With COVID-19 vaccines widely available in the United States and some other wealthier countries, public health communicators are focusing on how to reach those who are so far reluctant to be vaccinated. This hesitancy spans the continuum: from those who simply want to learn more about the vaccines’ safety and effectiveness, to those who just haven’t decided, to those who plain refuse to be vaccinated.

Recent headlines have focused on vaccine incentives to encourage people to be vaccinated against COVID-19. Krispy Kreme has offered a free donut a day to anyone showing proof of vaccination, while New Jersey breweries are offering free beer. The city of Detroit is giving out $50 to anyone who drives someone to a vaccination site and, in Maryland, all state employees who receive their shots will get $100.

But are vaccine incentives actually effective behavioral nudges for public health? CCP’s Stephanie Desmon sat down with CCP’s Doug Storey, an expert in health communication and behavioral economics, to talk about what could work to move the needle as we work to dramatically reduce COVID-19 transmission via vaccination and what that might mean for low-and-middle-income countries where they are still grappling with supply and access issues.

The following interview has been condensed for clarity.

Stephanie Desmon: We are hearing a lot about financial incentives as a way to encourage people to get vaccinated against COVID-19. Might they work?

Doug Storey: The behavioral economics literature provides a lot of evidence that incentives can motivate people to take that step to do something for their health, but those incentives can take all sorts of forms. In public health programs there are things like vouchers: If you give someone a voucher for services, they’ve got this piece of paper and they can go and claim services at a health facility. It may be a discount coupon or an actual payment for the full cost of services. Sometimes these vouchers vary in scale depending on what the inherent costs of the behavior are.

I think it’s important to note that incentives don’t have to be monetary. In the case of the vaccines, at least in the US, people don’t have to pay for them, they’re supposed to be free so a monetary incentive to get the vaccine itself may not be relevant, but some people may have trouble with transportation, getting to the vaccine site. Incentives that help overcome these challenges can be important.

One thing that has come up around the city of Baltimore is difficulty of parking near the vaccination sites so some kind of incentive like free parking or convenient parking might push someone over that barrier.

But then there are all kinds of non-monetary incentives that are sometimes highlighted in the literature, such as the perceived benefit of an action. This all stems from the social marketing literature that says any kind of a product adoption – in this case the adoption of a behavior – has some inherent value. People need to accept that value proposition, that is that vaccination is good for you, it helps your family, will get us to herd immunity. If you accept that value proposition, you’re willing to exchange your time, your effort, maybe disregard the inconvenience of it – you’re willing to do that because you believe that the non-monetary value of the behavior is greater than what you have to invest in achieving the behavior.

Stephanie: Does that mean we need to adjust how we talk about the vaccine to help people understand the non-monetary value?

Doug: I think so. A lot of the messaging around vaccination is already doing that to some extent. It’s trying to say things like the efficacy of these vaccines is very, very high and even if you’re reinfected the symptoms will be mild, it’s putting these behaviors into some kind of a value frame.

Stephanie: I’m sure you’ve heard that Krispy Kreme will give you a donut every day if you show your vaccination card. How do you feel about that sort of incentive?

Doug: It’s hard for me to believe that someone would be motivated to get vaccinated just so they could get a Krispy Kreme donut or two. So, it seems a bit gimmicky and of course you’ve heard the controversy about whether getting a donut every day is good for your health. But it might make people feel more comfortable about their vaccination decision, who might have felt anguished about that choice and maybe got vaccinated with some reluctance, it might make them feel better about that decision. Someone is recognizing that you did a good thing.

But the price of a donut seems a little low as a payment for vaccination.

Stephanie: Many people are still on the fence about being vaccinated. If financial incentives may or may not be the answer, what can we be doing to move the needle?

Doug: We are still learning more about the sources of concern. People have different concerns about vaccination: Some are concerned about the safety, some are concerned about how quickly the vaccines were rolled out, some people are concerned about the adequacy of the science behind the approvals, some people are distrustful of authority, whether it’s government or health authorities. I think one of the more challenging ones are the concerns related to trust. We know some minorities have a historic and probably justified distrust of health authorities and so hearing testimonials from people “like you” who have considered those concerns and have made a decision to get vaccinated may be a good strategy.

