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

Many Americans fail to get life-saving vaccines each year, and the availability of a vaccine for COVID-19 makes the challenge of encouraging vaccination more urgent than ever. We present a large field experiment (N = 47,306) testing 19 nudges delivered to patients via text message and designed to boost adoption of the influenza vaccine. Our findings suggest that text messages sent prior to a primary care visit can boost vaccination rates by an average of 5%. Overall, interventions performed better when they were 1) framed as reminders to get flu shots that were already reserved for the patient and 2) congruent with the sort of communications patients expected to receive from their healthcare provider (i.e., not surprising, casual, or interactive). The best-performing intervention in our study reminded patients twice to get their flu shot at their upcoming doctor's appointment and indicated it was reserved for them. This successful script could be used as a template for campaigns to encourage the adoption of life-saving vaccines, including against COVID-19.

Training Health Policy Researchers on Policy Engagement and Research Translation for Greater Impact: Evaluation of the Amplify@LDI Program.

BACKGROUND: Few researchers receive formal training in research translation and dissemination or policy engagement. We created Amplify@LDI, a training program for health services and health policy researchers, to equip them with skills to increase the visibility of their research through translation and dissemination activities. AIMS: To describe the program's participants and curriculum, and evaluate the first 2 years of the program. SETTING: The Leonard Davis Institute (LDI) at the University of Pennsylvania (Penn). PARTICIPANTS: An annual cohort of 12 LDI Senior Fellows (Penn faculty) from multiple schools, disciplines, and ranks at Penn. PROGRAM DESCRIPTION: The Amplify@LDI curriculum includes 6 sessions on different aspects of research translation and dissemination, including media and social engagement, writing Op-Eds, and policy engagement. PROGRAM EVALUATION: Participants reported measurable increases in time spent on translation and dissemination activities, as well as new enthusiasm for and confidence in policy engagement. Participants' reach (as measured by Altmetric) increased during the program, compared to smaller increases or reductions in reach for two comparator groups. DISCUSSION: In our preliminary evaluation of Amplify@LDI, we find strong evidence of positive impact from participant evaluations, and suggestive evidence that participation in the program is associated with significant increases in the reach of their research.

Correlates of COVID-19 vaccination intentions and opinions about mandates among four groups of adults in South Africa with distinct vaccine intentions: evidence from a large national survey.

INTRODUCTION: Despite a high number of recorded COVID-19 infections and deaths in South Africa, COVID-19 vaccine coverage remained low in March 2022, ten months into the national vaccine roll-out. This study provides evidence on the correlates of vaccine intentions, attitudes towards vaccination and opinions about mandates. METHODS: We used data from the second COVID-19 Vaccine Survey (CVACS), a telephone survey conducted February-March 2022 among 3,608 South African adults who self-reported not being vaccinated against COVID-19. The survey instrument was designed in consultation with government, policymakers, and civil society; and segmented the sample into four distinct groups with different vaccine intentions (synonymous with vaccine hesitancy levels). Kruskal-Wallis and Mann-Whitney tests were used to examine the sociodemographic characteristics, attitudes and behaviours associated with the different vaccination intentions groups. Thematic coding of responses to open-ended questions elicited insights on reasons for not being vaccinated and attitudes towards mandates. RESULTS: Intentions to get vaccinated were greater among individuals with lower socio-economic status (Mann-Whitney Z = -11.3, p < 0.001); those believing the vaccine protects against death (Kruskal-Wallis Χ2 = 494, p < 0.001); and those who perceived themselves at risk of COVID-19-related illness (Χ2 = 126, p < 0.01). Vaccine intentions were lower among individuals who believed that the vaccine causes death (Χ2 = 163, p < 0.001); believed that the vaccine is unsafe for the babies of pregnant/breastfeeding mothers, or the chronically ill (Χ2 = 123, p < 0.01); those not trusting government health information about COVID-19 and the COVID-19 vaccine (Kendall's τ = -0.41, p < 0.01); and those in opposition to mandates (τ = 0.35, p < 0.001). Only 25% supported mandates, despite 48% thinking mandates would work well, with 54% citing individual rights as their main reason for mandate opposition. CONCLUSION: The profile of individuals not vaccinated against COVID-19 as of March 2022 varied markedly by self-reported vaccination intentions, underscoring the importance of tailored demand-creation efforts. This paper highlights several factors which differ significantly across these groups. These findings could inform the design of future vaccination campaigns, potentially increasing their likelihood of success. This is an important policy objective given widespread vaccine hesitancy, and further work is required on this topic. Mandates remain an option to increase coverage but need to be carefully considered given extensive opposition.

