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Public health care and nudges: How Behavioral Economics can help the vaccination problem

As we are approaching the second anniversary of the dawn of the COVID-19 pandemic, one can take a moment to reflect on the development of the health emergency. Loss, lockdowns, curfews, overloaded health care systems, and the anticipation of vaccinations. When the vaccinations finally hit the markets, many were eager to finally get their shot – whilst some weren’t at all. Seen as the key to freedom from the ever-stretching chains, yet some 32.5% of the United States population is still to receive its 1st dose. The vaccines are there, but the people won’t come – what is there to be done?

Our Guests

In our first event of the academic year, we delved into public health care and nudges, and how behavioral economics might help in combating the vaccination problem. For this talk, we had the pleasure of having Professor Alessandra Casarico from the Department of Social and Political Science moderating our discussion, accompanied by our two guests: Professor Silvia Saccardo of Carnegle Mellon University, Assistant Professor at the Department of Social and Dcision Sciences, and professor Hasha Thirumurthy of University of Pennsylvania, Associate Professor at the Department of Medical Ethics and Health Policy.

Nudging Vaccine Uptake: Benefits and Limits

Professor Saccardo introduced us to the topic of nudging vaccine uptakes, presenting its benefits and limits. In 2019, the World Health Organization ranked the reluctance and failure to get vaccinated as one of the top 10 global health threats. The subsequent solution would be to find strategies for increasing and speeding up vaccinations, to which an approach of behavior change was proposed: through providing information and framing, peoples’ intentions could be changed, in turn reducing barriers to follow-through and increasing uptake.

As facilitating desired action is easier than enforcing mandates and suffering the (possible) consequences, Professor Saccardo’s research investigated the effectiveness of reminders – a popular nudge – in the context of promoting COVID-19 vaccinations. His team conducted two sequential randomized controlled trials (RCTs): one with a holdout arm and a follow-through reminder arm incorporating videos, message framing to facilitate psychological ownership, and a combination of both; and another with patients who failed to schedule an appointment or obtain their vaccine 9 days after the initial eligibility notification, with a holdout arm and a follow-through reminder arm with 6 sub-arms – self, prosocial, basic message, early access, and fresh start.

The findings of Professor Saccardo indicate that reminders increase vaccinations up to four weeks after the reminder is received – the effect, however, depends on the immediacy or the comprehensiveness of the outcome measure. Furthermore, adding ownership language strengthens the effect, whilst other framings have a limited impact. Interestingly, compared to online studies of the same topic, the results differ: in Saccardo’s study, the added videos did not create any added benefits, whilst in online studies the opposite happened – incorporating a video increased vaccination intentions, with no added benefit from ownership framing. This raises questions as to what extent can we learn from online studies, and how can we make hypothetical responses more predictive of actual behavior. Finally, the research found that the effects were stronger among people with higher baseline motivation to get vaccinated.

Incentivizing COVID-19 vaccination: an effective strategy for combatting the pandemic?

With Professor Harsha Thirumurthy’s presentation, we delved deeper into incentivizing the COVID-19 vaccinations and their suitability as a strategy to combat the pandemic. Looking at the current status of the United States – the setting of his study – we see that 66% of the population is vaccinated at least once and less than 60% is fully vaccinated, against the global target of 70% of coverage. Professor Thirumurthy then introduced us to the variation in vaccine demand, with very high demand in the first 3 months of availability of administration, followed by a steady fall over time, faster than expected. The problem here, then, is how to get people vaccinated when shots are already ready and free of charge?

The economists’ recommendation was to provide monetary incentives to the people for getting vaccinated. These strategies could include prizes such as guaranteed rewards, offsetting opportunity costs, and overcoming procrastination and the present bias. On the other hand, the prospect theory of behavioral economics suggests that instead, lotteries would be more motivating. Such action was taken by the state of Ohio, which introduced the Vax-a-Million program, where a lottery was drawn on five different dates on FOX News. Soon enough, many other states joined the ride. From a research point of view, this instance provided an opportunity to learn on a national level whether such policy measures were effective in motivating vaccinations.

The data Professor Thirumurthy’s research looked at was collected from state-wide incentive programs and included the type of incentive, the number of vaccines administrated daily per 100,000 individuals, and the state characteristic of voting either Republican or Democratic in the 2020 Presidential Elections. The analysis was conducted in subgroup analyses, such as lotteries vs. guaranteed rewards, early vs. late introduction of incentives, and Republican vs. Democratic-leaning states. Short-term response to incentives and comparison of pre-program time trends were also considered to compare daily vaccination rates between states with and without incentive programs in the two-week periods before and after the incentives were introduced. The results of the research showed that there were no significant changes in the vaccination rates with any of the incentives, leading to think that larger rewards may be necessary. However, an interesting finding was that in Republican states – although politically more aligned against the vaccination – the incentives were more effective, while in Democratic

states there was a more significant negative effect. In conclusion, Professor Thirumurthy points out the limitations of the study, stemming from no control for private sector or local governments’ incentives – which may dampen the effect of statewide incentives – and its underpower to detect small changes. Altogether, different approaches relying on political persuasion or mandates are more likely to be successful in incentivizing the vaccinations.


Interestingly, motivating some people to get their vaccines seems frustratingly hard. Whilst the spread of (mis)information and the dominant political discourses most likely have an impact on how people behave and frame their attitudes, one cannot but wonder if the things we have seen in the past few years had no impact whatsoever. Though there is definitely light at the end of the tunnel, we for sure have not yet reached the safe zone. Through research like that of professors Saccardo and Thirumurthy, it is possible to gain invaluable insights into how we can combat the future vaccination problems in the most unfortunate case that history would repeat itself.

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