A Blog by Jonathan Low


May 8, 2021

Will Incentives Sway the Vaccine Hesitant?

Results from research on the subject are ambiguous suggesting that incentives may not work for many. Part of the problem, at least in the US, is that the pandemic was so politicized so early that attitudes formed which are hard to change. 

The greatest incentive to vaccine resistance may ultimately be social and professional acceptance. JL

Sarah Holder reports in CityLab:

Would you get your second dose for a complimentary glazed donut? A free beer or a shot of tequila? A chance to win a new Camaro? Or would some cash be most likely to change your mind?  For those who are vaccine-hesitant, how much do such perks change their calculus, and which kinds work best? A third of unvaccinated respondents said that they’d be more likely to get vaccinated if they were given $100; a little less than a third would be more likely to get one for $50.  There’s a chance incentives could backfire. For those already nervous about vaccine side effects or safety, payments could make the shot seem more risky

Though West Virginia got a fast start on its vaccination rollout and expanded Covid-19 vaccine eligibility to residents as young as 16 on March 22, the pace of vaccinations has slowed in recent weeks, especially among young adults. With less than half of its eligible population one dose in, this cohort represents a major threat to tamping down disease — and a barrier to reaching Governor Jim Justice’s goal of inoculating more than 70% of the state. 

“West Virginians from 16 to 35 years of age are transmitting this thing faster than anyone,” Justice said in a press conference on April 28. “How many people are we going to have to put in body bags? How many people are going to have to die?”

That plea — take the vaccine for the safety of you and those around you — has been echoing from many levels of government in the past few months, but reluctance remains. So Justice became one of the first U.S. public officials to suggest a more tangible reward: a $100 savings bond for every 16- to 35-year-old who gets their shot. State officials haven’t revealed if the idea has improved vaccine uptake — and the details of implementing a mass savings-bond buy may be complicated — but the governor says he’s exploring other ways of delivering the same financial incentives. 

The rapid deceleration of West Virginia’s vaccination campaign is mirrored nationwide. While more than half of U.S. adults have now received at least one shot, a Washington Post-ABC poll shows that more than half of those who remain unvaccinated don’t plan on getting one at all. One new poll said that only 9% of U.S. adults who have not yet been vaccinated planned to do so. Finding out what would motivate those fence-sitters to change their minds has become an urgent task, if the U.S. wants to reach something near herd immunity before the variants catch up. “We’ve got the low-hanging fruit. As we climb higher in the tree, we’re going to have to work harder for each increment of additional vaccination,” said William Schaffner, a professor at the Vanderbilt University School of Medicine. “And to many of us, this reluctant group came upon us sooner than we anticipated.”

Federal authorities announced a revised strategy this week, focusing on smaller-scale local inoculation programs and pop-up and mobile clinics aimed at the 43% of the population who haven’t yet been vaccinated. The Biden Administration has mobilized its Covid-19 Community Corps to reach across demographic and geographic divides to get shots in arms.

Trusted messengers will continue to play a valuable role in sharing the health benefits and safety of vaccines to those who have health concerns; improving availability in rural communities and pharmacy or transit deserts will bridge convenience gaps for the vulnerable. But to reach the most reluctant or least motivated holdouts — many of whom skew younger, male, and/or Republican, according to focus groups and surveys — cities, corporations, institutions and public health leaders are getting creative.

Would you get your second dose for a complimentary glazed donut? A free beer or a shot of tequila? A chance to win a new Camaro? Or would some cash be most likely to change your mind? Detroit Mayor Jim Duggan is offering $50 gift cards to anyone who brings other eligible Detroit residents to a vaccine site. Maryland will give its vaccinated state employees $100 each. Houston Methodist Hospital offered a $500 bonus to employees as a thank you for their work during Covid, and made getting a vaccine one of the prerequisites to receiving it.

The question is: For those who are vaccine-hesitant, how much do such perks change their calculus, and which kinds work best?

