examines critical consciousness, COVID-19 vaccination attitudes and vaccination behaviour in a consistent sample of young adults (N = 1185). Participants were residents of Romania, aged 18 to 41 years. The Critical Consciousness Scale—Short Form (CCS-S) and the Vaccination Attitudes Examination (VAX) Scale were used. The results demonstrate the mediating role of two types of vaccination attitude—lack of confidence in the promoted vaccine benefits and worries about unforeseen effects—in the relationship between critical reflection and vaccination behaviour. Communication is fundamental in an initiative aimed at changing behaviour. When shaping a health-related campaign, communication and dialogue must be horizontal and characterised by empathy and mutual recognition to determine favourable health-related behaviour.

1. Introduction—COVID-19: Vaccination Intentions and Vaccine Hesitancy

Coronavirus 2019, known as COVID-19, started gaining the world’s attention after emerging as a global pandemic and one of the most prevalent public health issues in recent history. According to Platto et al. [1], the COVID-19 pandemic has spread to over 200 countries globally. After the virus spread to Europe and the United States, it gained enormous opportunities to increase prevalence and transmission. Since the development and global-level distribution of vaccines [2], there have been reports concerning vaccination intention [3,4] and vaccine hesitancy [4,5].

Vaccination is one of the most crucial public health tools for reducing the prevalence and harm caused by deadly diseases. However, vaccine hesitancy has resulted in a decrease in vaccine uptake and a rise in the prevalence of many diseases that could be prevented by vaccination [6]. Numerous studies have investigated COVID-19 vaccine hesitancy or intentions [7,8,9,10], and the results proved to be relatively similar across the world. Among nurses, stronger COVID-19 vaccination intention was attributed to greater vaccine confidence, younger age and a stronger sense of collective responsibility [7]. In the Turkish general population, age was negatively related to vaccination behaviour, while education and past experiences with other vaccines or with COVID-19 had positive association with intention [11]. Further, other aspects, such as vaccine safety, protecting others and the seriousness of the disease, were also linked with greater willingness to be vaccinated [12]. Hesitancy to vaccinate against COVID-19 is reported to have decreased during the lockdown, while acceptance of the COVID-19 vaccine might have been decreased by reference to the flu vaccine [8]. According to Malik et al. [13], factors such as gender, country location (rural/urban), income, level of education, perceived severity of infection, having a higher knowledge of COVID-19 and vaccination, perceived risk of being infected with the virus in the future, age and having previous vaccination experience after the age of 18 were found to significantly contribute to the acceptance of a vaccine for COVID-19. Additionally, a positive attitude towards government officials was related to higher intention to get vaccinated in the UK [14].

Guillon and Kergall [5] noted that a meticulously targeted vaccination awareness campaign with a view to promote vaccination among vaccine-hesitant individuals is likely to appeal to public policy decision-makers who are hoping to achieve herd immunity. Such campaigns can stress the positive benefit–risk balance of the virus vaccines, highlight the short-term advantages of being vaccinated and reassure the public about vaccine safety. Additionally, vaccination requires high acceptance and coverage rates before it can be successful; it also might even be mandatory in some situations [15].

2. State of Vaccination in Eastern Europe and Romania

Previous survey-based studies suggest that vaccination rates could be lower in some demographically defined groups, especially those with lower income and/or a lower level of education [3]. For this reason, it is only reasonable to give Eastern Europe, and explicitly Romania, special consideration in this study. Some Eastern European countries, such as Romania, Moldova and Ukraine, are reported to have quite a low number of expected deaths averted compared to many other countries in Europe. In this area, 60% or less of their population 60 years and older was fully vaccinated against COVID-19 by week 45 in 2021. Yet, the countries had a maximum of only 20% expected deaths averted over the study period [16]. Eastern European countries are among the worst in terms of COVID-19 vaccination rates, even though other countries experienced a lesser impact from vaccination [17].

