A megastudy of text-based nudges encouraging patients to get vaccinated at an upcoming doctor's appointment

Enhancing COVID-19 booster vaccination among the elderly through text message reminders

The BOOST (Booster promotion for older outpatients using SMS text reminders) program at Taipei Veterans General Hospital assessed the effectiveness of text message reminders in enhancing COVID-19 booster vaccination rates among the elderly, guided by the Health Belief Model (HBM). Targeting patients aged 65 and above, eligible yet unvaccinated for a COVID-19 booster, this cohort study sent personalized reminders a week prior to their scheduled appointments between April 18, 2022, and May 12, 2022, acting as cues to action to enhance vaccination uptake by overcoming perceived barriers and raising awareness of benefits. Over 5 weeks, the study observed a 38% increase in vaccination rate among 3,500 eligible patients, markedly surpassing the concurrent national rate increase of 4% for the same demographic. The majority of vaccinations occurred within two weeks after the reminder, illustrating the effectiveness of the strategy. Cox regression analysis identified age and time since last vaccination as significant predictors of responsiveness, with those aged 65-74 and 75-84 showing higher uptake, particularly when reminders were sent within 4 months after the last dose. A single reminder proved to be effective. The findings of this study demonstrate the potential of SMS reminders to promote COVID-19 vaccination among the elderly through the strategic use of HBM principles, suggesting a feasible and effective approach to public health communication.

The power of the family in times of pandemic: Cross-country evidence from 93 countries

The majority of the hospitalizations and deaths associated with COVID-19 occurred in people over the age of 65. In addition, previous studies have shown that intergenerational contacts played a key role in COVID-19-related infection and fatality. This paper utilized two large-scale multinational surveys to uncover the important role of family ties in infection prevention across 93 countries. Using the World Values Survey, we measured country-level family ties emphasizing respondents' view of their parents. We elicited individual willingness to uptake infection prevention measures from a panel study conducted each month in the early phase of the COVID-19 pandemic between March 2020 and July 2021. We find that in countries with stronger family ties, people show more support for non-pharmaceutical interventions and higher vaccine acceptance; moreover, young people are more supportive of mandatory vaccination. The association between strength of family ties and compliance with infection prevention measures was salient before COVID-19 vaccines became available and was persistent before the global vaccination coverage reached 25%.

A systematic review and meta-analysis of strategies to promote vaccination uptake

Although immunization can dramatically curb the mortality and morbidity associated with vaccine-preventable diseases, vaccination uptake remains suboptimal in many areas of the world. Here, in this meta-analysis, we analysed the results from 88 eligible randomized controlled trials testing interventions to increase vaccination uptake with 1,628,768 participants from 17 countries with variable development levels (for example, Human Development Index ranging from 0.485 to 0.955). We estimated the efficacy of seven intervention strategies including increasing access to vaccination, sending vaccination reminders, providing incentives, supplying information, correcting misinformation, promoting both active and passive motivation and teaching behavioural skills. We showed that the odds of vaccination were 1.5 (95% confidence interval, 1.27 to 1.77) times higher for intervention than control conditions. Among the intervention strategies, using incentives and increasing access were most promising in improving vaccination uptake, with the access strategy being particularly effective in countries with lower incomes and less access to healthcare.

Respecting Conversational Norms Improves Reception of Expert Messages Among Unvaccinated Individuals

The association of medical experts with politically left-leaning cities and states early in the COVID-19 pandemic may have exacerbated vaccine hesitancy in right-leaning states of the US. Criticism from outside experts violates rules of communication between social groups (i.e. an intergroup sensitivity effect), leading to rejection of messages promoting vaccine safety and efficacy. In two studies, we document the effects of shared geographical group membership for medical expert messages promoting vaccination. We also found evidence that satisfying conversational norms against intergroup criticism reduces message rejection. Specifically, an invitation from ingroup political elites for a doctor to speak reduced the negative effects of unshared group identity.

Mortality risk information and health-seeking behavior during an epidemic

In a context where pessimistic survival perceptions have been widespread as a result of the HIV/AIDS epidemic (Fig. 1 A), we study vaccine uptake and other health behaviors during the recent COVID-19 pandemic. Leveraging a longitudinal cohort study in rural Malawi that has been followed for up to 25 y, we document that a 2017 mortality risk information intervention designed to reduce pessimistic mortality perceptions (Fig. 1 B) resulted in improved health behavior, including COVID-19 vaccine uptake (Fig. 1 C). We also report indirect effects for siblings and household members. This was likely the result of a reinforcing process where the intervention triggered engagement with the healthcare system and stronger beliefs in the efficacy of modern biomedical treatments, which led to the adoption of health risk reduction behavior, including vaccine uptake. Our findings suggest that health information interventions focused on survival perceptions can be useful in promoting health behavior and participation in the formal healthcare system, even during health crises-such as the COVID-19 pandemic-that are unanticipated at the time of the intervention. We also note the importance of the intervention design, where establishing rapport, tailoring the content to the local context, and spending time with respondents to convey the information contributed to the salience of the message.

Knowledge, attitudes, and intentions regarding COVID-19 vaccination in the general population and the effect of different framing messages for a brief video on intentions to get vaccinated among unvaccinated individuals in the United States during July 2021

OBJECTIVE

To identify knowledge, attitudes, and beliefs (KABs) associated with COVID-19 vaccination intentions and assess the impact of vaccine-promoting messages on vaccination intentions.

METHODS

Our nationally representative survey measured KABs of COVID-19 vaccination and incorporated a randomized experiment to assess the impact of different framing messages for a video encouraging vaccination intentions among unvaccinated adults in the US. Multivariable multinomial logistic regression models were fitted to investigate the relationships of KABs, trust in public health authorities (PHAs), and vaccine confidence with vaccination intentions. Difference-in-difference estimation was conducted to assess the impact of framing messages for a video on unvaccinated individuals' vaccination intentions.

RESULTS

We observed that people with increasingly favorable vaccine KABs, trust in PHAs, and vaccine confidence were more likely to be vaccinated or intend to get vaccinated against COVID-19. Difference-in-difference estimates indicated a positive impact of exposure to the video on vaccination intentions while framing messages in some cases appeared to lower vaccination intentions. Associations between the video and vaccination intentions were more pronounced among Black/African American and Hispanic/Latinx populations and Democrats; however, associations did not vary by trust in PHAs or vaccine confidence.

CONCLUSION

Videos that encourage people to get vaccinated may provide an efficient approach to nudge vaccine-hesitant individuals towards getting vaccinated. However, framing messages may negatively impact vaccination intentions and need to be developed carefully.

PRACTICE IMPLICATIONS

This study provides solid experimental evidence for the importance of tailoring message framing to the characteristics and experience of the audience, while cautioning potential negative impacts of framing that does not match its intended audience. Our findings are applicable to health communication strategies on the population level, such as mass media campaigns, and the use of framing for messages to encourage vaccination but may also be informative for healthcare professionals consulting hesitant individuals about COVID-19 vaccinations.

Megastudy shows that reminders boost vaccination but adding free rides does not

Encouraging routine COVID-19 vaccinations is likely to be a crucial policy challenge for decades to come. To avert hundreds of thousands of unnecessary hospitalizations and deaths, adoption will need to be higher than it was in the autumn of 2022 or 2023, when less than one-fifth of Americans received booster vaccines1,2. One approach to encouraging vaccination is to eliminate the friction of transportation hurdles. Previous research has shown that friction can hinder follow-through3 and that individuals who live farther from COVID-19 vaccination sites are less likely to get vaccinated4. However, the value of providing free round-trip transportation to vaccination sites is unknown. Here we show that offering people free round-trip Lyft rides to pharmacies has no benefit over and above sending them behaviourally informed text messages reminding them to get vaccinated. We determined this by running a megastudy with millions of CVS Pharmacy patients in the United States testing the effects of (1) free round-trip Lyft rides to CVS Pharmacies for vaccination appointments and (2) seven different sets of behaviourally informed vaccine reminder messages. Our results suggest that offering previously vaccinated individuals free rides to vaccination sites is not a good investment in the United States, contrary to the high expectations of both expert and lay forecasters. Instead, people in the United States should be sent behaviourally informed COVID-19 vaccination reminders, which increased the 30-day COVID-19 booster uptake by 21% (1.05 percentage points) and spilled over to increase 30-day influenza vaccinations by 8% (0.34 percentage points) in our megastudy. More rigorous testing of interventions to promote vaccination is needed to ensure that evidence-based solutions are deployed widely and that ineffective but intuitively appealing tools are discontinued.

Effectiveness of patient reminders on influenza vaccination coverage among adults with chronic conditions: A feasibility study in Australian general practices

BACKGROUND

Influenza vaccination is recommended for Australians 18+ years old with medical risk factors, but coverage is suboptimal. We aimed to examine whether automatic, opportunistic patient reminders (SMS and/or printed) before appointments with a general practitioner increased influenza vaccination uptake.

