Cash Incentives May Help Nudge People to Get Vaccinated: Study

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Giving cash cards of $25 to adults who either received a COVID-19 vaccination or drove someone to receive their first dose had positive effects in a pilot study in North Carolina, according to new data published Monday.

This nonrandomized study involved a 2-week program in four counties in North Carolina. People who drove someone to get vaccinated would earn $25 for each trip but were not paid twice if they also got their first shot at the same time.

The program distributed 2890 cash cards to vaccine recipients and 1374 to drivers.

Vaccination rates in the United States were waning at the time of the intervention. The statistical analysis was performed from June 10, 2021, to Aug. 27, 2021.

Vaccination Decline Cut in Half After Intervention

Researchers in this study found that the slide was cut in half at sites offering the cash cards when compared with elsewhere in the same counties (−26.4% vs −51.1%) and the rest of the state (vs −48.6%; both difference-in-differences, P < .001.)

Among a subset of 401 vaccine recipients surveyed, 41% reported the cash card was an important reason for vaccination. The response rate was 92.4%; average age was 41.8 years.

Findings of the study, led by Charlene A. Wong, MD, MSHP, with the Office of the Secretary, North Carolina Department of Health and Human Services in Raleigh, NC, were published in a research letter in in JAMA Internal Medicine.

The intervention was designed to help improve equitable distribution of the vaccine. Incentivizing the drivers addressed access issues and added a personal conversation to help persuade those on the fence, Wong told Medscape Medical News.

“We saw that the drivers were particularly important for some of our historically marginalized populations,” she said.

“Someone driving me here today,” was an important reason for 49% of respondents, more commonly among Black (OR, 1.74; 95% [Confidence Interval (CI), 1.04-2.91), Hispanic (OR, 2.51; 95% CI, 1.32-4.77), and lower income individuals (OR, 2.77-6.09).

People with lower income (OR, 2.10-3.97) and older people (at least 50 years old; OR, 2.30; 95% CI, 1.33-3.98) were more likely to have been brought by a driver who received a cash card.

“We know that these one-on-one conversations between people who have remained unvaccinated and those that they trust and know are really important,” Wong said.

David Asch, MD, MBA, executive director of the Penn Medicine Center for Health Care Innovation in Philadelphia, told Medscape Medical News that incentivizing the drivers is “a novel idea and a clever one.”

“Think about having a running buddy, or forming a weight loss pact or quitting smoking with a spouse. People don’t want to let others down, and we all know that people are on their best behavior when they know that others are watching,” he said.

Small Rewards vs Lotteries

North Carolina is among states trying to motivate residents to get COVID-19 vaccinations with incentives including million-dollar lotteries.

But only a few lucky people benefit from such large prizes. Small, guaranteed cash incentives can offset transportation and childcare costs to get the vaccine, Wong said.

The $25 guaranteed amount was chosen she said to offer something meaningful but to avoid introducing coercion.

Respondents were from twice to four times as likely to say cash cards were important in getting the vaccine if they were Hispanic or identified as another non-white group (OR, 2.00-4.68) compared with white people.

Those with incomes lower than $40,000 were about twice as likely as those with higher incomes (ORs, 1.94-2.36) to say the cards were important in their choice and about 9% reported they would not have been vaccinated without the cash card offer.

“We were pleased to see that amount was motivating, especially for our historically marginalized population,” Wong said.

Asch, whose research focus includes behavioral economics and clinician and patient decision making, said about the lottery incentives, “I thought they would work the way most lotteries typically work, which is that people are drawn more to the size of the prize and often don’t consider the small odds of winning that prize. I was wrong, in that the evidence generally points to the ineffectiveness of the lottery programs to encourage COVID vaccination.”

Asch said he was surprised that small incentives seem to have worked, especially as far out as June of 2021.

“I would have thought that people who hadn’t been vaccinated at that point were revealing that they were dug in, and that it might take much larger incentives to move the needle or, in this case, receive the needle. The changes were not large, but there was an effect,” he said.

“I have to acknowledge that a lot of what I thought I knew about motivating health promoting behavior has not been correct in the context of COVID vaccines. I thought lotteries would work, but they don’t. I thought small incentives would not work, and this study suggests they do, but really in a small way, Asch said.”

Social context, he said, plays a huge role in how decisions are made.

“Let’s face it,” Asch said, “COVID vaccination decisions have political antecedents in a way that getting colon cancer screening does not. A lot of what we understand about human behavior flies out the window when politics walks in the door.”

Authors note that with the nonrandomized design, findings are preliminary and may not be generalizable to other states.

However, the results of this study may have important messages for areas struggling to make any difference in uptake.

‘With hundreds of millions of dollars being spent to accelerate COVID-19 vaccine uptake, these study findings suggest that this strategy for increasing vaccination merits greater investment,” the authors write.

A coauthor reports grants from the North Carolina Department of Health and Human Services during the conduct of the study, and personal fees from the World Health Organization, the US Centers for Disease Control and Prevention, and Merck outside the submitted work. No other relevant financial disclosures were reported.

Asch is a partner at the behavioral economics consulting firm, VAL Health.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and, and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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