Coercion, Correction or Cash? Which Matters for COVID-19 Vaccination in Pakistan?

• In Event: Poster Session: Advances in the Study of Religion and Politics & Health Politics and Policy
  In Poster Session: Poster Session: Health Politics and Policy

Abstract

Motivation

Misinformation has played a powerful role in seeding vaccine hesitancy globally both prior to and during the COVID-19 pandemic. This is especially the case in Pakistan where vaccination has long been a contentious political issue. Yet, it is increasingly recognized that regular COVID-19 boosters will be necessary for the continued management of the COVID-19 pandemic. While Pakistan has had high primary adoption of vaccines largely driven by coercive vaccine passports, booster uptake has been slow. As the perceived threat from COVID-19 subsides, efforts to encourage booster uptake will need to address not only factors that shape hesitancy but may also benefit from literature on how behavioral “nudges” that can improve voluntary compliance with public health guidelines. In this four-arm field experiment at a large, urban hospital in Pakistan, we examined how different messages that randomize emphasis on mandates, minimization of side-effects, quality of vaccines and entry into a cash lottery affected willingness to receive a COVID-19 vaccine booster on spot.

Methods

Here we report the preliminary results with a sample of 997 respondents who came in for routine care. Respondents were approached by the study team upon entry into the hospital and were randomized to receive four different messages incentivizing them to receive a booster during their visit. Respondents were then asked if they would be willing to receive a vaccine/booster shot on spot at the hospital during their visit. Those that said yes were handed a slip of paper with a unique identifier to hand over to the vaccination team. As data collection is ongoing, here we report the results of the proportion who said they would be interested in getting vaccinated/boosted on spot. In future analyses, we will report the results of the percent who vaccinated on spot and with a larger sample.

The first arm (Vaccine Mandates) emphasized that boosters may be required for certain travel destinations, work requirements etc. The second arm (Side-Effects) focused on the safety and minimal side effects of vaccines to dispel misinformation. The third arm (Manufacturer) informed participants they would get Pfizer or Moderna versions of the booster and not the earlier versions. The fourth arm (Lottery) emphasized that if participants agreed to get the booster their name would be entered in a lottery with a chance to win PKR 30,000 (USD 138). The control condition did not provide any messaging and simply asked respondents if they were interested in getting vaccinated/boosted during their visit.

Results
Eighty-eight percent of respondents had received the initial COVID-19 vaccine series. The top two reasons for getting vaccinated were to protect against Coronavirus (76%) and vaccine mandates (41%). Concern about side effects (77%) and lack of trust in the vaccine (39%) were the top two reasons for not getting vaccinated. However, booster uptake was very low; 99% of respondents had not received the booster shot.

Booster uptake for the lottery arm was 44.0 percent, while for the control group it was 4.4 percent. For the vaccine mandates, side-effects and manufacturer arms it was 11.4 percent, 10.7 percent and 5.7 percent respectively. Each of the four experimental conditions led to a statistically significant increase in the willingness to get a vaccine on spot compared with the control group except for the manufacturer arm. However, entering individuals into a cash-prize lottery had the largest effect of a sizable magnitude: our OLS model estimated that the lottery arm led to a 40 percentage point gain in uptake (coefficient: 0.40, p<0.001).

Discussion
The use of cash incentives may be a practical and cost-effective mechanism for many LMICs to increase booster uptake as we show that even a modest cash incentive substantially increased willingness to seek a booster. Cash incentives appear to be more impactful than either the threat of a renewed vaccine mandate or correction of misinformation/emphasis on the quality of the vaccines. However, the continued ability of countries to offer free vaccination through on-site vaccine clinics remains in question and may depend on global vaccine donation programs.

Authors

• Hina Khalid, Research and Data Analysis Division. Washington State Department of Social and Health Services.

• Ashley M Fox, SUNY at Albany