METHODS

This clustered non-randomised feasibility study in Australian general practice included patients aged 18-64 years with at least one medical risk factor attending participating practices between May and September 2021. Software installed at intervention practices identified unvaccinated eligible patients when they booked an appointment, sent vaccination reminders (SMS on booking and 1 h before appointments), and printed automatic reminders on arrival. Control practices provided usual care. Clustered analyses adjusted for sociodemographic differences among practices were performed using logistic regression.

RESULTS

A total of 12,786 at-risk adults attended 16 intervention practices (received reminders = 4066; 'internal control' receiving usual care = 8720), and 5082 individuals attended eight control practices. Baseline influenza vaccination uptake (2020) was similar in intervention and control practices (∼34%). After the intervention, uptake was similar in all groups (control practices = 29.3%; internal control = 30.0%; intervention = 31.6% (p-value = 0.203). However, SMS 1 h before appointments increased vaccination coverage (39.3%, adjusted OR = 1.65; 95%CI 1.20;2.27; number necessary to treat = 13), especially when combined with other reminder forms. That effect was more evident among adults with chronic respiratory, rheumatologic, or inflammatory bowel disease.

CONCLUSION

These findings indicate that automated SMS reminders delivered at proximate times to appointments are a low-cost strategy to increase influenza vaccination among adults at higher risk of severe disease attending Australian general practices.

The Costs of Polarizing a Pandemic: Antecedents, Consequences, and Lessons

Polarization has been rising in the United States of America for the past few decades and now poses a significant-and growing-public-health risk. One of the signature features of the American response to the COVID-19 pandemic has been the degree to which perceptions of risk and willingness to follow public-health recommendations have been politically polarized. Although COVID-19 has proven more lethal than any war or public-health crisis in American history, the deadly consequences of the pandemic were exacerbated by polarization. We review research detailing how every phase of the COVID-19 pandemic has been polarized, including judgments of risk, spatial distancing, mask wearing, and vaccination. We describe the role of political ideology, partisan identity, leadership, misinformation, and mass communication in this public-health crisis. We then assess the overall impact of polarization on infections, illness, and mortality during the pandemic; offer a psychological analysis of key policy questions; and identify a set of future research questions for scholars and policy experts. Our analysis suggests that the catastrophic death toll in the United States was largely preventable and due, in large part, to the polarization of the pandemic. Finally, we discuss implications for public policy to help avoid the same deadly mistakes in future public-health crises.

A behavioral economics approach to enhancing HIV preexposure and postexposure prophylaxis implementation

PURPOSE OF REVIEW

The 'PrEP cliff' phenomenon poses a critical challenge in global HIV PrEP implementation, marked by significant dropouts across the entire PrEP care continuum. This article reviews new strategies to address 'PrEP cliff'.

RECENT FINDINGS

Canadian clinicians have developed a service delivery model that offers presumptive PEP to patients in need and transits eligible PEP users to PrEP. Early findings are promising. This service model not only establishes a safety net for those who were not protected by PrEP, but it also leverages the immediate salience and perceived benefits of PEP as a natural nudge towards PrEP use. Aligning with Behavioral Economics, specifically the Salience Theory, this strategy holds potential in tackling PrEP implementation challenges.

SUMMARY

A natural pathway between PEP and PrEP has been widely observed. The Canadian service model exemplifies an innovative strategy that leverages this organic pathway and enhances the utility of both PEP and PrEP services. We offer theoretical insights into the reasons behind these PEP-PrEP transitions and evolve the Canadian model into a cohesive framework for implementation.

Postpartum Primary Care Engagement Using Default Scheduling and Tailored Messaging: A Randomized Clinical Trial

Importance

More than 30% of pregnant people have at least 1 chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face major barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition.

Objective

To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps.

Design, Setting, and Participants

An individual-level randomized clinical trial was conducted from November 3, 2022, to October 11, 2023, at 1 hospital-based and 5 community-based outpatient obstetric clinics affiliated with a large academic medical center. Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes, chronic hypertension, gestational diabetes, or pregnancy-related hypertension and a primary care practitioner (PCP) listed in their electronic health record.

Intervention

A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages.

Main Outcome and Measures

Completion of a PCP visit for routine or chronic condition care within 4 months of delivery was the primary outcome, ascertained directly by reviewing the patient's electronic health record approximately 5 months after their estimated due date. Intention-to-treat analysis was conducted.

Results

A total of 360 patients were randomized (control, 176; intervention, 184). Individuals had a mean (SD) age of 34.1 (4.9) years and median gestational age of 36.3 (IQR, 34.0-38.6) weeks at enrollment. The distribution of self-reported race and ethnicity was 6.8% Asian, 7.4% Black, 68.6% White, and 15.0% multiple races or other. Most participants (75.4%) had anxiety or depression, 16.1% had a chronic or pregnancy-related hypertensive disorder, 19.5% had preexisting or gestational diabetes, and 40.8% had a prepregnancy body mass index of 30 or greater. Medicaid was the primary payer for 21.2% of patients. Primary care practitioner visit completion within 4 months occurred in 22.0% (95% CI, 6.4%-28.8%) of individuals in the control group and 40.0% (95% CI, 33.1%-47.4%) in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95% CI, 9.1-28.2 percentage points). Intervention participants also had fewer postpartum readmissions (1.7% vs 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8% vs 28.3%), weight assessment (42.8% vs 27.7%), and depression screening (32.8% vs 16.8%).

Conclusions and Relevance

The findings of this randomized clinical trial suggest that the current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and well-being.

Trial Registration

ClinicalTrials.gov Identifier: NCT05543265.

Behavioral Interventions to Improve Breast Cancer Screening Outreach: Two Randomized Clinical Trials

Importance

Despite public health efforts, breast cancer screening rates remain below national goals.

Objective

To evaluate whether bulk ordering, text messaging, and clinician endorsement increase breast cancer screening rates.

Design, Setting, and Participants

Two concurrent, pragmatic, randomized clinical trials, each with a 2-by-2 factorial design, were conducted between October 25, 2021, and April 25, 2022, in 2 primary care regions of an academic health system. The trials included women aged 40 to 74 years with at least 1 primary care visit in the past 2 years who were eligible for breast cancer screening.

Interventions

Patients in trial A were randomized in a 1:1 ratio to receive a signed bulk order for mammogram or no order; in a factorial design, patients were concurrently randomized in a 1:1 ratio to receive or not receive text message reminders. Patients in trial B were randomized in a 1:1 ratio to receive a message signed by their primary care clinician (clinician endorsement) or from the organization (standard messaging); in a factorial design, patients were concurrently randomized in a 1:1 ratio to receive or not receive text message reminders.

Main Outcomes and Measures

The primary outcome was the proportion of patients who completed a screening mammogram within 3 months.

Results

Among 24 632 patients included, the mean (SD) age was 60.4 (7.5) years. In trial A, at 3 months, 15.4% (95% CI, 14.6%-16.1%) of patients in the bulk order arm and 12.7% (95% CI, 12.1%-13.4%) in the no order arm completed a mammogram, showing a significant increase (absolute difference, 2.7%; 95% CI, 1.6%-3.6%; P < .001). In the text messaging comparison arms, 15.1% (95% CI, 14.3%-15.8%) of patients receiving a text message completed a mammogram compared with 13.0% (95% CI, 12.4%-13.7%) of those in the no text messaging arm, a significant increase (absolute difference of 2.1%; 95% CI, 1.0%-3.0%; P < .001). In trial B, at 3 months, 12.5% (95% CI, 11.3%-13.7%) of patients in the clinician endorsement arm completed a mammogram compared with 11.4% (95% CI, 10.3%-12.5%) of those in the standard messaging arm, which was not significant (absolute difference, 1.1%; 95% CI, -0.5% to 2.7%; P = .18). In the text messaging comparison arms, 13.2% (95% CI, 12.0%-14.4%) of patients receiving a text message completed a mammogram compared with 10.7% (95% CI, 9.7%-11.8%) of those in the no text messaging arm, a significant increase (absolute difference, 2.5%; 95% CI, 0.8%-4.0%; P = .003).

Conclusions and Relevance

These findings show that text messaging women after initial breast cancer screening outreach via either electronic portal or mailings, as well as bulk ordering with or without text messaging, can increase mammogram completion rates.

Trial Registration

ClinicalTrials.gov Identifier: NCT05089903.

Implicit theories of health predict influenza vaccination intention among elder Chinese: The mediating role of anticipated regret

Receiving influenza vaccines is the most effective public health strategy to protect people against seasonal flu infection. However, influenza vaccination rates are extremely low in China. This study investigated the association between implicit theories of health and influenza vaccination intention among elder Chinese when the vaccine is free (vs not free), and examined the mediating effect of anticipated regret. The results suggested that implicit theories of health, especially incremental theory of health, significantly predicted Chinese elders' influenza vaccination intention and this relationship was mediated by anticipated regret. Implications of the current research for promoting influenza vaccination among elder Chinese and directions for future research are discussed.

