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Advances in Social Sciences Research Journal – Vol. 10, No. 5

Publication Date: May 25, 2023

DOI:10.14738/assrj.105.14669.

Makki, F., Haidar, A., Sedas, P. S., & Saleh, N. (2023). Cognitive Dissonance Induction to Decrease Vaccine Hesitancy Among Syrian

Refugees in Lebanon: A Cognitive Approach Towards the Promotion of Health Seeking Behaviors. Advances in Social Sciences

Research Journal, 10(5).84-94.

Services for Science and Education – United Kingdom

Cognitive Dissonance Induction to Decrease Vaccine Hesitancy

Among Syrian Refugees in Lebanon: A Cognitive Approach

Towards the Promotion of Health Seeking Behaviors

Fadi Makki

Partner & Director, Behavioral Science Lab,

BCG - Founder & Chairman, Nudge Lebanon

Aya Haidar

Nudge Lebanon, Beirut, Lebanon

Paola Schietekat Sedas

Nudge Lebanon, Beirut, Lebanon

Nabil Saleh

Nudge Lebanon, Beirut, Lebanon

ABSTRACT

Background: The rollout of the COVID-19 vaccine represented more than logistical

challenges. Lebanon, despite benefitting from the COVAX initiative that made

vaccines more accessible to everyone residing in the country, faced considerable

challenges encouraging the Syrian refugee population to register for a vaccine. The

reasons behind refugees’ reluctance to get vaccinated were mainly behavioral in

nature: fear of side effects, doubts about the vaccine’s effectiveness, and even the

belief that the vaccine was unnecessary. Methods: An RCT 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 survey

also collected data on refugees’ knowledge, attitudes, and practices regarding the

vaccine. Results: Results revealed that dissonance induction significantly reduced

vaccine hesitancy, with more pronounced effects detected among women, middle

aged adults. Conclusion: These findings have important implications on rethinking

the behavioral aspect of the delivery of public health services to the refugee

population in Lebanon and vulnerable populations elsewhere.

Keywords: Public health, vaccination, COVID-19, health policy, health services

INTRODUCTION

This paper analyzes one of the various policy efforts rolled out in different contexts in order to

increase the rate of fully vaccinated individuals against COVID-19. The Syrian refugee

population in Lebanon, constituting between 20-25% of the country’s demography has been

particularly considered as part of the Ministry of Public Health’s immunization strategy. Despite

close joint efforts with UNHCR, it was found that registrations in the dedicated platform were

still suboptimal by July 2021[1]. To this end, Nudge Lebanon collaborated with UNHCR and

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Makki, F., Haidar, A., Sedas, P. S., & Saleh, N. (2023). Cognitive Dissonance Induction to Decrease Vaccine Hesitancy Among Syrian Refugees in

Lebanon: A Cognitive Approach Towards the Promotion of Health Seeking Behaviors. Advances in Social Sciences Research Journal, 10(5).84-94.

URL: http://dx.doi.org/10.14738/assrj.105.14669

relevant stakeholders to tackle the behavioral barriers deterring refugees from registering for

the vaccine. In order to assess the knowledge, attitudes and practices of refugees towards the

COVID-19 vaccine, a survey was administered gathering representative data from all

governorates in Lebanon. The survey included three behavioral interventions, expected to

increase refugees’ willingness to get vaccinated against COVID-19 and reduce hesitancy. This

paper discusses the impact of the cognitive dissonance intervention on vaccination intentions.

This study complements ongoing efforts to shed light on the drivers of vaccine hesitancy.

Lebanon hosts close to two million refugees, mainly Syrian and Palestinian. It is estimated that

there are up to 1.5 million Syrian refugees in Lebanon that live in residential, non-residential

buildings and non-permanent shelters scattered across the country. UNHCR provides shelter,

advocacy, legal assistance, health and safeguarding to over 855,000 Syrian refugees as well as

14,800 other registered refugees and asylum seekers from different nationalities. In 2021, 89%

of Syrian refugees lived in poverty and only around 16% of those above the age of 15 had legal

residency. Due to the economic challenges faced by Lebanon, exacerbated by the COVID-19

pandemic, reports of tension and intolerance against refugees by host communities increased

[2].

