To control the spread of the SARS-CoV-2 virus, several vaccines have been available to most of the population worldwide.1 In Serbia, universal and free vaccination of all adults (≥18 years) has been implemented since January 2021. Serbian citizens were able to choose 1 of 4 vaccine manufacturers (Pfizer-BioNTech, Sinopharm, Sputnik V, and Oxford-AstraZeneca), while a fifth one (Moderna) became available in late 2021. The interest in vaccination was at its peak until May 2021, after which the coverage slowed down significantly. At this time, slightly more than 50% of the adult Serbian population has received at least 1 vaccine dose.2
To help increase the vaccination coverage the Serbian government proposed different incentives which included discounts for shopping in major shopping malls throughout the country and holiday packages for those who received the COVID-19 vaccines. Among these incentives, the Serbian government also offered a one-time financial reward of around 25 Euros in cash upon receiving COVID-19 vaccine.3 This strategy was put forward alongside several cash payments that were given to all adult citizens in Serbia to provide relief for financial losses sustained during COVID-19 lockdown.4
However, this public health policy involving cash payments in Serbia was labeled by some (professionals and media) as unethical.Reference Holt5 Specifically, it has been suggested that people who were socially deprived would be more accepting of the COVID-19 vaccines despite their previous reluctance to do so.Reference Holt5 In fact, the 25 Euro cash reward was labeled as “undue influence” particularly for those who lost their jobs during the pandemic and are challenged to get by.Reference Holt5 Further, it has been argued that because of financial incentives, people would question the quality and content of the vaccines.Reference Holt5 Receiving money could be interpreted as the compensation for risk taken on the people who expose themselves to vaccine compounds.Reference Persad and Emanuel6 As a result, this strategy may deepen the distrust of people toward health care institutions and the government. Also, there have been opinions that monetary rewards promote one-sided judgment to get the money as an end-goal, rather than think reasonably, act for public good,Reference Jecker7, Reference Jecker8, and be virtous.Reference Boyneburgk and Bellazzi9 Finally, it has been discussed that providing financial rewards would be a waste of resources.Reference Persad and Emanuel6
Serbia was 1 of few countries worldwide to offer monetary incentives to receive the vaccine against COVID-19.10 This phenomenon in the context of public health and infection prevention and control is entirely unique and new. As such, a qualitative approach to these events would provide a more nuanced view of various opinions and a deeper understanding of this issue. The underlying reasons as to why this issue merits further exploration of people’s perceptions of incentives for vaccination are grounded in the notion that infectious disease pandemics will expectedly be occurring in the forthcoming decades, particularly when emerging pathogens are considered.Reference Ukoaka, Okesanya and Daniel11 As a result, such findings may be helpful to public health policy creators in future health crises. The purpose of this study was to examine the opinions of Serbian citizens about incentives for vaccination against COVID-19.
Methods
In-depth interviews were conducted in February and March of 2022. To systematically approach the data collection, a thematic guide was defined prior to the start of the study (Table 1). The Ethics Committee of the University of Belgrade approved the study. All participants provided informed consent and agreed with audio-recording of interviews.
Thematic guide for the interviews
Selection of Study Participants
The study population consisted of pairs of university students and their parents. The research team made the choice to include people of different age because of potential differences opinions between generations. For example, young people, such as students who often do not have own source of income or a steady daily job, may be more inclined toward receiving and supporting the promotion of financial and non-financial incentives. The parents of students, on the other hand, are likely to have own source of income to support their household and children and may have different opinion about cash rewards and non-monetary incentives. In this way it was possible to explore this research topic from 2 generationally different angles.
Also in Serbia, it is common that adult children live with their parents in the same household until when they decide to move out by choice. So, students, whose parents do not reside in the city where the university is located, typically visit and stay with parents during school breaks and holidays. Thus, members of the same household (parents and their children who are students) likely have a similar set of living and economic conditions. Moreover, despite the age, people who live in the same household can either share similar social and moral values and attitude toward health or have individual opinions. The research team was mindful of this issue while interpreting the study findings.
