Political Partisanship, Confucian Collectivism, and Public Attitudes toward the Vaccination Policy in Taiwan

Abstract

Context: Conventional wisdom suggests that people with a collectivist tradition tend to comply more with the government's regulatory and even coercive disease-prevention policies. In addition to this sociocultural element, political partisanship is also an important aspect relating to people's willingness to cooperate with the government. This study aims to examine the relationships between these two factors and three dimensions of vaccination policy attitudes: common responsibility to take the vaccine, the government's vaccine mandate, and indignation over anti-vaxxers.

Methods: Using data from a nationally representative cross-sectional survey conducted in 2022 in Taiwan, this study applies multiple linear ordinary least squares regression to examine the relationships between vaccination policy attitudes and Confucian collectivism and political partisanship.

Findings: Confucian collectivism and political partisanship aligning with the ruling party are associated with attitudes supporting vaccination policy. For those who do not align with the ruling party, negative attitudes toward the vaccination policy appear in different dimensions according to the party they lean toward.

Conclusions: Confucian collectivism is prevalent in Taiwan and is related to public attitudes toward vaccination policy. This association is independent of political partisanship. Public health authorities should consider the sociocultural context and political atmosphere for the effectiveness of disease-prevention measures.

Vaccination is one of the most effective public health measures for tackling the health impacts brought on by the COVID pandemic. However, increasing vaccine hesitancy has challenged the effectiveness of vaccination policies. Besides vaccination, governments have adopted other nonpharmaceutical interventions, such as lockdowns, mask mandates, and social distancing, to prevent the transmission of SARS-Cov-2, the virus that causes COVID-19. Since the early stages of the COVID pandemic, there has been a debate regarding public attitudes toward and willingness to adopt or comply with these governmental measures.

While many people in the United States and European countries have argued that these measures are coercive in nature and have infringed on people's civil liberties and individual autonomy, in other places around the globe, particularly in East Asian countries, people seem to be relatively fine with these coercive measures. For example, Asians are more willing to uptake vaccines than other ethnic groups (Dorman et al. 2021). COVID vaccination rates are high (above 80%) in many East Asian countries, including Japan, Korea, China, Singapore, and Taiwan (TCDC 2022; WHO n.d.). A potential explanation for this compliance is that it is because East Asians inherit and uphold collectivist sociocultural traditions, specifically the Confucian tradition and the legacies and/or the current rule of authoritarian governance, and they are more willing to be “good” citizens or even obedient subjects; hence their compliance with coercive disease-prevention measures (Jennings 2020). Another related factor is that autocracy or authoritarian governance may be, under some circumstances, more effective than democracy when enacting strict, rapid responses to tackle the threats of pandemics in their early stages (Kavanagh 2020). If people uphold authoritarian values or do not oppose authoritarian governance, they would be more willing to comply with these seemingly coercive measures.

Other scholars have contended that these coercive measures are not passively complied with but instead are actively adopted by the citizens (Yeh and Cheng 2020; Yen and Liu 2021). They argue that East Asian people are more willing to adopt these disease-prevention measures autonomously because they care more about the collective interest, that is, the health and life of their fellow citizens and codwellers, and have a stronger sense of solidarity in health. Therefore, some East Asian societies maintained better health outcomes in the early stages of the pandemic and displayed stronger community resilience as the COVID pandemic continued.

Besides the sociocultural explanations, political partisanship has also been identified as a major aspect relating to public attitudes toward and willingness to adopt or comply with governmental disease-prevention measures that have been politicized and used by opposition parties (along with other conspiracies) as a means of political mobilization against the ruling party in the government (Grossman et al. 2020; Halimatusa'diyah and Durriyah 2023; Viskupič and Wiltse 2023). In certain democracies, radical political parties rise along with populist sentiments, which have negative impacts on the overall quality and effectiveness of political decision-making and public trust in the established scientific community, health authorities, and institutions that are crucial for actions addressing pandemics and other public health emergencies (Eberl, Huber, and Greussing 2021; McKee et al. 2021). People who lean more toward the populist parties are also less likely to acknowledge the effectiveness of vaccines (Kennedy 2019).

