Evaluating the Effectiveness of the Nudge Theory in Improving the Oral Self-Care of Schoolchildren with Refugee and Immigrant Backgrounds in Mashhad, Iran.

Nudge theory proposes using subtle interventions to encourage individuals to make better decisions. The aim of this study was to evaluate the effectiveness of the Nudge theory in plaque control and assess caries experience among third-grade primary schoolchildren with refugee and immigrant backgrounds in Mashhad, Iran. Moreover, Afghan and Iranian schoolchildren were compared to assess differences in oral health outcomes. A quasi-experimental field trial was conducted in three public primary schools, comprising 309 participants approximately 9 years old. Interventions were randomly assigned to three schools: School I Messages based on Social Norms (MSN), School II Messages based on Fear of Negative Outcome (MFNO), and School III control group (C). MSN and MFNO received customized motivational video clips at baseline, while C only received Oral hygiene instruction (OHI). All participants received OHI, a brush, and toothpaste. Baseline plaque index (PI) and caries experience in primary and permanent dentition (dmft/DMFT) were recorded. PI was reassessed at two weeks, two months, and six months post-intervention. All data were subjected to statistical analysis. The mean PI decreased significantly in all three groups at the two-week follow-up (p < 0.01). The PI improvements declined over a six-month follow-up period in all groups, and the mean PI difference after six months compared to the pre-intervention was significant only in MSN and MFNO (p < 0.01), while C reverted almost to the pre-study level. Schoolchildren with at least one filled tooth or Iranian nationality showed a greater PI reduction (p < 0.01, p = 0.05). The overall mean ± SD dmft and DMFT were 4.24 ± 2.11 and 1.70 ± 1.24, respectively. Among all the examined participants, 32 (10.40%) individuals were caries-free. The mean dmft was statistically significantly higher in Afghan children than in Iranians (p = 0.01). MSN was more effective on PI reduction in the short term, while MFNO was more long-lasting. Using the Nudge theory via visual aids was more effective in motivating children to perform better oral self-care than solely traditional OHI.

Mitigating the influence of message features on health misinformation sharing intention in social media: Experimental evidence for accuracy-nudge intervention.

RATIONALE: The escalating dissemination of health misinformation on social media platforms poses a significant threat to users' well-being. It is imperative to identify the types of health misinformation that are more susceptible to widespread dissemination and to explore strategies to curb its spread. METHOD: This study designed a 2 (emotional appeal type: positive vs. negative) × 2 (fabricated source type: pseudo-common vs. pseudo-authoritative) × 2 (accuracy-nudge label: No vs. Yes) online between-subjects experiment controlling for factors such as e-health literacy, prior sharing experience, and personal involvement. A snowball sampling approach was used to recruit 1952 participants through social media, resulting in a final sample of 1393 valid responses. RESULTS: Compared to positive emotional appeal and pseudo-common sources, negative emotional appeal and pseudo-authoritative sources resulted in higher levels of sharing intention. Under the condition of negative emotional appeal, the promotion effect of pseudo-authoritative sources on sharing intention was intensified. The accuracy-nudge intervention could significantly mitigate this tendency. The underlying mechanisms revealed more details: both negative emotional appeals and pseudo-authoritative sources increased the perceived credibility of health misinformation, thereby increasing users' sharing intention. However, in contrast to pseudo-authoritative sources, excessive negative emotional appeal induced vigilant verification behavior among users, which reduced sharing to some extent. Adding an accuracy-nudge label to health misinformation reduced users' misguided trust in health misinformation features and stimulated information verification, ultimately reducing health misinformation sharing intention. CONCLUSIONS: Negative emotional appeal and pseudo-authoritative sources can enhance the perceived credibility of health misinformation, thereby strengthening the sharing intention of social media users. Therefore, health misinformation with negative emotional appeal and pseudo-authoritative sources is more likely to be widely shared. The accuracy nudge intervention can trigger users' information verification behavior, suppress the persuasive effects of the misinformation features mentioned above, and help prevent the spread of health misinformation on social media.

Using Children's Artwork to Improve Adherence with Timely Antibiotic Administration in Open Fractures.