Text vs Patient Portal Messaging to Improve Influenza Vaccination Coverage: A Health System-Wide Randomized Clinical Trial

Importance

Increasing influenza vaccination rates is a public health priority. One method recommended by the US Centers for Disease Control and Prevention and others is for health systems to send reminders nudging patients to be vaccinated.

Objective

To evaluate and compare the effect of electronic health record (EHR)-based patient portal reminders vs text message reminders on influenza vaccination rates across a health system.

Design, Setting, and Participants

This 3-arm randomized clinical trial was conducted from September 7, 2022, to April 30, 2023, among primary care patients within the University of California, Los Angeles (UCLA) health system.

Interventions

Arm 1 received standard of care. The health system sent monthly reminder messages to patients due for an influenza vaccine by portal (arm 2) or text (arm 3). Arm 2 had a 2 × 2 nested design, with fixed vs responsive monthly reminders and preappointment vs no preappointment reminders. Arm 3 had 1 × 2 design, with preappointment vs no preappointment reminders. Preappointment reminders for eligible patients were sent 24 and 48 hours before scheduled primary care visits. Fixed reminders (in October, November, and December) involved identical messages via portal or text. Responsive portal reminders involved a September message asking patients about their plans for vaccination, with a follow-up reminder if the response was affirmative but the patient was not yet vaccinated.

Main Outcomes and Measures

The primary outcome was influenza vaccination by April 30, 2023, obtained from the UCLA EHR, including vaccination from pharmacies and other sources.

Results

A total of 262 085 patients (mean [SD] age, 45.1 [20.7] years; 237 404 [90.6%] adults; 24 681 [9.4%] children; 149 349 [57.0%] women) in 79 primary care practices were included (87 257 in arm 1, 87 478 in arm 2, and 87 350 in arm 3). At the entire primary care population level, none of the interventions improved influenza vaccination rates. All groups had rates of approximately 47%. There was no statistical or clinically significant improvement following portal vs text, preappointment reminders vs no preappointment reminders (portal and text reminders combined), or responsive vs fixed monthly portal reminders.

Conclusions and Relevance

At the population level, neither portal nor text reminders for influenza vaccination were effective. Given that vaccine hesitancy may be a major reason for the lack of impact of portal or text reminders, more intensive interventions by health systems are needed to raise influenza vaccination coverage levels.

Trial Registration

ClinicalTrials.gov Identifier: NCT05525494.

The Nudging Effect of a Reminder Letter to Reduce Duplicated Medications: A Randomized Controlled Trial

BACKGROUND

The increasing trend of multiple chronic conditions across the world has worsened the problem of medication duplication in health care systems without gatekeeping or referral requirement. Thus, to overcome this problem, a reminder letter has been developed in Taiwan to nudge patients to engage in medication management.

OBJECTIVE

To evaluate the effect of reminder letter on reducing duplicated medications.

RESEARCH DESIGN

A 2-arm randomized controlled trial design.

SUBJECTS

Patients with duplicated medications in the first quarter of 2019.

MEASURES

The Taiwanese single-payer National Health Insurance Administration identified the eligible patients for this study. A postal reminder letter regarding medication duplication was mailed to the patients in the study group, and no information was provided to the comparison group. Generalized estimation equation models with a difference-in-differences analysis were used to estimate the effects of the reminder letters.

RESULTS

Each group included 11,000 patients. Those who had received the reminder letter were less likely to receive duplicated medications in the subsequent 2 quarters (postintervention 1: odds ratio [OR]=0.95, 95% CI=0.87-1.03; postintervention_2: OR=0.99, 95% CI=0.90-1.08) and had fewer days of duplicated medications (postintervention 1: β=-0.115, P =0.015; postintervention 2 (β=-0.091, P =0.089) than those who had not received the reminder letter, showing marginal but significant differences.

CONCLUSIONS

A one-off reminder letter nudge could mildly decrease the occurrence of duplicated medications. Multiple nudges or nudges incorporating behavioral science insights may be further considered to improve medication safety in health systems without gatekeeping.

Increasing Postpartum Primary Care Engagement through Default Scheduling and Tailored Messaging: A Randomized Clinical Trial

Importance

Over 30% of pregnant people have at least one chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face significant barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition.

Objective

To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps.

Design

Individual-level randomized controlled trial conducted from November 3, 2022 to October 11, 2023.

Setting

One hospital-based and five community-based outpatient obstetric clinics affiliated with a large academic medical center.

Participants

Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes mellitus, chronic hypertension, gestational diabetes, or pregnancy-related hypertension, and a primary care practitioner (PCP) listed in their electronic health record (EHR).

Intervention

A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages.

Main Outcome

Completion of a PCP visit for routine or chronic condition care within 4 months of delivery.

Results

360 patients were randomized (Control: N=176, Intervention: N=184). Individuals had mean (SD) age 34.1 (4.9) years and median gestational age of 36.3 weeks (interquartile range (IQR) 34.0-38.6 weeks) at enrollment. The distribution of self-reported races was 7.4% Asian, 6.8% Black, 15.0% multiple races or "Other," and 68.6% White. Most (75.8%) participants had anxiety or depression, 15.9% had a chronic or pregnancy-related hypertensive disorder, 19.8% had pre-existing or gestational diabetes, and 40.4% had a pre-pregnancy BMI ≥30 kg/m2. Medicaid was the primary payer for 21.9% of patients. PCP visit completion within 4 months occurred in 22.0% in the control group and 40.0% in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95%CI 10.7-29.1). Intervention participants also had fewer postpartum readmissions (1.7 vs. 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8 vs. 28.3%), weight assessment (42.8 vs. 27.7%), and depression screening (32.8 vs. 16.8%).

Conclusions and Relevance

In this randomized trial of pregnant individuals with or at risk for chronic health conditions, default PCP visit scheduling, tailored messages, and reminders substantially improved postpartum primary care engagement. The current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and wellbeing.

Trial Registration

NCT05543265.

Testing the impact of differing behavioural science informed text message content in COVID-19 vaccination invitations on vaccine uptake: A randomised clinical trial

Behavioural science constructs can be incorporated into messaging strategies to enhance the effectiveness of public health campaigns by increasing the occurrence of desired behaviours. This study investigated the impact of behavioural science-informed text message strategies on COVID-19 vaccination rates in 18-39-year-olds in an area of low uptake in London during the first vaccination offer round in the United Kingdom. This three-armed randomised trial recruited unvaccinated residents of an urban Central London suburb being offered their first vaccination between May and June 2021. Participants were randomised to receive the control (current practice) text message or one of two different behavioural science-informed COVID-19 vaccine invitation strategies. Both intervention strategies contained the phrase "your vaccine is ready and waiting for you", aiming to evoke a sense of ownership, with one strategy also including a pre-alert message. The main outcome measures were vaccination rates at 3 and 8 weeks after message delivery. A total of 88,820 residents were randomly assigned to one of the three trial arms. Each arm had a vaccine uptake rate of 27.2 %, 27.4 % and 27.3 % respectively. The mean age of participants was 28.2 years (SD ± 5.7), the mean index of multiple deprivation was 4.3 (SD ± 2.0) and 50.4 % were women. Vaccine uptake varied by demographics, however there was no significant difference between trial arms (p = 0.872). Delivery was successful for 53.6 % of text messages. Our choice of behavioural science informed messaging strategies did not improve vaccination rates above the rate seen for the current practice message. This likely reflects the wide exposure to public health campaigns during the pandemic, as such text messages nudges were unlikely to alter existing informed decision-making processes. Text message delivery was relatively low, indicating a need for accurate mobile phone number records and multi-modal approaches to reach eligible patients for vaccination. The protocol was registered at clinicaltrials.gov (NCT04895683) on 20/05/2021.

Nudges and Prompts Increase Engagement in Self-Guided Digital Health Treatment for Depression and Anxiety: Results From a 3-Arm Randomized Controlled Trial

BACKGROUND

Accessible and effective approaches to mental health treatment are important because of common barriers such as cost, stigma, and provider shortage. The effectiveness of self-guided treatment is well established, and its use has intensified because of the COVID-19 pandemic. Engagement remains important as dose-response relationships have been observed. Platforms such as Facebook (Meta Platform, Inc), LinkedIn (Microsoft Corp), and X Corp (formerly known as Twitter, Inc) use principles of behavioral economics to increase engagement. We hypothesized that similar concepts would increase engagement in self-guided digital health.

OBJECTIVE

This 3-arm randomized controlled trial aimed to test whether members of 2 digital self-health courses for anxiety and depression would engage with behavioral nudges and prompts. Our primary hypothesis was that members would click on 2 features: tips and a to-do checklist. Our secondary hypothesis was that members would prefer to engage with directive tips in arm 2 versus social proof and present bias tips in arm 3. Our tertiary hypothesis was that rotating tips and a to-do checklist would increase completion rates. The results of this study will form a baseline for future artificial intelligence-directed research.