What Were the Information Voids? A Qualitative Analysis of Questions Asked by Dear Pandemic Readers between August 2020-August 2021.

In the current infodemic, how individuals receive information (channel), who it is coming from (source), and how it is framed can have an important effect on COVID-19 related mitigation behaviors. In light of these challenges presented by the infodemic, Dear Pandemic (DP) was created to directly address persistent questions related to COVID-19 and other health topics in the online environment. This is a qualitative analysis of 3806 questions that were submitted by DP readers to a question box on the Dear Pandemic website between August 30, 2020 and August 29, 2021. Analyses resulted in four themes: the need for clarification of other sources; lack of trust in information; recognition of possible misinformation; and questions on personal decision-making. Each theme reflects an unmet informational need of Dear Pandemic readers, which may be reflective of the broader informational gaps in our science communication efforts.This study highlights the role of an ad hoc risk communication platform in the current environment and uses questions submitted to the Dear Pandemic question box to identify informational needs of DP readers over the course of the COVID-19 pandemic. These findings may help clarify how organizations addressing health misinformation in the digital space can contribute to timely, responsive science communication and improve future communication efforts.

Do Incentives Crowd Out Motivation? A Feasibility Study of a Community Vector-Control Campaign in Peru.

Incentives are a useful tool in encouraging healthy behavior as part of public health initiatives. However, there remains concern about motivation crowd out-a decline in levels of motivation to undertake a behavior to below baseline levels after incentives have been removed-and few public health studies have assessed for motivation crowd out. Here, we assess the feasibility of identifying motivation crowd out following a lottery to promote participation in a Chagas disease vector control campaign. We look for evidence of crowd out in subsequent participation in the same behavior, a related behavior, and an unrelated behavior. We identified potential motivation crowd out for the same behavior, but not for related behavior or unrelated behaviors after lottery incentives are removed. Despite some limitations, we conclude that motivation crowd out is feasible to assess in large-scale trials of incentives.

Promoting COVID-19 vaccine acceptance: recommendations from the Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA.

Since the first case of COVID-19 was identified in the USA in January, 2020, over 46 million people in the country have tested positive for SARS-CoV-2 infection. Several COVID-19 vaccines have received emergency use authorisations from the US Food and Drug Administration, with the Pfizer-BioNTech vaccine receiving full approval on Aug 23, 2021. When paired with masking, physical distancing, and ventilation, COVID-19 vaccines are the best intervention to sustainably control the pandemic. However, surveys have consistently found that a sizeable minority of US residents do not plan to get a COVID-19 vaccine. The most severe consequence of an inadequate uptake of COVID-19 vaccines has been sustained community transmission (including of the delta [B.1.617.2] variant, a surge of which began in July, 2021). Exacerbating the direct impact of the virus, a low uptake of COVID-19 vaccines will prolong the social and economic repercussions of the pandemic on families and communities, especially low-income and minority ethnic groups, into 2022, or even longer. The scale and challenges of the COVID-19 vaccination campaign are unprecedented. Therefore, through a series of recommendations, we present a coordinated, evidence-based education, communication, and behavioural intervention strategy that is likely to improve the success of COVID-19 vaccine programmes across the USA.

Equitable implementation of S.A.F.E. Firearm: A multi-method pilot study.

