{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T06:59:01Z","timestamp":1764831541721,"version":"3.46.0"},"reference-count":57,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2025,11,30]],"date-time":"2025-11-30T00:00:00Z","timestamp":1764460800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000161","name":"National Institute of Standards and Technology","doi-asserted-by":"crossref","award":["60NANB22D052"],"award-info":[{"award-number":["60NANB22D052"]}],"id":[{"id":"10.13039\/100000161","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100005825","name":"U.S. Department of Agriculture, National Institute of Food and Agriculture","doi-asserted-by":"crossref","award":["7005426"],"award-info":[{"award-number":["7005426"]}],"id":[{"id":"10.13039\/100005825","id-type":"DOI","asserted-by":"crossref"}]},{"name":"Institute for Trustworthy AI in Law and Society","award":["IIS-2229885"],"award-info":[{"award-number":["IIS-2229885"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Behavioral Sciences"],"abstract":"<jats:p>Although viral outbreaks are increasing, vaccination rates are decreasing. Our aim was to explain this baffling behavior that seems to contradict rational self-interest, and, thus, be beyond the purview of rational choice theories. We integrated fuzzy-trace theory and major theoretical alternatives and applied them to influenza, testing theoretical predictions in two samples: young adults (who are major viral vectors), N = 722, and community members, N = 185. Controlling for prior knowledge and other psychosocial factors that influence vaccination, explained variance jumped significantly when key predictors from fuzzy-trace theory were added, reaching 62% and 80% for vaccination intentions and 37% and 59% for behavior for each sample, respectively. Single items assessing global gist perceptions of risks and benefits achieved remarkable levels of diagnosticity. Key predictors were intuitive in that they were gisty, imprecise, and non-analytical. In contrast, rational system 2 measures\u2014numeracy and cognitive reflection\u2014were not predictive. These results provide new insights into why individuals vaccinate or not and new avenues for interventions to improve shared clinical decision-making.<\/jats:p>","DOI":"10.3390\/bs15121645","type":"journal-article","created":{"date-parts":[[2025,12,1]],"date-time":"2025-12-01T13:03:02Z","timestamp":1764594182000},"page":"1645","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A New Look at Vaccination Behaviors and Intentions: The Case of Influenza"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2851-5797","authenticated-orcid":false,"given":"Valerie F.","family":"Reyna","sequence":"first","affiliation":[{"name":"Department of Psychology, Cornell University, G331D Martha Van Rensselaer Hall, Ithaca, NY 14850, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9431-5606","authenticated-orcid":false,"given":"Sarah M.","family":"Edelson","sequence":"additional","affiliation":[{"name":"Department of Psychology, Cornell University, G331D Martha Van Rensselaer Hall, Ithaca, NY 14850, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4903-9486","authenticated-orcid":false,"given":"David M. N.","family":"Garavito","sequence":"additional","affiliation":[{"name":"Department of Psychology, Cornell University, G331D Martha Van Rensselaer Hall, Ithaca, NY 14850, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1106-9754","authenticated-orcid":false,"given":"Michelle M.","family":"Galindez","sequence":"additional","affiliation":[{"name":"Department of Psychology, Cornell University, G331D Martha Van Rensselaer Hall, Ithaca, NY 14850, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9767-7901","authenticated-orcid":false,"given":"Aadya","family":"Singh","sequence":"additional","affiliation":[{"name":"Department of Psychology, Cornell University, G331D Martha Van Rensselaer Hall, Ithaca, NY 14850, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Julia","family":"Fan","sequence":"additional","affiliation":[{"name":"Department of Psychology, Cornell University, G331D Martha Van Rensselaer Hall, Ithaca, NY 14850, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-8839-1239","authenticated-orcid":false,"given":"Jiwoo","family":"Suh","sequence":"additional","affiliation":[{"name":"Department of Psychology, Cornell University, G331D Martha Van Rensselaer Hall, Ithaca, NY 14850, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,11,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1016\/0749-5978(91)90020-T","article-title":"The theory of planned behavior","volume":"50","author":"Ajzen","year":"1991","journal-title":"Organizational Behavior and Human Decision Processes"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1177\/0963721412471347","article-title":"Peer influences on adolescent decision making","volume":"22","author":"Albert","year":"2013","journal-title":"Current Directions in Psychological Science"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"781","DOI":"10.1037\/hea0000384","article-title":"Using fuzzy-trace theory to understand and improve health judgments, decisions, and behaviors: A literature review","volume":"35","author":"Blalock","year":"2016","journal-title":"Health