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Financial incentives for vaccination do not have negative unintended consequences

Health and Fitness

Financial incentives for vaccination do not have negative unintended consequences

F. H. Schneider, P. Campos-mercade, et al.

This study, conducted by Florian H. Schneider, Pol Campos-Mercade, Stephan Meier, Devin Pope, Erik Wengström, and Armando N. Meier, explores the unintended effects of financial incentives on COVID-19 vaccination. Surprisingly, the findings show no adverse impacts on vaccination uptake, moral perceptions, trust, or perceived safety, challenging existing concerns and guiding future policy decisions on behavior change incentives.

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Playback language: English
Introduction
The use of financial incentives to promote healthy behaviors like vaccination has been a subject of debate. While incentives often lead to initial behavioral changes, a substantial body of research expresses concerns about potential negative unintended consequences. These concerns include the crowding out of prosocial motivations, decreased trust in healthcare providers, and erosion of moral values. The difficulty in causally measuring these unintended consequences stems from the challenge of finding settings with random exposure to incentives and accessing comprehensive data on behaviors, morals, and perceptions. This study addresses these challenges using a unique combination of a randomized controlled trial (RCT) in Sweden and a complementary study in the US, leveraging both administrative vaccination records and rich survey data. The Swedish RCT offered participants 200 Swedish krona (approximately US$24) for receiving their first COVID-19 vaccine dose, while the US study examined the effects of informing participants about state incentive programs. Both studies aimed to causally assess the impact of financial incentives on various outcomes, including future vaccination uptake, moral attitudes, trust, and perceived vaccine safety and efficacy.
Literature Review
The existing literature presents conflicting views on the effectiveness and ethical implications of using financial incentives to encourage healthy behaviors. Proponents argue that incentives can effectively increase initial uptake, citing evidence from studies on blood donations, cancer screenings, smoking cessation, and vaccination. However, a significant counter-argument emphasizes the potential for negative unintended consequences. Philosophers and social scientists have raised concerns about the moral implications of incentivizing prosocial behaviors, suggesting that such incentives could undermine intrinsic motivation, erode trust, and diminish a sense of civic duty. Public health experts and policy advisors have also voiced concerns about the potential for incentives to backfire, possibly leading to decreased uptake when incentives are not offered. These concerns highlight the complex interplay between intrinsic and extrinsic motivation and the potential for incentives to signal negative aspects of the behavior being incentivized.
Methodology
The study employs a two-pronged approach. The first part involves a large-scale, pre-registered RCT conducted in Sweden from May to July 2021 (n=5019). Participants were randomly assigned to either a financial incentives condition (offered 200 SEK for the first COVID-19 vaccine dose) or a control condition. This RCT design allows for a causal assessment of the impact of incentives. The researchers combined RCT data with administrative vaccination records from the Public Health Agency of Sweden and detailed individual-level survey data collected in January and June 2022 to measure various outcomes. The survey captured intentions and actual uptake of second and third doses, other health behaviors (flu shots and blood donations), moral attitudes, perceived vaccine safety and efficacy, trust in providers, and feelings of coercion. The second part of the study involved a pre-registered experiment conducted in the US (n=3062) in June and July 2022. Participants were randomly assigned to either receive detailed information about their state's COVID-19 vaccine incentive program or not (control group). This leveraged the fact that many US residents were unaware of these programs. A follow-up survey was conducted to assess outcomes related to vaccination intentions, moral attitudes, and trust in government. Both studies used ordinary least squares (OLS) regressions with heteroscedasticity-robust standard errors. Equivalence testing was employed to rigorously assess the absence of meaningful negative impacts, using a pre-defined threshold of 0.2 standard deviations (Cohen's d) for a small effect size.
Key Findings
The Swedish RCT revealed no negative impacts of offering financial incentives for the first vaccine dose on the uptake of subsequent, unincentivized doses, or on other health behaviors. Furthermore, the study found no evidence of negative effects on morals, civic responsibility, trust in healthcare providers, perceived vaccine safety, or feelings of coercion. Equivalence testing strongly rejected the presence of even small negative effects (less than 0.2 standard deviations). The US study, focusing on the effect of informing participants about state incentive programs, also found no negative consequences on future vaccination intentions, moral attitudes, trust in government, perceived vaccine safety, or intentions regarding other health behaviors. Again, equivalence testing rejected even small negative effects. Subgroup analyses in both studies revealed consistent null findings across different demographic groups and vaccine hesitancy levels, indicating that the results generalize across various populations. The lack of negative effects was also consistent across different incentive types and implementing entities (government vs. researchers).
Discussion
The findings of this study directly challenge the prevalent concerns regarding the negative unintended consequences of financial incentives for vaccination. The robust results from both the Swedish RCT and the US study provide strong evidence that modest financial incentives can be a valuable tool to increase vaccination rates without detrimental effects on broader health behaviors or social attitudes. These findings have significant implications for policymakers considering the use of financial incentives to address public health challenges. They suggest that concerns about the ethical and practical downsides of such interventions may be overstated.
Conclusion
This research demonstrates that offering modest financial incentives for vaccination does not lead to significant negative unintended consequences. The findings from two independent studies, one using an RCT in Sweden and the other an experiment in the US, consistently show no detrimental effects on future vaccination uptake, health behaviors, moral attitudes, trust, or perceptions of vaccine safety. These results offer valuable insight for policymakers and challenge the prevailing concerns about the negative impacts of financial incentives in public health initiatives. Future research could explore the generalizability of these findings to low-income countries or different health interventions.
Limitations
The study's limitations include the focus on high-income Western countries, the potential influence of participant awareness of study participation, and the specific context of COVID-19 vaccination. The findings might not fully generalize to other contexts or populations. While the study aims for comprehensive data collection, the inherent limitations of self-reported data in surveys should be considered.
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