Deploying economic nudges to influence public health behavior has a long history. Some strategies, like insurance companies offering premiums to those who get gym memberships or lower rates to non-smokers, are more subtle. Others are more explicitly quid pro quo arrangements. One 2015 trial analyzed how people’s behavior might change if they got money to lower their cholesterol, or how doctors’ guidance might change if they were compensated based on their patients’ cholesterol levels. It only showed a significant difference when both patient and doctor were paid, lowering participants’ cholesterol levels by an average of 34 percentage points.

“There’s this idea that when you share incentives across different people, they worked better than focusing on either the patients or the providers,” said Ankur Pandya, an associate professor of health decision science at Harvard University. 

Maybe that takes the form of compensating both employees and employers if they have a fully vaccinated workforce — or, to take the West Virginia example, making sure states understand that incentivizing individuals to get vaccinated costs the government a whole lot less than paying for the broader toll of the disease. Giving $100 vaccine bonds to the entirety of the state’s under-35 population will cost an estimated $27.5 million, covered by federal CARES funding. That’s a fraction of West Virginia’s spending so far on coronavirus testing, which reached $75 million, according to the Washington Post; it’s also dwarfed by the prospect of saving lives, Justice said. 

Cash payments have also been used to encourage HIV prevention and consistent HIV testing and treatment among at-risk populations, with mixed effects. Covid-19 is a novel disease, however, and the stakes of vaccination and of contracting the disease differ from that of high cholesterol or HIV. It’s also a disease that became intensely politicized, in the U.S. and elsewhere. In this uncharted territory, scientists are studying anew how financial incentives interact with decision-making. 

Forthcoming research set to be published in npj Vaccines led by Sarah Kreps, a professor in Cornell University’s department of government, and four other researchers involved in epidemiology, injury prevention and pediatrics, asked more than 1,000 people to evaluate seven hypothetical vaccines based on a variety of different attributes, including side effects, efficacy, and financial inducement or cost. They found that the prospect of being paid $100 had no statistically significant impact on whether or not people wanted the vaccine; neither did $10. Having to pay a $20 copay to get vaccinated did, however, make people less enthusiastic about the sample shot. 

This month, results from a randomized survey conducted by the U.C.L.A. Covid-19 Health and Politics Project were released, this time showing that a third of unvaccinated respondents said that they’d be more likely to get vaccinated if they were given $100; a little less than a third would be more likely to get one for $50, or even $25. The $100 financial incentive had a greater impact on Democrats than Republicans. 

The discrepancy in findings between the two studies could be explained in part by the time at which the research was conducted — Kreps found the incentives had no impact when surveying respondents on hypothetical vaccines in October 2020, before the real-life rollout had started; the U.C.L.A. team has been continuously talking to subjects over the past 10 months, so it includes the early and ongoing stages of the vaccination campaign. 

Another recent paper argued that there’s a chance that incentives could backfire. For those already nervous about vaccine side effects or safety, payments could make the shot seem more risky, some researchers warn. As Kreps put it, her team’s hunch “is that paying people causes people to be suspicious about why a financial incentive would be necessary — in other words, if the product is so appealing, why do we need to pay people to take it?” 

Introducing financial motivations could also erode one of the clearest, most fundamental arguments for vaccination — that personal immunity benefits the collective good — in favor of a more selfish perk. “The idea there is that the extrinsic motivation of the money crowds out the intrinsic motivation of them just wanting to do it,” said Pandya. 

Nancy Jecker, a professor of bioethics at the University of Washington School of Medicine, has a different concern with the idea of giving cash payments to spur vaccination: The practice may have an outsized coercive effect on lower-income groups. 

“It can create undue inducement for someone who is unemployed, or who has a family member that is, depending on the size of the incentive,” Jecker said. A $500 bonus from a hospital would be less of a factor for an anesthesiologist than for the cafeteria worker, she said.

