Nudging vaccination

While most countries have begun the process of vaccinating against coronavirus, the data about who is getting vaccinated- or more importantly, who isn’t – are troubling. First, those least vulnerable to COVID-19 are being vaccinated before the highly at-risk individuals who don’t make or don’t attend their vaccination appointments. Second, vaccination rates are substantially lower amongst ethnic minorities. Although public health officials continue to promote vaccination, little information is being collected on which methods of encouraging participation are most successful. While concrete measures aimed at reducing the cost of vaccination- such as paid time off of work, free transportation and childcare, and additional clinics built in rural or low-income areas- are desperately needed, they take lots of time and money to implement.

Nudges, on the other hand, are quick and easy to implement, and could be a good starting place for increasing vaccination rates. Mitesh Patel, the director of the Penn Medicine Nudge Unit at the University of Pennsylvania, explains: “nudges are subtle changes in how choices are offered. They don’t involve mandates or changes to the price of care; they are usually shifts in how a message is framed.”^[1] For instance, due to the status quo bias, i.e., the “preference for the current state of affairs”, people are more likely to stick with any given default option. In some cases, people might even interpret the default option as a recommendation.^[2] The consequences are not trivial: a group of health care practices was able to save $32 million over two years simply by switching the default option in their electronic system to generic medication. In the context of the pandemic, governments and private health companies could increase vaccination rates at a low cost; nudges would encourage vaccination without requiring a fundamental shift in the understanding or perception of vaccines.^[3]

The first possible nudge is to frame vaccination as the default option, utilizing the status quo bias and social norms to elicit participation. Emily Anthes, a science journalist, suggests that “health officials could also consider leveraging social networks more explicitly. In a randomized trial conducted in Kenya, Dr. Thirumurthy found that providing women with two H.I.V. self-testing kits, and encouraging them to give one to their male partners, significantly increased the share of men tested for H.I.V.”^[4] A similar effort could be undertaken with coronavirus; for example, giving vaccine recipients bus tickets to the clinic to distribute to their friends and family. Another nudge is adding active choices to appointment-setting. For example, texts that necessitate a response to confirm or cancel an appointment. In previous studies, similar measures were found to increase influenza vaccination rates by 10 percentage points and increase scheduling of cancer screening tests by 22 percentage points. Hospitals could also use previous vaccination records to specifically target those least likely to get a vaccine.^[5] This, however, could be seen as a violation of patients’ privacy.

Nudges rely on psychological biases to manipulate decision-making, and this fact alone raises many ethical questions. Utpal Dholakia, a professor of Marketing at Rice University, discusses three of his main concerns with default opt-ins in an article in Psychology Today: “Which behaviors are virtuous and suitable for default opt-ins, and which ones are not? What criteria should be used to decide?”; “How much manipulation is acceptable, and at what point does it become excessive? Again, who gets to decide?”; and “How does the power asymmetry between the manipulator and the manipulated affect the previous two issues?”^[6] Values differ enormously from person to person, political party to political party, and country to country. What some might see as serving the greater good could be interpreted by others as a violation of their rights. How can public health officials agree upon what to advocate and how far to push? What happens when governments push misinformation or harmful practices? As nudges are implemented more and more by marketers, health officials, and governments, it is imperative that independent regulatory bodies are established to ensure best practices.

^[1] https://www.nature.com/articles/d41586-021-00329-z

^[2] https://thedecisionlab.com/biases/status-quo-bias/

^[3] https://www.nature.com/articles/d41586-021-00329-z

^[4] https://www.nytimes.com/2021/04/02/health/coronavirus-testing-behavior-hesitancy.html

^[5] https://www.nature.com/articles/d41586-021-00329-z

^[6] https://www.psychologytoday.com/us/blog/the-science-behind-behavior/202104/the-ethical-quandary-default-opt-ins