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The Role of Vaccine Attributes, Incentives, and Misinformation ✉ Sarah Kreps1, Nabarun Dasgupta2, John S

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The Role of Vaccine Attributes, Incentives, and Misinformation ✉ Sarah Kreps1, Nabarun Dasgupta2, John S www.nature.com/npjvaccines ARTICLE OPEN Public attitudes toward COVID-19 vaccination: The role of vaccine attributes, incentives, and misinformation ✉ Sarah Kreps1, Nabarun Dasgupta2, John S. Brownstein3,4, Yulin Hswen5 and Douglas L. Kriner 1 While efficacious vaccines have been developed to inoculate against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; also known as COVID-19), public vaccine hesitancy could still undermine efforts to combat the pandemic. Employing a survey of 1096 adult Americans recruited via the Lucid platform, we examined the relationships between vaccine attributes, proposed policy interventions such as financial incentives, and misinformation on public vaccination preferences. Higher degrees of vaccine efficacy significantly increased individuals’ willingness to receive a COVID-19 vaccine, while a high incidence of minor side effects, a co-pay, and Emergency Use Authorization to fast-track the vaccine decreased willingness. The vaccine manufacturer had no influence on public willingness to vaccinate. We also found no evidence that belief in misinformation about COVID-19 treatments was positively associated with vaccine hesitancy. The findings have implications for public health strategies intending to increase levels of community vaccination. npj Vaccines (2021) 6:73 ; https://doi.org/10.1038/s41541-021-00335-2 1234567890():,; INTRODUCTION becomes a limiting factor, understanding whether financial In less than a year, an array of vaccines was developed to bring an incentives can overcome hesitancy becomes a crucial question end to the SARS-CoV-2 pandemic. As impressive as the speed of for public health. Further, as new vaccines such as Johnson and development was the efficacy of vaccines such as Moderna and Johnson are authorized, knowing whether the vaccine manufac- Pfizer, which are over 90%. Despite the growing availability and turer name elicits or deters interest in individuals is also important, fi efficacy, however, vaccine hesitancy remains a potential impediment as are the corresponding ef cacy rates of different vaccines and to widespread community uptake. While previous surveys indicate the extent to which those affect vaccine preferences. The purpose that overall levels of vaccine acceptance may be around 70% in the of this study is to examine how information about vaccine fi United States1, the case of Israel may offer a cautionary tale about attributes such as ef cacy rates, the incidence of side effects, the self-reported preferences and vaccination in practice. Prospective nature of the governmental approval process, identity of the studies2 of vaccine acceptance in Israel showed that about 75% of manufacturers, and policy interventions, including economic the Israeli population would vaccinate, but Israel’s initial vaccination incentives, affect intention to vaccinate, and to examine the association between belief in an important category of misinfor- surge stalled around 42%. The government, which then augmented — — its vaccination efforts with incentive programs, attributed unex- mation false claims concerning COVID-19 treatments and will- 3 ingness to vaccinate. pected resistance to online misinformation . Research on vaccine hesitancy in the context of viruses such as fl in uenza and measles, mumps, and rubella, suggests that RESULTS misinformation surrounding vaccines is prevalent4,5. Emerging research on COVID-19 vaccine preferences, however, points to General characteristics of study population vaccine attributes as dominant determinants of attitudes toward Table 1 presents sample demographics, which largely reflect those vaccination. Higher efficacy is associated with greater likelihood of of the US population as a whole. Of the 1335 US adults recruited vaccinating6,7, whereas an FDA Emergency Use Authorization6 or for the study, a convenience sample of 1100 participants politicized approval timing8 is associated with more hesitancy. consented to begin the survey, and 1096 completed the full Whether COVID-19 misinformation contributes to vaccine prefer- questionnaire. The sample was 51% female; 75% white; and had a – ences or whether these attributes or policy interventions such as median age of 43 with an interquartile range of 31 58. incentives play a larger role has not been studied. Further, while Comparisons of the sample demographics to those of other fi previous research has focused on a set of attributes that was prominent social science surveys and U.S. Census gures are relevant at one particular point in time, the evidence and context shown in Supplementary Table 1. about the available vaccines has continued to