“Vaccine for lollapalooza!!” Are monetary incentive programs the answer to low vaccine uptake?
Thomas Schelling while working as a young staffer in the Executive Office of President Truman, in one of his interviews recalls that “People worked long hours,” “and felt compensated by the sense of accomplishment, and … personal importance.” There was a culture of working late into night and then resuming on Saturdays too. There were no loud cries because most of the people working in the office knew the work was important. But when the President issued an order that anyone who worked on Saturday was to receive overtime pay, Saturday meetings virtually disappeared. Why did the incentive not work when it was rewarding people for the extra hours being put? Can we rely on incentives to spur pro-social behaviours like uptake of vaccines?
Free Beer, a million dollar, a free pass into gentleman’s club, krispy creme’s free doughnuts, one day pass to Chicago’s Lollapalooza and many more such incentives have been showered upon the American population within the last two months in an effort to have at least 70% of adult population vaccinated with at least one dose. At least a half dozen states have introduced some form of lottery with cash prizes for the newly vaccinated. Leading the way was the state of Ohio with its 1 million dollar lottery, which saw a 29% rise in vaccination post that. California on the other hand has raised the stakes in order of a hundred million in different forms of incentives to entice its population in taking the jab. But US fell short of the 70% target by 4th of July with approximately 67% of the population having taken atleast one dose of the vaccine, which is still impressive but does not completely wipe off the risks posed to public health.
A study at the Boston University School of Medicine has not found evidence that the lottery based incentive in Ohio led to increase in vaccinations. Though the rate of decline of vaccinations was arrested. In another study, researchers from University of Pennsylvania and University of Chicago in a recent study did not see any significant difference in vaccination trends between states with and without incentives, measured 14 days before and after the incentive program announcement.
Though incentives like these are a step in the right direction, the question still remains: Are these enough? Is/Was just the absence of an incentive the reason behind an individual’s hesitancy or refusal towards vaccine? Can such economic incentives help in preference re-ordering and thereby human behavior? Delving into what is hesitancy and what it looks like, and what do we know about lottery and incentives as enablers of social choice might be helpful in understanding these recent splurge of incentives and also their effectiveness.
Hesitancy as a Spectrum
Vaccine hesitancy is defined by WHO as “the reluctance or refusal to vaccinate despite the availability of vaccines “. Vaccine hesitancy could prove to be a crucial roadblock in United States path to achieving herd immunity quickly and putting the COVID pandemic behind. The recent spike in COVID cases in American states with low rates of vaccination highlights the seriousness and urgency that this challenge must be dealt with.
Our research to understand the drivers of vaccine hesitancy in the US indicates that hesitancy exists as a spectrum ranging from cohorts who are anti-vaccination to ones who are skeptical, complacent, or confused about COVID vaccines. The tendency of delaying or refusing to take up vaccines within the hesitant cohorts is resulting from variability in factors such as trust in institutions and feelings about the risk/reward of taking the vaccine.
- Distrust Begets Distrust: Vaccine confidence is being adversely affected by widely proliferating information (often misinformation) raising concerns about the vaccines’ side-effects and their degree of effectiveness. But the information content per se cannot be seen in isolation from the source of the information. Trust in the source of information contributes significantly to the consumption and integration of the information itself. Trust involves an individual’s confidence towards agents of vaccinations (the government, the big pharma, local authorities) and the information sources. Trust in such institutions and agents has taken a hit during the pandemic due to reasons such as perceived mismanagement, perceived disproportionality of response and inconsistencies in communication (e.g., mask mandate, lab leak hypothesis). This then shapes the individuals outlook towards the vaccine. Lack of trust is also amplified by an individual’s or community’s historical experiences such as those of the African American community, which perceives many public institutions to be unfair and discriminatory towards them. In uncertain times like these, where there is an widespread crisis of trust, the influence of weaker social ties and external agents tends to diminish, and individuals start gravitating towards strong ties like family, friends and colleagues. The beliefs and sentiments within these strong networks are favored over external information, creating echo-chambers. These echo-chambers can lead to clusters of hesitancy if the dominant preference within the strong ties is to go against the vaccination, which tends to be the case in less urban communities which did not experience high caseloads even during the peaks of COVID.
- “What are the rewards? I don’t see any. “ : The feelings of risk and rewards is the other gear that powers the action tendency towards a vaccine. When President Biden informs the nation that vaccinated individuals can stop wearing masks, it signals that getting vaccinated can be the key to resuming one’s pre-covid life. But as we know, covid appropriate behaviours are now advised even after one gets vaccinated, if one is indoors or is among crowds. Thus, a positive vaccine action does not carry any immediate, definitive visible reward for the individual (a hesitant one). During our research we saw a variety of emotions towards the vaccines and the vaccination drive, such as indignation, confusion, resentment, being harboured among the different hesitant cohorts. These diverse set of emotions occur because different individuals use different ways to cope, assess risk and rewards, evaluate urgency, and have different mental models which they use while making the decision. Some individuals have low-risk perception regarding covid due to perceived adequacy of other covid appropriate behaviors, absence of COVID in their communities and a perceived sense of superior immunity. Others perceive high risk of side-effects from the vaccine due to perception of rushed development and trials, lack of FDA approval, personal history of adverse reactions, and reports of severe adverse events following immunization. Hence, vaccine hesitancy should not and cannot be seen as a uni-dimensional phenomenon and a one-size-fits-all solution like monetary incentives cannot address the diverse concerns and barriers within the hesitant populations.