METHODS

Overall, 13,224 new members registered between November 2021 and May 2022 for Evolution Health's self-guided treatment courses for anxiety and depression. The control arm featured a member home page without nudges or prompts. Arm 2 featured a home page with a tip-of-the-day section. Arm 3 featured a home page with a tip-of-the-day section and a to-do checklist. The research protocol for this study was published in JMIR Research Protocols on August 15, 2022.

RESULTS

Arm 3 had significantly younger members (F2,4564=40.97; P<.001) and significantly more female members (χ24=92.2; P<.001) than the other 2 arms. Control arm members (1788/13,224, 13.52%) completed an average of 1.5 course components. Arm 2 members (865/13,224, 6.54%) clicked on 5% of tips and completed an average of 1.8 course components. Arm 3 members (1914/13,224, 14.47%) clicked on 5% of tips, completed 2.7 of 8 to-do checklist items, and completed an average of 2.11 course components. Completion rates in arm 2 were greater than those in arm 1 (z score=3.37; P<.001), and completion rates in arm 3 were greater than those in arm 1 (z score=12.23; P<.001). Engagement in all 8 components in arm 3 was higher than that in arm 2 (z score=1.31; P<.001).

CONCLUSIONS

Members engaged with behavioral nudges and prompts. The results of this study may be important because efficacy is related to increased engagement. Due to its novel approach, the outcomes of this study should be interpreted with caution and used as a guideline for future research in this nascent field.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/37231.

Thinking about default enrollment lowers vaccination intentions and public support in G7 countries

Policymakers often face a conundrum between being transparent about policies and ensuring that those policies are effective. This challenge is particularly relevant for behavioral nudges, which are not usually disclosed. Rather than avoiding transparency, we suggest that policymakers encourage citizens to reflect on nudges to help them understand their own views and align those views with their behaviors. Using data from an online survey experiment with 24,303 respondents in G7 countries, we examine the impact of reflection on a hypothetical default nudge policy for COVID-19 booster appointments. Contrary to expectations, participants say they would be less likely to get the booster when automatically enrolled compared with a control condition. Similarly, encouraging citizens to think about the status quo (baseline) policy also reduces intentions for boosters. These interventions have no effect on approval of the policy. Further, encouraging people to think about automatic enrollment decreases approval of the policy and further decreases their intentions to get vaccinated. These findings suggest that reflection on a nudge can increase backlash from a nudge and also elicit policy disapproval, thereby aligning policy support with behavioral intentions.

Stress reduction experiments in daily life: Scaling from the lab to the world

Paced breathing-longer exhalation than inhalation-can show short-term improvement of physiologic responses and affective well-being, though most studies have relied on narrow sample demographics, small samples, and control conditions that fail to address expectancy effects. We addressed these limitations through an app-based experiment where participants were randomly assigned to paced breathing or sham control (hand closure) conditions. We first validated the conditions in an online sample (N = 201; Study 1) and in a lab environment (N = 72; Study 2). In the primary app-based experiment, participants (N = 3,277; Study 3) completed 3 days of baseline assessments that included three check-ins each day in which we obtained heart rate and blood pressure responses using an optic sensor and assessed current stress and emotions. Participants were then randomly assigned to either the paced breathing or hand closure condition for the next 6 days. Relative to baseline days, both conditions were associated with increased positive emotions and perceived coping, and reduced blood pressure. Moreover, the increase in positive emotions and perceived coping was not evident among a comparison sample (N = 2,600) who completed check-ins but did not participate in either of the paced breathing or sham-control conditions. However, their blood pressure declined over time, suggesting that the continual monitoring of one's blood pressure may result in detectable decreases. Our results highlight the importance of designing experiments with appropriately matched control conditions and suggest that changes associated with techniques like paced breathing, in part, may stem from positive incidental features of the technique. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Framing Effect of Digital Textual Messages on Uptake Rates of Medical Checkups: Field Study

BACKGROUND

Health care authorities often use text messages to enhance compliance with medical recommendations. The effectiveness of different message framings has been studied extensively over the past 3 decades. Recently, health care providers have begun using digital media platforms to disseminate health-related messages.

OBJECTIVE

This study aimed to examine the effectiveness of some of the most widely used message framings on the uptake rates of medical checkups.

METHODS

This study used a large-scale digital outreach campaign conducted by Maccabi Healthcare Services (MHS) during 2020-2021, involving a total of 113,048 participants. MHS members aged 50-74 years were invited to take their recommended medical actions from the following list: human papillomavirus (HPV), mammography, abdominal aortic aneurysm, fecal occult blood test (FOBT), and pneumococcal vaccination. Each member was randomly assigned to receive 1 of 6 message framings: control (neutrally framed; n=20,959, 18.5%), gains (benefits of compliance; n=20,393, 18%), losses (negative consequences of noncompliance; n=15,165, 13.4%), recommendation (a recommendation by an authoritative figure, in this context by a physician; n=20,584, 18.2%), implementation intentions (linking potential outcomes to future reactions; n=20,701, 18.3%), and empowerment (emphasizing personal responsibility for maintaining good health; n=15,246, 13.5%). The time frames for measuring a successful intervention were 14 days for scheduling screenings (ie, HPV, mammography, or abdominal aortic aneurysm), 30 days for performing the FOBT, and 60 days for receiving pneumococcal vaccination. We also examined the effectiveness of media channels (text message or email) on uptake rates and whether the subject-line length is correlated with message-opening rates.

RESULTS

No significant effect of message framing on uptake rates of medical checkups was observed. The rates of appointments for screening ranged from 12.9% to 14.1% across treatments. Based on a chi-square test, there was no evidence to reject the null hypothesis that these compliance rates are independent of the treatments (P=.35). The uptake rates for the FOBT and pneumococcal vaccination ranged from 23.3% to 23.8% across treatments, and we could not reject the hypothesis that they are independent of the treatments (P=.88). We also found that emails are more effective than text messages (P<.001) and that the subject-line length is negatively correlated with message-opening rates.

CONCLUSIONS

No evidence was found for an effect of the 5 message framings on uptake rates of medical checkups. To enhance compliance rates, public health officials may consider alternative framings. Furthermore, media channels and the subject-line length should be given careful consideration in the planning stages of health care campaigns.

TRIAL REGISTRATION

AEA RCT Registry AEARCTR-0006317; https://www.socialscienceregistry.org/trials/6317/history/201365.

Effectiveness of Multifaceted Strategies to Increase Influenza Vaccination Uptake: A Cluster Randomized Trial

Importance

Influenza vaccination rates remain low among primary school students and vary by school in Beijing, China. Theory-informed, multifaceted strategies are needed to improve influenza vaccination uptake.

Objective

To evaluate the effectiveness of multifaceted strategies in improving influenza vaccination uptake among primary school students.

Design, Setting, and Participants

This cluster randomized trial was conducted from September 2022 to May 2023 across primary schools in Beijing, China. Schools were allocated randomly in a 1:1 ratio to multifaceted strategies or usual practice. Schools were deemed eligible if the vaccination rates in the 2019 to 2020 season fell at or below the district-wide average for primary schools. Eligible participants included students in grades 2 and 3 with no medical contraindications for influenza vaccination.

Intervention

The multifaceted strategies intervention involved system-level planning and coordination (eg, developing an implementation blueprint, building social norms, and enhancing supervision), school-level training and educating school implementers (eg, conducting a 1-hour training and developing educational materials), and individual-level educating and reminding students and parents (eg, conducting educational activities and sending 4 reminders about vaccination).

Main Outcomes and Measures

The primary outcomes were influenza vaccination uptake at school reported by school clinicians as well as overall vaccine uptake either at school or outside of school as reported by parents at 3 months. Generalized linear mixed models were used for analysis.

Results

A total of 20 schools were randomized. One intervention school and 2 control schools did not administer vaccination on school grounds due to COVID-19, resulting in a total of 17 schools (9 intervention and 8 control). There was a total of 1691 students aged 7 to 8 years (890 male [52.6%]; 801 female [47.4%]) including 915 in the intervention group and 776 in the control group. Of all participants, 848 (50.1%) were in grade 2, and 1209 (71.5%) were vaccinated in the 2021 to 2022 season. Participants in the intervention and control groups shared similar characteristics. At follow-up, of the 915 students in the intervention group, 679 (74.5%) received a vaccination at school, and of the 776 students in the control group, 556 (71.7%) received a vaccination at school. The overall vaccination rates were 76.0% (695 of 915 students) for the intervention group and 71.3% (553 of 776 students) for the control group. Compared with the control group, there was significant improvement of vaccination uptake at school (odds ratio, 1.40; 95% CI, 1.06-1.85; P = .02) and overall uptake (odds ratio, 1.49; 95% CI, 1.12-1.99; P = .01) for the intervention group.

Conclusions and Relevance

In this study, multifaceted strategies showed modest effectiveness in improving influenza vaccination uptake among primary school students, which provides a basis for the implementation of school-located vaccination programs of other vaccines in China, and in other countries with comparable programs.

Trial registration

Chinese Clinical Trial Registry: ChiCTR2200062449.