Although vaccine hesitancy has been growing across continents, it is even more prevalent in Eastern Europe and Central Asia. A recent report [18] emphasised that most countries trust their doctors and nurses, whereas this is less true in Eastern European countries. This notion is further supported by the fact that only 75% of Romanian participants in a survey conducted in Eastern Europe agreed that vaccines are effective. This figure is even lower for Moldova and Ukraine; less than 50% of the participants from Moldova and Ukraine believed that the vaccines are effective [19]. This demonstrates significant disparity between these countries and other regions in Europe. Furthermore, a study conducted globally showed that Eastern Europe has the lowest scores for vaccine confidence in relation to other sub-regions worldwide [20].

De Figueiredo et al. [21] noted that parental education, employment status, workplace, religion, gender, poverty, distance to healthcare facilities and ethnic origin are linked to vaccine uptake with marked differences between countries. The trust of people in the government and healthcare professionals, political beliefs and perceived risks about potential side effects also impact on vaccine acceptance. Scholars have recommended that targeting mothers with low education, disseminating more information concerning vaccine benefits and risks, customising messages for specific groups and engagement efforts with people with low health literacy can help reduce vaccine hesitancy.

While the level of vaccination hesitancy is not encouraging in many countries, especially Romania, it represents an opportunity to change these perceptions. The issue of vaccine safety has long been discussed, as in the case of measles vaccinations. However, there is no reason to give up on positive vaccination messages. The current situation can be used to study the dynamics of vaccine hesitancy and, thereby, isolate and identify the issues that need to be addressed in an efficient vaccination campaign. Such an approach should provide solutions to an ongoing issue within Eastern European countries.

3. Critical Consciousness and Health-Related Behaviour

The literature on vaccination intention and hesitancy emphasises the negative impacts that social disparities, marginalisation and group inequities have on health-related attitudes and behaviours. Hence, there is growing interest in critical consciousness within health education [22,23,24,25]. The critical consciousness framework focuses on the role of the context within which individual perceptions of health are built. Therefore, critical consciousness can impact health-related behaviour in numerous ways. For example, health-related perceptions become the building blocks in forming health beliefs and the resulting actions. From this context emerges the need to focus on a broader concept of knowledge as the main outcome for health education and on raising critical consciousness as a central factor in building health-related attitudes [25].

Critical consciousness works to the benefit of individuals and groups by teaching them critical analysis skills and to reflect and act towards unjust social conditions. Therefore, critical consciousness is an analytical, constructive and mobilising process. The reflective and analytical component encourages participants to question everyday realities and think of the way in which health risks and other problems are related to larger, social aspects [23].

This part is fundamental because marginalisation causes individuals to believe that their perspectives are insignificant and they are powerless in facing, changing and overcoming social oppression. Therefore, as young people’s perception of social structures becomes more nuanced and complex, they become able to identify systemic inequities. As people mature and become more self-aware, they become less constrained by their social conditions and develop the capacity and degree of agency required to change these conditions; in this way, individuals overcome developmental challenges and set the course of their own lives [26,27].

Critical consciousness, defined as “the ability to engage in a reflective process regarding society’s prerogatives and action upon the world to transform it” [28] (p. 51), comprises three central elements: critical reflection, critical motivation and critical action. Critical Consciousness Theory requires critical reflection because it includes learning to identify contradictions within social, political and economic narratives and challenging the restrictive conditions of social reality. Critical reflection also refers to the cognitive changes that occur upon recognising the parts that power and dominance play in creating and maintaining systematic disparities between groups. Therefore, critical reflection involves the recognition that inequality and oppression are not moral and that change is required [27]. Critical action refers to individual or collective actions intended to change, challenge or contest perceived societal disparities [29]. Critical motivation/agency refers to one’s perceived ability to impact social change through one’s actions. People tend to engage in various actions if they feel that this will lead to some sort of change [26].