Psychology"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"642","DOI":"10.1080\/00909882.2024.2385348","article-title":"Straight from the horse\u2019s mouth: Communicating the gist of mRNA vaccines","volume":"52","author":"Brace","year":"2024","journal-title":"Journal of Applied Communication Research"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1037\/dec0000083","article-title":"A formal model of fuzzy-trace theory: Variations on framing effects and the Allais Paradox","volume":"5","author":"Broniatowski","year":"2018","journal-title":"Decision"},{"key":"ref_6","unstructured":"Centers for Disease Control and Prevention [CDC] (2025, November 20). Flu vaccination coverage, United States, 2023\u201324 influenza season, Available online: https:\/\/www.cdc.gov\/fluvaxview\/coverage-by-season\/2023-2024.html."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e70057","DOI":"10.1111\/irv.70057","article-title":"A missed opportunity? Exploring changes in influenza vaccination coverage during the COVID-19 pandemic: Data from 12 countries worldwide","volume":"19","author":"Guida","year":"2025","journal-title":"Influenza and Other Respiratory Viruses"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1763","DOI":"10.4161\/hv.24657","article-title":"Vaccine hesitancy: An overview","volume":"9","author":"Laberge","year":"2013","journal-title":"Human Vaccines & Immunotherapeutics"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1086\/695776","article-title":"Is the preference for certainty always so certain?","volume":"3","author":"Duke","year":"2018","journal-title":"Journal of the Association for Consumer Research"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"6269","DOI":"10.1016\/j.vaccine.2021.09.010","article-title":"Predicting COVID-19 vaccination intention using protection motivation theory and conspiracy beliefs","volume":"39","author":"Eberhardt","year":"2021","journal-title":"Vaccine"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1037\/dec0000231","article-title":"Dual-systems and fuzzy-trace theory predictions of COVID-19 risk taking in young adults","volume":"11","author":"Edelson","year":"2024","journal-title":"Decision"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"672","DOI":"10.1177\/0272989X07304449","article-title":"Measuring numeracy without a math test: Development of the Subjective Numeracy Scale","volume":"27","author":"Fagerlin","year":"2007","journal-title":"Medical Decision Making"},{"key":"ref_13","unstructured":"Fishbein, M. (1967). Attitude and the prediction of behavior. Readings in attitude theory and measurement, Wiley."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"834","DOI":"10.1177\/0272989X08326092","article-title":"A reasoned action approach to health promotion","volume":"28","author":"Fishbein","year":"2008","journal-title":"Medical Decision Making"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1257\/089533005775196732","article-title":"Cognitive reflection and decision making","volume":"19","author":"Frederick","year":"2005","journal-title":"Journal of Economic Perspectives"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"799","DOI":"10.1111\/j.1467-9280.2009.02372.x","article-title":"Moving beyond deliberative control of impulses: The effect of construal levels on evaluative associations in self-control conflicts","volume":"20","author":"Fujita","year":"2009","journal-title":"Psychological Science"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1002\/acp.3734","article-title":"Intentions to report concussion symptoms in nonprofessional athletes: A fuzzy-trace theory approach","volume":"35","author":"Garavito","year":"2021","journal-title":"Applied Cognitive Psychology"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1200","DOI":"10.1002\/acp.4002","article-title":"False memories for true and false vaccination information form in line with pre-existing vaccine opinions","volume":"36","author":"Greene","year":"2022","journal-title":"Applied Cognitive Psychology"},{"key":"ref_19","unstructured":"Kahneman, D. (2011). Thinking, fast and slow, Farrar, Straus and Giroux."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1689","DOI":"10.1038\/s41562-024-01940-6","article-title":"A systematic review and meta-analysis of strategies to promote vaccination uptake","volume":"8","author":"Liu","year":"2024","journal-title":"Nature Human Behaviour"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"23814683221115416","DOI":"10.1177\/23814683221115416","article-title":"Gist representations and decision-making processes affecting antibiotic prescribing for children with acute otitis media","volume":"7","author":"Marti","year":"2022","journal-title":"MDM Policy & Practice"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"114403","DOI":"10.1016\/j.socscimed.2021.114403","article-title":"Do cognitive styles affect vaccine hesitancy? A dual-process cognitive framework for vaccine hesitancy and the role of risk perceptions","volume":"289","author":"Martinelli","year":"2021","journal-title":"Social Science & Medicine (1982)"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1093\/cid\/ciae180","article-title":"Incidence