Moral foundations and HPV vaccine acceptance in the United States: State, parental, and individual factors.

RATIONALE: Appeals to intuitive morality may present a novel approach to addressing vaccine hesitancy. OBJECTIVE: To better understand the relationship between morality and vaccination by employing Moral Foundations Theory to studies surrounding the HPV vaccination at multiple different levels of decision making. METHOD: We employed three different study modalities which examined moralities link to vaccination by employing Moral Foundations Theory. A state-wide ecological study aimed to understand population level trends. Two randomized control interventional studies were then created to understand the effects of Moral Foundations Theory based interventions on both parents of children and individual decision makers. RESULTS: We demonstrated a negative association at the state level between the purity moral foundations and HPV vaccination rates (ß = -.75, SE 0.23; p < .01) and a positive association between loyalty and HPV vaccination rates (ß = 0.62 SE 0.24; p < .05). The parental study built upon this by demonstrating negative association between higher moral purity scores and attitudes towards the HPV vaccine and intention to vaccinate their children (ß = -0.27 SE 0.07; p < .001). Our final study demonstrated a Moral Foundations Theory based intervention was associated with an increase in the odds of indicating an intention to receive the HPV vaccination (adjusted Odds Ratio (aOR) 2.59, 95% Confidence Interval (CI) 1.62-4.14). This equates to a 20% increase in the predicted probability of the intention to receive an HPV vaccine (39% CI (36%-42%) vs 60% CI (57%-63%). CONCLUSIONS: Together, these studies demonstrate that moral foundations, specifically the purity foundation, appear to have a strong and consistent relationship with HPV vaccination. They also demonstrate the how moral values-based interventions may serve as a novel approach to increase HPV vaccine uptake with potential to be employed to target vaccine hesitancy more broadly.

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis.

BACKGROUND: Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries. METHODS: We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately. FINDINGS: Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes. INTERPRETATION: Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

A mentored hands-on training model for scaling up implementation and intervention research in India: "connecting the dots".

Despite the high burden of mental disorders in low- and middle-income countries (LMICs), less than 25% of those in need have access to appropriate services, in part due to a scarcity of locally relevant, evidence-based interventions and models of care. To address this gap, researchers from India and the United States and the Indian Council of Medical Research (ICMR) collaboratively developed a "Grantathon" model to provide mentored research training to 24 new principal investigators (PIs). This included a week-long didactic training, a customized web-based data entry/analysis system and a National Coordination Unit (NCU) to support PIs and track process objectives. Outcome objectives were assessed via scholarly output including publications, awards received and subsequent grants that were leveraged. Multiple mentorship strategies including collaborative problem-solving approaches were used to foster single-centre and multicentre research. Flexible, approachable and engaged support from mentors helped PIs overcome research barriers, and the NCU addressed local policy and day-to-day challenges through informal monthly review meetings. Bi-annual formal review presentations by all PIs continued through the COVID-19 pandemic, enabling interim results reporting and scientific review, also serving to reinforce accountability. To date, more than 33 publications, 47 scientific presentations, 12 awards, two measurement tools, five intervention manuals and eight research grants have been generated in an open-access environment. The Grantathon is a successful model for building research capacity and improving mental health research in India that could be adopted for use in other LMICs.

The Influence of Social Media Interactions and Behaviors on Depressive Symptoms Among Sexual and Gender Minority Young Adults in the United States: Protocol for a Mixed Methods Longitudinal Study.