Health education represents a tool aimed at promoting health-related behaviours. Most of these initiatives are based on social cognition frameworks; people will make rational health decisions if they have adequate information about a particular health issue [30]. Therefore, health education promotes accurate, accessible and appropriate information for the lay public. The strategies used include presenting scientific data and opinions of health professionals to the lay public via mass media or information campaigns. Unfortunately, most strategies are based on a monologue and have reduced efficacy [24]. Research results show that information related to health risks does not necessarily translate into health-relevant behaviours [31]. Nevertheless, unidirectional health promotion campaigns remain the dominant style.

In addition to weak health promotion strategies, feelings of powerlessness or of lacking control over one’s own destiny can trigger various risk factors for negative health outcomes, whereas agency and empowerment are important promoters of health [32]. Critical consciousness serves to identify social inequities that affect one’s health-related behaviours and enacts social efforts to overturn these conditions and ensure some empowerment and control. While empowerment provides some directions for understanding how social disparities affect health, critical consciousness provides the tools for shifting mindsets from oppression to empowerment and feelings of control and participation in health-promoting behaviours [22].

4. The Present Study

Previous studies showed that, among both the senior population and youth, the level of COVID-19-related knowledge is relatively high [33,34,35]. Despite this, vaccination hesitancy remains an important topic in recent research. A review comparing various vaccine acceptance rates in multiple countries showed that, in Europe, the rates varied between 56% and 79%. However, a decrease with time was also noted [36]. The demographic correlates of vaccine hesitancy were studied across the world, with gender, age, education, political orientation, minority status or previous experiences with vaccines being the most important ones [37,38,39]. At the same time, the psychological factors related to vaccine hesitancy, especially those related to critical thinking, were less explored.

Previous research emphasised the role of critical consciousness in structuring health-related attitudes and behaviours; however, the impact on vaccination attitudes and behaviour has remained unexplored. The first aim of this study was to explore how critical consciousness can predict COVID-19 vaccination behaviour. Additionally, we aimed to study the impact critical consciousness can have on attitudes towards vaccination. Such attitudes may manifest as mistrust of vaccine benefit and concern regarding future effects and about commercial profiteering and preference for natural immunity. Finally, we were interested in verifying the mediation role of vaccination-related attitudes in the relationship between critical consciousness and vaccination behaviour. In describing these processes, we approached critical consciousness through its structural components (critical reflection, critical motivation and critical action) and explored how critical consciousness components relate to vaccination attitudes. It has been presumed that these components develop at the same time and reinforce each other [40]. However, recent evidence suggests that they can manifest independently and in different combinations [41]. We extended this restricted approach in three important directions. First, we addressed the aforementioned connection between critical consciousness components and COVID-19 vaccination behaviour. Second, the mechanisms linking critical consciousness components and vaccination behaviour were considered. To our knowledge, although the mechanisms linking critical consciousness and health-related behaviour were studied in relation to the AIDS epidemic [42,43], no previous study has analysed vaccination behaviour and vaccination attitudes as mediators for the relation between critical consciousness and vaccination behaviour. Given these considerations, the present study assesses the mediating role of COVID-19 vaccination attitudes (mistrust of vaccine benefit, concern about future effects, concern about commercial profiteering and preference for natural immunity), as measured by the Vaccination Attitudes Examination (VAX) Scale [44], within the relationship between critical consciousness and vaccination behaviour. In addition, by taking into consideration the relatively reduced rates of vaccination acceptance in Eastern Europe [45], this study sheds some light on an important issue regarding this region.

Hypothesis 1.

Considering the existing theoretical framework, we expected that critical motivation, critical reflection and critical action predict vaccination behaviour.

Hypothesis 2.

These components are associated with decreased levels of mistrust of vaccine benefit, worries about future effects, concern about commercial profiteering and preference for natural immunity.

Hypothesis 3.

Consequently, the mediation role of relevant vaccination attitudes is investigated in the relationship between critical consciousness and vaccination behaviour.