Note that the public's attitudes toward the vaccine itself and toward vaccination policy are two related but different dimensions. Attitudes toward the vaccine reflect attitudes toward the vaccine as a health technology, a result of bioscience, a branded product, a means to prevent disease transmission, and the willingness or hesitancy to take the vaccine. These attitudes are relevant to public health activities aiming to enhance vaccination rates; however, they do not necessarily relate to the government's actions and exercise of coercive powers. Attitudes toward vaccination policy alternatively reflect attitudes toward policy arrangements, citizens’ relationships with one another and the government, and the acceptability of the government's measures limiting people's autonomy or rights (Yeh 2022). These attitudes are specific to the ethical dimensions of how citizens conceive of their responsibilities, which would constitute the legitimate foundation for state-based public health activities. Informed by these ethical considerations, this study focuses on attitudes toward vaccination policy, which have received less attention in the literature.

Using the data from a nationally representative survey conducted in 2022 in Taiwan, this study aims to consider both the sociocultural factors, particularly the Confucian tradition, and political partisanship and to examine their relationships with public attitudes toward vaccination policy during public health emergencies like the COVID pandemic.

The Politicization of Vaccination Policy in Taiwan

By politicization, we refer to actions that make a previously unpolitical topic “a subject of public discussion and will have . . . significant effects on the quality of political decision making” (Zürn 2014: 48). We are specifically interested in the actions that make disease-prevention measures political in Taiwan, so we first start with a brief overview of the nation's political context.

Taiwan is a democratic state in East Asia. On the one hand, it has a profound sociocultural tradition in Confucianism; on the other, it has a vigorous civil society and a mature environment for political activities after its democratization in the 1990s, which followed about 50 years of authoritarian governance. During the first approximately two years of the COVID pandemic, from January 2020 to April 2022, Taiwan managed to contain community transmission and maintained low infection and death rates by adopting strict border control, quarantines, case tracing, mask mandates, social distancing, universal vaccination, and other regulations influencing people's daily lives and economic activities (Wang, Ng, and Brook 2020; Yeh and Cheng 2020; Yen and Liu 2021). Decision-making about health affairs in Taiwan is often highly professional-oriented and unpolitical (Yeh and Cheng 2020; Yen and Liu 2021), and consequently the public had confidence in the government and supported these coercive measures. A nationally representative survey conducted in 2021 showed that nearly 90% of Taiwanese supported the authority of the government's coercive measures (Wu 2022). Instead of complaining that the government was doing too much and crossing the line, the public wanted the Taiwanese government to do more. In addition, most disease-prevention measures were not politicized as they were in other countries, with the exception of vaccination policy.

COVID vaccination policy had two stages of development in Taiwan. In the first stage, from the availability of the first COVID vaccine product to around the end of 2021, there was a vaccine shortage, and there was public pressure for the government to acquire as many vaccines as possible as quickly as possible. Rationing of vaccine doses was required. First priority for vaccination was given to health care workers and other workers essential to the disease-prevention mission; second priority was given to people with a high risk of a severe or fatal outcome if infected. Vaccine hesitancy was primarily about the uncertain nature of the COVID vaccines made available through the government's emergency use authorization (Kuan, Lin, and Liu 2022), including the homegrown vaccine developed by a Taiwanese company (Lin and Wu 2023).

In this stage, opposition parties politicized vaccination as they accused the government of intentionally delaying and refusing vaccines from sources in China because the ruling party abhorred China. Opposition parties also accused the ruling party of having financial ties with the Taiwanese company that developed vaccine products, and thus of favoring Taiwanese vaccines over Chinese ones because party figures would make money from sales of Taiwanese vaccines (Lin and Wu 2023). While many people were eager to access COVID vaccines, conspiracies began to spread alleging that there was high-level corruption in vaccine development and production and that the government was buying overpriced vaccines from other countries (also implying corruption),¹ using people as the subjects of vaccine experiments, and lying about the adverse effects of vaccines, resulting in political distrust of the ruling party and the government (Kuan, Lin, and Liu 2022). The spread of distrust and conspiracies was also exacerbated by cyberwarfare and cognitive warfare from the Chinese government and local collaborators (Hung and Hung 2022; Yu and Ho 2023).