Purposive sampling with maximum variation was applied to select student-parent couples who lived in different regions of Serbia. In Serbia, there are 5 regions: 1) the capital region Belgrade, 2) Vojvodina, 3) Sumadija and Western Serbia, 4) Southern and Eastern Serbia, and 5) Kosovo and Metohija. Because of this, the research team aimed at including students and parents from all 5 regions. In this study, 1 student-parent pair was from Belgrade, 3 student-parent pairs were from Vojvodina, 2 pairs were from Western Serbia, 2 pairs were from Eastern Serbia, and 1 pair was from Kosovo. The inclusion criteria were being an active university student, having a parent who was willing to participate in the study, and having permanent residence in 1 of 5 regions in Serbia.
Sampling was finalized after reaching thematic saturation, which was discussed amongst members of the research team.
Procedure
The research team comprised experts in public health and medical ethics and 1 university student who had previous experience with qualitative research and social science. The student researcher (BB) conducted all the interviews. First, students were approached by the interviewer in a student dormitory in Belgrade to explain the study purpose and to arrange the time and place of the interview. Upon scheduled time, face-to-face interviews were conducted in dormitory premises. Only the researcher and the interviewee were present during the interview. Identification of students from all 5 regions of Serbia was assisted by study participants who were previously interviewed.
Later, after the interview with the student has ended, their parent (either mother or father) was contacted via telephone. The purpose of the study was explained and the time and date of the interview with the corresponding parent were set. Interviews with all parents were conducted via telephone call. All interviews were conducted by the same researcher and audio recorded. Interviews were conducted in Serbian and lasted between 8 to 18 minutes. The same researcher transcribed the audio files verbatim. Following transcription, the audio files were deleted. The interview transcripts were not returned to student-parent pairs for comments.
Trustworthiness
In qualitative research, the investigator who takes on the data collection has a major role in the study because their knowledge on the subject, personal characteristics, and ability to conduct the interview and ask additional questions are essential in gathering as much data as possible and interpreting them to minimize deviation from the universal truth. For this reason, the interviewer in this study was the student who lived in the dormitory that was the place for the selection of student participants. In this way, the interviewer was able to have a direct contact with his peers and relate to their point of view as they were from the same generational cohort. Also, the interviewer himself comes from the population who experienced the offering of the financial reward, so he was able to have a comprehensive insight into this campaign when it has initiated. Because of the first interviews with students and overarching themes observed during data collection, the interviewer was able to have interviews with the parents (an older, mid-aged population) and have a clear understanding of parallel or contrasting opinions on financial and non-financial incentives.
Data Analysis
Naturalistic theoretical orientation was the methodology of choiceReference Bradshaw, Atkinson and Doody12, Reference Sullivan-Bolyai, Bova and Harper13 to collect as many descriptions, arguments, and explanations as possible and achieve optimum understanding of how financial and non-financial incentives were seen by the study participants. Qualitative content analysis was the chosen approach to data analysis.Reference Schreier and Flick14 Two members of the research team read through the transcripts line-by-line to employ qualitative content analysis. Codes were assigned to representative parts of text. Codes that were similar were grouped into themes and subthemes. Codes were compared to one another. In this way, the research team was able to re-define and adjust topics and subtopics. Topics were derived exclusively from the content of the interview. The coding was discussed with all members of the research team for clarity and consistency. The content analysis was performed on transcripts in Serbian. Representative quotes were translated to English.
Results
A total of 18 participants (9 student-parent pairs) were included (8 males and 10 females). On average, students were 22.3 years old and parents 54.3 years old. All parents were employed. Two parents had primary education level, 4 parents had secondary education level, and 3 parents were university graduates.
All vaccinated study participants made the decision on vaccination before the financial incentives were announced by the government. Of students, most (7 out of 9) received at least 1 dose of COVID-19 vaccines. Of parents, 5 of 9 were vaccinated with at least 1 dose.
The results are systematized and presented according to the following themes: 1) Attitudes about financial incentives for vaccination, 2) Non-financial incentives for vaccination, and 3) Suggestions to enhance the vaccination coverage.