Nudging Public Health Behaviors to Prevent COVID-19: A Systematic Review

Many countries have implemented strict preventive measures and mandatory policies to curb virus transmission during the COVID-19 pandemic. Some have adopted softer approaches, such as nudge-based intervention, to influence public health behavior. This systematic review, conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines, aims to determine if the nudge-based intervention can effectively influence people's preventive behavior during the early period of the COVID-19 pandemic. The review indicated an overall positive outcome, but results were mixed as nudge-based interventions substantially depended on the situational context. While the review found that the nudging technique that presents and conveys decision-related information was essential to nudging people, a secondary nudge would often applied to deliver the interventions. In addition, there was no indication of an ideal nudge technique that would be effective in most situations. Conversely, our findings indicate that the nudge would likely suffer from habituation after repeated intervention or backfire due to inappropriate use of nudges. Also, the ceiling effect would inhibit any nudge influences regardless of the technique(s) used. In sum, the results and the applicability of nudge-based interventions were mixed, highlighting the need for further research to advance the theory and practical developments.

Behavioural evidence on COVID-19 vaccine uptake

OBJECTIVES

The World Health Organization has declared that COVID-19 is no longer a public health emergency of international concern. Nevertheless, it remains a public health issue, and seasonal vaccinations, at the same time of year as influenza vaccinations, will be necessary. When the first vaccines were administered in 2020, decision-makers had to make assumptions about the best methods to communicate and administer vaccines to increase uptake. Now, a body of evidence can inform these decisions.

STUDY DESIGN

A narrative review written by three behavioural scientists who design research for policy.

METHODS

We searched the PubMed database for: (i) reviews of interventions to increase uptake of COVID-19 or influenza vaccines and (ii) empirical studies on uptake of COVID-19 and influenza vaccines. In addition, registered trials gathered by a Cochrane scoping review of interventions to increase uptake of COVID-19 vaccines were searched for updated results.

RESULTS

Results centre around two aspects of a vaccination campaign of interest to policymakers: communication and administration. Results suggest that communications highlighting the personal benefits of vaccination are likely to be more effective than those highlighting collective benefits. The efficacy of vaccination may be underestimated and stressing efficacy as a strong personal benefit may increase uptake. Keeping vaccines free, sending personalised messages, reminders and prebooked appointment times may also increase uptake.

CONCLUSIONS

There is now a body of evidence from behavioural science that suggests how vaccination campaigns for COVID-19 can be structured to increase uptake. These recommendations may be useful to policymakers considering seasonal vaccination campaigns and to researchers generating hypotheses for country-specific trials.

Academics are more specific, and practitioners more sensitive, in forecasting interventions to strengthen democratic attitudes

Concern over democratic erosion has led to a proliferation of proposed interventions to strengthen democratic attitudes in the United States. Resource constraints, however, prevent implementing all proposed interventions. One approach to identify promising interventions entails leveraging domain experts, who have knowledge regarding a given field, to forecast the effectiveness of candidate interventions. We recruit experts who develop general knowledge about a social problem (academics), experts who directly intervene on the problem (practitioners), and nonexperts from the public to forecast the effectiveness of interventions to reduce partisan animosity, support for undemocratic practices, and support for partisan violence. Comparing 14,076 forecasts submitted by 1,181 forecasters against the results of a megaexperiment (n = 32,059) that tested 75 hypothesized effects of interventions, we find that both types of experts outperformed members of the public, though experts differed in how they were accurate. While academics' predictions were more specific (i.e., they identified a larger proportion of ineffective interventions and had fewer false-positive forecasts), practitioners' predictions were more sensitive (i.e., they identified a larger proportion of effective interventions and had fewer false-negative forecasts). Consistent with this, practitioners were better at predicting best-performing interventions, while academics were superior in predicting which interventions performed worst. Our paper highlights the importance of differentiating types of experts and types of accuracy. We conclude by discussing factors that affect whether sensitive or specific forecasters are preferable, such as the relative cost of false positives and negatives and the expected rate of intervention success.

Nudging a Nation - The Danish NUDGE Trial Concept

Danish NUDGE Trial ConceptRandomized encouragement trials randomize to an opportunity to receive treatment instead of to the treatment. Here, Johansen and colleagues combine randomized encouragement trials with several advantages inherent in the Danish health system.

Reminder design and childhood vaccination coverage

A major policy concern across public vaccination programs is non-compliance. Exploiting Danish population data and three national reforms in regression discontinuity designs, we document the effects of reminders for childhood vaccination coverage. Retrospective reminders are primarily effective for families with small children and when sent out close to the recommended vaccination age. Digital and postal reminders are equally effective. Prospective reminders increase timely vaccinations in later childhood and help reaching high coverage for new vaccines in increasingly complex vaccination programs. While reminders prompt additional preventive care for focal children, we find no spillovers to other health behaviors or relatives.

The Effect of Adding Physician Recommendation in Digitally-Enabled Outreach for COVID-19 Vaccination in Socially/Economically Disadvantaged Populations Subtitle: A Randomized Controlled Trial

Introduction

People from backgrounds that are economically/socially disadvantaged experienced disproportionately high COVID-19 death rates and had lower vaccination rates. Effective outreach strategies for increasing vaccine uptake during the pandemic are not fully known. Among patients receiving care at a Federally Qualified Health Center, we tested whether community engaged digitally-enabled outreach increased COVID vaccine uptake.

Study Design Setting and Participants

A 3-parallel-arm randomized controlled trial with a hybrid effectiveness-implementation design was conducted among patients ≥18 years old on study enrollment during 2021 with 1,650 assigned in 3:10:20 ratio; 2,328 were later selected for two subsequent implementation rounds.

Interventions

From April 13 to June 10, 2021, patients were proactively sent a text-messaging invitation to make an appointment for vaccination as part of the routine practice (Arm 1, n=150) with added personalized clinician recommendation alone (Arm 2, n=500) or with an explicit nudge for answers to frequently asked questions (Arm 3, n=1,000). Further implementation used messaging addressing vaccine hesitancy (n=1,323) or adverse reactions to vaccines (n=1,005).

Main Outcomes and Measures

The primary outcome was the completion of the first SARS-Cov-2 vaccine dose determined at 14, 30 and 90 days after outreach.

Results

Of 1,650 patients in effectiveness Arms, 61% was female. Vaccination rates for Arms 1, 2, and 3, were 6% (n=9), 5.4% (n=27) and 3.3% (n=33) at 14 days, and 11.5% (n=17), 11.6% (n=58), and 8.5% (n=85) at 90 days, respectively, which were similar in pairwise comparisons. At 90 days, vaccination rates were similar across the two implementation rounds (3.9% vs. 3.6%) and were similar to the rate (3.3%) among patients who were not selected for intervention arms or implementation rounds (n=8,671).

Conclusions

Digitally-enabled outreach that included SMS messaging outreach augmented with clinician recommendations did not improve COVID-19 vaccination rates.

Trial Registration

This study is registered at ClinicalTrails.gov Identifier: NC-T04952376.

Consequences of a shortage and rationing: Evidence from a pediatric vaccine

Shortages and rationing are common in health care, yet we know little about the consequences. We examine an 18-month shortage of the pediatric Haemophilus Influenzae Type B (Hib) vaccine. Using insurance claims data and variation in shortage exposure across birth cohorts, we find that the shortage reduced uptake of high-value primary doses by 4 percentage points and low-value booster doses by 26 percentage points. This suggests providers largely complied with rationing recommendations. In the long-run, catch-up vaccination occurred but was incomplete: shortage-exposed cohorts were 4 percentage points less likely to have received the ir booster dose years later. We also find that the shortage and rationing caused provider switches, extra provider visits, and negative spillovers to other care.

Protocol for a pragmatic stepped wedge cluster randomized clinical trial testing behavioral economic implementation strategies to increase supplemental breast MRI screening among patients with extremely dense breasts

BACKGROUND

Increased breast density augments breast cancer risk and reduces mammography sensitivity. Supplemental breast MRI screening can significantly increase cancer detection among women with dense breasts. However, few women undergo this exam, and screening is consistently lower among racially minoritized populations. Implementation strategies informed by behavioral economics ("nudges") can promote evidence-based practices by improving clinician decision-making under conditions of uncertainty. Nudges directed toward clinicians and patients may facilitate the implementation of supplemental breast MRI.

METHODS

Approximately 1600 patients identified as having extremely dense breasts after non-actionable mammograms, along with about 1100 clinicians involved with their care at 32 primary care or OB/GYN clinics across a racially diverse academically based health system, will be enrolled. A 2 × 2 randomized pragmatic trial will test nudges to patients, clinicians, both, or neither to promote supplemental breast MRI screening. Before implementation, rapid cycle approaches informed by clinician and patient experiences and behavioral economics and health equity frameworks guided nudge design. Clinicians will be clustered into clinic groups based on existing administrative departments and care patterns, and these clinic groups will be randomized to have the nudge activated at different times per a stepped wedge design. Clinicians will receive nudges integrated into the routine mammographic report or sent through electronic health record (EHR) in-basket messaging once their clinic group (i.e., wedge) is randomized to receive the intervention. Independently, patients will be randomized to receive text message nudges or not. The primary outcome will be defined as ordering or scheduling supplemental breast MRI. Secondary outcomes include MRI completion, cancer detection rates, and false-positive rates. Patient sociodemographic information and clinic-level variables will be examined as moderators of nudge effectiveness. Qualitative interviews conducted at the trial's conclusion will examine barriers and facilitators to implementation.

