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Cash incentives for vaccines? Up the pay and watch the COVID away

OPINION: Financial incentive programs to bolster U.S. vaccinations, albeit not perfect, are a step in the right direction. 

Vaccination rates in Black communities continue to lag, but a recent uptick spurred by New York Mayor Bill de Blasio‘s cash incentive plan is giving some public health officials hope.

As of Aug. 12, over 50,000 new vaccinees (yes, I made that term up) have received the $100 incentive, with 43% self-identifying as Hispanic and 21% as Black, according to data at city-run vaccination sites.

Social behavioral scientists, like myself, are watching the success of these cash incentive programs closely, and with cautious optimism. Coaxing people into pro-health behavior isn’t new to public health. In fact, it’s been a staple — we’ve all been offered game tickets, travel credits, and food vouchers to entice us to give blood, for example. But throughout history financial incentives programs have been most successful in bolstering vaccination efforts. In Nigeria, for example, conditional cash transfers increased childhood measles vaccination rates by 27%

That’s why many politicians and public health officials believe that ‘cash for COVID-19 vaccine’ campaigns to get shots in the arm is an effective vaccine distribution plan. While anti-vaxxers are unlikely to be persuaded by any amount of money, a well-executed cash incentive program may convince some people who are teetering on the edge of committing to a shot. 

Employing a public health strategy that essentially amounts to bribery may seem tacky, and maybe it is on some level, but we have to ask ourselves if the benefits outweigh the risks. On the one hand, bribing people to protect themselves and others sounds ridiculous, and it is — imagine how vaccine-deprived nations like Haiti and India feel — but political polarization, declining trust in government, mounting skepticism in science, and a diminishing sense of obligation to the common good are very real obstacles that we must contend with. 

A man holds a sign and dresses as a plague doctor to encourage people to be vaccinated and help prevent prolonging the COVID-19 pandemic March 25, 2021 on Capitol Hill in Washington, DC. (Photo by Alex Wong/Getty Images)

As a scientist who has studied the historical use of rewards to move public health efforts forward, I’ve come to accept that what we use as bribes to accomplish has changed over time, but the reliance on bribes, on behaviorist doctrine, has not. So we must ask ourselves, do rewards work? And, if so, do they work as well today as they have in the past? The answer depends on what we mean by “work.” 

Research suggests that rewards succeed at securing temporary compliance, because once the rewards run out, people often revert to their old ways. They don’t alter the attitudes that underlie our behaviors or create an enduring commitment to living a healthy lifestyle. Rather, incentives merely — and temporarily — change what we do. But when it comes to vaccinations, that’s exactly what we want. 

While temporary compliance is detrimental to general public health efforts, it is immeasurably important and almost welcomed, in times of crisis. Temporary compliance suffices for mass vaccination efforts because getting shots in arms is the goal. A temporary change of heart to make that happen is OK, which is why we should leverage what we know about our propensity for short-lived behavioral change to both maximize and energize our vaccination efforts. 

Components of a Successful Vaccination-Incentive Program 

A health worker gives a man a shot of the Jenssen COVID-19 vaccine from the Johnson & Johnson. (Photo by Guillermo Legaria/Getty Images)

We have to create incentive programs that do not feel increasingly off-putting and potentially counterproductive. For starters, incentives work best when the burden of participation is at its lowest. This is why, in theory, Johnson & Johnson would be the best vaccine candidate in an incentive-driven model because people only need to take one shot. Unfortunately, cash incentives may not be enough to overcome skepticism in the pharmaceutical company given its checkered past. 

Secondly, the reward has to be worth the perceptual risk. Studies show that a tiered incentive model leads to better compliance. Public health officials should disperse two — or three if you need a booster shot — separate payouts that are paid after each dose is administered. If the total amount is $250 instead of $100  — a full day’s pay for many Americans  — not only will it increase participation, but it will result in higher rates of compliance. For health departments on tighter budgets, lotteries are also highly successful; much like direct payment programs, they increase the perceived benefit of getting the vaccine, motivating indecisive people to get the shot, but at a fraction of the cost.

Lastly, public health officials need to have realistic expectations. Cash incentive programs may be enough to persuade those on the fringe, but it may feel disingenuous or even more, like bullying, to those who feel bombarded by pro-vaccine health campaigns. If you offer an incentive and receive a no, accept it. 

Reward Programs Aren’t the Fix, But it’s a Start

Latiah Haley receives a dose of the Johnson & Johnson COVID-19 vaccine, the newest vaccine approved by the U.S. FDA for emergency use, at an event put on by the Thornton Fire Department on March 6, 2021 in Thornton, Colorado. (Photo by Michael Ciaglo/Getty Images)

There is no doubt that moving forward we need to rely on a multi-prong approach to meet our immunization goals. Free transit/metro cards and gift cards don’t address mistrust and misinformation about vaccines. Pro-vaccine campaigns must continue to walk the delicate line of education and encouragement and outright bullying. Public health officials need to be more visible in the actual communities where vaccines are needed most. Employers should offer paid time off to get the vaccine and rideshare companies like Uber and Lyft must continue their free-rides-to-vaccine-appointment programs. 

This nation is in dire need of relief and vaccination is our only way out. Financial incentive programs, albeit not perfect, are a step in the right direction. 

According to the CDC, 99% of COVID-19 hospitalizations are among the unvaccinated; and the virus has killed more than 600,000 people with the delta variant lying in wait ready to take many more. These numbers alone should be reason enough to take the vaccine, but sadly, this isn’t the world we live in, leading some to believe that taking the drastic measure of paying people to take the vaccine is the only way to make COVID go away. I hope not.

Dr. Shamard Charles is an assistant professor of public health and health promotion at St. Francis College and sits on the anti-bias review board of Dot Dash/VeryWell Health. He is also host of the health podcast, Heart Over Hype. He received his medical degree from the Warren Alpert Medical School of Brown University and his Masters of Public Health from Harvard’s T.H. Chan School of Public Health. Previously, he spent three years as senior health journalist for NBC News and served as a Global Press Fellow for the United Nations Foundation. You can follow him on Instagram @askdrcharles or Twitter @DrCharles_NBC.

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