Attention to health equity is critical in the implementation of firearm safety efforts. We present our operationalization of equity-oriented recommendations in preparation for launch of a hybrid effectiveness-implementation trial focused on firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. In Step 1 of our process, pre-trial engagement with clinican partners and literature review alerted us that delivery of a firearm safety program may vary by patients' medical complexity, race, and ethnicity. In Step 2, we selected the Health Equity Implementation Framework to inform our understanding of contextual determinants (i.e., barriers and facilitators). In Step 3, we leveraged an implementation pilot across 5 pediatric primary care clinics in 2 health system sites to study signals of inequities. Eligible well-child visits for 694 patients and 47 clinicians were included. Our results suggested that medical complexity was not associated with program delivery. We did see potential signals of inequities by race and ethnicity but must interpret with caution. Though we did not initially plan to examine differences by sex assigned at birth, we discovered that clinicians may be more likely to deliver the program to parents of male than female patients. Seven qualitative interviews with clinicians provided additional context. In Step 4, we interrogated equity considerations (e.g., why and how do these inequities exist). In Step 5, we will develop a plan to probe potential inequities related to race, ethnicity, and sex in the fully powered trial. Our process highlights that prospective, rigorous, exploratory work is vital for equity-informed implementation trials.

Public attitudes about equitable COVID-19 vaccine allocation: a randomised experiment of race-based versus novel place-based frames.

Equity was-and is-central in the US policy response to COVID-19, given its disproportionate impact on disadvantaged communities of colour. In an unprecedented turn, the majority of US states used place-based disadvantage indices to promote equity in vaccine allocation (eg, through larger vaccine shares for more disadvantaged areas and people of colour).We conducted a nationally representative survey experiment (n=2003) in April 2021 (before all US residents had become vaccine eligible), that examined respondents' perceptions of the acceptability of disadvantage indices relative to two ways of prioritising racial and ethnic groups more directly, and assessed the role of framing and expert anchors in shaping perceptions.A majority of respondents supported the use of disadvantage indices, and one-fifth opposed any of the three equity-promoting plans. Differences in support and opposition were identified by respondents' political party affiliation. Providing a numerical anchor (that indicated expert recommendations and states' actual practices in reserving a proportion of allocations for prioritised groups) led respondents to prefer a lower distribution of reserved vaccine allocations compared with the randomised condition without this anchor, and the effect of the anchor differed across the frames.Our findings support ongoing uses of disadvantage indices in vaccine allocation, and, by extension, in allocating tests, masks or treatments, especially when supply cannot meet demand. The findings can also inform US allocation frameworks in future pandemic planning, and could provide lessons on how to promote equity in clinical and public health outside of the pandemic setting.

Longitudinal changes in COVID-19 vaccination intent among South African adults: evidence from the NIDS-CRAM panel survey, February to May 2021.

BACKGROUND: COVID-19 vaccine hesitancy has threatened the ability of many countries worldwide to contain the pandemic. Given the severe impact of the pandemic in South Africa and disruptions to the roll-out of the vaccine in early 2021, slower-than-expected uptake is a pressing public health challenge in the country. We examined longitudinal changes in COVID-19 vaccination intent among South African adults, as well as determinants of intent to receive a vaccine. METHODS: We used longitudinal data from Wave 4 (February/March 2021) and Wave 5 (April/May 2021) of the National Income Dynamics Study: Coronavirus Rapid Mobile Survey (NIDS-CRAM), a national and broadly representative panel survey of adults in South Africa. We conducted cross-sectional analyses on aggregate and between-group variation in vaccination intent, examined individual-level changes between waves, and modeled demographic predictors of intent. RESULTS: We analysed data for 5629 (Wave 4; 48% male, mean age 41.5 years) and 5862 (Wave 5; 48% male, mean age 41.6 years) respondents. Willingness to get a COVID-19 vaccine significantly increased from 70.8% (95% CI: 68.5-73.1) in Wave 4 to 76.1% (95% CI: 74.2-77.8) in Wave 5. Individual-level analyses indicated that only 6.6% of respondents remained strongly hesitant between survey waves. Although respondents aged 18-24 years were 8.5 percentage points more likely to report hesitancy, hesitant respondents in this group were 5.6 percentage points more likely to change their minds by Wave 5. Concerns about rushed testing and safety of the vaccines were frequent and strongly-held reasons for hesitancy. CONCLUSIONS: Willingness to receive a COVID-19 vaccine has increased among adults in South Africa, and those who were entrenched in their reluctance make up a small proportion of the country's population. Younger adults, those in formal housing, and those who trusted COVID-19 information on social media were more likely to be hesitant. Given that stated vaccination intent may not translate into behaviour, our finding that three-quarters of the population were willing to accept the vaccine may reflect an upper bound. Vaccination promotion campaigns should continue to frame vaccine acceptance as the norm and tailor strategies to different demographic groups.