In the second stage of the development of vaccine policy in Taiwan, after the supply of vaccines became stable, the major ethical challenge became the extent to which the government should implement vaccine mandates (Yeh 2022). Soft mandates and nudges were adopted, such as requiring a vaccine certificate for entry to certain workplaces and nonessential recreational facilities (e.g., gyms, movie theaters, spas, etc.) and giving vouchers and cash benefits to senior citizens (65 or older) as a gift if they received vaccines and boosters (Yeh and Ou 2022). The inconvenience and the loss of business caused by these measures, compounded with the perception of reduced risk as a result of the variants of SARS-Cov-2 with milder symptoms and less fatality, caused people's growing resentment against the vaccination policy and the government that was ultimately responsible for all of the disease-prevention measures.

Rising political distrust and the emergence of conspiracies both suggest that political partisanship would be an important factor influencing people's attitudes toward COVID vaccination policy in Taiwan. Dissatisfaction with disease-prevention measures would have a mutually reinforcing relationship with political conspiracies. These observations, if true, would conform with international observations (Halimatusa'diyah and Durriyah 2023; Hornsey et al. 2020; Motta 2021; Viskupič and Wiltse 2023; Ward et al. 2020). Several studies have investigated the factors associated with people's attitudes toward COVID vaccination in Taiwan, but the influences of political partisanship and identity have received less attention (Lee, Leng, and Chan 2022). One study found that people tended to interpret COVID-related information differently according to their political partisanship (Huang and Lo 2023); however, the study used an online survey with nonprobability sampling. Another exploratory study on physicians’ attitudes toward vaccination policy found that political partisanship was not a major consideration for physicians in Taiwan (Ou 2023). Following this line of inquiry, this study systematically analyzes the relationship between political partisanship and attitudes toward COVID vaccination policy. We hypothesize that public attitudes toward vaccination policy will have a positive association with their partisanship aligning with the ruling party, the Democratic Progressive Party (DPP).

Confucian Collectivism in Taiwan

In addition to political partisanship, this study also focuses on a specific sociocultural characteristic salient in Taiwan's context: Confucian collectivism. Collectivism, in general, refers to sociocultural sentiments and moral beliefs that value the community interest (i.e., the common good) over the individual's interest. In the context of a pandemic, collectivism would demand that the government, or any other ruling entity that represents the political community, should be responsible and have the legitimate political authority to take action to prevent harms caused by the pandemic. These actions may, under the circumstances, override considerations of individual rights and liberties. There are many forms and origins of this collectivist sentiment around the globe; however, in Taiwan the major origin of collectivism is Confucianism.

Whether Confucianism still thrives in East Asia today is debatable. Taiwanese society inherited multiple cultural traditions throughout its colonial history, including that of its indigenous peoples, the Japanese Empire, and the Han people who brought Confucianism from China. After World War II, under the authoritarian governance of the Chinese Nationalist Party (also known as the Kuomintang, or KMT), the government of Taiwan (also known as the Republic of China) further emphasized the Confucian tradition in an effort to declare that the Republic of China was the genuine China (as against the fake China—the People's Republic of China—which has ruled China as we know it today since 1949). A carefully trimmed version of this worldview was systematically taught through the compulsory public education system (Chen 2015). Starting in the late 1980s, Taiwan underwent a democratization process through which the Taiwanese people developed a modern sense of citizenship, with the expectations of civil liberties, individual autonomy, the protection of human rights, and other progressive agendas that often directly opposed the trimmed version of Confucian ethics as well as the broader Confucian tradition (Wong 2003). The tension between the Confucian tradition and democratic ideals persists to this day.

This study uses the term Confucian collectivism to describe the sociocultural sentiments and moral beliefs that sometimes value the community interest over the individual in Taiwan. Confucian collectivism contains two core dimensions that normatively regulate people's relationships with one another and with the government. One is the value of familism. In every version of Confucian teachings, the family is the most basic social unit (Park and Chesla 2007). The ethical relationships between each social member and between different social positions are rooted in and function like the relationships among members of a family. The fundamental ethics is filial piety, which regulates two-way interactions between parents and children. Parents should take responsibility for their children's care needs, education, and subsistence; in return, the children should generally comply with what their parents request (even if they are already adult children) (Yeh 2023). The other core dimension of Confucian collectivism relevant to this study is people's perceptions of government authority. People's relationship with the government is similar to the relationship between parents and children. The government should take responsibility for the people's care needs, subsistence, and prosperity by implementing benevolent governance (or benevolent rule) (Chan 2013). The people, in return, should comply with what the government requests (Yeh 2023). This compliance is not construed as a response to coercion; rather, it is understood to arise from the genuine belief that the government is indeed implementing benevolent governance for the sake of the greatest good of the people.