Introduction: Antibiotics for open fractures (OFs) administered within 60 min of emergency department (ED) arrival reduce patients' infection risk. We tested a novel method of displaying children's drawings to prompt clinicians to improve adherence with early antibiotics for OFs. Methods: Registry-based pre- (January 1, 2016-June 30, 2019) and post- (July 1, 2019-March 31, 2022) intervention at a level 1 trauma center. In July 2019, children's artwork depicting OF was displayed in the ED alongside OF guidelines and E-mailed to faculty and residents. Primary outcome: proportion of OF patients who received antibiotics within 60 min of arrival. Time to antibiotics was calculated from ED arrival to time-stamped administration in the electronic health record. We compared time to antibiotics as continuous variables between the two groups. Proportions are presented with percentages and 95% confidence interval (CI); continuous variables as median and quartiles. Chi-square or Mann-Whitney U-tests were used for group comparisons. Results: Five hundred fifty-four total OF patients were identified (excluded: transferred = 1, ED death = 4, unclear time to antibiotics = 11); 281 pre-implementation and 257 post-implementation. The median age was 34 years (quartiles 24 and 46). Trauma mechanisms of injury included 300 blunt (56%) and 238 penetrating (44%). Gustilo OF classification by type were as follows: 71% I, 13% II, 15% III, 1% unclassified. There was a significant difference (P = 0.001) in both percentage of patients who received antibiotics within 60 min (58%, 95% CI, 52%-63% vs. 79%, 95% CI, 74%-84%) and time to antibiotics (median: 46 min vs. 25 min) between pre- and postphases, respectively. Conclusions: Children's artwork in our ED improved adherence with OF guidelines and decreased time to antibiotics.

You can't nudge into vaccination: Comparing the effects of nudge types and Covid-19 vaccination attitudes on vaccine willingness.

Nudges can be an effective strategy to promote vaccination. However, it is necessary to better identify the characteristics of nudges that produce the strongest effects and how they interact with individuals' attitudes. Here we sequentially test the effectiveness of three nudge characteristics (framing, nudge type, and presentation modality) and the role of participants' attitudes toward Covid-19 vaccination, social solidarity and authoritarianism in vaccination decisions. In studies 1-4, participants were presented with a nudge manipulating a target characteristic (e.g. positive/negative framing, nudge type) and measuring willingness to vaccinate and related variables compared a control nudge. Study 5 used a single combined nudge reflecting the combination of successful nudges in previous studies. Results over all studies show that nudging has unreliable effects while vaccine attitudes are more reliably linked to all measures of vaccines willingness. These results suggest that attitudes play a more reliable role on effective adoption of vaccinations.

Effects of Nudge Strategy-Based Dietary Education Intervention in Patients with Type 2 Diabetes Mellitus: A Cluster Randomized Controlled Trial.

OBJECTIVES: We aimed to assess the clinical effects of dietary education intervention utilizing the nudge strategy in individuals with type 2 diabetes mellitus (T2DM). BACKGROUND: The global prevalence of T2DM and its associated complications presents a significant health challenge. While the benefits of dietary education intervention for blood glucose management are widely acknowledged, patients often struggle to adhere to dietary recommendations. The implementation of the nudge strategy may offer a promising solution to change unhealthy dietary behavior and enhance diabetes control among individuals with T2DM. METHODS: This is a sub-study within a broader cluster-randomized trial that evaluated the effects of nudge-based dietary education and traditional dietary education intervention. Measurements of HbA1c, fasting blood glucose (FBG), body mass index (BMI), blood lipid levels, blood pressure, dietary behavior, and diabetes distress were assessed at baseline and 3 months after the intervention in 147 individuals with T2DM from six primary care practices in Beijing, China. RESULTS: All outcome measurements were complete at two time points for 134 participants. Results showed that compared to the control group, the intervention group achieved a significantly greater reduction in HbA1c, FBG, BMI, total cholesterol, low-density lipoprotein cholesterol, blood pressure, total energy intake, carbohydrate intake, fat intake, and protein intake and had lower diabetes distress. The intervention group also maintained HDL-C levels and had a significantly greater increase in vegetable intake, while changes in triglycerides were similar in the two groups . CONCLUSION: The present study provides evidence that nudge strategy-based dietary education intervention is effective in improving blood glucose, BMI, blood lipid levels, and blood pressure and facilitating changes in patients' dietary behavior and diabetes distress. These findings suggest that implementing nudge strategies can contribute to the optimization of T2DM dietary management and overall patient well-being.