Jecker argues that there are less coercive ways to get people on board, like clear communication from community members and trusted leaders; enhanced education and access for harder-to-reach groups, and advertising the benefits of being able to see family safely and travel again. Indeed, the U.C.L.A. survey found that for unvaccinated Republicans, especially, the prospect of dropping mask mandates enhanced willingness to get vaccinated as much as the $25 did. 

That’s the tack West Virginia will take in the next phase of its get-the-shot campaign: This week, Governor Justice announced that he’d only drop the state’s mask mandate when the vaccination rate improves.

Meanwhile, the menu of post-shot giveaways has expanded dramatically since March, when Krispy Kreme announced that they’d give a donut a day throughout 2021 to those who showed their vaccination card, kicking off a domino effect of perks (along with backlash from anti-vaccination activists, and muted concern from public health experts who fretted about the long-term effects of a daily donut). The company said it did not yet have an update on how many people had taken advantage of the offer.

In April, Connecticut Governor Ned Lamont announced that some restaurants would be giving out free drinks to those who flashed their vaccine ID along with their regular ID. New Jersey Governor Phil Murphy and D.C. Mayor Muriel Bowser joined the free-beer train. On April 20, cannabis activists handed out joints to people in New York City and D.C. with a vaccination card, to celebrate the auspicious weed holiday while celebrating social responsibility. At the Snoqualmie tribal vaccination clinic in Seattle, some of the inoculated went home with tree saplings to nurture. Seattle Sounders pro soccer games now come with a walk-up vaccination clinic. 

So is there any real harm in handing out some free stuff? Probably not, says Vanderbilt’s Schaffner. “The joke is, if you want residents to come to an educational conference, provide food. They’ll be there for that.”

But practical incentives, such as paid time off to make it to an appointment and allow for side-effect recovery, are the best sell, he says. “One way to incentivize is to cover transportation costs, or reimburse people for their time off … so that people don’t incur expenses by doing the right thing,” added Jecker. “That, to me, is a way of covering costs without creating undue inducement, and it’s also a way of making vaccination more accessible to those who are most vulnerable.”

Outside the U.S., the vaccine outreach story looks very different. As a devastating surge of new Covid cases strains fragile medical systems in India and South America, vaccines remain scarce or unavailable in many communities. There may appear to be less need to bribe people with snacks to get shots, but vaccine hesitancy is a major challenge in places that have struggled to mount inoculation campaigns. In Mexico City, for example, the city has filled vaccine sites with a range of entertainment options, including live music, yoga classes and appearances by a troupe of Lucha Libre wrestlers, to boost turnout and ease anxieties.

Aided by grant funding from Bloomberg Philanthropies, cities in 18 countries will be getting up to $50,000 in funding to optimize their vaccination campaigns from the beginning. Buenos Aires, for example, will dispatch formerly homeless outreach workers to encourage vaccination among isolated, elderly and hesitant residents; transgender people will do the same with their communities in hard-hit Rio de Janeiro. (Disclosure: Michael Bloomberg is the founder and owner of Bloomberg LP, the parent company for Bloomberg CityLab.)

“We have not started mass vaccination of the population yet. However, national surveys have shown that there is a degree of vaccine hesitancy,” fostered by fears about side effects and a preference toward natural immunity by contracting the virus, said Dan Plato, mayor of Cape Town, South Africa, in an email. With its grant, the city plans to flood the radio and paper minibus taxis with vaccine ads, and try to reach the half a million unhoused people, as well as residents without cell phones, with mobile registration sites. 

More rigorous testing will be needed to see what incentive campaigns work, researchers say: Are they reaching people who wouldn’t have been vaccinated otherwise? Are they balancing social pressure with preserving autonomy? Are they meeting people where they’re at? 

“You really want to make sure that they’re not going in the opposite direction,” said Harvard’s Pandya. “And it’s worth knowing if they’re having no effect, because you could use that money to in other ways to help promote vaccinations. It’s a question of where you want to allocate your resources.”


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