Confucian collectivism is a crucial sociocultural characteristic in Taiwanese society (Yeh 2023). With its familism and its perception of strong government authority, it captures the sentiments of a proportion of people upholding traditional values. In sum, this study hypothesizes that, as suggested by scholars and observers, Confucian collectivism is an essential factor associated with people's attitudes of support for (or compliance with) vaccination policy in Taiwan. This study contributes to the literature by providing evidence regarding the conventional wisdom that suggests a positive relationship between the Confucian collectivist tradition and compliance with vaccination policy, and by adding to the understanding of the role of political partisanship in the Taiwanese context.

Methods

Data

The data in this study are drawn from the Taiwan Society Political and Moral Values Survey 2022, a nationally representative cross-sectional survey conducted by the Survey Research Center, Department of Political Science, National Chung-Cheng University, between October 19 and November 6, 2022. The Research Center for Humanities and Social Sciences, Academia Sinica, Taiwan, commissioned the survey. During the survey period, Taiwan had prevalent community transmission of the omicron variant of SARS-CoV-2, but the government had started to loosen border controls and other measures in preparation for embracing a post-COVID life. The general public held that the impact of the COVID pandemic had gradually been ameliorated, and current circumstances no longer warranted the government's coercive measures in the name of solidarity. Vaccination was common and had become a less politicized issue. On October 31, 2022, 93.9% of the general population in Taiwan had received the first dose, 88.3% the second dose, and 74.3% the booster dose of a COVID vaccine (TCDC 2022). These high vaccination rates indicate the overall broad public acceptance of vaccination.

The survey population consists of persons aged 18 or older living in Taiwan during the survey period. All the respondents were interviewed through phone calls. The sample size of this survey is 1,206. Observations that were missing any values in the variables used in the analysis were excluded. There were 8 observations deleted because of missing data for Confucian collectivism, 37 deleted because of missing data for political partisanship, 31 deleted because of missing data in any of the three questions about attitudes toward the vaccination policy, and 17 deleted because of missing data on the respondent's demographic background. An observation may be excluded for missing data in one or more variables that were used in the analysis. The study included 1,118 observations in the final analysis.

Measurements

Political partisanship is a variable of four categories of partisan self-identification: pan-green, pan-blue, Taiwan People's Party (TPP), and nonpartisan. The question is, “Among the extant political parties in our country, which one do you think you are more supportive of?” We classified people into these groups according to their self-reported party leanings. Drawing on the classification of partisans in Taiwan (Wang 2019), in this study those who leaned toward the parties aligned with the DPP were coded as pan-green (as supporting pro-Taiwan independence/secession, including the New Power Party, the Green Party, the Social Democratic Party, the Taiwan Statebuilding Party, and the DPP). Those who leaned toward the parties aligned with the main opposition party, namely the KMT, were coded as pan-blue (as supporting pro-China invasion/unification, including the KMT, the New Party, the People First Party, the Nonpartisan Solidarity Union, and the Unionist Party). The TPP is a newly emerging party formed in 2019 and has become the third-largest party in Taiwan. Although from an ideological standpoint the TPP is now considered to be closer to the pan-blue camp, it strategically adopts a self-declared neutral political stance (Chan and Zhao 2023). As a result, we categorized those who leaned toward TPP in their own TPP group. Those who did not have particular party leanings were coded as nonpartisan.