shift in ways that could shape public willingness to accept the vaccine. For example, Vaccination preferences governments, employers, and economists have begun to think Each subject was asked to evaluate a series of seven hypothetical about or even devise ways to incentivize monetarily COVID-19 vaccines. For each hypothetical vaccine, our conjoint experiment vaccine uptake, but researchers have not yet studied whether randomly assigned values of five different vaccine attributes— paying people to receive the COVID-19 vaccine would actually efficacy, the incidence of minor side effects, government approval affect likely behavior. As supply problems wane and hesitancy process, manufacturer, and cost/financial inducement. Descriptions 1Department of Government, Cornell University, Ithaca, NY, USA. 2Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC, USA. 3Department of Pediatrics, Harvard Medical School, Boston, MA, USA. 4Computational Epidemiology Lab, Boston Children’s Hospital, Boston, MA, USA. 5Epidemiology and Biostatistics, University of ✉ California, San Francisco, CA, USA. email: [email protected] Published in partnership with the Sealy Institute for Vaccine Sciences S. Kreps et al. 2 Table 1. Sample demographic. Table 2. Attributes and attribute levels for hypothetical COVID-19 vaccines. N Percentage Vaccine attributes Levels Age 18–29 240 (22%) Efficacy 50% 30–44 336 (31%) 70% 45–59 277 (25%) 90% >= 60 243 (22%) Risk of mild side effects (fever, 1in2 headaches, muscle pain) Sex 1in4 Male 523 (48%) 1in10 Female 562 (51%) Vaccine approval Full FDA approval Prefer not to say 11 (1%) Emergency Use Authorization Race/ethnicity Manufacturer AstraZeneca White 827 (75%) Pfizer Black 141 (13%) Moderna Latinx 85 (8%) Johnson and Johnson Asian 70 (6%) Cost or financial incentive You pay: $20 co-pay Native American 37 (3%) Free Other 6 (1%) You receive: $10 incentive Education You receive: $100 incentive Less than High School 25 (2%) High School/GED 220 (20%) Note: Full text of the Full FDA approval and Emergency Use Authorization treatments are provided in the Supporting Information. Some College 308 (28%) 1234567890():,; 4-Year College Degree 224 (20%) Graduate School 319 (29%) fi Income Ef cacy had the largest effect on individual vaccine preferences. An efficacy rate of 90% increased uptake by about 20% relative to < $20,000 197 (18%) the baseline at 50% efficacy. Even a high incidence of minor side $20,000 to $39,999 205 (19%) effects (1 in 2) had only a modest negative effect (about 5%) on $40,000 to $59,999 166 (15%) willingness to vaccinate. Whether the vaccine went through full $60,000 to $79,999 133 (12%) FDA approval or received an Emergency Use Authorization (EUA), $80,000 to $99,999 100 (9%) an authority that allows the Food and Drug Administration mechanisms to accelerate the availability and use of treatments or = > $100,000 295 (27%) medicines during medical emergencies9, significantly influenced Political Partisanship willingness to vaccinate. An EUA decreased the likelihood of Democrat (including those who leaned toward 501 (46%) vaccination by 7% compared to a full FDA authorization; such a the party) decline would translate into about 23 million Americans. While a Republican (including those who leaned toward 513 (47%) $20 co-pay reduced the likelihood of vaccination relative to a no- the party) cost baseline, financial incentives did not increase willingness to Political Ideology vaccinate. Lastly, the manufacturer had no effect on vaccination Very Liberal 166 (15%) attitudes, despite the public pause of the AstraZeneca trial and prominence of Johnson & Johnson as a household name (our Liberal 161 (15%) experiment was fielded before the pause in the administration of Somewhat Liberal 96 (9%) the Johnson & Johnson shot in the United States). Moderate 317 (29%) Model 2 of Table 3 presents an expanded model specification to Somewhat Conservative 89 (8%) investigate the association between misinformation and will- Conservative 106 (10%) ingness to vaccinate. The primary additional independent variable of interest is a misinformation index that captures the extent to Very Conservative 161 (15%) which each subject believes or rejects eight claims (five false; three Note: Categories may not sum to 100% because of rounding. true) about COVID-19 treatments. Additional analyses using alternate operationalizations of the misinformation index yield substantively similar results (Supplementary Table 4). This model of each attribute and the specific levels used in the experiment are also includes a number of demographic control variables, including summarized in Table 2. After seeing the profile of each vaccine, the indicators for political partisanship, gender, educational attain- subjectwasaskedwhethershewouldchoosetoreceivethevaccine ment, age, and race/ethnicity, all of which are also associated with described, or whether she would
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