Confidence, complacency and convenience: part two

Should we use vaccine incentives and mandates? Plus, an important announcement (12 minute read)

Welcome to The Turnstone. I’m Melanie Newfield, and once a week I bring you my personal perspective on science, society and the environment. Before we get to this week’s article, I have an important announcement.

New Zealand is reaching a critical point in its vaccination programme. While it’s great news that 75% of people have either been vaccinated or are booked to be vaccinated, that still leaves a lot of people who aren’t there yet. Research suggests that the majority of these people are not consciously rejecting vaccines. Some face barriers, such as difficulties with transport or finding time. Some may be afraid of needles. Some may have genuine fears and concerns about vaccination and aren’t sure who to trust for advice. Some may have too much on their plate to worry about Covid-19 and vaccines. Some may have been drawn into the vortex of disinformation and conspiracy theories.

All of us can play a part in helping people overcome these barriers. To help with these conversations, I have brought together a set of amazing resources. Some of these resources come from global experts, such as Heidi Larson, founder of the Vaccine Confidence Project. Others come from ordinary people with something important to say.

Over the next two weeks, I will be sending you information to help you in conversations with your friends and family. If you already subscribe to The Turnstone, you will receive this – no need to do anything. If you aren’t yet a subscriber, you can sign up now. I’ll also be sharing everything on social media and on my website here.

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At the end of the two weeks, I’ll be hosting an online discussion where some of us will share what we have learned. I’m still firming up my plans, so I’ll let you know the date and time soon.

And now, onto this week’s article...


In late July, the Australian government released an information sheet for businesses, encouraging them to offer rewards to vaccinated Australians. Some businesses were already on board, the information sheet proclaimed, including Qantas, Virgin Australia and the travel booking website Luxury Escapes. Virgin Australia had launched a competition called VA-X & Win. Luxury Escapes offered vouchers for members to use when booking their next trip. And Qantas offered both rewards and a competition.

I admit, I’m rolling my eyes at this. After all, each of these companies has a rather obvious self-interest in seeing the pandemic brought to an end. Their generosity towards vaccinated Australians probably has more to do with the impact of Covid-19 on the global travel industry than it does public health. And I wonder who is going to be motivated by these rewards. I’m getting vaccinated because I know that’s the best way to protect myself and others from Covid-19. I’m not getting vaccinated on the off-chance of discount travel. I’m sure I’m not alone.

The Australian vaccine reward scheme isn’t the only measure aimed at encouraging more people to get vaccinated. France and Italy have introduced a “green pass”, where people must show that they’ve either been vaccinated, recovered from Covid-19 or had a recent negative test to access public transport, museums and restaurants. In the USA, some companies have made vaccination mandatory for employees, or imposed increased costs on the unvaccinated.

But while these measures are all aimed at increasing vaccination rates, I’ve got some nagging doubts. The doubts aren’t about vaccination – on the contrary, I want to see as many people as possible vaccinated, as soon as possible. My doubts are precisely because I’m in favour of vaccination. I’m worried that some of the strategies aimed at encouraging people to get vaccinated might have the opposite effect.

Last week, I wrote about the “confidence, complacency, convenience” model used by the World Health Organisation to help understand vaccine hesitancy. This model explains that people who are reluctant to get vaccinated have three main reasons which can be summarised as – they don’t trust the vaccine, they don’t think they need the vaccine and it’s too difficult for them to get the vaccine.

Source: World Health Organisation, Report of the Strategic Advisory Group of Experts on Vaccine Hesitancy

As soon as you look at these reasons, you can probably see the problem with Australia’s vaccine incentive scheme. Exactly who is going to be encouraged by the scheme? If someone doesn’t trust the vaccine, the promise of extra airpoints or discount travel isn’t going to convince them. If it’s difficult for someone to access vaccination because they don’t have a car or spare money for public transport, then they’re probably not the target of any campaign to encourage tourism. I suppose it is possible that someone who thinks vaccination is unnecessary might get vaccinated for the discount travel, but it does seem rather unlikely.

