As the COVID-19 pandemic enters a third year, the emergence of highly-transmissible variants has made increasing vaccine uptake even more important.
As decision makers across the country consider different interventions to increase uptake of vaccinations, this new guidance from the Societal Experts Action Network identifies strategies that state and local decision makers can use when designing requirement and incentive programs.
Vaccine requirement programs function by requiring or mandating vaccination for one to work, travel, and attend school or an entertainment venue, for example. Past vaccine requirement programs offer lessons that can inform the design of an effective requirement program for the COVID-19 vaccine.
From an ethical viewpoint, when promoting vaccinations and designing requirements programs, the least intrusive effective method to increase vaccination has been shown to be most helpful. It is important that vaccine requirements are implemented only after other efforts (including communication efforts and removing barriers to access) to increase vaccination uptake have been exhausted. In addition, the principles of public health and ethics require that any interventions that impact autonomy need to be reasonable and necessary.
A more forceful policy does not necessarily result in a higher rate of vaccination because the limitations on personal choice might lead to strong resistance. Instead, a middle-of-the-road approach, with strict mandates but with room for exemptions, may be most effective. Past research shows that requirement programs that allowed for exemptions, and made those exemptions difficult to obtain, potentially limited the use of exemptions by individuals with sincerely held beliefs. In the context of COVID-19, finding this balance is important for reducing anti-vaccination sentiments.
Requirements are more likely to be enforceable if they are targeted to specific groups (for example hospital workers and school children) and not the population at-large. These targeted mandates are also preferable from an ethical standpoint. Targeted requirements for schools and higher educational institutions, individual employers, hospitals, nursing homes, indoor dining, and museum visitation, among others can be successful in raising vaccination rates. For example, targeted workplace vaccine requirements have been successful in increasing the coverage for the flu vaccine by up to 25 percent.
Vaccine incentives programs provide a reward in exchange for getting vaccinated. The reward may be monetary or non-monetary and may be guaranteed or provide a chance of winning something of value (e.g., a lottery). Incentives have not proven to be consistently effective as a means of promoting first doses of the COVID-19 vaccine in the United States, but may be more effective in promoting boosters as the population in need of boosting has already demonstrated a willingness to be vaccinated. The available literature points to some key design considerations that may improve the effectiveness of financial incentive programs for boosters.
As with other vaccination efforts, targeted communication will be important so that people are aware of the incentive. Examples of some marketing strategies that have been used include social media ads, press releases, local television coverage, and other digital media.
Widely advertising incentives has an additional benefit: it can increase public knowledge of the importance of vaccination. It can also provide a public justification for getting a vaccine among people who in the past have been vaccine hesitant, generating a sense that “everyone else must be getting vaccinated now.” In this way, they change the perceived social norm, which in turn can change behavior.
Economic and psychological research shows that rewards are more effective when they are handed out immediately. Rewards that are immediate are valued more due to people’s tendency to discount anything they will need to wait to receive. Receiving rewards immediately also adds to the positive experience of the task. For example, people could receive gift cards or other incentives at the vaccination site.
Designing successful incentives requires understanding what is valued among the target population. Research has shown that cash incentives are more effective than non-cash incentives because cash can be used to purchase whatever a person values most. The amount of the incentive also matters depending on the value assigned by the target population.
However, non-cash incentives can still be valuable. For example, a hunting license may be a popular incentive for people in rural areas, but less so for people in urban areas.
Incentive programs need to do a cost-effective analysis before being implemented. For example, past research shows that incentive programs like lotteries have proven to be particularly cost effective in motivating health behaviors because individuals tend to overestimate their chance of winning, making these incentives more cost-effective motivators of behavior change relative to guaranteed payments.
Incentive programs need to be designed in a way to ensure that they are not coercive, particularly for low-income people who might be forced to accept the incentive because of their economic circumstances. Even modest cash awards could unduly induce the least well-off, and race-related differences in wealth could compound this effect for some groups. Ethicists have justified the use of incentives based on the principles of decreasing overall harm from COVID-19 by reducing its spread, reducing the burden on health care systems, and protecting disadvantaged populations who have faced greater barriers to accessing vaccination.
When designing and implementing an incentive program, there are also risks that need to be considered. First, one concern is that people may come to expect payment for any future vaccination.
Previous studies have shown that associating a behavior with an incentive may set the expectation for incentives in the future. In the context of COVID-19 vaccines, this means people may adopt a perception that they have to be paid for any future vaccination.
Second, people might construe the incentive as compensation for a potential risk associated with the vaccine, which can adversely affect other outcomes (e.g., trust, perceptions of vaccine efficacy). Finally, incentives that are posed as rewards for vaccination can be economically inefficient, if they end up being used to reward those who would have gotten vaccinated anyway.
The continuing pandemic has necessitated employing additional approaches to increase uptake of COVID-19 vaccines. While implementing requirement programs can be an effective strategy for increasing vaccinations, to be successful they must be designed in ways that are targeted, effective, and build trust. There is limited evidence that incentives can improve first-dose vaccine uptake, but there is potential for incentives to move the needle on booster uptake.
This rapid expert consultation was produced by SEAN, an activity of the National Academies of Sciences, Engineering, and Medicine that is sponsored by the National Science Foundation and the Alfred P. Sloan Foundation. SEAN links researchers in the social, behavioral, and economic sciences with decision makers to respond to policy questions arising from the COVID-19 pandemic. This project is a collaboration with the National Academies’ Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats, which is sponsored by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, and the White House Office of Science and Technology Policy.
Read the guidance online at https://www.nap.edu/resource/26084/interactive.
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SEAN is a network of experts in the social, behavioral, and economic sciences poised to assist decision makers at all levels as they respond to COVID-19. The network appreciates any and all feedback on its work. Please send comments to SEAN@nas.edu.