Cognitive Dissonance Induction to Decrease Vaccine Hesitancy Among Syrian Refugees in Lebanon: A Cognitive Approach Towards the Promotion of Health Seeking Behaviors

"The success of this intervention on a specific segment in the willingness continuum stresses the fact that vaccine hesitancy has many drivers and therefore must be addressed with different tools."

When the COVID-19 vaccine was made available in Lebanon, any resident could register on the Ministry of Public Health-COVAX platform (IMPACT). However, the registration process presented significant barriers for impoverished refugees without a legal status in the country. Beyond logistical issues, the reasons behind refugees' reluctance to get vaccinated were mainly behavioural in nature: fear of side effects, doubts about the vaccine's effectiveness, and even the belief that the vaccine was unnecessary. Thus, as part of a project carried out by Nudge Lebanon and United Nations High Commissioner for Refugees (UNCHR), a trial was conducted in order to test the impact of "dissonance induction" on the level of willingness of Syrian refugee survey respondents who had not been vaccinated (n=1,569). The Syrian refugee population in Lebanon makes up 25% of the country's residents.

The theory of cognitive dissonance, developed in 1957 by Leon Festinger, is often cited to account for behavioural and attitudinal changes resulting from individuals engaging with a behaviour that is inconsistent with the type of person they want to be or they want to project socially. In these cases, individuals may either seek to rationalise their behaviour, even if incongruent with their beliefs, in order to appease this feeling of discomfort, or to adjust their behaviours or attitudes in order to reconcile the two ideas into a coherent discourse.

The intervention discussed throughout this paper sought to induce cognitive dissonance in the minds of respondents by highlighting the contradiction between recognising the effectiveness of other vaccines in controlling dangerous diseases but rejecting the COVID-19 vaccine. In this case, those who were most fearful of the vaccine were presented with information that highlighted how vaccines they had received as children safely protected them from a list of dangerous diseases that had come under control precisely due to vaccines. By comparing the COVID-19 vaccines to the vaccines that save more than 4 million lives every year, refugees were made aware that the benefits of vaccination were far superior to any risks. This was a one-off intervention that exposed participants to the prompt once; it is possible that sustained exposure would yield a more discernible change in attitudes or behaviour.

A survey was developed in order to gain insights of refugees' attitudes towards the COVID-19 vaccine, as well as to test the impact of behavioural messages on their willingness to get vaccinated. The survey was conducted by trained UNHCR call centre interviewers between November 15 and December 16 2021.

Prior to the intervention, regarding willingness to get vaccinated, most respondents (67%) were willing to get vaccinated, from whom 55% were "definitely willing". Nevertheless, 14% of respondents were unsure whether to receive the vaccine or not, and 19% were not willing, with 10% of those "definitely not willing" to get vaccinated. The proportion of unwilling individuals largely equivalent to rates of COVID-19 vaccine hesitancy worldwide. Results revealed that around 43% of respondents believed that more than 60% of the Lebanese would be willing to get vaccinated, and only 12% believed that Lebanese willingness would be 40% or less. This finding contrasts with perceptions of their own refugee communities, as only 25% believed that more than 60% of Syrians would be willing to get vaccinated, and 30% of respondents sustained uptake of the vaccine by Syrians would be of 40% or below.

Most refugees who were apprehensive about getting vaccinated feared the possible side effects. The availability bias exacerbated this fear, as refugees often heard of adverse reactions to the vaccine from family and friends and from the media, leading them to think that these reactions were much more common than they actually were. These narratives were likely to compromise their trust in the vaccine, even if it was recommended by trusted institutions. The fact that 42% of respondents said that being provided with more facts about the safety and effectiveness of the vaccine would increase their uptake and that 19% said their willingness would increase if they clearly knew what the benefits and potential risks of the vaccine are indicates a need for reassurance.

Results of the trial revealed that dissonance induction significantly reduced vaccine hesitancy, with more pronounced effects detected among women and middle-aged adults. The percentage of hesitant individuals, those who would definitely or probably be unwilling to get vaccinated, decreased by 31% (p<0.05) after being exposed to the dissonant message. Specifically, among those who were definitely unwilling to get vaccinated, there was a 28% decrease in their hesitancy, shifting from 10% to 7%. The effect of the intervention was mainly centred around reducing hesitancy, showing that it reached the specific segment of respondents that was most hesitant. What was observed was a gradual shift of attitudes, from hesitancy to uncertainty and probable willingness.

The dissonant message may have been more successful for women in the sample because they have typically had higher levels of hesitancy attributed to reports of side effects experienced by women but not disclosed by manufacturers or health institutions, as well as the lack of conclusive advice given to pregnant or breastfeeding women on vaccination. The sample had a larger pool of hesitant women who cited fear of side effects as a main barrier (8 percentage points more frequently than men), which may explain why the effect was larger.

The effect of cognitive dissonance was mainly captured by those who were very reluctant to get vaccinated, in part, because the stronger the discrepancy between ideas and thoughts, the greater motivation to reduce it. For dissonance to elicit a change in attitude or behaviour, the two confronted opinions must create some tension; otherwise, people may settle for some degree of variation from their views and trivialise the matter rather than resolving it.

UNHCR used these results to inform their ongoing activities and campaigns, although data on this later stage of implementation (e.g., whether knowing people's intentions to behave a certain way correlated with actual behaviour) were not collected for the purpose of this study.

In conclusion: "By highlighting the behavioral drivers of vaccine hesitancy and providing evidence of effective behavioral interventions to reduce hesitancy, this study contributes to an ongoing public health discourse that is increasingly focusing on mainstreaming behavioral insights in health policy."