COVID-19 risk perception, cognitive dissonance, and vaccine hesitancy

ABSTRACT

The COVID-19 pandemic has shown that despite having high risk for severe disease, some individuals had low-risk perception and consequently they refused vaccination. This was more common among individuals with distrust in the government and the scientific organizations. Cognitive dissonance occurs when a person participates in an action that goes against one’s beliefs. In order to reduce the dissonance, the individual often avoids the action. Recently, dissonance-based interventions have been shown to be effective in changing various health, environmental, and social behaviors. The impact of these interventions may persist for several years. Cognitive dissonance may be another mechanism for vaccine refusal among people with mistrust in the system. There is a need to investigate the role of cognitive dissonance in vaccine refusal and the effectiveness of dissonance-based interventions to reduce vaccine hesitancy among individuals with high risk for severe disease and low vaccination rates.

KEYWORDS:

• COVID-19
• risk perception
• vaccine hesitancy
• cognitive dissonance

Black and Hispanic Americans tend to have lower incomes and are more likely to be employed in front-line jobs that have an increased risk of COVID-19 exposure.¹ Furthermore, Black and Hispanic Americans have higher rates of comorbidities, such as diabetes, heart disease, and obesity that increase the risk for COVID-19 related morbidity and mortality.² Despite being aware of the higher rates of COVID-19 and mortality among people with comorbidities³, Black Americans have been significantly less likely to report anxiety or depression during the pandemic.⁴

Disease risk perception has been shown to directly correlate with vaccination rate.⁵ Although the COVID-19 vaccine has been shown to prevent severe disease and death among people with comorbidities, vaccination rate has been lowest among Black Americans,⁶ and this has been mainly attributed to the higher rates of mistrust in the U.S. health-care system and the U.S. government, along with misinformation on vaccine safety.⁷ Chronic inability to access health care also lead to a resilient, “nothing will happen to me,” attitude.⁸

Another population with low levels of trust in the government and health-care system and low rate of COVID-19 vaccination is first-responders.⁹ First-responders are also expected to have “brave and duty-focused” personality traits, which often correlate with a low level of personal risk perception.

Cognitive dissonance is described as the psychological stress experienced when a person participates in an action that goes against one’s beliefs.¹⁰ Cognitive dissonance “creates a motivational drive in an individual to reduce the dissonance by making one or more inconsistent elements consistent with other elements in the system (e.g., by changing their attitude to align with publicly displayed behavior), by decreasing the perceived importance of an inconsistent element, or by adding new consistent elements to the system.”^10,11 Cognitive dissonance may play a role in vaccine hesitancy.¹²

Errors in thinking often occur when people make a complex decision and have incomplete or contradictory information. For example, most people have difficulty in understanding how the vaccines work, and if they are also concerned about the safety, and they are not confident about their effectiveness, they may think that they are not at risk for infection, and they may avoid the vaccine. Indeed, people with a low level of trust in health-care and scientific organizations were less likely to get the COVID-19 vaccine during the pandemic.¹³ Disconcertingly, in order to reduce the dissonance and be consistent, the increase in the systemic distrust during the pandemic might have led to a broader refusal of CDC health-related recommendations, and further decrease in the immunization rates with other vaccines, such as the annual flu vaccine.¹³

Dissonance-based interventions may be effective in changing various health, environmental, and social behaviors and the impact may persist for several years.¹⁴ Currently, the strongest data on the effectiveness of dissonance-based attitude change are on risk reduction to develop eating disorders and on cessation of smoking tobacco.¹⁴ Dissonance-based interventions could potentially be applied to reduce vaccine hesitance/resistance and to improve health resource utilization.

Inducing dissonance often creates a discrepancy between a person’s beliefs and their current behavior.¹⁴ This leads to feelings of discomfort, which can prompt people to either change their cognitions and/or behavior to promote better health outcomes.

The most commonly studied dissonance-based intervention is the hypocrisy paradigm where people publicly promoting a behavior are privately reminded of their own transgressions and inconsistencies; this leads to a behavior change rather than an attitude change.¹⁴ Other approaches used to create dissonance include belief disconfirmation paradigm, free choice paradigm, effort justification paradigm, and induced compliance paradigm.¹⁴ In the belief disconfirmation approach, the person is provided information inconsistent with their existing beliefs, for example “COVID-19 vaccination decreased severe disease in all high-risk individuals.” In the free choice approach, the person is asked to decide between two or more alternatives and think about the positive aspects of the rejected option and the negative aspects of the accepted option; for example, a patient who refuses to get vaccinated may be asked to think about the consequences of being severely ill with COVID-19 in the family. In the effort justification approach, people are asked to freely engage in a laborious task with little purpose. For example, the person may be asked to make a list of the health promotion behaviors they have engaged in to protect or respond to a family member or a friend. In the induced compliance approach, the person is asked to role-play and argue for a position contrary to their existing beliefs. For example, the person may be asked to make a list of benefits of the COVID-19 vaccine.

Recently, Dr. Pearse and Dr. Cooper from Princeton University examined whether cognitive dissonance may be used as a guide to increase compliance with anti-COVID-19 strategies including vaccination.¹⁵ The investigators induced dissonance by having the subjects advocate for consistent adherence to the safety protocols and then recall the instances when they have not. The following week, the investigators observed that dissonance participants were more likely to follow the guidelines and got vaccinated than the subjects in the non-dissonance cohort.¹⁵

Early data suggest that cognitive dissonance may be another factor in vaccine resistance. Future studies are needed to assess the impact of novel strategies targeting dissonance to decrease vaccine resistance.

Acknowledgments

MiOra thanks Robert Watson, M.D, M.Eng, for the valuable discussion and insights on the experience of frontline workers and Anna Equils for conversation on cognitive dissonance.

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No potential conflict of interest was reported by the author(s).

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Funding

The author(s) reported that there is no funding associated with the work featured in this article.