How can we make sure people get the second COVID-19 vaccine dose?

The light at the end of the pandemic tunnel is getting brighter. This week, the first health care workers will receive the first doses of an FDA-approved coronavirus vaccine. Soon, so will other front-line workers in health care and beyond, and residents of long-term care facilities.

The availability of COVID-19 vaccines, however, will not necessarily result in people getting fully vaccinated.

For the first vaccines that will reach the public, everyone who gets a first dose must have a second dose within a few weeks to get full protection against severe COVID-19.

While Mark Fendrick, M.D. hails the rapid development of vaccines as a scientific breakthrough, he is anxious.

For decades, the University of Michigan primary care physician and researcher has studied what it takes to make sure that Americans get the essential preventive services that can help them stay healthy.

So what’s his worry?

“There are several factors and behaviors that prevent many well-intentioned people from completing a two-step process, like that recommended for the COVID-19 vaccines,” he says. “We need to provide everything necessary to support those who receive the first shot to make sure they complete their second dose.”

This lack of completion has been well established for other two-dose vaccines, like those that prevent less contagious and less lethal conditions, such as shingles, human papilloma virus (HPV), and hepatitis B. Fendrick worked on studies of the latter vaccine early in his career.

“On the positive side, out-of-pocket costs—one of the most significant barriers for vaccine uptake—has been removed for COVID-19 vaccines, thanks to federal action,” says Fendrick, a general internist at Michigan Medicine and director of the Center for Value-Based Insurance Design, which has fostered research and policy initiatives to enhance access to preventive care.

“But vaccines that require more than one dose create additional behavioral and environmental challenges, including reports of side effects, false claims regarding vaccine safety, logistical barriers, and the politicization of the program, that may deter people from getting vaccinated or returning for their second dose,” he says. “Studies of other high-value vaccines and medications to manage chronic conditions show that even when provided at no cost, patients take them half the time.”

What might help?

Vaccination kits will include a card that health providers can distribute when giving first doses, to help educate patients about the vaccine and to encourage the pre-scheduling of second-dose appointments.

While useful, Fendrick has advocated that a smartphone-based vaccine adherence support program, built on research by his team and others, be added to optimize vaccine uptake.

“We have the technology,” he points out. “Smartphone apps and wearables already succeed in getting people to take their medicine, check their blood pressure or blood sugar, or even measure their heart rhythm.”

Beyond automated reminders, a quick call or email from someone at a trusted source could do wonders, he says.

“Just knowing that someone cares and is willing to reach out has worked wonders in getting more people engaged in their health care behaviors,” says Fendrick. “This is particularly true for under-served groups that are at the greatest risk from COVID-19, like the elderly, and those with low incomes and without stable housing.”

The tailored messaging elements of a COVID-19 vaccine support program would include:

• Education about how the vaccine works
• Information about vaccine side effects and their treatment
• Scheduling and reminders of second dose appointment
• Updates and easily understandable and accessible information to dispel misinformation and rumors that could give someone doubts about getting a second dose
• Transportation options to second dose appointment

This last one is especially crucial, Fendrick notes. Lack of access to transportation has stood in the way of other preventive health services. Making sure that people know where to turn if they need help to get to their second-dose appointment, and making it possible for them to get the second dose at a convenient location, will be critical.

“Given the enormous stakes, we should aim for the same high level of customer service used the most effective online retailers, where they regularly check in after you visit their site and buy something,” Fendrick says. “They know what works to make consumers feel appreciated. This same personalized approach should be used to let each person who needs to return for a second vaccine dose feel like the most important person in the world—which, in my opinion, they are.”

What about cash incentives?

In addition to customized messaging, Fendrick feels that small financial rewards like a $50 gift card would further increase vaccine uptake.

While some experts have suggested paying people to get the first vaccine dose, Fendrick lands on the side of enrolling people in a no cost adherence support program after they receive their first dose, and but paying the financial reward after they complete the two-dose regimen.

“We need to focus the rewards for those who have made the effort to get both doses and for fulfilling their broader societal role in reducing the disease’s impact.”

What can providers and employers do?

Having surmounted incredible hurdles to develop, test, produce and distribute the vaccines, hospitals, clinics, pharmacies and state and local health agencies are making a similarly massive push to get the vaccine to everyone who can take it.

Employers, who have a big stake in the ability of their employees to avoid COVID-19 and safely return to work, may also want to consider offering support programs that include monetary incentives or other perks such as a charitable donation to encourage full vaccination.

Whether or not the vaccine is mandated, this would reward employees for reducing the spread of the virus and contributing to the opening of the economy.

Those who administer the vaccine also play a key role to make sure people complete the two-shot regimen.

“The good news is that the federal government has put in place a financial incentive for those who dispense the vaccine by paying a higher reimbursement rate for the second dose than for the first,” Fendrick says. “Why not also give incentives to patients?”

Fendrick has long supported the idea of aligning patient- and provider-focused tactics to increase use of essential medical care.

Published research has shown that when both patient and provider are given incentives to complete a specific behavior, like taking medicines to lower cholesterol, the impact is greater than the individual parts. He is quite confident that alignment of incentives will result in higher vaccine uptake.

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