This research aims to advance knowledge in the field of critical consciousness and health-related behaviour—specifically COVID-19 vaccination behaviour—using a consistent sample of young adults in Eastern Europe. Hence, this study aims to provide supporting evidence of how critical consciousness helps to shape vaccination attitudes and, subsequently, how it relates to vaccination behaviour (Figure 1).

5. Method

5.1. Participants

Our study included a convenience sample recruited from urban and rural areas of Romania. The participants completed an online survey. Information related to informed consent was displayed on the first page. Participants received information concerning data security, the type of information being collected, how the information would be stored and how any identifying information would be delinked from the survey data. Participants were also informed that, by completing the survey, they were consenting to participate in the study. Further, they were instructed to save a copy of the document. Study participation was voluntary and anonymous. The entire sample comprised 1185 adults aged 18 to 41 (M = 22.67, SD = 5.90). The majority were women (84.1%), and 15.9% were men. There were no exclusion criteria for the participants based on demographic variables. Out of the entire sample, 46.8% (N = 554) were vaccinated, while 53.2% (N = 631) were not. The participants’ characteristics are reported in

Table 1. Sample characteristics.

Sample Characteristics	N	%	M	SD
Age			22.67	5.90
Gender
Female	997	84.1%
Male	188	15.9%
Country living area
Rural	663	55.9%
Urban	522	44.1%
Level of education
High school	229	19.3%
Bachelor level	781	65.9%
Master level	168	14.2%
Doctorate level	7	0.6%
COVID-19 vaccination status
Yes	554	53.2%
No	631	46.8%

.

5.2. Procedure

The study received approval from the Research Ethics Committee of the university. The research took place during October and December 2021. The participants were recruited from various social media groups. Announcements regarding the research were posted on Facebook groups and on Instagram. They contained the link to the online form containing the questionnaires. The participants were invited to read the informed consent form and provide their demographic information. Before starting the study, the respondents were informed that participation was voluntary, and they could withdraw from the study at any point. They also received information regarding data gathering, security and maintenance. The questionnaire took around 15–20 min to complete. This study was carried out following the recommendations of the Code of Ethics of the university. The protocol was approved by the Ethics Committee for Research of the Faculty of Psychology and Educational Sciences (no. 1220/6 September 2021). Following the Declaration of Helsinki, all participants gave written, informed consent for their participation in the study.

6. Measures

All measuring instruments were translated from English into Romanian using the forward-backward translation design [46]. Where necessary, we corrected the translations based on the back-translation process.

6.1. Critical Consciousness

Components of the Critical Consciousness Scale—Short Form (CCS-S) [47] were used to measure critical consciousness. This scale evaluates three components: critical reflection/perceived inequalities (three items), critical motivation (four items) and critical action (four items). For the first two sub-scales, respondents responded using a six-point Likert-type agreement scale ranging from 1 (strongly disagree) to 6 (strongly agree). The critical action sub-scale reflects the frequency of involvement in socio-political actions. This measure supports inquiry intended to elicit a more nuanced understanding of the pathways of critical consciousness [47]. The construct validity of the measure was tested by employing confirmatory factor analysis (CFA) and Cronbach’s alpha reliability index. The Cronbach’s alpha coefficient ranged from 0.72 for critical motivation and 0.75 for critical action to 0.81 for critical reflection. The confirmatory factor analysis carried out indicated a good model fit (χ2 (71) = 651.75, p < 0.001; RMSEA = 0.063 (90% CI = (0.058, 0.067)); CFI = 0.935; TLI = 0.916).