The evidence doesn’t favour this kind of approach either. The same working group that came up with the “confidence, complacency, convenience” model also reviewed strategies for increasing vaccine uptake. There was some evidence supporting the use of “non-financial incentives”, but they weren’t among the most effective strategies.

What interested me was that making vaccination mandatory was one of the strategies that worked, at least in some circumstances. That does make some sense, at least for some people who are vaccine hesitant. It may work on those who are reluctant to get vaccinated because they don’t think it’s necessary. But a closer inspection of the report reveals some drawbacks of mandatory vaccination, particularly the erosion of trust.

Overall, the evidence suggested nothing very surprising about the methods that improved vaccine uptake. The most important point was that no single method was universally effective. Different methods worked in different places and with different vaccines, and strategies employing multiple methods worked better than relying on one method alone. Sometimes it worked to make vaccines easier to access. Sometimes, sending reminders to people worked. Sometimes it worked to engage religious and other community leaders, as it did in Nigeria during their vaccine boycott. Sometimes it worked to train healthcare workers to have better conversations with their patients. Often, suggested strategies to overcome vaccine hesitancy and improve vaccine uptake hadn’t been evaluated at all, so nobody was sure whether they were actually achieving anything.

There has been little research on overcoming vaccine hesitancy (although more on improving vaccine uptake), but there is evidence from other areas that may be useful. The field of risk communication, in particular, has some important insights which could help us vaccinate our way out of this pandemic. Risk communication is particularly important when thinking about people who lack confidence in vaccines, because as much as vaccine advocates may want to deny it, being vaccinated is a risk.

Whenever the topic of risk communication comes up, I always think of Peter Sandman, whose work has informed and inspired me through most of my career. For the last 40 years, Sandman has been describing risk as a combination of hazard (how likely something is to hurt people) and outrage (how much it upsets people). Hazard and outrage, he explains, are not closely linked. You can’t tell how likely something is to hurt you by how upset people are about it. And you can’t tell how upset people are going to get by the likelihood the hazard will hurt you.

Vaccination is one example of a risk that’s got a very small chance of hurting you, but gets a lot of people really upset. As an example of how small that chance is, there’s a risk of a heart condition called myocarditis with the Pfizer/ BioNTech vaccine for Covid-19, and it’s particularly a risk for younger people. So far, there are a few hundred cases in the USA in people aged under 30, out of around 20 million people in that age range vaccinated. Myocarditis is usually fatal around 5% of the time, but in the USA the death rate for vaccine-linked myocarditis is lower than that. I’m using this example because one woman in New Zealand died of myocarditis after receiving the vaccine, so if you are in New Zealand, it may be on your mind.

These numbers say that your chances of getting sick or even dying after receiving the Pfizer vaccine are pretty small. The risks are similar for blood clots associated with the Oxford/ AstraZeneca vaccine for Covid-19. The chance of a severe allergic reaction after vaccination is around a million to one. But while the numbers are small, they aren’t zero. Vaccines do have risks.

Even though the chance of being harmed by a vaccine is small, there’s something about vaccines that many people find upsetting. Even if you yourself are in favour of vaccines, the chances are that you know people who are concerned about them, or are even opposed. Some anti-vaccine sentiment can be traced back to 1998, when a fraudulent paper (since refuted and retracted) claimed that the measles, mumps and rubella (MMR) vaccine was linked to autism. But there are other reasons, too, connected to the psychology of how we perceive risk.

When we judge how dangerous or safe we think something is, we aren’t thinking about how likely it is to hurt us. When you get into your car, do you know what the chances are of having an accident? Do you even think about having an accident at all? For me, even when I’m actually putting my seatbelt on, I never think about crashing. On the other hand, the thought of a plane crash often pops into my head when I’m sitting on a plane and about to take off. It’s not enough to make me anxious, but it’s there. If you calculate the odds, the chances of me crashing my car are much higher than a commercial plane I’m in crashing, but that isn’t what influences my judgement of the risk. Driving a car, I’m in control, doing something that I do most days, and that most people I know do most days. I don’t fly as often, and I’m not in control.