Confucian collectivism consists of two dimensions—familism and perceived government authority—that are measured by five questions on a 6-point Likert scale (ranging from 1 “strongly agree” to 6 “strongly disagree”). For familism, the questions are (1) “One of my life goals is to make my family proud of me,” (2) “Parents should apologize to the public if their adult child kills others,” and (3) “Parents are always considerate of their children, so children should obey their parents in all instances.” For perceived government authority, the questions are (4) “I am not obligated to obey the government's rules if they are nonsense,” and (5) “The government has the responsibility to take care of their people; meanwhile, the people have the responsibility to obey the decisions their government makes for them.” Except for question (4), the other four questions were coded inversely so that a higher score indicates a higher degree of Confucian collectivism. We only included respondents who answered at least three questions in the analyses, and we constructed the Confucian collectivism variable as the average score of the answered questions for each respondent (Cronbach's alpha = 0.39). Considering that the data source was not tailored for this concept, we took content validity over construct validity and included all the related questions when constructing this concept, despite the low Cronbach's alpha. More detailed information about the distribution of each question and the construct validity of Confucian collectivism and the sensitivity analysis applying different constructs of Confucian collectivism are provided in the supplement.

The dependent variables—attitudes toward vaccination policy—consist of three different dimensions: common responsibility, government mandate, and indignation over anti-vaxxers. Common responsibility for vaccination reflects a utilitarian account of reasoning, that is, the better the consequence, the stronger the justification (Savulescu 2021); therefore, in the name of preventing harm and promoting health at the societal level, one should be responsible for taking that action. A government vaccine mandate is a direct recognition of the government's ethical legitimacy in using coercive power on individuals to protect public health, regardless of the individual's autonomy (Yeh 2022). Indignation over anti-vaxxers is an expression of political anger when one is frustrated by seeing that others are deliberately harming or intending to harm one's fellow citizens or dwellers (Collins 1990), which implies that one has a preexisting ideal or conception of responsibility that is subject to threat, and that one would be willing to take collective action, such as supporting a vaccination policy, to remedy harms (Gamson 1992). These three dimensions reify the abstract idea of supportive attitudes toward the vaccination policy without binding to any particular forms or administrative details of the implementation of the vaccination policy, thus avoiding the potential confusion between the idea itself and the respondents’ impression regarding the actual policies that have been implemented by national or local governments ruled by different parties in Taiwan.

These three dimensions are measured by asking respondents whether they agree with the following items on a 6-point Likert scale (ranging from 1 “strongly agree” to 6 “strongly disagree”): (1) Common responsibility is measured by the question “To protect the whole society from health harms and economic losses, everyone has the responsibility to take vaccines.” (2) Government mandate is measured by the question “During the pandemic, the government has the authority to mandate people to receive the vaccine unless they have proper medical exemptions.” (3) Indignation over anti-vaxxers is measured by the question “I would be irritated if I saw people on the TV or the internet emphasize that they are not going to take vaccines.” In the analysis, all three variables were inversely coded so that a higher score indicates a higher agreement with the statements.

We included sex, age, and years of education as covariates in our analysis. Sex was coded as binary, with males set as the reference group. Both age and years of education are continuous. Years of education were transferred from the level of education that was asked in the original question. The years of education for those whose highest level of education is elementary school was coded as 6 years, junior high school was 9 years, senior high school was 12 years, junior college was 14 years, college was 16 years, and graduate school was 18 years.

Analytic Strategy

We first explored the distribution of Confucian collectivism among social groups of different sexes, ages (10-year cohort), levels of education, and party leanings. We then applied multiple linear regression using ordinary least squares estimation to examine the relationships between Confucian collectivism and attitudes toward vaccination policy after controlling the covariates. We also performed a sensitivity analysis with ordinal logistic regression because of the ordinal attributes of the dependent variables measured with a Likert scale. Since linear regression is more straightforward to interpret, we only displayed the linear regression models in the main tables. The results of the ordinal logistic regression are provided in the supplement.

Results

Confucian Collectivism among Different Social Groups

Table 1 shows the descriptive statistics of age, years of education, degree of Confucian collectivism, and vaccination policy attitudes of the sampled population. Among vaccination policy attitudes, the score of indignation over anti-vaxxers was 2.64, indicating that people were not likely to be irritated by anti-vaxxers. Nevertheless, the scores of common responsibility and government mandate were 4.62 and 4.28, respectively, demonstrating the overall supportive attitudes toward these two dimensions in Taiwanese society.