Overall, there were few differences in opinions between students and their parents.
Theme 1: Attitudes About Financial Incentives for Vaccination
This theme was classified into 4 different subthemes: general response to money, dissatisfaction and satisfaction with financial incentives, and amount of money to change people’s opinion.
General response to money
Almost all study participants expressed the opinion that money inherently changes people’s minds and behavior. The majority of participants agreed that money offers could make people do what they were being asked to even if they were initially against doing it (Table 2).
Participants’ citations according to themes and subthemes
Nevertheless, almost all agreed that if a person is absolutely sure about their decisions and determined to act only according to their beliefs, no type of incentives could have influenced their opinions and actions. Therefore, the study participants considered that financial incentives have no influence on people who are strict anti-vaxxers. They articulated that financial incentives are appropriate motivators only for those people who are hesitant and indecisive, so they should be targeted to increase the vaccination coverage.
Conversely, there were few participants who believed that offering money was even counterproductive regarding people’s attitude toward vaccination. These participants considered that financial incentives could instigate fear and distrust in vaccination, which could subsequently lead people to do the exact opposite from what they are being asked to do. Some participants had a feeling that people were being paid to compensate for potential adverse effects (Table 2).
Dissatisfaction with financial incentives
The majority of parents and some students expressed a clear dissatisfaction and disapproval of the concept of financial incentives for compliance with vaccination. People in this study stated that involving money in the realm of vaccination and public health is unnecessary, because compliance with vaccination represents a civil duty. No incentive/compensation/reward is necessary in such a situation, but protection from the infection and contributing to better health of the general population worldwide is a reward in itself (Table 2).
People in this group also articulated that this type of stimulation is immoral because it represents a “bribery” of the vaccine hesitant citizens, especially those who are socially deprived. Several study participants believed that incentives for vaccination discriminated against people who did not want to receive the vaccine or cannot be vaccinated due to various medical reasons (Table 2).
Satisfaction with financial incentives
Somewhat fewer participants in this study were satisfied and in favor of the financial incentive offered for vaccine acceptance. Additionally, more students than parents welcomed this initiative. Some of the interviewed students believe that money is welcome, but that the decision to receive the vaccine should still be independent of external influences.
They believed that financial incentives were symbolic rewards for taking socially responsible actions. In fact, they felt that money was as acceptable as any other incentive to increase the vaccination coverage as much as possible. Some articulated that it might be particularly relevant for vaccine hesitant people who are economically deprived (Table 2).
Moreover, practically none of the students and their parents considered that there were ill intentions in proposing financial incentives. They agreed that financial incentives cannot represent mitigation of risks because the vaccine was approved by the Serbian agency for medicines and medical devices. Incentives in their opinion were just 1 of the actions undertaken by the government to increase the vaccination coverage. Moreover, they were more inclined to consider the offered money as a symbolic reward compensating for a loss of a daily wage for leaving work to get vaccinated or for the cost of transportation to reach the vaccination site.
Amount of money to change people’s opinion
Most people stated that if they firmly decided upon something no amount of money could make them change their mind. However, the majority also believed that the amount of an average monthly salary in Serbia (approximately 500 Euros) could easily change the opinion of many people to receive the vaccine, especially those people who have financial difficulties.
Still, the majority agreed that 25 Euro reward for vaccination was too small for an individual to receive the vaccine while ignoring their own feelings of fear, insecurity, and acceptance of risks that prevented them from being vaccinated in the first place (Table 2).
Some study participants considered that it would be more appropriate to allocate more money for the poorest population. Nevertheless, the majority of study participants thought that if financial incentives were offered, then everybody should receive the same amount of money. Uneven distribution of incentives could be discriminatory (Table 2). Moreover, offering higher amounts of money would surely affect economically deprived groups to change their attitudes and get vaccinated.
Non-financial Incentives for Vaccination
The majority expressed a negative opinion of non-financial incentives as well. Most participants did not make a difference between these 2 types of incentives and still believed that even non-monetary incentives can be seen as unnecessary and morally inappropriate, mostly for the same reasons as the financial ones. In addition, some participants did not consider non-financial incentives as effective or motivating, because they can be less simulative for people who have different spending habits and needs (Table 2).