Behavioural intervention for adolescent uptake of family planning: a randomized controlled trial, Uganda.

OBJECTIVE: To evaluate the impact of a peer-referral and clinic welcome programme for reducing barriers to adolescents' uptake of family planning services in Uganda. METHODS: We developed an intervention using behavioural design and carried out a stratified, randomized controlled evaluation of the intervention in girls aged 15-19 years. Sexual and reproductive health clinics were randomized into control (56 clinics) and intervention groups (60 clinics). All intervention clinics received the core intervention (materials to create an adolescent-friendly environment and referral cards to give to friends), while a subset of clinics additionally received training in youth-friendly service provision. We collected clinics' routine data on monthly numbers of visits by adults and adolescents over a 15-month baseline and 6-month intervention period, 2018-2020. FINDINGS: In multivariate regression analysis we found significant effects of the intervention on primary outcomes in the pooled intervention group compared with control. Mean monthly visits by adolescents increased by 45% (incidence rate ratio, IRR: 1.45; 95% confidence interval, CI: 1.14-1.85), or over five additional adolescent clients per clinic per month. The mean adolescent proportion of total clients improved by 5.3 percentage points (95% CI: 0.02-0.09). Within treatment arms, clinics receiving the training in youth-friendly service provision showed the strongest effects: a 62% increase (IRR: 1.62; 95% CI: 1.21-2.17) in adolescent clients, or over seven additional adolescents per clinic per month, relative to the control group. CONCLUSION: A behavioural change intervention designed to target identified barriers can increase adolescents' uptake of family planning counselling and services.

Undetectable = Untransmittable (U = U) Messaging Increases Uptake of HIV Testing Among Men: Results from a Pilot Cluster Randomized Trial.

HIV testing coverage in sub-Saharan Africa is lower among men than women. We investigated the impact of a peer-delivered U = U (undetectable equals untransmittable) message on men's HIV testing uptake through a cluster randomised trial with individual mobile clinic days as unit of randomisation. On standard of care (SOC) days, peer promoters informed men about the availability of HIV testing at the mobile clinic. On intervention days, peer promoters delivered U = U messages. We used logistic regression adjusting for mobile clinic location, clustering by study day, to determine the percentage of invited men who tested for HIV at the mobile clinic. Peer promoters delivered 1048 invitations over 12 days. In the SOC group, 68 (13%) of 544 men invited tested for HIV (3, 4.4% HIV-positive). In the U = U group, 112 (22%) of 504 men invited tested for HIV (7, 6.3% HIV-positive). Men in the U = U group had greater odds of testing for HIV (adjusted odds ratio = 1.89, 95% CI 1.21-2.95; p = 0.01). Tailored, peer-delivered messages that explain the benefits of HIV treatment in reducing HIV transmission can increase men's HIV testing uptake.

Community stakeholder preferences for evidence-based practice implementation strategies in behavioral health: a best-worst scaling choice experiment.