of influenza-related medical encounters and the associated healthcare resource use and complications across adult age groups in the United States during the 2015\u20132020 influenza seasons","volume":"79","author":"McGovern","year":"2024","journal-title":"Clinical Infectious Diseases"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e2409191121","DOI":"10.1073\/pnas.2409191121","article-title":"Cognitive reflection is a distinct and measurable trait","volume":"121","author":"Meyer","year":"2024","journal-title":"Proceedings of the National Academy of Sciences of the United States of America"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"246","DOI":"10.1017\/S1930297500007683","article-title":"The non-effects of repeated exposure to the Cognitive Reflection Test","volume":"13","author":"Meyer","year":"2018","journal-title":"Judgment and Decision Making"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1111\/j.1467-9280.2008.02104.x","article-title":"Explaining contradictory relations between risk perception and risk taking","volume":"19","author":"Mills","year":"2008","journal-title":"Psychological Science"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1038\/s41467-020-20226-9","article-title":"Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom","volume":"12","author":"Murphy","year":"2021","journal-title":"Nature Communications"},{"key":"ref_28","unstructured":"National Academies of Sciences, Engineering, and Medicine (2020). Encouraging protective COVID-19 behaviors among college students, The National Academies Press."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Peters, E. (2020). Innumeracy in the wild: Misunderstanding and misusing numbers, Oxford University Press.","DOI":"10.1093\/oso\/9780190861094.001.0001"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"6451","DOI":"10.1016\/j.vaccine.2014.09.047","article-title":"Relative timing of influenza disease by age group","volume":"32","author":"Peters","year":"2014","journal-title":"Vaccine"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"850","DOI":"10.1177\/0272989X08327066","article-title":"A theory of medical decision making and health: Fuzzy trace theory","volume":"28","author":"Reyna","year":"2008","journal-title":"Medical Decision Making"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"3790","DOI":"10.1016\/j.vaccine.2011.11.070","article-title":"Risk perception and communication in vaccination decisions: A fuzzy-trace theory approach","volume":"30","author":"Reyna","year":"2012","journal-title":"Vaccine"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e1912441117","DOI":"10.1073\/pnas.1912441117","article-title":"A scientific theory of gist communication and misinformation resistance, with implications for health, education, and policy","volume":"118","author":"Reyna","year":"2021","journal-title":"Proceedings of the National Academy of Sciences of the United States of America"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1111\/1539-6924.00332","article-title":"Fuzzy-trace theory, risk communication, and product labeling in sexually transmitted diseases","volume":"23","author":"Reyna","year":"2003","journal-title":"Risk Analysis"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1016\/j.lindif.2007.03.010","article-title":"The importance of mathematics in health and human judgment: Numeracy, risk communication, and medical decision making","volume":"17","author":"Reyna","year":"2007","journal-title":"Learning and Individual Differences"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"421","DOI":"10.1038\/s44159-023-00188-7","article-title":"Numeracy, gist, literal thinking and the value of nothing in decision making","volume":"2","author":"Reyna","year":"2023","journal-title":"Nature Reviews Psychology"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1016\/j.jarmac.2021.08.004","article-title":"Viruses, vaccines, and COVID-19: Explaining and improving risky decision-making","volume":"10","author":"Reyna","year":"2021","journal-title":"Journal of Applied Research in Memory and Cognition"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jarmac.2015.12.003","article-title":"How fuzzy-trace theory predicts true and false memories for words, sentences, and narratives","volume":"5","author":"Reyna","year":"2016","journal-title":"Journal of Applied Research in Memory and Cognition"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"741","DOI":"10.1177\/0272989X221105473","article-title":"Supporting health and medical decision making: Findings and insights from fuzzy-trace theory","volume":"42","author":"Reyna","year":"2022","journal-title":"Medical Decision Making"},{"key":"ref_40","first-page":"1125","article-title":"Neurobiological and memory models of risky decision making in adolescents versus young adults","volume":"37","author":"Reyna","year":"2011","journal-title":"Journal of Experimental Psychology: Learning, Memory, and Cognition"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1111\/j.1529-1006.2006.00026.x","article-title":"Risk and rationality in adolescent decision making: Implications for theory, practice, and public policy","volume":"7","author":"Reyna","year":"2006","journal-title":"Psychological