When the COVID-19 vaccine was made available in Lebanon, any resident could register on the

Ministry of Public Health-COVAX platform (IMPACT), irrespective of their status. However, the

registration process presented significant barriers for impoverished refugees without a legal

status in the country: they had to register online using a computer or mobile device and they

had to provide a valid identification document, which many do not have. By June 2021 only 4%

of the eligible Syrian refugees had registered for the vaccine, even though Syrian refugees made

up around a quarter of the population in Lebanon [3]. UNHCR assessment exercises revealed

that many of the reasons deterring refugees from getting vaccinated were behavioral in nature

and thus called for behavioral interventions.

The theory of cognitive dissonance, coined in 1957 by Leon Festinger, conceptualizes “the

uncomfortable tension that can exist between two simultaneous and conflicting ideas or

feelings” [4]. It is often cited to account for behavioral and attitudinal changes resulting from

individuals engaging with a behavior that is inconsistent with the type of person they want to

be, or that they want to project socially. In these cases, individuals may either seek to rationalize

their behavior, even if incongruent with their beliefs, in order to appease this discomfort, or to

adjust their behaviors or attitudes in order to reconcile the two ideas into a coherent discourse.

An example of the former is illustrated by Champan et al, where smokers rationalized their

habits by holding self-exempting beliefs that led them to discredit the evidence showing that

smoking causes cancer and excessively rely on arguments citing examples of smokers outliving

non-smokers [5]. The latter can be exemplified by a study carried out by Dickerson et al, where

people were made aware of their water consumption habits and then asked to urge others to

commit to take shorter showers.

Results revealed that those urging others to take shorter showers through commitment pledges

started taking shorter showers themselves, even when they were under no obligation or

pressure. However, the change in their behavior was explained by the discomfort of a

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Advances in Social Sciences Research Journal (ASSRJ) Vol. 10, Issue 5, May-2023

Services for Science and Education – United Kingdom

‘hypocrisy condition’ where they would just remind others to reduce their water consumption,

without contributing to what they were publicly preaching [6].

More specifically, Festinger identified four strategies used to reduce the discomfort caused by

cognitive dissonance: first, individuals may change their behavior so that it is consistent with

the conflicting thought. Second, individuals may change one of the dissonant thoughts in order

to restore consistency. Third, individuals may add a consonant thought to justify or reduce the

dissonance of the conflicting thought, diminishing the inconsistency. Finally, individuals may

trivialize the inconsistency altogether, therefore avoid addressing it. When related to health

outcomes, there is no conclusive way of predicting what strategies would individuals follow to

resolve the dissonance. The aforementioned example on smoking revealed that some may opt

for the third strategy, justifying harmful behaviors despite evidence of their detriments. This

may be explained by the fact that smoking is an addictive behavior that is hard to cut off, making

the third strategy more attractive than the effort of halting the habit [7]. Another study by Ent

and Gerend, participants were made aware of an unpleasant but beneficial medical test for a

fictitious virus, where the treatment group was made to believe they qualified for the test and

the control group was told they did not. Among the treatment group, attitudes towards the test

were significantly more negative than those in the control group; people were conflicted

between the obligation they felt to preserve their health and their reluctance to experience the

discomfort of getting tested. As a result, many participants skipped the test, trivializing the

inconsistency, which is not an expected strategy to address a health-related behavior unless the

dissonance and behavioral changes required to resolve it are deemed less desirable than a

health threat [8].

In contrast with the previous evidence, a comprehensive review of twenty studies about

cognitive dissonance on health-related behavior reveals a trend where most studies reported a

positive effect on one or more health behaviors, attitudes or intentions, following a dissonance

induction intervention. Changes in participants’ attitudes and intentions were usually

consistent with changes in their health-related behavior [9]. The hypocrisy paradigm was the

most commonly used in the studies, and it also appeared to be the most effective in prompting

behavioral, attitudinal and intentional change. Hypocrisy occurs when people publicly advocate

to a behavior and are then made mindful that they have not performed or lived up to that

behavior. This discrepancy “poses a threat to their self-integrity”, which is reduced when

people bring their behavior into line with initial standards. A clear example is the

aforementioned study on water consumption by Dickerson et al, although Stone and Focella

also find that their research supports the “use of hypocrisy for changing health attitudes and

behavior”, also stating that cognitive dissonance can be a “powerful strategy for engaging self- regulation processes that improve health” [10].

MATERIALS AND METHODS

A survey was developed in order to gain insights of refugees’ attitudes towards the vaccine, as

well as to test the impact of behavioral messages on their willingness to get vaccinated. The

survey was conducted by trained UNHCR call center interviewers between 15 November and

16 December 2021.