Incentive Vs Incentive Compatibility
Now that we have explored the dynamics of COVID vaccine hesitancy, let’s try to understand the mechanics behind incentives and preferences. The theory of rational choice centres around the idea that individuals have preferences and choose accordingly. But sometimes these preferences (e.g. savings over expenses) may not be aligned to a pro-social goal such as filing taxes, purchasing EVs etc. or in the context of vaccine, the desirable goal of taking the two doses of vaccine.
Incentives are fundamental to the discipline of economics, but advances in behavioral economics show that social preferences, such as altruism, reciprocity, intrinsic pleasure in helping others, inequity aversion, and other motives that people indulge in than their own-material-payoff maximizing individual, also have an impact on economic behaviour. Thus, separating economic incentives from social preferences might not be conducive to the desired behaviour at an aggregate level. For instance, providing financial incentives for sustainable energy installations does not necessarily lead to sustainable energy behaviour if it does not align to some intrinsic motivation to address environmental issues. Moreover, advances in neuroscience suggest that explicit incentives can diminish activation of zones mapped to social rewards, thus reducing a voluntary drive to act for greater good.
Efficiency of incentives are studied in the field of market (or mechanism) design. One of the important aspects there is the concept of incentive compatibility. That is under incomplete information, a mechanism such as lottery must be able to induce actors to be truthful, resulting in separate set of actions which will help in identification of who is who ( eg. High risk actors from low risk actors).
Can incentives work for all?
As our research indicates, hesitancy should not be seen through a simplistic binary lens: people who are vaccine confident vs people who are hesitant. The different cohorts present within the hesitancy spectrum have distinct preferences, and require bespoke interventions to help move them towards vaccine confidence and uptake.
In our study, two groups: The Opposers and The Distrusters, were found to be quite apprehensive towards the COVID vaccine. The opposers are ideologically anti-vaccine because of their beliefs about vaccine constitution, safety and ethics, whereas the distrusters’ attitudes and decisions are informed by their negative perceptions regarding the governments and health system. With these groups, the lotteries and monetary incentives are not likely to work well to dispel the existing distrust. Incentives may actually aggravate the distrust and alienate these sections further, because incentives have the potential to reinforce the perceptions of coercion and hidden agendas. Few quotes from these groups from our study illustrate the unique nature of their hesitancy:
“The media keeps talking about the COVID vaccine as if it’s wonderful, but I don’t buy it…the vaccination is a way of pushing for ID chips.. …this is all about money, this is not about illness……no one should take this vaccine”. — Distruster
“The main base in vaccines is an aborted, 14-weeks old, white, male foetus. Other ingredients are also toxic…I know it has lots of side-effects… efficacy is dubious…. FDA approval is not clear…. putting any foreign object in my body without knowledge is dangerous” — Opposer
While we have groups with high hesitancy, we also found groups we call “Cautious” and “Avoiders” for whom monetary incentives might work well as these groups though not against the vaccine are delaying the uptake owing to sense of low rewards.
“I think that I am more protected as I don’t have any co-morbidities. It’s all about what you eat and what you think — when people are stressed out their body releases Cortisol — which makes you more prone to illness etc.. I take care to keep my body and mind healthy..” — Avoiders
Therefore, while some groups of vaccine hesitant population may be motivated to get vaccinated through incentives, others may become more skeptical and distrustful due to the introduction of external pushes. By neglecting the concerns of the distrustful cohorts, we run the risk of altogether alienating them, and thus resulting in long-term adverse impact on engagement with public health systems.
Health decisions are complex and highly consequential for the decision-makers’ well-being. Economic incentives may be helpful in addressing certain barriers to well-being conducive decisions, but overreliance on these to drive critical behaviors such as vaccine uptake is a costly and avoidable mistake. It is utmost critical to understand the specific barriers and concerns that may be contributing to hesitancy towards COVID vaccine in the population, and deploy targeted, customized interventions to address those. Unfortunately, though, the current administration’s response to the problem of COVID vaccine hesitancy appears to lack an appreciation of the nuances of the issue, and is over reliant on one-size-fits-all approaches and assumptions about the drivers of vaccine hesitancy which lack basis in evidence.
Considering how quickly the COVID pandemic spreads, speed is of essence in responding to various challenges, so it is natural that some solutions are scaled quickly before assessing their true impact. But any effort to address complex behavioral challenges such as vaccine hesitancy must take a nuanced view of the issue and avoid generalized assumptions and templative solutions.
- Bowles, Samuel, and Sandra Polania-Reyes. 2012. “Economic Incentives and Social Preferences: Substitutes or Complements?” Journal of Economic Literature, 50 (2): 368–425.
- Shen SC, Dubey V. Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents. Can Fam Physician. 2019;65(3):175–181.
- Walkey AJ, Law A, Bosch NA. Lottery-Based Incentive in Ohio and COVID-19 Vaccination Rates. JAMA. Published online July 02, 2021. doi:10.1001/jama.2021.11048
- Thirumurthy, Harsha and Milkman, Katherine L. and Volpp, Kevin and Buttenheim, Alison and Pope, Devin G., Association between statewide financial incentive programs and COVID-19 vaccination rates (August 27, 2021).
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