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In every job that must be done, there is an element of fun. You find the fun and snap, the jobs a gain.

A spoonful of sugar helps the medicine go down,

The medicine go down

The medicine go down

Just a spoonful--

Sarah Gonzalez: This famous song from Mary Poppins, here's how it came about. Back in the 1960s, during production of the film, the songwriter son was scared of getting shots, but when his school placed the oral vaccine for polio on a sugar cube, the boy took the vaccine without a problem. This inspired Richard Sherman and the boy's father, Robert Sherman, to write Spoonful of Sugar, a little something to help the medicine go down.

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Sarah: The story behind this song gives us a little glimpse into just how broad and creative some of the efforts were to encourage polio vaccinations. Everything from subtle messaging in a song to official public service announcements have, throughout history, been used to encourage certain behaviors to improve public health.

Speaker 1: You can avoid all the expense, suffering and heartache that paralytic polio causes, if you make use of the vaccine that is now available.

Speaker 2: Don't let that be you or someone you know. Stop the clot. Spread the word.

Speaker 3: Protect yourself and your loved ones this flu season. Get a flu shot today.

Speaker 4: Let's stop HIV together.

Speaker 5: Meth destroys. The high is a lie.

Speaker 6: I get angry, just thinking about it makes me mad. Little kids doing drugs. It turns my stomach. that stuff hurts.

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Sarah: Past and recent PSAs like this are meant to nudge us in the right direction and sometimes the nudge can involve the chance to win a prize or win some money. Here in the US to encourage you to donate plasma, for example, some centers offer up to $60 twice a week. With the rise in vaccine hesitancy around the COVID vaccine, we're seeing businesses and states try to encourage vaccinations with little extra nudges like this, incentives from companies offering workers perks for getting vaccinated, to businesses offering a free pizza and a shot if you get your shot, or free French fries for a month every time you show your vaccination card.

This week, the republican governor of Ohio announced that teens in the state who get vaccinated could win free tuition, a full ride college scholarship, and vaccinated adults will be entered into a million dollar lottery every week. For five weeks, one adult will win a million dollars in Ohio. The point is to encourage residents to get the vaccine. Some even say the new guidance from the CDC this week could it be viewed as an incentive of sorts, vaccinated people no longer need to wear masks in most places. Do incentives like this actually work? I'm Sarah Gonzalez, host and reporter at NPR's Planet Money podcast, in for Tanzina Vega.

Breaking down vaccine incentives is where we start today on The Takeaway. For more on this we talk to Stacy Wood, Langdon distinguished University Professor of Marketing at North Carolina State University. Stacy, welcome to the show.

Stacy Wood: Thanks. Glad to be here.

Sarah: Also with us is Emily Largent, the Emanuel and Robert Hart Assistant Professor of medical ethics and health policy at the University of Pennsylvania. Emily, great to have you with us also.

Emily Largent: Thank you.

Sarah: Stacy, let's zoom in on one of these programs for just a minute, Ohio's vax a million lottery program. What do you think of giving people the chance to become a millionaire just for getting the vaccine?

Stacy: Well, I think it's actually a fairly effective use of dollars, which I think is a surprising thing to say given many people's reaction to the lottery. The thing that many people don't realize is that advertising costs a lot of money. The Ad Council in the US has spent over $50 million and has gotten, I think, over a 400 million in contributed ad spend to get out the message, to make PSAs. If you think about taking $1 million and making it a lottery, that might move some people who think of the vaccine as something that's not a bad thing to do, just not the top of their priority list.

Sarah: A million dollars in the context of tens of millions of dollars on a public service announcement or on public service announcements seems like a pretty good deal in this case, then.

Stacy: I think that the thing that is often overlooked is that there are lots of different reasons why people don't get the vaccine. Some of them are truly worried and scared about what long term side effects may occur. Others may have some really deep seated philosophical reason against vaccines or medical care. For many people, it's just not top of the priority list, it's not something that they feel is really urgent for them to do. A little perk like this is actually quite fun. I think there are people who actually drive to other states to buy real lottery tickets.

I don't know that Ohio is allowing other people to come into their state to qualify for the lottery, but we've already seen that people are willing to spend their own money at a chance at a million dollars. I hear a little shot in the arm might not be such a bad thing.

Sarah: People wait in long lines, they went on the phone for hours just for the chance to win a lot less money. Emily, in the Journal of the American Medical Association, you wrote that, in general, there are problems with paying people to get vaccinated for COVID-19. What are some of the concerns you have?

Emily: Sure. I would agree with what Stacy said, that when we offer payment to people, we're not necessarily addressing core concerns they have like misinformation or mistrust. When we offer payment in these contexts, because we're not addressing those core issues, we're unlikely to move those individuals. Another thing that can happen is that we have good evidence from behavioral economics that when we offer people money to do things, it can make that things seem riskier or more burdensome than it actually is. Right now, we have good evidence that getting a vaccine is safe, it's effective, it protects us, it protects our communities, but people often see things like a million dollars as perhaps too good to be true. We might reinforce concerns they already have, or in some cases, we might create new concerns.