BACKGROUND: Sexual and gender minority (SGM; ie, lesbian, gay, bisexual, transgender, and otherwise queer) young adults experience disparities in depression and other internalizing psychopathology. Although social media use is widespread and SGM people have more social media accounts and are more socially active on them than non-SGM individuals, few studies have examined the impact of social media on depression in this group. OBJECTIVE: The PRIDE iM study will be the first longitudinal, mixed methods research conducted to determine the impact of social media interactions and behaviors as pathways to depressive symptoms among SGM young adults living in the United States. METHODS: PRIDE iM uses a bookends variation of the longitudinal sequential mixed methods design. Participants will be recruited nationally from social media. First, between July 2019 and February 2020, we conducted a qualitative phase (T1) comprising web-based individual interviews (N=58) to inform the building and content of the quantitative survey. Second, from February 2022 to September 2022, we will conduct a series of web-based surveys (N=1000 at baseline) with 4 data points (T2-T5), each one collected every 6 to 8 weeks. Third, from October 2022 to December 2022, we will conduct a second qualitative phase (T6) of web-based interviews using outcome trajectories found in the longitudinal survey analyses to purposively sample survey participants and conduct web-based interviews to contextualize and explain survey findings. Qualitative data from T1 and T6 will be analyzed using a reflexive thematic analysis approach. As we sought to capture change over time in the association between the main predictors (ie, social media interactions and behaviors) and depressive symptoms, we propose analyzing T2 to T5 data using latent growth models with a structural equation modeling framework. Data integration at the method, interpretation, and reporting levels will be achieved through building and connecting and the use of a staged approach and joint displays, respectively. At all stages, we will assess the fit of data integration as recommended by the principles of best practice for mixed methods research in psychology. RESULTS: Data collection will be completed by December 2022. Qualitative data analyses will be completed by March 2023, and quantitative analyses of the primary outcome of interest will be completed by June 2023. CONCLUSIONS: PRIDE iM will confirm, reject, or uncover the presence of potential relationships between social media interactions and behaviors and depressive symptoms among SGM people. This study represents fundamental groundwork to develop social media-based interventions that target modifiable interactions and behaviors that are most likely to influence mental health outcomes, thus seizing the opportunity to merge the popularity of this medium among SGM people with evidence-based approaches. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43627.

Testing persuasive messaging to encourage COVID-19 risk reduction.

What types of public health messages are effective at changing people's beliefs and intentions to practice social distancing to slow the spread of COVID-19? We conducted two randomized experiments in summer 2020 that assigned respondents to read a public health message and then measured their beliefs and behavioral intentions across a wide variety of outcomes. Using both a convenience sample and a pre-registered replication with a nationally representative sample of Americans, we find that a message that reframes not social distancing as recklessness rather than bravery and a message that highlights the need for everyone to take action to protect one another are the most effective at increasing beliefs and intentions related to social distancing. These results provide an evidentiary basis for building effective public health campaigns to increase social distancing during flu pandemics.

Persuasive messaging to increase COVID-19 vaccine uptake intentions.

Widespread vaccination remains the best option for controlling the spread of COVID-19 and ending the pandemic. Despite the considerable disruption the virus has caused to people's lives, many people are still hesitant to receive a vaccine. Without high rates of uptake, however, the pandemic is likely to be prolonged. Here we use two survey experiments to study how persuasive messaging affects COVID-19 vaccine uptake intentions. In the first experiment, we test a large number of treatment messages. One subgroup of messages draws on the idea that mass vaccination is a collective action problem and highlighting the prosocial benefit of vaccination or the reputational costs that one might incur if one chooses not to vaccinate. Another subgroup of messages built on contemporary concerns about the pandemic, like issues of restricting personal freedom or economic security. We find that persuasive messaging that invokes prosocial vaccination and social image concerns is effective at increasing intended uptake and also the willingness to persuade others and judgments of non-vaccinators. We replicate this result on a nationally representative sample of Americans and observe that prosocial messaging is robust across subgroups, including those who are most hesitant about vaccines generally. The experiments demonstrate how persuasive messaging can induce individuals to be more likely to vaccinate and also create spillover effects to persuade others to do so as well. The first experiment in this study was registered at clinicaltrials.gov and can be found under the ID number NCT04460703. This study was registered at Open Science Framework (OSF) at: https://osf.io/qu8nb/?view_only=82f06ecad77f4e54b02e8581a65047d7.

Timing of COVID-19 vaccine approval and endorsement by public figures.

The global spread of COVID-19 has created an urgent need for a safe and effective vaccine. However, in the United States, the politicization of the vaccine approval process, including which public figures are endorsing it, could undermine beliefs about its safety and efficacy and willingness to receive it. Using a pair of randomized survey experiments, we show that announcing approval of a COVID-19 vaccine one week before the presidential election compared to one week after considerably reduces both beliefs about its safety and efficacy and intended uptake. However, endorsement by Dr. Anthony Fauci increases confidence and uptake among all partisan subgroups. Further, an endorsement by Dr. Fauci increased uptake and confidence in safety even if a vaccine receives pre-election approval. The results here suggest that perceptions of political influence in COVID-19 vaccine approval could significantly undermine the viability of a vaccine as a strategy to end the pandemic.

The Politics of Taxes for Health: An Analysis of the Passage of the Sugar-Sweetened Beverage Tax in Mexico.