Nurse-led sequential multiple assignment randomized trial of nudging intervention for early antiretroviral therapy initiation among patients with HIV/AIDS: Implementation study protocol.

AIMS: In China, more than 30% of patients have not initiated treatment within 30 days of HIV diagnosis. Delayed initiation has a detrimental influence on disease outcomes and increases HIV transmission. The study aims to evaluate the effectiveness of a nurse-led antiretroviral therapy initiation nudging intervention for people newly diagnosed with HIV in China to find the optimal intervention implementation strategy. METHODS: A Hybrid Type II sequential multiple assignment randomized trial will be conducted at four Centers for Disease Control and Prevention in Hunan, China. This study will recruit 447 people newly diagnosed with HIV aged ≥18 years and randomly assign them into two intervention groups and one control group. On top of the regular counselling services and referrals, intervention groups will receive a 4-week, 2-phase intervention based on the dual-system theory and the nudge theory. The control group will follow the currently recommended referral procedures. The primary outcomes are whether treatment is initiated, as well as the length of time it takes. The study outcomes will be measured at the baseline, day 15, day 30, week 12, week 24 and week 48. Generalized estimating equations and survival analysis will be used to compare effectiveness and explore factors associated with antiretroviral therapy initiation. Both qualitative and quantitative information will be collected to assess implementation outcomes. DISCUSSION: Existing strategies mostly target institutional-level factors, with little consideration given to patients' decision-making. To close this gap, we aim to develop an effective theory-driven nudging strategy to improve early ART initiation. IMPACT: This nurse-led study will help to prevent delayed initiation by employing implementation science strategies for people newly diagnosed with HIV. This study contributes to the United Nations' objective of ending the AIDS pandemic by 2030. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2300070140. The trial was prospectively registered before the first participant was recruited. PATIENT AND PUBLIC INVOLVEMENT: The nudging intervention was finalized through the Nominal Group Technique where we invited five experts in the related field and five people living with HIV to participate.

Nudging against consent is effective but lowers welfare.

Behavioural nudges are often criticised because they "work best in the dark". However, recent experimental evidence suggests that the effectiveness of nudges is not reduced when they are delivered transparently. Most people also endorse transparent nudges. Yet, transparent nudging may undermine human autonomy-a minority may oppose to being nudged and feel manipulated, even if they know what is happening. We propose an alternative way of maintaining autonomy that is not reducible to transparency: individuals can be asked if they consent in advance to being nudged. To assess whether consensual nudges are effective, we ask consent from 1518 UK citizens to be nudged. Subsequently, we default all participants into donating to a charity of their choice, irrespective of self-reported consent. We find that the default nudge is equally effective for both consenting and non-consenting individuals, with negligible difference in average donations. However, non-consenting individuals report higher levels of resentment and regret and lower levels of happiness and support compared to the consenting group. Based on these findings, we argue that ignoring consent can have serious ethical ramifications for policy-making with nudges.

Bridging the Gap in United Nations Environment Programme's Report: The Potential of Nudges to Reduce Plastic Pollution and Health Risks.

Plastic pollution is increasingly becoming a threatening problem worldwide, with highlighted health risks associated with plastic waste incineration. Among the immediate measures to address this problem, proper recycling of polyethylene terephthalate (PET) bottles is a pertinent strategy. Considering the urgent need for administrative-led reforms, we assessed the separation rates of PET bottle caps and labels by 125 administrative staff in a government office of a prefectural in Japan during a four-day period; only 59.3% (48/81) of the pet bottles had both caps and labels removed and properly separated to each trash can. One potential solution for the low separation rate is the use of nudges, which are effective methods for promoting behaviors such as healthy actions. Since both health and environmentally conscious behaviors involve choices across different time points, leveraging insights from nudges developed in the field of health behavior to environmental behaviors is considered crucial, even from a health promotion perspective.