Sarah: This could backfire. People can say like, "There must be some risk here otherwise, why would they pay me to do this?"

Emily: I think it will make some people a little suspicious.

Sarah: Do you have any examples you can point to where offering money of any amount has been counterproductive?

Emily: Well, sometimes we see this in human subjects research. When you pay people money to participate in research, it can actually signal to them that there is risk, and they read consent forms more carefully, they think about it a little bit harder.

Sarah: Why don't you tell us, Emily, about what some of the evidence based incentive strategies are that we know do a good job of encouraging people to do something like get vaccinated?

Emily: Well, in terms of strategies to get people vaccinated, I think a lot of things are important, like we need to overcome any financial barriers people have. Right now there are some people who say they aren't being vaccinated because they're worried about missing time from work, particularly if they have side effects. We should be offering paid time off of work, covering expenses related to getting to the vaccine site, if that's a barrier for people. Then there are a lot of non incentive strategies that need to be employed. We should be thinking about great public health messaging that really addresses those core concerns people have that can't be addressed by financial means.

We need to be really actively listening to communities, finding trusted leaders, getting vaccines to where people are with mobile clinics. They're these evidence based strategies that aren't as exciting as lotteries, but are going to be a huge part of how we move the needle, so to speak, on COVID vaccines.

Sarah: Stacy, what is the range of, let's say, more creative, maybe non tested incentives being offered up right now across the country?

Stacy: Well, one of the things that is interesting is to see how diverse the incentives are. If we speak just of incentives, not have some of the other important behavioral strategies that Emily mentioned, we see everything from sure thing payments, like $50 in hand, or we see crazy incentives like well. I call it crazy, I also call it delicious. Krispy Kreme offer for a free donut every day for a year. All of these are coming from different sources who are trying to contribute in some way in their own special way to the incentive cause. Whether it's free beer, whether it's sporting events. I really like the diversity of incentives, because I think they address the diversity of hurdles that people have to get vaccinated.

If you think about someone like Emily mentioned, who has the difficulty getting transportation to the vaccination site or getting time off or childcare to cover them during that time period, $50 in hand may be perfect. For somebody who is really not convinced that they personally need the vaccine, they're young, they're active, they're healthy, then a sporting event might seem like a lot of fun. I know that when I announced to my college class that Krispy Kreme had decided to give everyone a free donut a day for vaccination I asked the class what they thought and all the hands went up.

When I called on someone, the question was, "Is there a vaccination site on campus?" It is interesting to see what moves us. I know people have signed up for credit cards for a free slice of pizza and a free t-shirt.

Sarah: I'm still getting the mail from one of my first credit cards that I believe was some not-so-great perk that convinced me to sign up for it.

Stacy: Exactly. The cool thing here though, is that Kevin Schulman and I wrote a paper that was published in the New England Journal of Medicine in January about 12 comprehensive, behaviorally based strategies for promoting the vaccine. One of them was create fear of missing out or FOMO, and that's the idea of incentives. This is just one thing within a more comprehensive strategy. However, we envisioned at that time that there would be one overriding institution that would coordinate all of these strategies and put them all out there. It's interesting to me to see that the beauty of it happening in this shotgun-style with everybody just, you know coming up with their own incentives is that it really actually matches the heterogeneity of the population and what's interesting to them.

Should this be fun? Should this be less worrisome making? Should it be something that is really practical? Should it be something that's just a sugary treat? There seemed to be such a variety of incentives that matched the variety of people who we're trying to address

Sarah: Emily. I'm curious, do you know what tends to work when you're trying to encourage new behavior, the carrot approach or the stick approach?

Emily: Well, certainly, in vaccines, we have carrots and sticks available to us. We've talked a lot about perhaps not the carrot, but the donut or the French fry dangling out in front of us. The stick approach here would be mandates. That could be your employer telling you that you have to have the vaccine. That could be the state telling you that you need to have your child vaccinated at some point when children are eligible, before they can go to school or your college telling you you need to be vaccinated. In cases like that, oftentimes in ethics, we say that there needs to be a voluntary period of uptake before we think about instituting the mandates.

Carrots are a great start, but there are some people who, when surveyed, say that they will only take the vaccine or are much more likely to take it if they're told they have to take it and so I do think that we'll see a combination of carrots and sticks.

Sarah: Emily, are there ethical or moral complications inherent in incentive programs, especially monetary ones? Is that the main issue?

Emily: Well, I don't think that it's only in money, but certainly money can be uncomfortable for people to think about or talk about and so we might think that those are more concerning situations.

Sarah: Emily, we know that vaccine access has been an issue and that there are disparities in who has been able to get vaccinated. Do incentive programs address that at all or does it maybe do the opposite and contribute further?