Table 1 also shows the distribution of the sample and the degree of Confucian collectivism among each stratum in sex, cohort, level of education, and political partisanship. The degree of Confucian collectivism exists heterogeneously in different social groups. It is higher in males, older cohorts, people with lower education levels, and those with political partisanships either in the pan-green group or the pan-blue group.

Confucian Collectivism among the Three Dimensions of Vaccination Policy Attitudes

Figure 1 shows the distribution of the degree of Confucian collectivism among different attitudes toward vaccination policy. In general, we observed a trend of increasing degrees of Confucian collectivism along with increased supportive attitudes. Among the three dimensions, indignation over anti-vaxxers shows the strongest trend.

Confucian Collectivism, Political Partisanship, and the Attitudes Toward Vaccination Policy

Table 2 shows the results of multiple linear ordinary least squares regression of attitudes toward vaccination policy on Confucian collectivism and political partisanship. After controlling for covariates, we found that Confucian collectivism significantly related to people's attitudes toward vaccination policy. Upholding a higher degree of Confucian collectivism has a positive association with the belief that everyone is responsible for being vaccinated to reduce health harms and economic losses for the whole society (b = 0.32; p < 0.001). Confucian collectivism is also positively associated with acknowledgement of the government's authority to implement vaccine mandates during the pandemic (b = 0.27; p < 0.001) and with stronger feelings of anger when seeing others emphasizing that they were not going to get vaccinated (b = 0.24; p < 0.001).

As expected, political partisanship also plays an essential role. Political partisanship aligning with the ruling party, DPP (pan-green), presents positive relations with all three dimensions when compared to nonpartisans (common responsibility: b = 0.43; p < 0.001; government mandate: b = 0.33; p < 0.01; indignation over anti-vaxxers: b = 0.43; p < 0.001). In contrast, pan-blue partisanship is related to a more negative attitude toward the government's authority to implement vaccine mandates, compared to nonpartisans (b = –0.31; p < 0.05). TPP partisanship negatively associates with the belief that people share a common responsibility to get vaccinated (b = –0.43; p < 0.01).

Besides Confucian collectivism and political partisanship, we also noticed that education and age were associated with attitudes toward vaccination policy. Increasing years of education shows a negative relation to agreeing that everyone is responsible for taking vaccines to protect the whole society (b = –0.06; p < 0.001). Meanwhile, age presents a positive association with support for government's authority to issue vaccine mandates (b = 0.01; p < 0.01) and with irritation at others’ emphasis on not getting vaccinated (b = 0.01; p < 0.01).

Discussion

This study finds that the moral beliefs of Confucian collectivism and political partisanship aligning with the ruling party, DPP, have a positive association with supportive attitudes toward vaccination policy during public health emergencies. Adding to the inconclusive findings from previous studies in Taiwan (Huang and Lo 2023; Ou 2023), this study provides more systematic evidence for the association between political partisanship and attitudes toward vaccination policy. The study also provides evidence to support the conventional wisdom that people with a Confucian tradition or background tend, on the one hand, to be more compliant with the regulatory and even coercive disease-prevention policies imposed by the government; on the other hand, they tend to be more willing to carry the costs, take the responsibility, and actively support the kind of policies that would value the common good over the individual interest.

A debatable issue is to what extent these collectivist sentiments and moral beliefs are specifically Confucian and whether the questions used in the survey could capture them. One may reasonably argue that values of familism and perceived government authority could be observed in any traditional community. In Taiwan's particular historical context, these kinds of traditional values would be highly likely to be Confucian or at least the legacies of Confucianism. In addition, the survey questions are similar to the measurement of Confucian values in other well-established surveys (Chang, Wu, and Weatherall 2017; Park and Shin 2006; Shin 2021). Considering the overall high degree of Confucian collectivism among the respondents, it may be inferred that Taiwanese society has indeed inherited the Confucian tradition.

Whether the measurement of perceived government authority could distinguish Confucian values from authoritarian values is another issue. Authoritarian values are often measured in terms of people's attitudes toward the form of government or the design of political institutions (Chang, Chu, and Park 2007) or in terms of authoritarian personality (Bilewicz and Soral 2021; Oleksy et al. 2022; Roberts et al. 2022). Nonetheless, these studies examine the relationship between authoritarian attitudes and attitudes toward vaccines, not toward vaccination policy. The measurement used in our study directly regards the respondents’ relationship with the government and hence captures the “perceived” authority of the government, which is essential to the Confucian understanding of government. Additional research is needed to examine whether this relationship is observable in other societies with Confucian legacies.