Familiarity and control are two of the factors that influence how we think about risk. The more familiar something is, and the more control we have over it, the safer it seems. There are many other factors too, summarised in Peter Sandman’s excellent and concise book on risk communication. We feel safer with something we perceive as “natural” compared to something we think is “unnatural”, which partly explains why some people think that getting a dangerous disease like measles or Covid-19 is better than vaccination. We feel safer with risks that are voluntary than risks that are coerced or involuntary, meaning that people tend to be less worried about drinking alcohol than the possibility of toxins contaminating drinking water.

The difference between voluntary and coerced or involuntary risks is crucial for the vaccine debate. It explains why making vaccines mandatory in some circumstances, or even using strong incentives, can backfire. For those who are worried about vaccines, the risks magnify if they are told they have to take them. Even though the evidence suggests vaccine mandates can increase vaccination rates, there’s a delicate balance of advantages and disadvantages. A mandate may spur the complacent to finally get a shot, but it may also reinforce the views of those who don’t trust vaccines, or doctors, or the government. Mandatory vaccination is polarising, and it damages trust. That’s not helpful when we all need to pull together.

New Zealand doesn’t have mandatory childhood vaccination. Nor does it have coercive policies such as making certain benefits available only to parents of vaccinated children, or requiring them for school attendance. However, when I began to turn over stones, I found that mandates and coercive policies are relatively common in other wealthy countries, including Australia, France, Italy, and a number of states in both the USA and Canada. All of these countries, except Canada, have higher vaccination rates for one-year-olds than New Zealand. The contrast with Australia is even more marked for five-year-olds – Australia has reached their target of vaccinating 95%, while only 85% of New Zealand children of the same age are vaccinated. On the other hand, France is the country with the highest degree of mistrust in vaccines, and that’s not something we want to emulate.

Vaccine mandates and incentives don’t explain the UK and Denmark, however. Both countries make childhood vaccination entirely voluntary and have higher vaccination rates than New Zealand. The UK and Denmark are important reminders that successful vaccination programmes don’t need to rely on coercive policies.

The most compelling argument in favour of mandatory vaccination, at least in some circumstances, is that vaccination is not just about individual health, it’s about public health. The Pfizer vaccine doesn’t just protect people from serious illness and death from Covid-19, it significantly reduces the chances of someone passing it on – even with the Delta variant. That’s important, especially for those whose immune systems are weaker, such as people undergoing cancer treatment. It’s also important for our children, because we can’t yet vaccinate children under 12. Unvaccinated adults increase the risk to children. Even though I have misgivings about mandatory vaccination, I can’t argue against requiring vaccines for people working in places like cancer wards or care homes for the elderly, and there’s also a strong argument to require vaccination for staff in schools and childcare centres.

But we shouldn’t forget that the vaccination rate affects all of us, even if we ourselves are fully vaccinated and healthy. The more unvaccinated people there are in a community, the more the virus can circulate. That means there are more chances for new variants to emerge and for “breakthrough” infections (serious disease in vaccinated people) to occur.

Right now, as last week’s graph showed, New Zealand’s vaccination rate is rising. We are more worried about vaccine stocks running out, or being delayed, than about a fall in the number of people wanting to be vaccinated. But we will, at some point, see our vaccination rates slow down. Before we reach that point, we need to have some serious conversations about what, if any, mandates or incentives we should use. Maybe they will help, but there are risks in trying to coerce people into being vaccinated. We need to take a strategic approach – looking carefully at the reasons that people aren’t vaccinated and what works in those specific circumstances, rather than just using policies that “feel right”.

We also need to think about what we, personally, can do. Vaccine hesitancy is much more than people following conspiracy theories down a rabbit hole. It’s about people you know. And so, next week, I will talk about what we can do, in our communication with others, to support people we know to make good choices about vaccination.

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