Emily: Well, the solution really needs to fit the problem in addressing vaccine uptake. It's important not to blame groups who have not yet had high rates of vaccination, particularly when they have access issues. Incentives aren't going to help them overcome barriers that exist, like lack of vaccine sites in their community or difficulty getting time off of work to get vaccinated. Again, we need to really be tailoring strategies to meet people and address their particular barriers or concerns.

Sarah: Stacy, as someone who studies consumer behavior and marketing, did you expect that we would reach this point where we're seeing a push for incentives like this?

Stacy: Yes. I did. In the fall of 2020, even before the vaccines were available, my co-author Kevin Schulman and I started talking about the eventual need to promote the vaccine to those who either would not get the vaccine or would want to wait to get the vaccine. We started to talk about these strategies to promote vaccination. Early on, a lot of people in organizations and in the government were really resistant, thinking, "Well, our first thing is to get access to people. We are concerned about there being too much demand, where demand is greater than a supply."

It was hard to imagine a day when supply would be greater than demand, but here we are. Other countries looking at us right now are surely thinking, "Those crazy Americans, they're having to pay people to get the shots that we don't even have." There will come a time too in their countries where supply outpaces demand, and they too will be thinking about incentives of all manner, not just financial incentives. There have been many situations where, in the diffusion of innovation, that the adoption of any innovation is just slow, slower than we expect, even when it's a wonderful thing.

If you look at flu shots, the uptake for flu shots in the US I don't think is very much more than 50%. That's a very well-established, easily accessible, oftentimes free or low-cost vaccine that's available to us. If we look just at that as an analogy, we can see that we're really actually at a pretty big marketing challenge to get 80% of the population to do something.

Sarah: Emily, as Stacy said, there are other parts of the world are in dire need of vaccines and yet here we are in the US trying to offer free donuts and possible lottery wins to encourage people to use our supply. Is this a uniquely American thing? How do you think these programs appear to the rest of the world?

Emily: Sure. Well, to Stacy's point that other countries are going to find themselves at a place where they're also trying to induce demand by offering incentives or thinking about creative strategies. In Romania right now, you can actually go to Dracula's castle and get free entry into the torture exhibits if you get a shot in the arm, rather than a stake in the heart. Certainly, there will be that kind of creative thinking internationally. As an ethicist, I have to say I look around with a lot of disappointment that people aren't rolling up their sleeves and doing the right thing. I think it's really a moral failing and a tremendous amount of privilege that we have this excess of vaccines right now while so much of the world is still waiting to have their first doses.

Sarah: Emily, what might these incentive programs mean down the line? Could they create some long-term problems for public health that we should be concerned about?

Emily: One of the concerns I have is that the CDC is already thinking about whether or not people are going to need booster shots. Certainly, there's been research happening into the potential use of boosters against different variants already. If we offer some of these incentives, particularly the cash and larger payment incentives, I worry that we habituate people to getting that spoonful of sugar to get the medicine to go down, and that we might actually have challenges in future vaccination campaigns if people are holding out, waiting to see if there's going to be some perk if they wait a little bit longer. That can build inefficiency, I think, into the systems, as well as increased costs.

Sarah: Stacy, it's probably too soon to know, but do you have a sense of how much of a dent these incentives could make? How much they could increase vaccinations in the US?

Stacy: I think it's hard to predict that because we actually don't know the size of the population that is not getting the vaccine strictly because of just putting it off. We might have people who, when they're surveyed and people say, "Are you going to get the vaccine, or are you not likely to get the vaccine?" We have all of these intention measures that are being taken across our country. People often say, "I may get it." Then when they're asked why they're waiting, they say, "Well, I'm concerned about safety."

While lots of people are concerned about safety, some portion of those people are likely people who aren't as concerned about safety, but that is a really logical, socially desirable way to answer the question. We don't have a sense of who's out there who's just like, "I'm going to get around to it." "I just don't really think it's that big of a deal." "I don't really think I need it. I guess I could get it if I'm ever like forced to buy a mandate, but a nice carrot might be more persuasive."

That's what is going to be interesting to see, is how many people this move will give us some sense of how big that more apathy-based population is.

Sarah: Stacy Wood is a professor of marketing at North Carolina State University. Emily Largent is an assistant professor of medical ethics, and health policy at the University of Pennsylvania. Stacy and Emily, thank you both for joining us.

Stacy: Thank you.

Emily: Thank you.

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Tony: Hi, this is Tony from Greenville, South Carolina. My employer, City Range Steak House Grill, also located in Greenville, South Carolina, has an incentive for all of its employees. Once you are fully vaccinated, they will give you a $50 bonus. Very nice of them. However, I would still have gotten fully vaccinated without the bonus because I'm not an anti-vaxxer.

Janie: My name is Janie Starr. I live on Vashon Island in Washington state. I was one of the first ones in line to get my jabs. I did it for personal safety, as well as for the community at large. I support most anything legitimate to encourage folks to get vaccinated as long as it's culturally sensitive and no one is getting gouged. I'd rather people were receiving the education they need to overcome their reluctance, but ultimately we just need to get it done. Thanks.

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