DISCUSSION

This study will add to the growing literature on the effectiveness of behavioral economics-informed implementation strategies to promote evidence-based interventions. The design will facilitate testing the relative effects of nudges to patients and clinicians and the effects of moderators of nudge effectiveness, including key indicators of health disparities. The results may inform the introduction of low-cost, scalable implementation strategies to promote early breast cancer detection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05787249. Registered on March 28, 2023.

Behaviourally-informed household communications increase uptake of radon tests in a randomised controlled trial

Exposure to radon gas is a leading cause of lung cancer. Testing homes for the gas is straightforward, yet most people do not undertake tests even when offered freely. We report a pre-registered randomised controlled trial of communications to encourage test uptake. Households (N = 3500) in areas at high risk of radon exposure were randomly assigned to receive (i) a the control letter from the national Environmental Protection Agency; (ii) a behaviourally-informed version of the control letter that incorporated multiple nudges, including reciprocity messages and numeric frequencies of risk; (iii) this same behaviourally-informed letter in a re-designed envelope; (iv) the behaviourally-informed letter in the re-designed enveloped with a radon risk map of the household's county. The behaviourally-informed letter led to a large increase in test uptake, from 22% in the control condition to 33% (a 50% increase). There was no additional benefit of the re-designed envelope, which generated uptake of 30%. Including the map led some households to respond faster, but the overall uptake (26%) was weaker. The results have implications for public health communications with households and show the potential for techniques from behavioural science to help mitigate environmental risks.

The Effectiveness of mHealth Interventions Targeting Parents and Youth in Human Papillomavirus Vaccination: Systematic Review

BACKGROUND

The prevalence of human papillomavirus (HPV) and its related cancers is a major global concern. In the United States, routine HPV vaccination is recommended for youth aged 11 or 12 years. Despite HPV being the most common sexually transmitted infection and the vaccine's proven efficacy, the vaccination rate among US youth remains below the recommended 80% completion rate. Mobile health (mHealth) interventions have demonstrated promise in improving health. Examining and synthesizing the current evidence about the impact of mHealth interventions on vaccination coverage in youth and intervention characteristics could guide future mHealth interventions aimed at mitigating the vaccination gap and disease burden.

OBJECTIVE

This study aims to conduct a systematic review to assess the effectiveness of mHealth interventions on parental intent to vaccinate youth against HPV and youth's vaccine uptake.

METHODS

We searched empirical papers through databases including Google Scholar, PubMed, CINAHL, PsycINFO, and Cochrane Library. The inclusion criteria were the following: (1) published between January 2011 and December 2022; (2) using mHealth aimed to improve HPV vaccination rate; (3) targeted unvaccinated youth or their parents; and (4) measured HPV-related knowledge, vaccination intention, or vaccine uptake. Overall, 3 researchers screened and appraised the quality of the eligible papers using the Melnyk Levels of Evidence and the Cochrane Grading of Recommendations Assessment, Development, and Evaluation methodology. Disagreements in search results and result interpretation were resolved through consensus.

RESULTS

Overall, 17 studies that met the inclusion criteria were included in the final review. Most studies were conducted in the United States (14/17, 82%), used a randomized controlled trial design (12/17, 71%), and adopted behavior change theories or a culture-centric approach (10/17, 59%). mHealth interventions included SMS text message reminders, motivational SMS text messages, computer-tailored or tablet-tailored interventions, smartphone apps, web-based tailored interventions, social media (Facebook) campaigns, digital videos, and digital storytelling interventions. Approximately 88% (15/17) of the mHealth interventions demonstrated positive effects on knowledge, intention, or behaviors related to HPV vaccination. Overall, 12% (2/17) reported limited or no intervention impact on vaccine uptake or vaccine series completion. Effective vaccine uptake was commonly seen in interventions based on behavior change theories and those that provided culturally relevant information.

CONCLUSIONS

This systematic review identified the impact of mHealth interventions among unvaccinated youth and their parents, which showed improvement in HPV-related knowledge, vaccination intention, or vaccine initiation. The interventions that incorporated theories and culture-centric approaches revealed the most promising results. Although these outcomes are encouraging, future studies are needed to investigate factors associated with the success of interventions using SMS text messaging or social media. More studies are also needed for a better understanding of the intervention elements that boost the responses of age-specific and ethnicity-specific populations.

Effective health communication depends on the interaction of message source and content: two experiments on adherence to COVID-19 measures in Türkiye

OBJECTIVE

Following the COVID-19 outbreak, authorities recommended preventive measures to reduce infection rates. However, adherence to calls varied between individuals and across cultures. To determine the characteristics of effective health communication, we investigated three key features: message source, content, and audience.

METHODS

Using a pre-test and two experiments, we tested how message content (emphasizing personal or social benefit), audience (individual differences), message source (scientists or state officials), and their interaction influence adherence to preventive measures. Using fliers advocating preventive measures, Experiment 1 investigated the effects of message content and examined the moderator role of individual differences. Experiment 2 presented the messages using news articles and manipulated sources.

RESULTS

Study 1 found decreasing adherence over time, with no significant impact from message content or individual differences. Study 2 found messages emphasizing 'protect yourself' and 'protect your country' to increase intentions for adherence to preventive measures. It also revealed an interaction between message source and content whereby messages emphasizing personal benefit were more effective when they came from healthcare professionals than from state officials. However, message source and content did not affect vaccination intentions or donations for vaccine research.

CONCLUSION

Effective health communication requires simultaneous consideration of message source and content.

Acceptance of a Future Gonorrhea Vaccine in a Post-Coronavirus Disease 2019 World: Impact of Type of Recommendation and Changing Levels of Trust in Health Institutions and Authorities

Widespread uptake of a future gonorrhea vaccine could decrease the burden of disease and limit the spread of antibiotic resistance. However, gonorrhea vaccination will occur in the backdrop of the roll-out of the coronavirus disease 2019 (COVID-19) vaccine, which could have influenced parental perceptions about other, non-COVID-19 vaccines. In an internet-based cross-sectional survey, 74% of parents would get a gonorrhea vaccine for their child, and this was higher among those whose trust in pharmaceutical companies increased since the start of the COVID-19 pandemic. About 60% of adults aged 18 to 45 would receive a vaccine for themselves.

Testing Likely Response to Behavioral Nudges and Shoves to Promote COVID-19 Vaccine Uptake Amongst Segments of the Unvaccinated Population of South Africa

In early 2022, as the vaccination rate in South Africa slowed, there was a strong need for COVID-19 communications to evolve from mass information and education campaigns targeting the general population, to more targeted approaches to motivate uptake amongst population segments facing convenience, complacency, and confidence barriers.Project Last Mile (PLM) and Ipsos conducted a representative study of the population of South Africa to: (1) understand population segments with regards to their likelihood of getting the COVID-19 vaccine, (2) understand the drivers and barriers around getting the COVID-19 vaccine for each segment; and (3) test the likelihood of adoption of a range of enabling, incentivizing, and mandating behavioral interventions ("nudges and shoves").The study demonstrated that a significant proportion of the unvaccinated population is willing to get vaccinated, given the right conditions. Making it easy and convenient to get vaccinated (enabling) is likely to deliver moderate to strong impact. Ease of access, the ability to take time off from work, the provision of a reservation, and free transportation were the most influential factors in encouraging vaccination for the largest number of people.

A national nudge study of differently framed messages to increase COVID-19 vaccine uptake in Saudi Arabia: A randomized controlled trial

Background

During the COVID-19 pandemic, Saudi Arabia witnessed hesitancy from a proportion of the population toward taking the vaccine; thus, it was necessary to nudge them to uptake it. This study was conducted to assess the impact of using different types of messages to nudge the public to increase the proportion of vaccinated individuals.

Methods

This study is a multi-arm randomized controlled trial aiming to assess the efficacy of using differently framed messages that appear as pop-notifications in Sehatty application. Of those who preregistered to receive a COVID-19 vaccine but didn't take it according to the Saudi national vaccine registry (n = 1,291,686), 12,000 individuals were randomly recruited and randomly assigned to one of five intervention groups (commitment, loss aversion, salience, social norms, and ego) or a control group. To ensure the exposure occurred in the intervention groups, we included only those who received the notification, which was confirmed by checking the information technology system. We used the Chi-square test to compare each intervention group against the control group separately. Also, we used the same test to investigate whether sex and age influenced the percentage of booked appointments in the intervention groups.