This article explores the politics of passage of the sugar-sweetened beverage (SSB) tax in Mexico, using published documents, media articles, and interviews with key stakeholders. The article examines first the period of agenda setting when the tax was included in the President's fiscal reform package; and second, the period of legislative passage, when the bill was introduced in Congress and was passed. The analysis uses Kingdon's three streams theory of agenda setting, to explain how the tax emerged on the agenda and how agenda setting shaped and enabled legislative passage. The article offers five lessons related to the politics of passing the SSB tax in Mexico. First, passing an SSB tax was difficult and required high-level organization, cooperation, planning, and effort. Second, supporters needed an understanding of how to manage the political and economic context, facilitated by a grant from Bloomberg Philanthropies. Third, framing the tax as generating revenue helped get the proposal onto the policy agenda and enabled buy-in from the powerful Ministry of Finance (Hacienda). Fourth, forming networks within the legislature early on allowed tax proponents to have a network of allies within Congress ready when the SSB tax was introduced as a bill. Finally, early public relations campaigns helped shape public perception that Mexico's obesity epidemic was driven in part by SSB consumption. This is the first paper that uses political science theory and primary data collection and interviews with a broad range of stakeholders, to explain how Mexico passed an SSB tax despite opposition from a strong national SSB industry.

Distributional health and financial benefits of increased tobacco taxes in Colombia: results from a modelling study.

BACKGROUND: In Colombia, smoking is the second leading modifiable risk factor for premature mortality. In December 2016, Colombia passed a major tax increase on tobacco products in an effort to decrease smoking and improve population health. While tobacco taxes are known to be highly effective in reducing the prevalence of smoking, they are often criticised as being regressive in consumption. This analysis attempts to assess the distributional impact (across socioeconomic groups) of the new tax on selected health and financial outcomes. METHODS: This study builds on extended cost-effectiveness analysis methods to study the new tobacco tax in Colombia, and estimates, over a time period of 20 years and across income quintiles of the current urban population (80% of the country population), the years of life gained with smoking cessation and the increased tax revenues, all associated with a 70% relative price increase of the pack of cigarettes. Where possible, we use parameters that vary by income quintile, including price elasticity of demand for cigarettes (average of -0.44 estimated from household survey data). FINDINGS: Over 20 years, the tax increase would lead to an estimated 191 000 years of life gained among Colombia's current urban population, with the largest gains among the bottom two income quintiles. The additional annual tax revenues raised would amount to about 2%-4% of Colombia's annual government health expenditure, with the poorest quintiles bearing the smallest tax burden increase. CONCLUSIONS: The tobacco tax increase passed by Colombia has substantial implications for the country's population health and financial well-being, with large benefits likely to accrue to the two poorest quintiles of the population.

Non-technical health care quality and health system responsiveness in middle-income countries: a cross-sectional study in China, Ghana, India, Mexico, Russia, and South Africa.

BACKGROUND: While there is increasing recognition that the non-technical aspects of health care quality - particularly the inter-personal dimensions of care - are important components of health system performance, evidence from population-based studies on these outcomes in low- and middle-income countries is sparse. This study assesses these non-technical aspects of care using two measures: health system responsiveness (HSR), which quantifies the degree to which the health system meets the expectations of the population, and non-technical health care quality (QoC), for which we 'filtered out' these expectations. Pooling data from six large middle-income countries, this study therefore aimed to determine how HSR and QoC vary between countries and by individuals' sociodemographic characteristics within countries. METHODS: We pooled individual-level data, collected between 2007 and 2010, from nationally representative household surveys of (primarily) adults aged 50 years and older in China, Ghana, India, Mexico, Russia, and South Africa. The outcome measure was a binary indicator for a 'bad' rating (HSR: "very bad" or "bad" on a five-point Likert scale; QoC: a worse rating of one's own visit than that of the character in an anchoring vignette) on at least one of seven dimensions for the most recent primary care visit. RESULTS: 23 749 adults who reported to have sought primary care during the preceding 12 months were includedin the analysis. The proportion of participants who gave a bad rating for their last primary care visit on at least one of seven dimensions varied from 4.3% (95% confidence interval (CI) = 2.8-6.7) in China to 33.1% (95% CI = 23.6-44.2) in South Africa for HSR, and from 17.0% (95% CI = 11.4-24.5) in Russia to 50.8% (95% CI = 46.0-55.6) in Ghana for QoC. There was a strong negative association between increasing household wealth and both bad HSR and QoC in India and South Africa. CONCLUSIONS: Achieving universal health coverage (UHC) with good-quality health services ("effective UHC") will require efforts to improve HSR and QoC across the population in Ghana and South Africa. Additionally, a particular focus on raising HSR and QoC for the poorest population groups is needed in India and South Africa.