BACKGROUND: Community behavioral health clinicians, supervisors, and administrators play an essential role in implementing new psychosocial evidence-based practices (EBP) for patients receiving psychiatric care; however, little is known about these stakeholders' values and preferences for implementation strategies that support EBP use, nor how best to elicit, quantify, or segment their preferences. This study sought to quantify these stakeholders' preferences for implementation strategies and to identify segments of stakeholders with distinct preferences using a rigorous choice experiment method called best-worst scaling. METHODS: A total of 240 clinicians, 74 clinical supervisors, and 29 administrators employed within clinics delivering publicly-funded behavioral health services in a large metropolitan behavioral health system participated in a best-worst scaling choice experiment. Participants evaluated 14 implementation strategies developed through extensive elicitation and pilot work within the target system. Preference weights were generated for each strategy using hierarchical Bayesian estimation. Latent class analysis identified segments of stakeholders with unique preference profiles. RESULTS: On average, stakeholders preferred two strategies significantly more than all others-compensation for use of EBP per session and compensation for preparation time to use the EBP (P < .05); two strategies were preferred significantly less than all others-performance feedback via email and performance feedback via leaderboard (P < .05). However, latent class analysis identified four distinct segments of stakeholders with unique preferences: Segment 1 (n = 121, 35%) strongly preferred financial incentives over all other approaches and included more administrators; Segment 2 (n = 80, 23%) preferred technology-based strategies and was younger, on average; Segment 3 (n = 52, 15%) preferred an improved waiting room to enhance client readiness, strongly disliked any type of clinical consultation, and had the lowest participation in local EBP training initiatives; Segment 4 (n = 90, 26%) strongly preferred clinical consultation strategies and included more clinicians in substance use clinics. CONCLUSIONS: The presence of four heterogeneous subpopulations within this large group of clinicians, supervisors, and administrators suggests optimal implementation may be achieved through targeted strategies derived via elicitation of stakeholder preferences. Best-worst scaling is a feasible and rigorous method for eliciting stakeholders' implementation preferences and identifying subpopulations with unique preferences in behavioral health settings.

A pilot study of participatory and rapid implementation approaches to increase depression screening in primary care.

BACKGROUND: Most individuals with depression go unidentified and untreated. In 2016 the US Preventive Services Task Force released guidelines recommending universal screening in primary care to identify patients with depression and to link them to treatment. Feasible, acceptable, and effective strategies to implement these guidelines are needed. METHODS: This three-phased study employed rapid participatory methods to design and test strategies to increase depression screening at Penn Medicine, a large health system with 90 primary care practices. First, researchers solicited ideas and barriers from stakeholders to increase screening using an innovation tournament-a crowdsourcing method that invites stakeholders to submit ideas to address a workplace challenge. Second, a panel of stakeholders and scientists deliberated over and ranked the tournament ideas. An instant runoff election was held to select the winning idea. Third, the research team piloted the winning idea in a primary care practice using rapid prototyping, an approach that quickly refines and iterates strategy designs. RESULTS: The innovation tournament yielded 31 ideas and 32 barriers from diverse stakeholders (12 primary care physicians, 10 medical assistants, 4 nurse practitioners, 2 practice managers, and 4 patient support assistants). A panel of 6 stakeholders and scientists deliberated on the ideas and voted for patient self-report (i.e., through tablet computers, text message, or an online patient portal) as the winning idea. The research team rapid prototyped tablets in one primary care practice with one physician over 5 five-hour shifts to examine the feasibility, acceptability, and effectiveness of the strategy. Most patients, the physician, and medical assistants found the tablets acceptable and feasible. However, patient support assistants struggled to incorporate them in their workflow and expressed concerns about scaling up the process. Depression screening rates were higher using tablets compared to usual care; follow-up was comparable between tablets and usual care. CONCLUSIONS: Rapid participatory methods engaged and amplified the voices of diverse stakeholders in primary care. These methods helped design an acceptable and feasible implementation strategy that showed promise for increasing depression screening in a primary care setting. The next step is to evaluate the strategy in a randomized controlled trial across primary care practices.

Dear Pandemic: Nurses as key partners in fighting the COVID-19 infodemic.

The COVID-19 pandemic and subsequent proliferation of misinformation have created parallel public health crises. Social media offers a novel platform to amplify evidence-based communication to broader audiences. This paper describes the application of science communication engagement on social media platforms by an interdisciplinary team of female scientists in a campaign called Dear Pandemic. Nurses are trusted professionals trained in therapeutic communication and are central to this effort. The Dear Pandemic campaign now has more than 97,000 followers with international and multilingual impact. Public health strategies to combat misinformation and guide individual behavior via social media show promise, and require further investment to support this novel dissemination of science communication.

