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Martin W. Kane/University of North Carolina at Greensboro

Colleges are giving out a wide range of freebies -- gift cards, T-shirts, free courses or hard cash -- for students who can show proof of receiving the COVID-19 vaccine. But decisions about whether to incentivize the vaccine and how to go about it are fraught with ethical questions for scholars and campus leaders.

At the University of North Carolina at Greensboro, students who upload a copy of their vaccination card through April 28 receive gift cards for a drink at the Starbucks on campus. They can also win serious money toward food or textbooks, and even free housing. The university is raffling off 10 $150 flex meal plans and 10 $350 bookstore scholarships. One student will receive free on-campus housing for the next full academic year. The funds for the raffle come from federal Higher Education Emergency Relief Funds, which were part of the coronavirus relief package passed in late December.

The list goes on. Vaccinated students at the College of Wooster in Ohio get free shirts bearing a Scottie dog, the college’s mascot, wearing a mask with the hashtag #ScotsProtectScots. Students with campus jobs will also be compensated if they miss work hours for a vaccine appointment, which is in line with the college’s policy to pay student workers through the pandemic even if their campus jobs were shut down.

Danville Area Community College in Illinois will allow students to take any summer course for free if they prove, in person or via email or text, that they were vaccinated. Students may still need to buy books or lab equipment, but tuition and fees for the course will be waived, according to the college’s website.

Julia Jackson-Newsom, associate vice chancellor for strategy and policy at UNC Greensboro, said despite the blunt enticements, students are having a hard time deciding whether to get vaccinated. She described “really nervous” students coming to the campus vaccination clinic and asking staff if getting vaccinated is the right choice.

She wants the incentive program to convey the message that "we really do think this is important and we really do think this is the right thing to do and we really, really hope that you’ll seriously think about this,” she said.

A Pew Research Center study, conducted in April and May, found that, in a case where vaccines were immediately available, more than 30 percent of Americans age 40 or younger reported they would not get vaccinated.

But scholars debate whether incentives are an effective -- and equitable -- way to influence students in the context of COVID-19.

Erin Bronchetti, an associate professor of economics at Swarthmore College in Pennsylvania, said it partly depends on why students are hesitating to get vaccinated. If students intend to get the vaccine and put it off -- perhaps because of competing demands on their time, such as course work -- a “carrot versus a stick approach” can be an efficient nudge, while a mandate can lead people to resist. Bronchetti co-authored a study that found that a $30 incentive was enough to double the rate of students getting flu vaccinations on a college campus.

“A financial incentive is helping to compensate people -- students, in this case -- for the benefit that they’re providing for their society or their college campus by getting vaccinated,” she said. “In that way, a financial incentive for vaccination seems like a perfectly ethical and fair thing to do. It’s rewarding people for this contribution to the public good.”

Tara Singleton, student body president at the University of Arizona, also sees incentives as a simple way to repay students for protecting each other. She and another student leader devised the institution’s reward program, which gives students a $5 gift card to the student union each time they complete a series of four weekly coronavirus tests and an additional $5 if they submit proof of vaccination.

“I definitely don’t think that, for people who have strong opinions about vaccination, that the reward is going to make or break that,” she said. But it is "kind of a nice thank-you, a nice incentive" to get vaccinated before the summer.

For larger incentives, however, Bronchetti said universities need to consider that students -- especially low-income students who could use the money -- could be swayed to make a medical decision they would not otherwise, which is more ethically questionable.

“We might want to be aware of the fact that low-income students or students who are cash-strapped are more sensitive or responsive to these financial incentives, so to the extent that we’d be influencing behavior, it might be on those particular subgroups to a larger extent,” she said. Campus leaders need “to strike a balance between what will move behavior, what will cause people to overcome particularly those biases like procrastination or a little bit of uncertainty … while not offering an incentive that’s so large as to feel coercive.”

To Nancy Jecker, a professor of bioethics and humanities at the University of Washington School of Medicine in Seattle, disparities in how much incentives influence and impact different students is reason not to use them at all. For example, if a student from an upper-income family -- who wanted to get vaccinated regardless -- wins free housing, that risks “entrenching inequalities” rather than confronting inequities.

“There’s more at stake than shots in arms,” she said.

Jackson-Newsom, of UNC Greensboro, said the value of vaccinations is worth the risk that a more privileged student, who already intended to get a vaccine, might win rewards. She also thinks there is a high likelihood that the incentives will be won by students who really need them, given how many students have been affected by the pandemic and its accompanying economic downturn.

“Even if there end up being students who would have been vaccinated anyway, I’m OK with that, because I know that the financial benefit will still be meaningful and can really make a difference for them,” she said. “Even if in the end it only makes a difference or changes the mind or pushes a few students past that point who wouldn’t have been vaccinated, it’s still worth it.”

The incentive program at Johnson County Community College in Kansas avoided student equity questions by only rewarding vaccinated faculty and staff with $250, which they can choose to keep or donate to the Johnson County Community College Foundation for student scholarships. The institution excluded students for logistical reasons, not ethical ones, said Chris Gray, the college's vice president of strategic communication and marketing. The funds for the vaccine incentive come from an insurance refund from partly employee-paid health-care premiums, so the college put the money toward "re-enforcing healthy decisions" among employees. The community college would need to find a separate funding source and decide who qualifies -- full-time students, part-time students or both -- if it created a similar program for students.

"We didn't even get to that point in the discussion," Gray said.

Harald Schmidt, an assistant professor of medical ethics and health policy at the University of Pennsylvania, argued that financial incentives as a whole fail to alleviate the more deep-seated problems that would prevent a student, or anyone, from getting a vaccine -- a lack of “opportunity and trust.” For example, he noted that an incentive will not resolve a person’s work schedule conflicting with vaccination appointments, a lack of access to nearby clinics or “reservations and bad experiences because of racism embedded in the medical system.”

A New York Times analysis in early March, based on race and ethnicity data from 38 states, found that the vaccination rate for white Americans is double that of Black Americans.

“If you think of those concerns, they’re not really addressed by waving a little money in front of people,” Schmidt said. “What’s really a lot more important … is to make it easy for people to get vaccinated in settings that they trust and to have information available from sources that they trust.”

Toward that end, Wooster is concentrating its efforts on providing clear information about how to get vaccinated on campus and “removing as many of the barriers” as possible, rather than cash incentives, said Myrna Hernández, the college’s vice president for student affairs and dean of students.

The free T-shirts are more of a “celebration of what we all did together,” added Melissa Anderson, chief communications and marketing officer at the college. The shirts send the message, “We all got this far.”

Sandra Boham, president of Salish Kootenai College, a tribal institution in Montana, said paying students and staff to get vaccinated is about access, not reward. Other tribal colleges such as Little Big Horn College in Montana and Oglala Lakota College in South Dakota plan to offer financial incentives as well.

Salish Kootenai will also use federal COVID-19 relief funds for prepaid Visa cards -- $200 for students starting on May 3, and $300 for faculty members and staff, starting on April 26 -- with proof of vaccination. The $100 difference for faculty and staff is to compensate them for hours of work missed, Boham said.

Aside from the vaccine clinic on campus, which serves the tribal community at large, the closest vaccination sites are about eight miles north and 20 miles south of the college. About 80 percent of Salish Kootenai College students are eligible for federal financial aid, and Boham believes if they have to choose whether to spend money on groceries or transportation to a vaccination site, they will pick groceries.

“You don’t want a tank of gas to be the reason somebody didn’t get a vaccination,” she said.

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