Science in the Public Interest"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1627","DOI":"10.1037\/a0036717","article-title":"Theoretically motivated interventions for reducing sexual risk taking in adolescence: A randomized controlled experiment applying Fuzzy-Trace Theory","volume":"143","author":"Reyna","year":"2014","journal-title":"Journal of Experimental Psychology: General"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"746","DOI":"10.3758\/s13415-022-01058-0","article-title":"Critical tests of fuzzy trace theory in brain and behavior: Uncertainty across time, probability, and development","volume":"23","author":"Reyna","year":"2023","journal-title":"Cognitive, Affective & Behavioral Neuroscience"},{"key":"ref_44","first-page":"1453","article-title":"High in numeracy, high in reflection, but still irrationally biased: How gist explains risky choices","volume":"51","author":"Reyna","year":"2025","journal-title":"Journal of Experimental Psychology: Learning, Memory, and Cognition"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1080\/00223980.1975.9915803","article-title":"A protection motivation theory of fear appeals and attitude change","volume":"91","author":"Rogers","year":"1975","journal-title":"The Journal of Psychology: Interdisciplinary and Applied"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1177\/109019817400200403","article-title":"Historical origins of the health belief model","volume":"2","author":"Rosenstock","year":"1974","journal-title":"Health Education Monographs"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"S276","DOI":"10.2105\/AJPH.2020.305908","article-title":"Who is susceptible to online health misinformation?","volume":"110","author":"Scherer","year":"2020","journal-title":"American Journal of Public Health"},{"key":"ref_48","first-page":"573","article-title":"Typical versus atypical unpacking and superadditive probability judgment","volume":"30","author":"Sloman","year":"2004","journal-title":"Journal of Experimental Psychology: Learning, Memory, and Cognition"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1495","DOI":"10.1093\/cid\/civ630","article-title":"Association of influenza vaccination coverage in younger adults with influenza-related illness in the elderly","volume":"61","author":"Taksler","year":"2015","journal-title":"Clinical Infectious Diseases"},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"Thoma, V., Weiss-Cohen, L., Filkukov\u00e1, P., and Ayton, P. (2021). Cognitive predictors of precautionary behavior during the COVID-19 pandemic. Frontiers in Psychology, 12.","DOI":"10.3389\/fpsyg.2021.589800"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"3256","DOI":"10.1007\/s12144-019-00268-z","article-title":"Cognitive and emotional factors in health behaviour: Dual-process reasoning, cognitive styles and optimism as predictors of healthy lifestyle, healthy behaviours and medical adherence","volume":"40","author":"Tomljenovic","year":"2021","journal-title":"Current Psychology"},{"key":"ref_52","unstructured":"von Neumann, J., and Morgenstern, O. (1944). Theory of games and economic behavior, Princeton University Press."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"714","DOI":"10.1002\/acp.3448","article-title":"Effects of probabilities, adverse outcomes, and status quo on perceived riskiness of medications: Testing explanatory hypotheses concerning gist, worry, and numeracy","volume":"32","author":"Wilhelms","year":"2018","journal-title":"Applied Cognitive Psychology"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1177\/0272989X14535983","article-title":"Efficacy of a web-based intelligent tutoring system for communicating genetic risk of breast cancer: A fuzzy-trace theory approach","volume":"35","author":"Wolfe","year":"2015","journal-title":"Medical Decision Making"},{"key":"ref_55","unstructured":"World Health Organization (2025, November 20). Influenza (seasonal), Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/influenza-(seasonal)."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"5131","DOI":"10.1016\/j.vaccine.2020.04.076","article-title":"Vaccine hesitancy and perceived behavioral control: A meta-analysis","volume":"38","author":"Xiao","year":"2020","journal-title":"Vaccine"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"127002","DOI":"10.1016\/j.vaccine.2025.127002","article-title":"Applying the health belief model (HBM) to understand COVID-19 vaccine uptake among youth and young adults: Findings from a 6-month follow-up study in the United States","volume":"54","author":"Xu","year":"2025","journal-title":"Vaccine"}],"container-title":["Behavioral Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-328X\/15\/12\/1645\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T05:24:17Z","timestamp":1764825857000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-328X\/15\/12\/1645"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,30]]},"references-count":57,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["bs15121645"],"URL":"https:\/\/doi.org\/10.3390\/bs15121645","relation":{},"ISSN":["2076-328X"],"issn-type":[{"type":"electronic","value":"2076-328X"}],"subject":[],"published":{"date-parts":[[2025,11,30]]}}}