6.2. Vaccination Attitudes

The Vaccination Attitudes Examination (VAX) Scale [44] investigates four distinct attitudes to the vaccine: mistrust of vaccine benefit, worries about unforeseen effects, concern about commercial profiteering and preference for natural immunity. Each factor includes three items, and each statement is evaluated on a six-point Likert-type scale ranging from strongly agree to strongly disagree. For this study, the validity of this scale was tested by employing confirmatory factor analysis and Cronbach’s alpha reliability coefficient. The confirmatory factor analysis indicated a good model fit (χ2 (48) = 465.26, p < 0.001; RMSEA = 0.065 (90% CI = (0.059, 0.070)); CFI = 0.976; TLI = 0.967). The Cronbach’s alpha coefficients were 0.72 for worries about unforeseen effect, 0.84 for preference for natural immunity, 0.88 for concerns about commercial profit and 0.94 for mistrust of vaccine benefits. Although this short scale represents a general vaccination attitude measure, the respondents were asked to rate their responses thinking of the COVID-19 vaccination. The authors acknowledge that attitudes towards vaccination can change by vaccine type, but negative attitudes may co-occur. Therefore, a single measure may be the most suitable way to identify individuals that harbour vaccine-related concerns [44].

6.3. Vaccination Behaviour

Vaccination behaviour was assessed with a dichotomous item (yes/no), asking whether the respondent decided to receive a COVID-19 vaccine in the prior year.

7. Results

Descriptive Statistics and Preliminary Analysis

Table 2. Descriptive statistics, reliability estimates and correlations among study variables.

Variables		1	2	3	4	5	6	7	8
Critical consciousness
1.	Critical reflection	0.816
2.	Critical motivation	0.014	0.729
3.	Critical action	0.099 **	0.087 **	0.757
Vaccination attitudes
4.	Mistrust of vaccine benefits	−0.114 **	−0.079 **	0.003	0.944
5.	Worries about unforeseen effects	−0.065 *	0.033	0.005	0.540 **	0.723
6.	Concerns about commercial profit	−0.029	0.030	0.080 **	0.681 **	0.631 **	0.884
7.	Preference for natural immunity	−0.034	0.034	0.098 **	0.561 **	0.534 **	0.679 **	0.844
Vaccination behaviour
8.	COVID-19 vaccination behaviour	0.117 **	0.061	−0.018	−0.612 **	−0.401 **	−0.440 **	−0.385 **	1
Mean		7.78	19.76	3.11	10.69	13.08	10.43	10.91
SD		3.47	3.89	3.79	5.32	3.92	4.82	4.38

Note: ** p ≤ 0.01 (two-tailed); * p < 0.05 (two-tailed) Cronbach’s alpha coefficients are shown on the diagonal.

reports the Spearman correlations for all the correlations involving vaccination behaviour and the Pearson’s correlations, Cronbach’s alpha reliability index, means and standard deviations between the investigated variables. Critical reflection showed significant correlations between mistrust of vaccine benefits and worries about unforeseen effects in the investigated directions. Specifically, critical reflection was negatively associated with mistrust of vaccine benefits and worries about unforeseen effects and positively associated with vaccination behaviour. Moreover, we explored the relationship between critical reflection and vaccination behaviour and the linking mechanisms by exploring the mediation role of vaccination attitudes. Due to the non-significant correlations, i.e., the lack of a linear relationship between critical action, critical motivation and vaccination attitudes, we decided to no longer include critical action and critical motivation in the analysis as predictors.

8. Testing the Mediational Role of Vaccination Attitudes

Based on the observed correlations, we tested the mediational role of mistrust of vaccine benefits and worries about unforeseen effects. To test the hypothesised mediation model, the custom dialogue Process 4.0 for IBM SPSS version 24 for Windows was used [48]. The Process 4.0 macro can be used to test mediation effects when the dependent variable in the model is binary. This solution enables simultaneous testing of multiple mediators while providing bootstrap confidence intervals (CIs) for the indirect effects [48]. In addition, this protocol allows building bootstrap-based confidence intervals to test the significance of mediation effects in nonparametric and reduced biased conditions [49]. In the present study, the multiple mediation analysis was carried out using regression analysis and 5000 resamples (for estimating 95% CI). Age and gender were controlled by being introduced as covariates in the model.

