Health Incentives: Lessons for COVID-19 Vaccine Campaigns

While most countries still lack adequate access to COVID-19 vaccines, in the U.S., vaccine supply has begun to outstrip demand. As of July 2021, nearly 70 percent of adults have received at least one shot.¹ But vaccination rates vary significantly across the country, and in some regions, opposition to vaccines is entrenched, with estimates of “hesitancy” and “strong hesitancy” hovering at one-third of a state’s population.² To promote public health efforts — and to draw customers back through their doors — businesses have begun to offer incentives for vaccinated customers: Krispy Kreme made headlines in March 2021 when it announced free donuts for anyone who could prove they had been inoculated, and the New York Yankees and Mets are offering free tickets to fans who get vaccinated at ballparks before games. Local governments are approving six-digit budgets for vaccine perks and giveaways, and many states are instituting incentives-based programs as well: Maryland is paying fully vaccinated state employees $100, and in West Virginia, 16- to 35-year-olds who get vaccinated can receive $100 savings bonds.³

In spite of the popular appeal of vaccine incentives, some scholars have questioned their ethics. In a JAMA Network paper published in July 2021, Govind Persad and Dr. Ezekiel Emanuel respond to worries about coercion and exploitation by arguing that vaccination’s benefits — among them preventing harm from COVID-19 and protecting disadvantaged populations facing barriers to vaccination — do not threaten to deprive anyone of anything to which they were entitled. They do validate the legitimacy of two particular concerns: the potential to waste public funds and the potential to make vaccination look riskier than it is by offering compensation. They write that the former could be addressed by carefully calibrating benefits to what is needed to encourage vaccination and that the latter could be addressed by targeting vaccine incentives to only the most receptive groups.⁴

However, designing incentive programs that strike this balance is notoriously difficult. Positive incentives have proven to be effective in other health campaigns. For example, participants in a fitness-based employee wellness program who received a mere $20 monthly incentive maintained higher levels of exercise than non-participants over a 3-year period, after adjusting for pre-intervention differences in activity levels. However, those who had previously exercised the least were also the least likely to join the program.⁵ The results of studies like this one and others^6,7 indicate that rewards-based incentives can be powerful tools for swaying certain segments of the population to change their behaviors, but that those most entrenched in their practices or beliefs may not be reached so easily.

An Axios-Harris poll from May 2021 found that nearly one-third of unvaccinated Americans say they’ll either “get the vaccine whenever they get around to it” or “will wait awhile and see before getting the vaccine” — suggesting that with well-strategized incentivization, the U.S. can continue to narrow the gap toward heard immunity.³ However, the question stands as to how to persuade the most staunchly opposed groups.

The backlash prompted by Israel’s brief consideration of a vaccination mandate is indicative of why tactical public health education programs are necessary.⁸ Though Israel acquired a sufficient supply of vaccines early on, many groups’ distrust of the vaccine compelled the state to implement a “Green Pass,” in which proof of vaccination or recovery from COVID-19 serves as a passport to communal events and spaces.⁹ The program’s punitive edge — barring unvaccinated individuals from the social, commercial, and cultural opportunities they may crave — comes with its own controversies. For example, Mexico’s tax on sugar-sweetened beverages has been criticized as an unfair instance of a government overstepping its place. On the other hand, Mexico’s sugar tax reduced purchases by nearly 10% in 2015.¹⁰ The tax is projected to prevent 239,900 cases of obesity and 61,340 cases of diabetes, which a Health Affairs article estimates saves $3.98 per dollar spent on the tax’s implementation.¹¹ As for Israel’s Green Pass, over 80 percent of the adult population has now been fully vaccinated.⁹ Incentives can be powerful, but they must be implemented alongside robust public-health education campaigns.

References 

1. The New York Times. See how vaccinations are going in your county and state. The New York times. https://www.nytimes.com/interactive/2020/us/covid-19-vaccine-doses.html. Published July 16, 2021. 

2. Vaccine hesitancy for COVID-19: State, county, and local estimates. U.S. Department of Health and Human Services. Published June 17, 2021. https://aspe.hhs.gov/pdf-report/vaccine-hesitancy 

3. Ducharme J. From free beer to $100 payments, states are incentivizing COVID-19 vaccination. Will it work? Time. Published online May 5, 2021. https://time.com/6046238/covid-19-vaccine-incentives/ 

4. Persad G, Emanuel EJ. Ethical considerations of offering benefits to COVID-19 vaccine recipients. JAMA. Published online 2021. doi:10.1001/jama.2021.11045

5. Crespin DJ, Abraham JM, Rothman AJ. The effect of participation in an incentive-based wellness program on self-reported exercise. Prev Med. 2016;82:92-98. 

6. Strohacker K, Galarraga O, Williams DM. The impact of incentives on exercise behavior: a systematic review of randomized controlled trials. Ann Behav Med. 2014;48(1):92-99. 

7. Burns RJ, Donovan AS, Ackermann RT, Finch EA, Rothman AJ, Jeffery RW. A theoretically grounded systematic review of material incentives for weight loss: implications for interventions. Ann Behav Med. 2012;44(3):375-388. 

8. Wilf-Miron R, Myers V, Saban M. Incentivizing vaccination uptake: The “Green Pass” proposal in Israel. JAMA. 2021;325(15):1503-1504. 

9. Kershner I. With most adults vaccinated and case numbers low, Israel removes many restrictions. The New York Times. Published June 1, 2021. https://www.nytimes.com/2021/06/01/world/middleeast/israel-covid-restrictions.html.

10. Colchero MA, Rivera-Dommarco J, Popkin BM, Ng SW. In Mexico, evidence of sustained consumer response two years after implementing A sugar-sweetened beverage tax. Health Aff (Millwood). 2017;36(3):564-571. 

11. Basto-Abreu A, Barrientos-Gutiérrez T, Vidaña-Pérez D, et al. Cost-effectiveness of the sugar-sweetened beverage excise tax in Mexico. Health Aff (Millwood). 2019;38(11):1824-1831.