For policy makers, while social norms and cultural values often change relatively slowly in comparison with policy changes brought by reforms, further understanding of public attitudes toward disease-prevention measures compounded with Confucian traditions and the modern sense of democratic citizenship could provide policy makers the insights needed for more effective and ethical public health preparedness for future emergencies (Emanuel, Upshur, and Smith 2022; Yeh and Lee 2023).

The finding that political partisanship is associated with vaccination policy attitude, as expected, echoes the international observation that the supporters of the ruling party tend to be more willing to support the government's vaccination and broader disease-prevention policies, while nonpartisans and the opposition remain suspicious (Halimatusa'diyah and Durriyah 2023; Klymak and Vlandas 2022; Kreps and Kriner 2023). Another strand of literature examines the concept of partisanship based on right-left political ideology (Grossman et al. 2020; Jones and McDermott 2022; Peng 2022; Viskupič and Wiltse 2023; Wollebæk et al. 2022; Ye 2021). These studies are not relevant to our findings because partisanship in Taiwan is not differentiated by right-left ideologies but instead by pro-Taiwan/pro-China ideologies (Achen and Wang 2017). The way we categorized political partisanships outlined this feature of the political field in Taiwan.

This study also provides a more nuanced understanding of the relationship between partisanship and vaccination policy attitude in the Taiwanese context. First, it is the supportive attitudes that matter. As shown in table 2, the supporters of the ruling party, DPP, and other parties ideologically closer to the DPP have positive association with all three dimensions of supportive attitudes toward vaccination policy: common responsibility, government mandate, and indignation over anti-vaxxers. A negative relationship between political partisanship and attitudes toward vaccination presents in the government mandate dimension among pan-blue supporters, and in the common responsibility dimension among TPP supporters. This asymmetrical phenomenon may be explained by the fact that political partisanship is a relatively sensitive question in the Taiwanese context because of the nation's history of authoritarian governance, under which people were taught not to engage with politics and that politics are “dirty” or corrupt. Many people might be reluctant to reveal their true partisanship, particularly those who like to consider themselves as rational-pragmatic voters, to appear to be more enlightened than the irrational and “dirty” partisan supporters. If the nonpartisans, on average, were actually leaning more toward the pan-blue group (Wang 2019), then it would blur the difference between the nonpartisan and the pan-blue group and would hence imply that the study has underestimated the negative association.

Another explanation might be that, since the pro-Taiwan/pro-China ideologies involve different conceptions of the boundary and overall legitimacy of state sovereignty (Chen et al. 2023), the pan-green and pan-blue supporters who are more sensitive to these conceptions would also be more sensitive to the governing authority under different ruling parties, which, in the case here, was the DPP. This may explain why pan-blues tend to oppose the government's authority for vaccine mandates but not common responsibility and anti-vaxxers. In contrast, nonpartisans and TPP supporters may consider serving their self-interest more than any particular ideals or ideologies, and hence may oppose the notion of common responsibility in vaccination policy.

The TPP presents an interesting anomaly. TPP supporters tend to see themselves as disappointed by the dirty politics of “the evil struggle between blue and green” and as wiser people who are truly rational, neutral voters. TPP politicians brand themselves in this manner, in response to their voters’ expectations (Chan and Zhao 2023). In other words, TPP supporters are “more nonpartisan” than the nonpartisans to the extent that they could form a nonblue, nongreen partisan party. It is not surprising that they were more likely to disagree with the notion of common responsibility.

In contrast to societies where traditional ideology has closely related to political partisanship (such as partisanship based on right-left political ideologies), our findings suggest that in Taiwan the relationships between attitudes toward vaccination policy and Confucian collectivism (and the possible authoritarian inclination underneath) are, to some extent, independent of political partisanship. The questions of whether such patterns exist in other societies with the Confucian tradition and how they vary are worthy of future research.

