Bribery and punishment rarely work to incentivise good behaviour, so John Key should put down the wooden spoon about vaccine-hesitant people, writes Jess Berentson-Shaw
Sometimes at my most desperate parenting point all I have left is bribery swiftly followed by increasingly wild (and usually empty) threats. I have been heard to threaten to ban screens for an entire year and to cancel all holidays. I do have a friend whose mum actually did cancel Christmas once and someone gave that woman a medal for sheer bloody-mindedness.
But bribery and punishment rarely work to incentivise good behaviour from the kids. Long term it has zero impact on their understanding and willingness to engage in what I will euphemistically call, “prosocial” behaviour with us or each other.
So when I read John Key suggesting that “incentives” should make up a core part of our vaccination strategy (that means offering a mix of material “rewards” for getting vaccinated and sanctions for not), I rolled my eyes.
Save us from conservative men with opinions telling us that what hesitant people really need to get themselves vaccinated is a bit of tough love. It's the rhetorical equivalent to shouting “boot camps!” in response to youth crime.
We have more creative, and more effective, approaches to encouraging vaccination. So put the wooden spoon/sticker chart away John and sit yourself down.
What do we know about 'incentives'?
Well, we know the evidence for them working is far from compelling. The body of evidence (that is when we take all the studies we have in an area, and use a systemised approach to evaluate them and draw conclusions about the findings as a whole), says the evidence is patchy and not of very high quality. Basically nothing compelling. There is what we call a lot of heterogeneity in the studies. That means the various studies were done in different places, at different times, using different vaccinations and types of people (for example people who use drugs, versus parents of children), and different types of incentives (some used money, some used lottery tickets , some used punishments, some used a lot of money, some a little). Best we can say is “maybe, for some people, in some situations?”
Of course the absence of evidence is not evidence of absence of an effect. So perhaps they are worth a go in some situations for some people? There is something we should consider, however, before we use rewards and punishments to get hesitant people to get vaccinated – the message it sends and the impact it has on people’s understanding and attitudes toward vaccination.
What message does it send using money and punishment to motivate a prosocial behaviour like vaccination?
Paying people may communicate that we think vaccinations are important, that we value them. However, it may just signal that a lot of people are not getting vaccinated, creating a type of social evidence that vaccination is not normalised by people in certain groups because we have to pay/punish people to get vaccinated. That is one possibility.
Others have argued that if we see that people need to be paid or punished to motivate the act of getting vaccinated, this sends a message that the case for the benefits of vaccination are so weak that people need an external motivator.
Importantly, by paying people to get vaccinated (and punishing them) we frame vaccination only in the context of individual-level gain and loss. Yet vaccination is a prosocial activity which, to work best, needs people to think about and act for the benefit of the collective. That is because vaccination confers the best protection to everyone (including people who cannot get vaccinated) when we have collective immunity. High levels of immunity in a population shields everyone from the worst of the virus; it is in this way much more powerful that the individual level benefits.
Yet few people understand how vaccination, immunity and especially how collective protection works. This may be because vaccination has been communicated through a very individualistic risk and benefit lens for some decades now. Framing vaccination as being entirely about personal loss and gain has likely suppressed people’s understanding of the “social, political and moral work” vaccinations do for our community.
Continuing to frame and trying to motivate vaccination through individualistic values, therefore, won't help improve understanding of this collective nature of vaccination. Not just for vaccinating for Covid-19 but for all infectious diseases (including future pandemics). So we could be cutting off our nose to spite our face.
The practical issue is that there are things we do know work to improve vaccination uptake, and we should be doing those things first, and most.
What should we be doing most of?
People don't get vaccinated for many reasons. Hesitancy is driven by social, historical, political, environmental and vaccine specific issues. It can be any mix of past experience, distrust of the health system and the people in it, bad information, a lack of knowledge, peer behaviour, fear of needles, and it can just be hard to get vaccinated – inconvenient, costly to get there, scary.
Here are three of many good evidence-based approaches to address some of these drivers of hesitancy effectively and improve rates of vaccination:
1. Vaccinations everywhere, all the time
Making vaccinations very easy to get is a big factor in people getting vaccinated because most people do want to get vaccinated even those with doubts. It's not a black and white thing for most. That means outreach clinics in communities and places people are comfortable. Vaccinations given by people who are trusted within a community, in workplaces, vaccination reminders, recalls, and reminders again. Vaccinations at KFC, on buses! The evidence is good for this. We learned this lesson in New Zealand with childhood vaccinations in the late 1990s and 2000s. Take vaccinations to the people.
Easy access needs to be accompanied by a removal of all the barriers people experience. Not just physical ones. Removing all the financial, social and physical barriers to getting vaccinated is one of the significant drivers we can control. That means loads of community and social support to get people vaccinated. Rides to centres, time off work, childcare, support for needle phobia, places for people with disabilities to get vaccinated, etc.
2. Provide the 'social proof'
If people we trust do things, we are more likely to do these things also. In the case of vaccination, when we know that people we trust have been vaccinated, we are more likely to get vaccinated. And trust is not about recognition or formal qualifications. Trust is about shared values, shared experiences, shared understanding. This means that people in government need to ramp up the information and resources going into communities where vaccination rates are low – and, most importantly, ensuring trusted people in those communities are in charge of their own vaccination communication programmes. Grassroots is where it is at.
3. Vaccination as the default
Another interesting approach to emerge from the evidence is framing vaccination as an opt-out not an opt-in thing. This looks like healthcare providers assuming a person has positive intent to get vaccinated and approaching discussions with that presumption, e.g., “Right, let's get you vaccinated”. Recall systems and invitations that assume vaccination intent. Providing Covid-19 vaccination in combination with other vaccination also frames it as opt-out. Pre-scheduled appointments that people need to call to change removes one of the barriers (time, effort, energy to book) and increases vaccination rates. For Covid-19, effective opt-out strategies might combine a reminder for a person's vaccination with a pre-scheduled appointment.
The opt-out strategy is really just a core public health strategy - making the healthy option the default one, as we did with smoking. The places we live, work, play, and learn are all tobacco-free by default now. We assume people don't want to smoke and we do everything we can to leverage those good intentions. We can do the same with vaccinations: less talk about “choice” - that is the frame vaccine deniers use - and more presumption of healthy vaccination behaviours.
So the research is filled with good ideas that good quality evidence supports. And there are some interesting ideas that may be good to try as long as we think through the unintended effects first. It is why people in politics and public life with opinions need experts to do the research on what does work, how it works and for whom. So let’s be practical and use our best knowledge - not just some reckons to get this job done well. Fewer boot camps, more wise heads.
You can find more information on encouraging Covid-19 vaccinations in people who are hesitant in this guide How to talk about Covid-19 vaccinations to build trust.
