COVID-19 Vaccination Personas in Syria: Evidence from a Cross-Sectional Survey

"...reinforces the need for people-centered research to understand the issues from the community perspective."

Since 2011, Syria has been plagued by unrest, and a February 2023 earthquake came on top of a worsening economic crisis, disease outbreaks, localised hostilities, mass displacement, and weak public infrastructure. Against this backdrop, Syria has also weathered the effects of COVID-19. Achieving a high level of COVID-19 vaccination coverage in a setting like this one is challenging. The objective of this paper is to shed further light on the main determinants of vaccination coverage using a large, cross-sectional sample (October-November 2022) of over 17,000 adults in Syria.

Subjects eligible for receiving the COVID-19 vaccine were randomly selected and enrolled in the study. Participants were mainly health workers and teachers; key informants were employees from related ministries.

A large majority of the sample (77.5%) were vaccinated; healthcare workers were highly vaccinated (94%). Among the total sample, 3.3% had not been vaccinated but were willing to do so, while 6.5% were not vaccinated and undecided. Finally, vaccine refusal was reported to be at 12.7%. In other words, about one in ten respondents from the sample were not vaccinated and not willing to be vaccinated.

The research identified a core set of vaccination personas:

• Vaccinated: Men, older respondents, and those who are more educated and trust information received from healthcare authorities are more likely to be vaccinated. Respondents with more positive views towards COVID-19 vaccines are also more likely to be willing to be vaccinated. For example, 94.6% of respondents who strongly believed that the vaccines were safe had been vaccinated.
• Willing: Respondents who believed in the importance of the vaccines and in the protection they provide to family and community were more likely to be willing to be vaccinated. Similar to those who already had been vaccinated, those who were willing tended to receive their COVID-19 information from healthcare staff. They reported a need for more information about the vaccines related to side effects and safety. Resuming normal travel along with an increase in the feeling of being protected were considered the main benefits of COVID-19 vaccination among this vaccination persona.
• Undecided: Unlike the other two personas mentioned above, those who were undecided about being vaccinated trusted healthcare workers less and relied more on social media (40%) when receiving COVID-19-related information. In particular, 44.6% stated they would like to know more about side effects, while 34.3% stated they would like to receive more information about vaccine safety. They also tended to trust private doctors and clinics. Respondents with a neutral attitude towards aspects of the vaccine (e.g., safety, effectiveness, and side effects) were more likely to be undecided.
• Unwilling: Respondents who believe that vaccines are associated with significant side effects were more likely to refuse vaccination. In addition, younger respondents and women, as well as those with a lower level of education, were more likely to refuse to be vaccinated. (On the gender piece, the researchers report that, in many settings, women face restrictive social norms that limit decision-making power and mobility and imply a heavy burden of care - all of which can affect the priority of vaccination as well as the practical aspects of accessing sites. In addition, men are more likely than women to be in formal work in the Middle East and North Africa (MENA) region and may have had more motivation from employers to be vaccinated.) Respondents refusing to get vaccinated were more likely to trust the information received from private doctors, private clinics, as well as social media and, more broadly, the internet.

Table 5 in the paper provides a snapshot of reported information needs by persona. It appears that receiving more information on vaccines' safety and side effects could help persuade some of those who are undecided, as well as the unwilling, to receive the vaccination. Some other practical recommendations that stem from this research include:

1. Given the differences observed, efforts should focus on tailoring responses to the different persona categories. Furthermore, those who are undecided or willing to be vaccinated (who tend to be a majority) are more likely to change their view in the short term, rather than those who are unwilling. In addition, reframing the goal around increasing vaccination acceptance, rather than hesitancy, may be useful in that it reinforces the positive outcome rather than the negative. The findings also show that motivation for vaccination goes beyond health-related benefits. For example, access to travel was a significant motivator, which suggests that further exploration of motivations relevant to different personas could improve intervention results.
2. Interventions should take into account gender and education attainment. For example, experience in Sudan, where interventions were designed to appeal to women, improved uptake by making structural changes to vaccination sites, such as providing female vaccinators and additional privacy, as well as addressing misinformation and specific concerns, such as vaccination during pregnancy or for nursing mothers and effects on menstruation and fertility.
3. Providing consistent access to reliable trusted information channels can help in allaying fears and increasing confidence in the vaccines; however, the channels tend to vary for different persona groups, as summarised above. Where information is carefully tailored to the needs of different personas, the effect is more likely to be positive, e.g., addressing specific misinformation about fertility is likely to influence women. A review of studies in MENA reiterates the centrality of religion in the region; however, the correlation with vaccine acceptance can be positive or negative. Taken together, these findings reinforce the need for various "influencers" to be well trained and supported to use different approaches when interacting with different personas.

In conclusion: "The use of personas is a practical way to tailor and localize responses to the needs of communities, rather than applying a 'one size fits all' approach. While this study focuses on COVID-19 vaccination, the implications for this type of behavioral analysis to form personas also applies to other behaviors or outbreaks, especially for protracted situations where 'response fatigue' can be a challenge."