The JHU Get the Facts About the Vax campaign is using that strategy. One of the latest initiatives is to feature people from all walks of life, different ethnicities, different genders are being featured with narratives about why they made the decision to get vaccinated and how they feel about that decision. Hearing from someone like you is often a very positive strategy that addresses your personal concerns or the sources of reluctance you might have. That seems like one of the more promising strategies right now:  if we can give voice to people who have wrestled with these concerns and have decided to get vaccinated and can talk about how they made that decision and how they feel about it subsequently, that can really resonate with some people.

One thing to note: What we are talking about here is people who are vaccine hesitant, not hard core anti-vaxxers. The latter are in the minority and basically a lost cause in terms of persuasion. If everyone or most people who are hesitant eventually come around, we don’t need to turn around the anti-vaxxers in order to reach herd immunity.

Stephanie: At this point, it seems like the people who really wanted the vaccine have gone out and gotten it. Do we need to rethink the strategies about how we convince people to get vaccinated with this new population? Do we need to change clinic hours? Do we need to bring vaccines directly to people? How do we move forward?

Doug: Making it convenient is a big thing and a lot of universities that are planning to reopen in the fall are now requiring and providing vaccination for faculty, staff and students that makes it easier for people who haven’t been able to get vaccinated up to this point. If you build it into the back-to-campus process, when they check back into campus – make it available right then and there – those kinds of things ease the burden.

One of the concerns people have is the science isn’t specific enough for certain age groups or certain ethnicities. The fact that these vaccines have been rolled out so quickly means that clinical trial data for specific subsets of the population are not available yet. For example, we don’t have strong science yet on how children respond to the vaccine. Those studies are underway, but the results aren’t widely available yet and I think that applies to other smaller subsets, too, that may have unique health conditions. So, some reluctance around vaccination may be normal if you don’t think that your particular subgroup has been studied thoroughly.

Communicating those results as soon as they are available and trying to reassure people that the CDC and WHO are concerned about the safety for specific subgroups that may not have been covered will be important as the science evolves.

If you think of the non-rational parts of decision making — that unease that you feel if you don’t have total confidence that your particular needs are being met — then it is easier to understand how people make a decision based on how they feel about it rather than what they know about the science and what people are telling them about it. Anything we can do to reassure people that the science is sound is important: “For people like you, we may not have all the answers yet, but we’re working on it and we’ll let you know when that information is available.”

Stephanie: We’ve been acting as if this is a knowledge problem, but as you said, it’s also about gut feelings. As a behavior change expert, how much do you think each weigh into the decision making

Doug: I think that for people who are informed about the science, most of those people have already decided and probably decided to get vaccinated. It’s the people who are still influenced by their feelings, their emotions – including distrust but also fear about whether the science is really there yet. Those are the people who need our support now to understand what their underlying concerns are, and how they can be addressed. The testimonial approach is promising, and transparency about how the science is progressing, those are important parts of the strategy.

It’s the people who have something that is nagging at them about the process that we need to figure out. We really need to figure out what the smaller subgroups’ unique concerns are so we can provide the emotional support, the specialized information they might need to get over this emotionally loaded decision that they’re trying to make.

Stephanie: You’ve studied behavior change for a long time, studied how to get people to adopt healthy behaviors. Is there anything about this that surprises you?

Doug: Not really. This all seems kind of familiar. We’ve all sort of seen this before, with say, cancer screening and detection and early treatment. There are really deep emotional issues around mortal diseases like cancer or perhaps HIV/AIDS. It poses such an existential crisis for people. People resist cancer screening like colonoscopies and breast cancer screening because they really don’t want to know if they are sick and they’re afraid to find out. A lot of people just don’t want to take that first step and there are probably analogies to COVID-19 and vaccination too.

Stephanie: We’ve talked a lot about the United States today. What about the rest of the world?

Doug: There are supply and access issues that are so difficult right now in so many places, countries that are not at the front of the line to get the quantity of vaccines that they need desperately; and overcoming that, that’s a logistics issue as much as anything. Even after vaccines start to become more available in a lot of low-and-middle-income countries, all of those access barriers – how do you get to the place where you can get a vaccine, how much does it cost to get there, what’s the cost of deferred income for the day, what does it cost if you have side effects so you can’t work that day, what good is it if I get vaccinated and my neighbors can’t. All of these access and equity issues are amplified in many of the low resource settings where CCP works and the need is frankly much greater than what we face in the United States.