Compared with political partisanship and Confucian collectivism, the effects of age and education are more of a conundrum. A possible explanation for age might be that those with more social experiences (as represented by greater age) tend to cherish the value of the common good. They may have a better idea of how the risks they would encounter are uncontrollable at the individual level, and therefore they may be more willing to support vaccination policy as a form of protection against pandemics. As for education, a possible explanation might be that when one has received more years of education, one would cultivate a (somewhat illusory) confidence that one could be the master of one's own fate and would hence value self-interest more than the common good. For them, the pandemic threat would not be worth sacrificing the absolute autonomy and liberties one could enjoy.

Limitations

While the results supported our hypotheses, limitations remained because of some potential omitted variables. First, regarding the sociodemographics, we did not have the respondents’ income and occupation information. However, previous studies have suggested that income and occupation have no significant effect on attitudes toward policies that are not income- or occupation-based (Yeh, Tsai, and Lue 2017). Also, we did not include self-reported health status, which might be reflected in age. As shown in the results, older people tend to agree that the government has the authority to implement vaccine mandates and are more likely to be irritated by others’ emphasis on not being vaccinated. Because older people are usually less healthy and more vulnerable to COVID-19 than younger people, they may expect the government to take more robust measures to keep them safe and may feel threatened when seeing others state their unwillingness to be vaccinated.

Second, COVID-19 prevalence in respondents’ living areas may also play an important role. However, the survey was conducted during the period when community transmission was already prevalent in Taiwan, and the geographical difference in perceived threat had decreased. Therefore, the influence of COVID-19 prevalence might be limited.

Third, other ideological factors were not included, such as vaccine hesitancy in general (Biswas et al. 2021; Wang et al. 2022) and suspicion of “modern” or “Western” medicine (Hornsey, Lobera, and Díaz-Catalán 2020). In addition, if DPP supporters somehow cared more about common interest in health, we would not be able to distinguish this effect from the effect of the DPP being the ruling party.

Lastly, previous experience in tackling pandemics might also relate to people's attitudes. In Taiwan's context, the most significant pandemic before COVID was severe acute respiratory syndrome (SARS) in 2003. Because the SARS pandemic happened about 20 years ago, cross-sectional surveys today would not be able to detect related attitudes from that time. In the literature, discussion of the SARS experience focuses on the structural and institutional reforms of infectious disease control governance and experts’ capacity (Hsu et al. 2020; Su, Wu, and Lee 2017; Wang, Ng, and Brook 2020; Yen 2020). While there is reasonable speculation on how the SARS experience may influence people's positive attitudes toward disease prevention measures, the evidence is limited (Loduhova and Kironska 2022). Even if there were a positive influence, it would not intervene in the relationships of the interest in this study, as the SARS experience was negative for all people regardless of partisanship because both the central government ruling party (DPP) and the local government ruling party (KMT) for Taipei City, where the SARS pandemic cost the most lives, were very ineffective in tackling the transmission.

Conclusion

Taiwanese society generally shows supportive attitudes toward vaccination policy. The findings of this study support the conventional wisdom that Confucian collectivism and political partisanship contribute to compliance with or support for vaccination policy, echoing findings from other countries. In addition, age and education are associated with vaccination policy attitudes. Whether this pattern is observable in other societies with Confucian legacies and whether Confucian collectivism is essentially different from other traditional values and authoritarian attitudes are questions worth investigating.

This study provides a more nuanced understanding of partisanship in the Taiwanese context. While the pan-blue camp and the TPP do not align with the ruling party, their negative attitudes toward vaccination policy appeared in different dimensions. In addition, since the TPP has been discussed in only a few studies, this analysis contributes to our understanding of this newly emerging party's features and its impact on the Taiwanese political landscape.

As public health policy makers and health authorities consider how to prepare for future pandemics, this study shows that it is important to consider the sociocultural contexts and the political atmosphere that matters for different target populations to maintain social trust and enhance the overall effectiveness of disease-prevention measures.

Acknowledgments

An earlier draft of this article was presented at the 2022 Taiwan Society Political and Moral Values Survey Symposium, Academic Sinica, Taipei, Taiwan, on March 24, 2023. The authors thank the discussant Chen-I Kuan for her useful comments.

Note

References