The Role of Behavioral Economics in Addressing COVID-19 Vaccine Hesitancy

The COVID-19 pandemic has disrupted the lives of individuals around the world. At home, the Johns Hopkins University COVID-19 database has recorded 43 million confirmed cases of COVID-19, while the CDC estimates the number of total infections to be much greater at approximately 147 million.^1,2

A similar disconnect can be found in the number of deaths attributable to COVID-19, with the CDC and Johns Hopkins University reporting an estimated 921k and 700k deaths, respectively.^1,2

Managing COVID-19 during the early stages of the pandemic was limited to reducing the risk of exposure and spread. Strategies such as social distancing, handwashing/sanitization, and masking were recommended. Therapies such as remdesivir and antibody treatments helped manage individuals with complications, with the first vaccine from Pfizer-BioNTech given emergency use authorization (EUA) by the FDA in late 2020. This was followed by EUA for vaccines from Moderna and Johnson & Johnson.

Vaccines have proven to be safe and effective to protect people against outcomes such as infection, symptomatic illness, hospitalization, and death. Despite this evidence, there is significant vaccine hesitancy throughout the world.

The World Health Organization defines vaccine hesitancy as a “delay in acceptance or refusal of vaccination despite availability of vaccination services.” Vaccine hesitancy represents a significant barrier to reducing the spread of COVID-19.

Multiple factors play a role in vaccine hesitancy, such as the degree of trust in vaccines, manufacturers, health care systems, and policymakers, perception of low risk from COVID-19, access challenges, potential adverse effects, and outright misinformation.³

Among communities of color, who are at a higher risk of severe disease, the lack of distrust in the health care system may stem from previous experiences, such as the Tuskegee syphilis study.

Additionally, social media may have fueled the dissemination of myths and misinformation associated with vaccine hesitancy.^4,5 Some of these myths include beliefs such as “natural immunity is better than immunity from COVID-19 vaccination,” or more far-fetched concerns such as “COVID-19 vaccines contain microchips,” or “COVID-19 vaccines can alter my DNA.”

Several strategies have been adopted to address vaccine hesitancy, including policy-level approaches, monetary incentives, education, and community engagement activities. Workplace mandate for COVID-19 vaccinations is an example of policy-level approach.

To comply with this requirement, several employers have provided monetary incentives to their employees to get vaccinated. In addition, several states, such as Massachusetts, Michigan, Ohio, and California, have launched lottery campaigns for state residents to bolster vaccination rates.

Although mandates can be perceived as coercive, incentives can nudge individuals who are unsure about getting vaccinated. However, the evidence supporting the efficacy of the lottery campaigns is inconclusive.^6,7 In fact, a study indicated that the campaign may have cost an additional $49 per vaccinated individual for the state.⁸

Behavioral economics is the science behind the lottery campaigns. It attempts to apply psychological insights into human behavior to explain economic decision-making. In the case of lotteries, people may overestimate the odds of winning, which motivates them to get vaccinated. Also, people may focus on the magnitude of the reward and not necessarily the likelihood of winning.

There are several components in the vaccine lotteries that work together to motivate individuals to get vaccinated. First, compared to other factors in health outcomes such as proper nutrition or exercising, getting vaccinated is a discrete event. The likelihood of lotteries working for discrete events such as vaccinations is far greater than for chronic lifestyle modifications.

Next, many states had relatively simple and easy to understand rules and regulations that increased transparency. In addition, getting rewarded in a relatively short time is another positive for the vaccine lotteries. Despite these motivators in the vaccine lottery program, states were not able to achieve their vaccination goals.

There are several reasons and possible solutions to optimize the value of vaccine lotteries and incentives. Individuals can be broadly categorized into 3 groups: those who believe in vaccines, those who are adamantly opposed to the vaccine, and those who are in the middle. It is highly likely that people who believe in vaccines will get vaccinated barring any access issues.

Having vaccine lotteries for this group will only reward them for positive behavior and not necessarily motivate them since they are already motivated. Those who are in the middle could be persuaded with a combination of education, conversation, and modest incentives, such as lotteries with modest winning amounts.

The prime target for “mega” vaccine lotteries is the group who is adamantly opposed. Since the goal of the lotteries is to increase vaccination rates, these programs should be targeted to those who are reluctant to be vaccinated.

Next, the program should auto-register all individuals who are not vaccinated. In addition, these lotteries should have a “regret” component, wherein the person winning the lottery can only redeem the award if they were vaccinated.

In the event they were not vaccinated, the award will be forfeited. The fear of losing the winnings can be a big motivator to get vaccinated, especially if the amount is significant. Some of these strategies have been adopted in certain programs, such as the Philadelphia Vaccine Lottery program.

We continue to grapple with COVID-19 and the new emerging variants. Amid the disruption, vaccines play an important role in getting life back to normal. Although mandates have been adopted across various settings, they can be coercive and perceived negatively. Well-designed nudges, incentives (financial and social), and education can help address vaccine hesitancy and bolster vaccination rates.

References

1. Centers for Disease Control and Prevention – Estimated COVID-19 Burden. Accessed from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/burden.html on December 23rd, 2021
2. Johns Hopkins University – Coronavirus Resource Center. Accessed from https://coronavirus.jhu.edu/us-map on December 23rd, 2021
3. MacDonald NE; SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036
4. Muric G, Wu Y, Ferrara E. COVID-19 Vaccine Hesitancy on Social Media: Building a Public Twitter Data Set of Antivaccine Content, Vaccine Misinformation, and Conspiracies. JMIR Public Health Surveill. 2021;7(11):e30642. Published 2021 Nov 17. doi:10.2196/30642
5. Puri N, Coomes EA, Haghbayan H, Gunaratne K. Social media and vaccine hesitancy: new updates for the era of COVID-19 and globalized infectious diseases. Hum Vaccin Immunother. 2020;16(11):2586-2593. doi:10.1080/21645515.2020.1780846
6. Walkey AJ, Law A, Bosch NA. Lottery-Based Incentive in Ohio and COVID-19 Vaccination Rates. JAMA. 2021;326(8):766–767. doi:10.1001/jama.2021.11048
7. Acharya B, Dhakal C. Implementation of State Vaccine Incentive Lottery Programs and Uptake of COVID-19 Vaccinations in the United States. JAMA Netw Open. 2021;4(12):e2138238. doi:10.1001/jamanetworkopen.2021.38238
8. Sehgal NKR. Impact of Vax-a-Million Lottery on COVID-19 Vaccination Rates in Ohio. Am J Med. 2021;134(11):1424-1426. doi:10.1016/j.amjmed.2021.06.032