Results

Social norms, ego, salience and loss aversion groups had higher percentages of booked appointments when compared to the control group (21.0%, p = 0.001; 19.1%, p = 0.011; 19.0%, p = 0.013; 18.4%, p = 0.034, respectively). Moreover, when combining the intervention groups, the percentage was higher than the control group (p < 0.001). The percentages of booked appointments made by Young adults (18-35 years old) were higher than that of adults over 35 years old in the social norms (22.6%, p = 0.016) and ego groups (21.0%, p = 0.010). At the same time, sex didn't affect the percentages of booked appointments in any group.

Conclusion

Using different framings of messages to nudge the public to take vaccines can help increase the percentage of immunized individuals in a community. Nudges can boost the public health of a population during an unusual spread of vaccine-preventable diseases. Findings might also inspire governmental responses to other public health situations.

Use of Information and Communication Technology Strategies to Increase Vaccination Coverage in Older Adults: A Systematic Review

BACKGROUND

Coverage rates of routinely recommended vaccines in older adults still fall below the targets established by international and national advisory committees. As a result, related diseases still have a high incidence, morbidity, and mortality. Information and Communication Technologies (ICT) could provide useful tools to improve immunization rates by bringing information directly to the target user at a relatively low cost. The present research aims to systematically review recent literature on interventions applying ICT to improve the uptake of influenza, pneumococcal, COVID-19 and herpes zoster immunization rates among older adults.

METHODS

Studies published in English between 1 January 2000 and 10 November 2022 were identified by searching electronic medical databases (PubMed, Scopus) and were independently reviewed by two different authors. A total of 22 studies were included in this review.

FINDINGS

Interventions applied the following ICT tools: phone calls, text messages, messages sent via personal electronic medical records, automated phone calls, remote patient monitoring in a home telehealth program and emails. In terms of the vaccines promoted, 11 studies prompted the influenza vaccine, four prompted the influenza and pneumococcal vaccines, three the pneumococcal vaccine, two the herpes zoster vaccine, one the COVID-19 vaccine and one both the pneumococcal and herpes zoster vaccines. Overall, more than half of the studies (n = 12) found some level of effectiveness of these ICT strategies in increasing vaccination rates among older adults, while five studies were partially effective (for specific vaccines or population subgroups), and five reported no significant effect.

CONCLUSIONS

Prevention programs using ICT tools could be effective in promoting immunizations among older adults.

Counter-stereotypical messaging and partisan cues: Moving the needle on vaccines in a polarized United States

This paper reports results from a large-scale randomized controlled trial assessing whether counter-stereotypical messaging and partisan cues can induce people to get COVID-19 vaccines. The study used a 27-s video compilation of Donald Trump's comments about the vaccine from Fox News interviews and presented the video to millions of U.S. YouTube users through a $100,000 advertising campaign in October 2021. Results indicate that the number of vaccines increased in the average treated county by 103 (with a one-tailed P value of 0.097). Based on this average treatment effect and totaling across our 1014 treated counties, the total estimated effect was 104,036 vaccines.

Knowledge, attitudes, practices and intention to get vaccinated against COVID-19: results from a cross-sectional survey in three peri-urban communities in South Africa

Introduction

South Africa has the largest number of confirmed cases of COVID-19 in Africa. Data to inform public health strategies to mitigate the spread of new variants and severity of disease is needed, including information on knowledge, attitudes and practices (KAP) regarding COVID-19, factors associated with intention to get vaccinated, and viewpoints on reliable sources of data.

Methods

we investigated these topics as part of the COVID-19 healthcare utilization and seroprevalence (HUTS) cross-sectional survey in three communities in South Africa: Mitchell´s Plain (Western Cape Province), Pietermaritzburg (KwaZulu-Natal Province) and Klerksdorp (North West Province) during and after the second wave of COVID-19 prior to vaccine availability.

Results

primary caregivers from 5799 households participated in the study, 41.1% from Pietermaritzburg, 34.2% from Klerksdorp and 24.7% from Mitchells Plain. Two-thirds and 94.7% of respondents had correct knowledge on the cause and spread of COVID-19, respectively. Knowledge measures were significantly associated with age less than 65 years, the highest level of education and site (Mitchells Plain). Desired preventive behaviors were associated with higher socio-economic status. While 64.7% of people intended to get vaccinated, those over 64 years of age were more likely to intend to vaccinate (aOR: 1.25, 95% CI: 1.06-1.47). Vaccine intention related to protection of self (58.4%) and family (40.0%). The most trusted source of COVID-19 information was television (59.3%) followed by radio (20.0%).

Conclusion

these data can be used to design targeted public health campaigns for the current COVID-19 and future epidemics, ensuring that socio-economic constraints and preference for trusted information are considered.

How does nudging the COVID-19 vaccine play out in people who are in doubt about vaccination?

In spite of the growing availability of COVID-19 vaccines, a substantial number of people is reluctant or uncertain about getting the vaccine. Nudges may improve vaccine uptake but it is unclear how this plays out with the experience of autonomous choice, decision competence, decision satisfaction, and being pressured to make a choice. In an online experiment among a representative sample (N = 884), we examined whether a social norm nudge or a default nudge (either or not transparent) was effective in steering the desired choice of making a hypothetical early vaccination appointment as compared to making a later appointment or no appointment. We also examined how both nudges affected autonomy and related downstream consequences. None of the nudges proved effective in making the desired choice of early vaccination and neither did they impact on downstream consequences. Rather, our results indicate that participants who were certain about their choice (i.e., opted for the earliest available vaccination opportunity or not getting vaccinated at all) reported higher levels of autonomy, competence and satisfaction than participants who did not know yet about vaccination or who postponed the moment of getting their vaccination. We conclude that the experience of autonomy and related downstream consequences is determined by having made up one's mind about vaccination, and is not affected by attempts to nudge the individual.

How does the vaccine approval procedure affect COVID-19 vaccination intentions?

People's willingness to vaccinate is critical to combating the COVID-19 pandemic. We devise a representative experiment to study how the design of the vaccine approval procedure affects trust in newly developed vaccines and consequently public attitudes towards vaccination. Compared to an Emergency Use Authorization, choosing the more thorough Conditional Marketing Authorization approval procedure increases vaccination intentions by 13 percentage points. The effects of the increased duration of the approval procedure are positive and significant only for Emergency Use Authorization. Treatment effects do not differ between relevant subgroups, such as respondents who had (did not have) COVID-19, or between vaccinated and unvaccinated respondents. Increased trust in the vaccine is the key mediator of treatment effects on vaccination intentions.

The Effect of Anticipated Regret on Flu Vaccination Campaigns

The anticipation of regret is known to be a primary motivator of receiving a vaccination. Aim of this study is to evaluate whether the use of messages that leverage the anticipated emotion of regret can increase the intention to get the flu vaccination. The participants (N = 110) randomly received a leaflet containing a standard prevention message (control condition) or message modified to induce the anticipation of regret over not being vaccinated (experimental condition), along with a questionnaire. The experimental condition's participants reported significantly higher levels of regret and higher intention to vaccinate than the participants in the control condition. Anticipated regret resulted to be a significant mediator of the intention to get vaccinated. Manipulating the salience of regret appears to be a simple and inexpensive way of effectively promoting preventive behaviour. The implications of this result for reducing COVID-19 vaccine hesitation are discussed.

Evaluation of behavioral economic strategies to raise influenza vaccination rates across a health system: Results from a randomized clinical trial

Influenza vaccination rates are low. Working with a large US health system, we evaluated three health system-wide interventions using the electronic health record's patient portal to improve influenza vaccination rates. We performed a two-arm RCT with a nested factorial design within the treatment arm, randomizing patients to usual-care control (no portal interventions) or to one or more portal interventions. We included all patients within this health system during the 2020-2021 influenza vaccination season, which overlapped with the COVID-19 pandemic. Through the patient portal, we simultaneously tested: pre-commitment messages (sent September 2020, asking patients to commit to a vaccination); monthly portal reminders (October - December 2020), direct appointment scheduling (patients could self-schedule influenza vaccination at multiple sites); and pre-appointment reminder messages (sent before scheduled primary care appointments, reminding patients about influenza vaccination). The main outcome measure was receipt of influenza vaccine (10/01/2020-03/31/2021). We randomized 213,773 patients (196,070 adults ≥18 years, 17,703 children). Influenza vaccination rates overall were low (39.0%). Vaccination rates for study arms did not differ: Control (38.9%), pre-commitment vs no pre-commitment (39.2%/38.9%), direct appointment scheduling yes/no (39.1%/39.1%), pre-appointment reminders yes/no (39.1%/39.1%); p > 0.017 for all comparisons (p value cut-off adjusted for multiple comparisons). After adjusting for age, gender, insurance, race, ethnicity, and prior influenza vaccination, none of the interventions increased vaccination rates. We conclude that patient portal interventions to remind patients to receive influenza vaccine during the COVID-19 pandemic did not raise influenza immunization rates. More intensive or tailored interventions are needed beyond portal innovations to increase influenza vaccination.