The mediational analysis showed that the effect of critical reflection on mistrust of vaccine benefits is negative and significant (b = −0.13, SE = 0.04, p < 0.001), indicating that individuals scoring higher on critical reflection are more likely to trust the vaccine benefits. The path from critical reflection to worries about unforeseen future effects is negative and significant (b = −0.07, SE = 0.03, p < 0.050). Moreover, the path from mistrust to vaccination behaviour is negative and significant (b = −0.27, SE = 0.01, p < 0.001), as is the effect of worries about unforeseen future effects on vaccination behaviour (b = −0.08, SE = 0.02, p < 0.001). This shows that if individuals worry a lot about future vaccine effects or mistrust its benefits, then they are more likely to refuse vaccination. The direct effect of critical reflection on vaccination behaviour is positive and significant in the model.

Table 3. Results for the regression models used for testing the multiple mediation.

	Coefficient	SE	t	p
Mistrust of vaccine benefits as outcome (M)
Critical reflection	−0.13	0.04	−3.04	0.000
Worries about unforeseen future effects as outcome (M)
Critical reflection	−0.07	0.03	−2.10	0.035
Vaccination behaviour as outcome (DV)
Critical reflection	0.05	0.02	2.43	0.014
Mistrust of vaccine benefits	−0.27	0.01	−15.15	0.000
Worries about unforeseen future effects	−0.08	0.02	−3.89	0.000

displays the complete results of the multiple regressions testing these effects.

The indirect effects of mistrust of vaccine benefits (B = 0.037, SE = 0.013, 95% BCa CI: 0.012, 0.062) and worries about unforeseen future effects (B = 0.006, SE = 0.003, 95% BCa CI: 0.001, 0.014) support the mediation hypothesis presumed between critical reflection and vaccination behaviour (see

Table 4. Mediation effects between critical reflection and COVID-19 vaccination behaviour.

	Coefficient	Standard Error	Confidence Interval	95%
			Lower Limit	Upper Limit
Critical reflection (IV)
Mistrust of vaccine benefits	0.037 a	0.013	0.012	0.062
Worries about unforeseen future effects	0.006 a	0.003	0.001	0.014

Boldface highlights significant mediation effects ^a Indirect effect of critical reflection on vaccination behaviour for each proposed mediator.

).

Overall, the results partially support our hypothesised mediation model (see Figure 2), revealing that the link between critical reflection and vaccination behaviour is mediated by vaccination attitudes (see Table 4). Using a post hoc power calculator [50], the statistical power for the indirect effect for the used sample was shown to be 91% at p < 0.05 with 20,000 Monte Carlo replications.

9. Discussions

Considering the persistent issue of vaccination hesitancy in Eastern Europe, the present study approached vaccination behaviour from a different perspective. Besides good forecasting and diagnosis techniques [51,52], fostering the psychological factors that can also impact vaccination behaviours is also necessary. As a core process in critical consciousness, critical reflection represents a learning process that identifies social, political and economic contradictions. In other words, individuals learn to analyse the elements and structures present in their social environment. Therefore, critical reflection concerns the recognition of inequality and disparities, and, through critical motivation and action, change is acquired [27]. During this process, individuals learn to identify useful resources for overcoming negative aspects of limiting conditions. From a socio-economic point of view, Romania represents a cultural region affected by significant social disparities. Vaccination hesitancy has represented an issue in the region for many years now, as with the case of measles vaccinations. The COVID-19 vaccination situation creates an opportunity to study the dynamics of vaccine hesitancy and to help create efficient vaccination campaigns, thus, providing solutions to an ongoing health issue in this region.

The present research examined the relationship between critical consciousness components, vaccination attitudes related to COVID-19 and vaccination behaviour in a large sample of adults. We examined whether vaccination attitudes mediate the relation between critical consciousness and vaccination behaviour. Our results show that critical reflection is positively associated with vaccination behaviour while being negatively associated with two types of negative vaccination attitude: mistrust of vaccine benefits and worries about unforeseen effects of vaccination. Our results are in line with other findings that evaluated the development of critical consciousness to support health-related behaviours, especially regarding the AIDS epidemic [23,42,43]. Collectively, these results show that the development of critical consciousness can be an impactful way to reduce the negative effects of large-scale health crises.

