A recent preprint study indicates that none of the vaccination incentive programs—from the small, guaranteed rewards to the lotteries for $1 million or more—led to an increase in Covid-19 vaccination rates. According to Advisory Board's Rachel Woods, Pam Divack, and Andrew Mohama, it’s time to abandon the current approach and start asking five key questions for an updated strategy.
For the study, researchers looked at statewide incentive programs through the National Governors' Association and Google News. Focusing on data from April 1 (before the first statewide incentive program) to July 29, the researchers found that 24 states implemented vaccine incentive programs.
They then calculated the rate of vaccine doses administered daily per 100,000 persons in each state using CDC data for the 14 days before and after incentive programs were implemented.
The researchers found that daily vaccination rates dropped in the 14 days following the implementation of the incentives. However, researchers noted that in the 26 states without incentive programs, vaccination rates also declined during comparable 14-day periods.
In total, the study found vaccine incentive programs were associated with a non-significant drop in daily vaccination rates of 8.9 per 100,000 persons, and there were no significant trends discovered between states with or without vaccine incentives in any of the 14-day periods studied.
The researchers noted that incentive programs have been effective in other contexts, but for Covid-19 vaccines, "their impact may be attenuated if misinformation or distrust is shaping vaccine intentions." They also suggested that low awareness of the incentive programs could have reduced their effectiveness. Considering the study's results, Alison Buttenheim, an author of the study, said in a tweet that she believes it's time for mandates. (Thirumurthy et al., SSRN, 8/27)
We were hopeful that positive incentives, like lotteries, cash awards, or free meals, could increase vaccination rates among the unvaccinated population. However, the findings from this study should compel leaders to re-think their approach to increasing vaccine acceptance and uptake, especially as it relates to incentive-based approaches.
We think it is safe to say we've been tackling vaccine uptake by throwing spaghetti at a wall—and none of it is sticking. It's time to abandon our current trial and error approach. Incentives don't need to be left out of the solution, but without a purposeful approach that maps the right messages to the right people, and without continued efforts to ensure an equitable vaccine rollout, you will continue to throw money towards initiatives that don't actually change existing behaviors.
Take this as a turning point in your vaccination strategy. How can we nudge people, especially in large masses, towards vaccination? Who should own these interactions? And how do mandates play a role in your strategy? While we don’t have all the answers, we believe the information in this report requires leaders to adjust their posture towards vaccine nudges.
Here are five questions to consider as you update your strategy:
The current set of incentives seem to follow a one-size-fits-all approach, but this neglects the diverse makeup of the unvaccinated population and their remaining concerns. For example, a cash-based incentive will impact a variety of socioeconomic groups differently. In areas of high wealth, financial benefits may not move the needle. Health leaders can leverage their existing, community-based data to better tailor incentives to different populations. They can also use direct patient relationships to understand motivators and implement solutions that might move the needle. Always consider the population you are targeting, how an incentive or penalty will be received among the group, and how you can effectively tailor it.
The key to improving vaccination for large groups is to scale personalized outreach—even within targeted segments of the population. The United States is now more than six months into having widely available vaccines, so it's likely that people are becoming apathetic about large-scale vaccine messaging—like that commercial you've heard a million times and just phase out. All nudges, positive or negative, must be personalized, but how can you actually grab someone's attention? Messages need to feel like you are speaking directly to the recipient. This may involve strong efforts upfront, but the long-term benefits of a protected population make it worthwhile.
There may be a way to use technology reach patients at scale. STAT+ recently reported a cancer center in North Carolina that used their EHR to identify patients without access to email or online portals who might have missed digital messages about vaccine signups. After calling 500 patients, they were able to schedule appointments for 100 patients. Examples like this should compel leaders to innovate and scale personalized outreach.
Nothing is better than a one-on-one personal conversation, but it's important to think about scale with vaccine strategies. External partnerships may provide a pathway to scaling these conversations while preserving the empathy that is crucial in building trust.
Health care leaders must also expand their traditional definitions of external partners. Early efforts focused largely on personalized messaged from physicians, but remember that community-based organizations, religious leaders, and educators play a role in reaching more people, relating to community members based on their own interests and experience with vaccination. These non-traditional partnerships are crucial to scaling the personalized outreach that we know can motivate behavior change.
The study analyzed results of incentive-based approaches to increase vaccine uptake, but it did not track punitive measures. This is likely because we are not seeing many punishments on a large-scale basis, but some companies have chosen to go this route. Delta Air Lines is raising health insurance premiums for unvaccinated employees by $200 a month to cover higher Covid-19 costs. While this may sound intense, companies have tried similar approaches previously to encourage healthier lifestyles that lower health care costs, such as charging smokers more for health care coverage. Employee relations are a natural concern with measures like these, so ensure your leadership team is on board with the decision and that you are communicating with compassion and transparency at every step in the process.
Equity should be involved in every conversation about health care initiatives, and vaccination strategies are no exception. Features like offering paid time off work for employees to get their vaccine, covering transportation, or even company-wide vaccine days can help ensure equitable approaches.
It's also worth considering who the messenger is in these efforts. We know there is a long history of substantiated medical mistrust among different cultural and ethnic groups, so you should consider the demographic of your organization and how personalized messaging can instill trust.
Considering the study's results, Alison Buttenheim, an author of the study, said in a tweet that she believes it's time for mandates. And whether or not you agree with the approach, vaccine mandates do increase uptake. If your organization isn’t ready to mandate today, leadership teams must come to consensus on a clear threshold for when they would enact a mandate and how that mandate will be implemented. If we’ve learned anything from this pandemic, it’s that leaders cannot wait for a moment of true crisis to implement solutions. Take the time now to gather the right stakeholders and build the communication cascade should you need to press "go" on a vaccine mandate. At the bare minimum, have a conversation with your team about mandates and what their prospect is for your organization.
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