Applying NUDGE to Inform Design of EBP Implementation Strategies in Community Mental Health Settings.

We demonstrate the application of NUDGE (Narrow, Understand, Discover, Generate, Evaluate), a behavioral economics approach to systematically identifying behavioral barriers that impede behavior enactment, to the challenge of evidence-based practice (EBP) use in community behavioral health. Drawing on 65 clinician responses to a system-wide crowdsourcing challenge about EBP underutilization, we applied NUDGE to discover, synthesize and validate specific behavioral barriers to EBP utilization that directly inform the design of tailored implementation strategies. To our knowledge, this is the first study to apply behavioral economic insights to clinician-proposed solutions to implementation challenges in order to design implementation strategies. The study demonstrates the successful application of NUDGE to implementation strategy design and provides novel targets for intervention.

Behavioral barriers to the use of modern methods of contraception among unmarried youth and adolescents in eastern Senegal: a qualitative study.

BACKGROUND: Many unmarried young people in low- and middle-income countries (LMIC) want to avoid pregnancy but do not use modern methods of contraception-as a result, half of teen births in these countries are unintended. Researchers have identified numerous barriers that prevent youth from using contraception. However, much of the research in West Africa is narrowly focused on married women, and relatively little research has been done to understand the needs, preferences, barriers, and solution set for sexually active unmarried young people who would like to avoid pregnancy. The purpose of this study was to gain insight into the behavioral barriers that prevent unmarried young people in eastern Senegal from using modern methods of contraception. METHODS: This qualitative study conducted in 2017 in the Tambacounda and Kedougou regions in Senegal explores attitudes and beliefs relating to sex and contraception among unmarried young women and men through 48 in-depth individual interviews with young people aged 15-24 and parents of youth and 5 sex-segregated focus groups with 6-9 young people per group. The research team conducted a thematic content analysis and synthesized the findings by major theme following the behavioral diagnosis methodology. RESULTS: Drawing insights from behavioral science, the analysis yields five key findings: (1) unmarried young people avoid making a decision about contraception because thinking about contraceptive use provokes uncomfortable associations with a negative identity (i.e., being sexually active before marriage); (2) unmarried young people see modern methods as inappropriate for people like them; (3) unmarried young people are overconfident in their ability to prevent pregnancy through traditional and folk methods; (4) unmarried young people overestimate the social and health risks of modern contraceptive methods; and (5) unmarried young people fail to plan ahead and are not prepared to use modern contraceptive methods before every sexual encounter. CONCLUSIONS: Interventions aimed at increasing uptake of contraceptives among unmarried young people in eastern Senegal must address several significant behavioral barriers in addition to structural, informational, and socio-cultural barriers in order to be successful.

California's Senate Bill 277: Local Health Jurisdictions' Experiences With the Elimination of Nonmedical Vaccine Exemptions.

Objectives. To understand the experiences of local health jurisdictions with Senate Bill 277 (SB277), the California law that eliminated nonmedical vaccine exemptions for public- and private-school entry.Methods. We conducted semistructured telephone interviews with health officers and local health department (LHD) staff in California between August and September 2017.Results. Two overall themes emerged: (1) vague legislative and regulatory language led to variation in the interpretation and implementation of SB277, and (2) lack of centralized review of medical exemptions allowed medical exemptions that are not consistent with valid contraindications for immunizations to be accepted. Variation in the interpretation and implementation was commonly reported with provisions related to individualized education programs and special education, and independent study programs and homeschooling. Without a centralized review of medical exemption requests, respondents reported variation in the interpretation of which specialties of physicians can write medical exemptions, which conditions constitute a valid contraindication for immunization, and the process for reporting a questionable or suspicious medical exemption.Conclusions. The regulatory language within SB277 led to variation in how the law was interpreted and implemented within and across LHD jurisdictions and school districts.