Electronic nudges to increase influenza vaccination uptake in Denmark: a nationwide, pragmatic, registry-based, randomised implementation trial

BACKGROUND

Influenza vaccination rates remain suboptimal despite effectiveness in preventing influenza infection and related complications. We investigated whether behavioural nudges, delivered via a governmental electronic letter system, would increase influenza vaccination uptake among older adults in Denmark.

METHODS

We did a nationwide, pragmatic, registry-based, cluster-randomised implementation trial during the 2022-23 influenza season in Denmark. All Danish citizens aged 65 years or older or turning 65 years by Jan 15, 2023 were included. We excluded individuals living in nursing homes and individuals who had an exemption from the Danish mandatory governmental electronic letter system. Households were randomly assigned (9:1:1:1:1:1:1:1:1:1) to usual care or nine different electronic letters designed on the basis of different behavioural nudging concepts. Data were sourced from nationwide Danish administrative health registries. The primary endpoint was receipt of influenza vaccination on or before Jan 1, 2023. The primary analysis assessed an analytical set of one randomly selected individual per household, and a sensitivity analysis included all randomly assigned individuals and accounted for within-household correlation. The trial is registered with ClinicalTrials.gov, NCT05542004.

FINDINGS

We identified 1 232 938 individuals aged 65 years or older in Denmark and excluded 56 436 (4·6%) individuals living in nursing homes and 211 632 (17·2%) with an exemption from the electronic letter system. We randomly assigned 964 870 (78·3%) participants across 691 820 households. Compared with usual care, influenza vaccination rates were higher in the group receiving an electronic letter highlighting potential cardiovascular benefits of vaccination (81·00% vs 80·12%; difference 0·89 percentage points [99·55% CI 0·29-1·48]; p<0·0001) and the group receiving repeated letters at randomisation and at day 14 (80·85% vs 80·12%; difference 0·73 percentage points [0·13-1·34]; p=0·0006). These strategies improved vaccination rates across major subgroups including those with and without established cardiovascular disease. The cardiovascular gain-framed letter was particularly effective among participants who had not been vaccinated for influenza in the previous season (p_interaction=0·0002). A sensitivity analysis of all randomly assigned individuals accounting for within-household clustering yielded similar findings.

INTERPRETATION

Electronically delivered letters highlighting potential cardiovascular benefits of influenza vaccination or sent again as a reminder significantly increased vaccination uptake across Denmark. Although the magnitude of effectiveness was modest, the low-touch, inexpensive, and highly scalable nature of these electronic letters might be informative for future public health campaigns.

FUNDING

Sanofi.

Short Message Service Reminder Nudge for Parents and Influenza Vaccination Uptake in Children and Adolescents With Special Risk Medical Conditions: The Flutext-4U Randomized Clinical Trial

Importance

Children with chronic medical conditions are at increased risk of severe influenza. Uptake of influenza vaccination in children and adolescents with these identified special risk medical conditions (SRMCs) is suboptimal.

Objective

To assess the effectiveness of Flutext-4U, a parent short message service (SMS) reminder nudge intervention, in increasing influenza immunization in children and adolescents with SRMCs.

Design, Setting, and Participants

This randomized clinical trial was conducted at a tertiary pediatric hospital in Adelaide, South Australia, from April 15 to September 30, 2021. Children and adolescents aged 6 months to younger than 18 years with SRMCs and a subspecialist outpatient appointment over a 5-month period during the Australian seasonal influenza vaccination season (April-August 2021) were eligible to participate. Follow-up was until September 30, 2021.

Interventions

Participants were randomly assigned (1:1 ratio) to control: clinician nudges (hospital vaccine availability, ease of access, and recommendation from hospital subspecialists) or SMS intervention (control conditions plus an additional SMS reminder nudge to parents), with randomization stratified by age group (<5 years, 5-14 years, or >14 to <18 years).

Main Outcomes and Measures

The primary outcome was influenza vaccination, as confirmed by the Australian Immunisation Register.

Results

A total of 600 participants (intervention group: 298 [49.7%]; mean [SD] age, 11.5 [4.6] years; 162 female participants [54.4%]; control group: 302 [50.3%]; mean [SD] age, 11.4 [4.7] years; 155 female participants [51.3%]) were included. Influenza vaccination was 38.6% (113 of 293) in the SMS intervention group compared with 26.2% (79 of 302) in the control group (adjusted odds ratio [aOR], 1.79; 95% CI, 1.27-2.55; P = .001). Time to vaccine receipt was significantly lower among SMS participants (adjusted hazard ratio, 1.67; 95% CI, 1.25-2.22; P < .001). For participants randomly assigned by June 15, a significantly greater proportion receiving the SMS intervention were vaccinated during the optimal delivery period April to June 30 (SMS group: 40.0% [76 of 190] vs 25.4% [50 of 197]; aOR, 1.97; 95% CI, 1.28-3.06; P = .002).

Conclusions and Relevance

Results of this randomized clinical trial suggest that an additional SMS reminder nudge for parents delivered in the tertiary care hospital setting to children and adolescents with SMRCs resulted in higher influenza vaccine uptake compared with clinician nudges alone.

Trial Registration

ANZCTR Identifier: ACTRN12621000463875.

Influenza Vaccine Hesitancy: Scope, Influencing Factors, and Strategic Interventions

Influenza vaccination rates in children are suboptimal. One underlying reason is influenza vaccine hesitancy. Tools such as the Parent Attitudes about Childhood Vaccines survey and the Vaccine Hesitancy Scale can be used to measure influenza vaccine hesitancy. The adapted Increasing Vaccination Model from Brewer and colleagues can help identify factors that influence influenza vaccine hesitancy, motivation, and uptake. Several strategies can be used to address influenza vaccine hesitancy, which we discuss further in this review.

A Randomized Trial of Behavioral Nudges Delivered Through Text Messages to Increase Influenza Vaccination Among Patients With an Upcoming Primary Care Visit

PURPOSE

To evaluate if nudges delivered by text message prior to an upcoming primary care visit can increase influenza vaccination rates.

DESIGN

Randomized, controlled trial.

SETTING

Two health systems in the Northeastern US between September 2020 and March 2021.

SUBJECTS

74,811 adults.

INTERVENTIONS

Patients in the 19 intervention arms received 1-2 text messages in the 3 days preceding their appointment that varied in their format, interactivity, and content.

MEASURES

Influenza vaccination.

ANALYSIS

Intention-to-treat.

RESULTS

Participants had a mean (SD) age of 50.7 (16.2) years; 55.8% (41,771) were female, 70.6% (52,826) were White, and 19.0% (14,222) were Black. Among the interventions, 5 of 19 (26.3%) had a significantly greater vaccination rate than control. On average, the 19 interventions increased vaccination relative to control by 1.8 percentage points or 6.1% (P = .005). The top performing text message described the vaccine to the patient as "reserved for you" and led to a 3.1 percentage point increase (95% CI, 1.3 to 4.9; P < .001) in vaccination relative to control. Three of the top five performing messages described the vaccine as "reserved for you." None of the interventions performed worse than control.

CONCLUSIONS

Text messages encouraging vaccination and delivered prior to an upcoming appointment significantly increased influenza vaccination rates and could be a scalable approach to increase vaccination more broadly.

Self-esteem influences the willingness to engage in COVID-19 prevention behavior and persuasion efficacy

RATIONALE

Behaviors such as hand-washing and vaccination save human lives during the COVID-19 pandemic and beyond. Yet, people differ widely in their willingness to engage in them. This investigation examines whether people's willingness to protect themselves physically from contracting coronavirus depends on their self-esteem. Based on self-verification theory, we propose that people who hold negative self-views are less motivated to protect their health which reduces their willingness to engage in recommended preventive measures such as mask-wearing and social-distancing.

OBJECTIVE

We set out to test (i) whether self-esteem predicts people's willingness to engage in COVID-19 prevention behaviors, (ii) whether this relationship is due to variance in motivation to protect one's health (as well as alternative mechanisms), and (iii) whether health messages can more successfully persuade low self-esteem people to follow preventive measures by framing those behaviors around protecting the health of others (vs. oneself).

METHODS

Four studies were conducted with U.S. and German residents. In Study 1, we examine the association between self-esteem, willingness to engage in self-protection behavior, health motivation, and several alternative accounts. In Study 2, we manipulate state self-esteem, and in Studies 3 and 4, we vary the target of COVID-19 prevention behaviors (self vs. other).

RESULTS

People with chronic or temporarily induced low self-esteem report a lower willingness to engage in COVID-19 prevention behaviors because they lack motivation to protect their health. Varying the protection target of preventive behaviors (self vs. others) interacts with self-esteem: Low self-esteem people are more willing to follow preventive measures (e.g., vaccination) when they are framed as protecting others (vs. oneself).

CONCLUSIONS

Self-esteem impacts people's behavior during a global pandemic and needs to be considered when designing health communications. Public health messages can increase compliance among individuals with lower self-esteem by framing prevention behaviors as a way to protect the health of others.