Engage, Embrace, Empathize: Addressing Vaccine Hesitancy in Lebanon

In between conversations of failing economies and flailing politicians, the COVID-19 crisis continues to be one of the most critical threats to the welfare of the Lebanese people. While persistently high infection rates and inconsistent lockdowns are unprecedented, the topic of vaccination seems to highlight familiar systemic inequalities of which many remain wary.

Experts believe herd immunity is the only way to move past this pandemic. Now a household term, herd immunity is when enough people become immune to a disease, making further spread very unlikely. While the exact proportion of people needed to achieve it is still uncertain, many fear it may be unreachable in Lebanon due to the high number of people who have expressed hesitation towards getting inoculated. In fact, a survey conducted by the World Bank in February 2021 found only 3 out of 10 people are willing to take the vaccine.¹

This statistic, while discouraging, is not without basis. Lebanese are being presented with limited vaccine options and a frustratingly slow roll out while their political representatives skip the queue. In a country that also has a reputation of importing, distributing and administering expired medications, an uphill battle lies ahead.

I spoke to several experts to explore this issue, and while the short story is “it’s complicated,” the upside is that multiple opportunities exist to address hesitancy. Many among the Lebanese diaspora are already taking action to increase vaccine uptake. Our readers can help Lebanon overcome this once-in-a-lifetime pandemic by lending an ear to family and friends and exploring ways to help.

Hesitancy is Complicated

The first thing to know is that there is not one type of hesitancy. A survey from Internews Lebanon’s Rooted in Trust project found that reservations stemmed from concern about side effects and safety, doubt in its effectiveness, and suspicion of ulterior motives such as financial gain or population control. The World Bank survey revealed, in addition to these concerns, very low trust in institutions along with questions around the necessity of a vaccine. Views can also vary by context, such as region, and demographics, like age, gender, and income.

Ferras Mohssen, who signed up on the government’s vaccine registration platform along with his mother, reflected on conversations they had about the vaccine. “New technology used to develop the vaccine worried her, as well as the relative speed with which the vaccine was created.” She is not alone in these concerns; almost 1 in 2 respondents in the World Bank survey said they are unsure if they would take the vaccine when available.

Messaging Has Often Failed

Failures in conveying information may be partly to blame for vaccine hesitancy. A focus on efficacy, a measure traditionally limited to research circles to describe how well a vaccine performs in a clinical trial, and fear of irresponsible behavior after vaccination have influenced communication campaigns in many countries. These messages, while well-intentioned, create confusion among the general public and inflate reluctance to getting the vaccine.

In Lebanon, the Risk Communication and Community Engagement (RCCE) Plan created by key ministries and their partners identifies several target communities for vaccine messaging, but fails to present distinct strategies for each group. Critics of this plan point out a one-size-fits-all approach falls short in addressing the constellation of concerns, fears, and questions related to hesitancy.

The timing of communication campaigns is also key. Haley McCoin, Project Coordinator for Internews Lebanon’s COVID-19 project, pointed out that rumors about vaccines were already well-circulated by the time the Ministry of Public Health (MoPH) and United Nations Children’s Fund (UNICEF) launched their vaccine awareness campaign. “This leaves it up to people to make their own decisions through information by way of rumors. People had already formed their perceptions of the vaccine.”

Weaknesses Were Already Present

Challenges in vaccine uptake in Lebanon are not a new phenomenon. In a study conducted in 2015, for example, only 27.6 percent of respondents reported receiving an annual influenza vaccine, even among high-risk groups. With the absence of a seasonal influenza vaccination program in Lebanon, people are left to pay out of pocket to receive the shot, which may be a contributing factor to these low numbers.

Similar themes are emerging in Lebanon’s COVID-19 vaccine campaign. While the Minister of Public Health announced plans to vaccinate 80 percent of the population by the end of 2021, this is only feasible with the private sector supplementing doses purchased by the government. Thus far, only one company has secured a deal. Pharmaline is importing the Russian Sputnik V vaccine and charging companies 38 US Dollars (USD) for two doses.

Although not yet available for purchase by individual consumers, it should go without saying that this price point is unreachable for many, given more than half of Lebanon’s population is below the poverty line. The dollar crisis is a facet of the larger economic and political crises, further skewing people’s perceptions of COVID-19. According to findings from the United Nations Development Programme (UNDP), “COVID-19 seems to be strongly linked to political and economic considerations that respondents believe have a direct impact on their daily life.” This is exemplified by a phrase heard frequently on the streets during lockdowns, “I’d rather die of COVID than die of hunger.”