Still, considerably more participants had a positive attitude toward the non-financial compared to the financial incentives. Some participants pointed out that there is a certain discomfort when money is mentioned, primarily because it may affect people’s sense of dignity (Table 2). Conversely, people believed that non-financial incentives are ethically tolerable because they could be beneficial for the population but are less likely to influence one’s judgment than when money is offered.
Suggestions to Enhance Vaccination Coverage
Virtually all study participants agreed that vaccination in general should be promoted. Still, they thought that it should be done in a subtle way and not so bluntly with monetary offerings. However, there were few study participants who supported obligatory vaccination (Table 2). According to study participants, the most important things for adequate vaccination coverage are education and information (Table 2). They think that this information needs to come from health care professionals, through constant education of the younger generations through schooling, public forums and panel discussions, as well as through media. Experts should talk about vaccination in media using clear and simple language in a way that the masses of people who are not medical professionals can understand. Finally, organization of vaccination sites in terms of working hours and availability should be done in such a way to accommodate working hours.
Discussion
Overall, financial offers would not make our participants change their position on whether to receive the vaccine, as no major differences in attitude towards vaccinations between the vaccinated and the non-vaccinated study participants was observed. A potential explanation for these results could be the fact that in Serbia all citizens have universal access to health care, and therefore, they consider that paying out of pocket and health care do not align. Paying people to take care of their own health and that of their family is seen as unusual because such a public health policy has not been proposed and implemented previously. Furthermore, study participants thought that receiving vaccine against COVID-19 should also be mandatory to ensure better health of the entire population may be due to mandatory immunization of children against 11 infectious diseases.Reference Veljkovic, Loncarevic and Kanazir15
Previous studies examined the amount of financial incentives offered to people to receive the vaccine. A randomized-controlled trial conducted in Sweden found that an incentive amounting to $24 US dollars increased the coverage by a little more than 4%.Reference Campos-Mercade, Meier and Schneider16 Offers from 25 to 200 Euros in Germany were not found to increase the likelihood of people accepting COVID-19 vaccines.Reference Sprengholz, Eitze, Felgendreff, Korn and Betsch17 Some interviewees in this study suggested that an incentive amounting to several days’ wages or the average monthly salary would potentially influence more people to change their attitude. However, larger sums of money (i.e., larger than daily wage of unskilled worker) may be “too good to refuse” and therefore undermine free decision-making. In Russia, for example, financial rewards of 120 Euros were offered only to older people and were considered significant relative to the average monthly pension of 190 Euros.Reference Haman and Khakimova18 However, the effectiveness of this strategy remains unclear.
Bearing these findings in mind, financial incentives may not always increase the vaccination rate in various population groups. In fact, a study by Sargent et al.Reference Sargent, Laurie and Moncada19 suggested that offers such as $25 gift card would make almost one third of non-vaccinated people less likely to receive the vaccine. The same held true for $100 000 lottery incentive.Reference Sargent, Laurie and Moncada19 In this study, some participants were disturbed by money offers which made them equate an incentive with a bribe.
This study showed that there are several factors involved in the decision-making process about vaccine acceptance and that they differ between people which is in line with similar research.Reference Haman and Khakimova18–Reference Carroll, Arias Hernandez and Brooks-Greisen20 The most important factor that influenced the study participants to receive the vaccine was the belief that it is their civil duty to protect themselves and other people. Next, they highlighted the importance of doctor’s recommendations. By contrast, financial incentives were less relevant for changing vaccination intention. Thus, our results support the findings of other authors.Reference Sprengholz, Eitze, Felgendreff, Korn and Betsch17, Reference Sargent, Laurie and Moncada19 Still, evidence suggests that financial incentives may encourage those who are “not yet ready” to get the vaccine.Reference Rosen, Beltran and Thomas21 This means that financial incentives may be the “final push” to acceptance. However, the question remains how hesitant people can be persuaded to change their mind to accept the vaccine when money is not offered.