Furthermore, our results provide evidence for the mediational role of vaccination attitudes in the relationship between critical consciousness and vaccination behaviour, showing significant indirect effects. Previous theoretical formulations [23,24,31,42,43] emphasised the importance of critical consciousness in developing health-related behaviours, especially its core process, critical reflection, which facilitates the recognition of society’s prerogatives and leads to social action. Moreover, critical consciousness was previously related to well-being during the COVID-19 pandemic. Critical reflection was linked to both higher anxiety and higher hopefulness [53]. This could explain the associations we found between critical reflection, vaccination attitudes and vaccination behaviours. When people recognise the inequalities and disparities in their environment, they could become more aware of the dangers of the pandemic, as well as more hopeful that they can overcome them. Thus, they become less susceptible to misinformation and develop more positive attitudes towards vaccination, which, in turn, can act as a strong incentive to vaccinate.

Critical reflection can assist individuals in developing health-related attitudes by identifying social inequities that may negatively impact their health-related behaviours, enacting social action efforts to combat these conditions and building an overall sense of empowerment and control. The results of the present study could assist in shaping future health promotion campaigns. Most of these initiatives are based on the idea that people tend to make rational decisions with respect to their health if they have access to information regarding a particular health issue [30]. Therefore, health education has focused mostly on providing accurate and accessible information to the lay public. The channels used to disseminate information from field experts to the lay public have been mass media and awareness-raising campaigns. Unfortunately, this type of communication constitutes a monologue and has reduced efficacy in terms of behaviour [24].

The main issues for health-related campaigns, such as vaccination, regard the nature of the communication, i.e., whether the communication occurs between oneself and others or between actors and whether the ideal of genuine communication is achieved regardless the field (e.g., health education, teaching or raising awareness over an issue). To reach authentic communication, dialogue must be framed as a horizontal relationship between parts and characterised by empathy and mutual recognition [54]. In opposition, anti-dialogue represents a vertical relationship that lacks empathy or recognition. Communication is at the core of behaviour-changing initiatives across a range of sectors. However, for communication to occur, there is a need for all participants in the communicative interaction (e.g., experts, laypeople, teachers, students and those who are agentic or marginalised) to change their mentality, which is far less often acknowledged by those working towards social change [24]. If genuine communication is reached, then it manages to authentically raise awareness that will engage individuals in social behaviour, including vaccination acceptance. Additionally, mistrust in authorities was shown to be an important determinant of vaccine hesitancy, while also being related to negative attitudes towards the vaccines [55,56]. In order to foster critical consciousness and, thus, decrease negative vaccination attitudes and behaviours, the authorities can work towards increasing people’s opportunities to become involved in local community organisations and in community decision making, giving them more citizen power and more chances to know and appreciate communal help in increasing positive behaviours [43].

In interpreting these results, some limitations should be noted. First, our research was limited to only COVID-19 vaccination behaviour and did not investigate attitudes towards other vaccine types. Second, using a cross-sectional design prevented us from drawing any inferences regarding the causality of the relationships between critical consciousness, vaccination attitudes and vaccination behaviour. Moreover, the research sample characteristics were also a source of limitations as the sample consisted mostly of female, young and well-educated participants, which limits the generalisation of the results. Although the sample was large, given that we used convenience sampling, the characteristics of our participants also followed the general characteristics of the population that usually use social media. Thus, we cannot generalise the results to any other age groups except young adults. Therefore, future research should consider samples with similar ratios of men and women. In addition, given that senior individuals are especially at risk and that their lifestyle was particularly altered during the pandemic [34], future studies could expand our results by taking into consideration more elderly populations. Further, extensive measures of critical reflection should be used to avoid measurement errors. Despite the limitations, the research findings enrich both the literature on critical consciousness and health-related education. In conclusion, our results highlight the importance of incorporating critical consciousness development in health-related campaigns such as vaccination campaigns.