Medical Professionals are Both a Hindrance and a Help

Perhaps those best situated to address people’s concerns about vaccines are medical professionals. The powerful influence of providers has been observed with the flu vaccine in Lebanon, where they educated, promoted, and reinforced influenza vaccination. It was also offered during routine health care visits. Although they are among the most trusted sources of information about COVID-19, they are not the most used, according to UNDP findings.

Providers themselves are often uncertain about the vaccine, though. The World Bank survey found attitudes and hesitancy did not greatly differ between the general public and health workers, with 46 percent of provider participants stating they are unsure whether they will take the vaccine when it becomes available.

Some medical professionals even perpetuate rumors on social media. When asked to reflect on her work with Internews, McCoin stated “the single most striking thing for me is the role that medical professionals are playing in spreading these rumors.” Omar Meksassi, who served as Humanitarian Information Manager for the same project, echoed this sentiment and expressed concern about the lack of response from the MoPH and Lebanon’s doctors’ syndicate, “I saw how fragile the ministry is in terms of information delivery and coordination.”

Dr. Salma Makhoul-Ahwach, a Lebanese expatriate working as an endocrinologist in Jackson, Florida commented, “We all have fears, even as medical professionals.” With this in mind, and in hopes of fighting misinformation among providers and the general public, Dr. Makhoul-Ahwach worked in partnership with fellow International Lebanese Medical Association-USA (ILMA-USA) members to develop a vaccine awareness campaign for people in Lebanon.

Family and Friends are Trusted Sources

Family and friends are also a critical source of vaccine information. Findings from the UNDP emphasized that for COVID-19, “people are more responsive to information communicated on a personal level. The ability to ask questions without being judged proved important.” McCoin said listening groups were one of the most useful components of the Rooted in Trust project. “People need an informal space to ask questions.”

Ferras Mohssen took this to heart when speaking with his mother about registering for the vaccine. “I connected her with friends of mine who took the vaccine that are in her age group and they helped put her mind at ease. The last thing you want to do is be aggressive; you have to guide them and be understanding of their fears.”

Dr. Makhoul-Ahwach explained that reasons for hesitance can be complicated and deep-rooted. “We have a history of Lebanon importing expired medications and selling them to people. The best way to educate and provide the right information is to actually address the concerns of the people.” It is for this reason empathy can be central in engaging people.

Her ILMA-USA colleague, Dr. Khalil Diab, also pointed out rates of vaccine registration vary across Lebanon. “It seems that registration rates are much higher in the greater Beirut area than in other areas of the country. Awareness campaigns should focus on these regions targeting vaccination hesitancy and helping people to register on the online platform,” remarked the Washington-based pulmonologist.

Meet People Where They Are

During a time when experts are observing a race between the virus and the vaccine, we must stay focused on the opportunities at hand to boost vaccine uptake in Lebanon. It is being sold as a ticket back to normalcy to encourage the most staunchly opposed to get on board, but after the last year in Lebanon, what is normal anymore? Shouting “just take this!” surely won’t convince anyone to accept a needle in their arm. Alternatively, let us examine the lessons presented previously in this article:

• There are many reasons people may be concerned about getting a COVID-19 vaccine.
• Messaging must be responsive, specific, and timely to speak to people’s concerns.
• Reduce the barriers associated with registration, cost, and location.
• Educate and leverage medical professionals to listen, inform, and vaccinate.
• One-on-one conversations are powerful tools in addressing fear, uncertainty, and doubt.

This is also where our readers come in. You, along with your family and friends, may still have concerns about the vaccine. Share your thoughts and experiences with your community and help them sign up for the vaccine if needed. Provide them with information if they have questions and if they are uncertain of whom to listen to, share sources that you trust. “There’s a really important role that Lebanese living in other countries can play in supporting their family here, sharing about how the rollout is going in their countries, and addressing questions they may have,” per McCoin.

As the number of vaccinated people grows, so will the number of people that can speak to their experience with the shot. In other words, “the more people that take it, the more the trust will be for people to take it,” according to Dr. Makhoul-Ahwach. There is a strong association between individual attitudes and local norms, according to the World Bank survey. In tandem with promising results from around the world that the vaccine is certainly reducing both the spread and severity of COVID-19, the quickest way to address hesitancy may simply be ensuring that people who want to get the vaccine can get it. “I do believe that focusing on the positive part of the vaccine and raising awareness about its use and benefits would increase positive sentiment toward the vaccine in Lebanon,” commented Meksassi.

“The overall purpose of the vaccine is to protect our loved ones and ourselves,” said Mohssen. “If we all work together, take the vaccine, and practice safe guidelines, then we can finally beat this and bounce back. We may be down, but we are most certainly not out.”

¹ World Bank Mind, Behavior, and Development Unit. (2021). ‘Behaviorally Informed Interventions for COVID-19 Vaccine Take-Up: Update and preliminary insights from Lebanon’