Overall, people in this study believed that mandates would fall short of the expected increase in vaccination coverage. It is important to highlight that this opinion was held both by the non-vaccinated and the vaccinated people in our study, not just the non-vaccinated. Instead, they propose that vaccination promotion and education of the public in mainstream media and online sources would yield better results. Another important issue is the trust in governmental decisions and recommendations.Reference Liu and Chu22 Furthermore, vaccine hesitancy is a dynamic state and changes over time,Reference Siegler, Luisi and Hall23 which means that adequate information delivery has a strong potential to changing peoples’ attitudes toward vaccination.
Some authors suggest that financial incentives may be the most effective kind of incentives.Reference Brewer, Buttenheim and Clinton24 Participants in this study believed that non-financial incentives would be a more suitable reward for people in Serbia to get vaccinated. They also mentioned that some types of non-monetary incentives may be beneficial only for some people (e.g., free parking for those who own cars) rather than for everyone. Globally, non-financial incentives included food or kitchen appliances.Reference Brewer, Buttenheim and Clinton24 For this reason, when offering non-monetary incentives, it is important to consider those incentives which may be equally used by all and not only by a specific group of people.
Many participants in this study articulated that the financial rewards put forward by the Serbian government were morally wrong. That claim was refuted in previous research because: 1) the financial reward was 1 of several measures implemented by the Serbian government at the national level to help overcome financial losses due to the COVID-19 lockdown; 2) this payment was not undue because it equals the daily wage of unskilled workers in Serbia and no coercion was in place, because the vaccinated people received a benefit instead of sustaining a loss; and 3) poor and disadvantaged people have equal access to health care as any other citizen regardless of their socio-economic status.Reference Dotlic, Jeremic Stojkovic and Cummins25, Reference Dotlic, Jeremic Stojkovic and Cummins26 While there are ethicists who argue that financial incentives are more appropriate than mandatory immunization for COVID-19,Reference Savulescu27, Reference Reese and Pies28 others consider that communication with the public would have a greater impact than any incentive.Reference Pennings and Symons29 Some ethicists emphasize that vaccination is a moral duty to oneself and to others and that financial incentives should be ranked the lowest on the priority list of strategies to enhance vaccination coverage, but not excluded.Reference Largent and Miller30 Finally, it is regarded that the strongest and most lasting policies on vaccine uptake might involve behavioral strategies such as having a vaccination certificate as a condition to access various settings valued by people.Reference Volpp, Loewenstein and Buttenheim31, Reference Volpp and Cannuscio32
In consideration of study limitations, this study included younger adults and their mid-aged parents, but not older people. Older people (aged 65 and above) account for approximately 1 quarter of the population in Serbia. They also represent the group which had the highest vaccine coverage rates and lowest income. For this reason, our results may not reflect the perception of the entire Serbian population. Another limitation may be the fact that none of the participants were economically deprived and consequently more likely to be influenced to accept vaccine. On the other hand, none of the participants belonged to the highest income bracket and were, therefore, able to critically assess money as an incentive for vaccinations. Finally, all vaccinated participants were already vaccinated when the financial incentive was announced. So, it was not possible to appraise the change in attitude when the financial incentive was offered. Still, public data showed that almost all vaccinated people in Serbia signed up to receive this financial reward, which implies that they did not ignore the offered incentives.
In conclusion, most people considered that financial rewards were not an effective method to enhance vaccination coverage. Non-financial incentives were found more acceptable compared to the financial ones, but they were also seen as beneficial for some and not the others. Without further evidence, financial incentive programs’ potential for inefficiency and public mistrust make other methods to boost vaccine uptake better public health choices for now.
Author contribution
BB contributed to study design, data analysis, and interpretation and drafted the manuscript. JD, VJS, PC, MM, and TG contributed to study design, collected data, analyzed and interpreted data and provided critical review of the intellectual content of the manuscript. The authors agree to be held accountable for all aspects of the manuscript and approve its final version before submission.
Funding statement
None.
Competing interests
The authors declare that they have no conflict of interest.