Nudge theory and gambling: a scoping review.

Background: Gambling disorder (GD) is a pressing public health concern with significant societal costs. The recently developed nudge theory, which is rooted in behavioral economics, aims to influence the decision-making behaviors of individuals by implementing changes in the environment. Aim: This scoping review aims to synthesize the literature on nudge theory as it relates to gambling. Methods: This scoping review accords with the Arksey and O'Malley framework, as refined by Levac et al. It includes only articles from peer-reviewed journals that focus, as main themes, on both nudge theory and gambling. The final study selection includes six articles. Results: The scoping review process led to studies explaining how (1) nudges aim to prod people toward healthier gambling choices, fostering the adoption of more responsible gambling practices, and (2) some gambling features, called dark nudges (or sludges), exploit and harm the decision-making processes of people who gamble. Conclusion: This scoping review highlights the fact that many stakeholders are involved in the field of gambling, and that better cooperation between them would promote safer and more responsible gambling practices. Future research is also needed to empirically test nudges to develop a better understanding of their impact on those who gamble.

Self-management behavior strategy based on behavioral economics in patients with hypertension: a scoping review.

Hypertensive patients often do not make the most favorable choices and behaviors for managing disease. Behavioral economics strategies offer new ideas for guiding patients toward health behavior. The scoping review aimed to summarize behavioral economics strategies designed to improve hypertension self-management behaviors. A literature search was conducted in September 2022 using the following electronic databases: Embase, Medline, CINAHL, PsycINFO, Web of Science, Cochrane Library, CNKI, Wan Fang Database for Chinese Periodicals, and CBM-SinoMed. We screened the literature for experimental studies written in Chinese or English reporting on BE strategies designed to improve self-management behavior in hypertension. We searched 17 820 records and included 18 articles in the final scoping review. We performed qualitative synthesis by the categories of choice architecture. The most common BE strategies were those targeting decision information and decision assistance, such as changing the presentation of information, making information visible, and providing reminders for actions. Most strategies targeted BP, diet, medication adherence, and physical activity behavior. Ten out of 18 studies reported statistically significant improvement in self-management behavior. Further research on BE strategies should focus on addressing the challenges, including changing the decision structure, encompassing a more comprehensive range of target behaviors, and examining the long-term effects of BE strategies.

Self-management of hypertension is a long-term effort, but people often make bounded rational decisions and act in ways that deviate from health goals. Behavioral Economics (BE) strategies make small changes in the decision-making environment to alter choices, steering individuals' behavior consistent with their goals or preferences. We summarized the BE strategies to improve self-management behavior in hypertension and described the study results using the categories of choice architecture. We found that the most widely used BE strategy is changing the presentation of information in the decision-making environment. Most BE strategies positively affect the target behaviors, which have the potential of BE strategies to enhance self-management behavior for hypertension. Further research is needed to identify the origins of these strategies, modify decision-making structures, and incorporate a broader range of health behaviors to showcase the practicality and sustainability of implementing BE strategies.

Health or environment? Understanding which informative message is more effective in replacing red meat with mushroom-based alternatives.

Current concerns regarding the health and environmental consequences associated with excessive meat consumption have underscored the importance of guiding consumers towards more sustainable diets. Given this perspective, this study seeks to evaluate the effectiveness of tailored informative messages in shaping consumer behaviour, particularly within the framework of replacing meat with mushroom-based alternatives. Additionally, it explores the factors influencing informative message effectiveness. An experimental online survey was conducted on a sample of 951 Italian consumers. Specifically, the sample was divided into three groups, of which 309 individuals formed the control group, 311 participants received informative messages on the health risks associated with red meat consumption, and 331 participants received informative messages emphasizing the environmental damages linked to red meat consumption. In both treatments, there was support for mushroom-based alternatives. Analyses included subgroup assessments, tests to verify treatments effectiveness, along with OLS regression to pinpoint variables influencing message effectiveness. The results underscore a fair positive impact of the two informative messages (mean scores: 8.75 for health message; 7.01 for environmental message). Noteworthy psychosocial variables, including lifestyle patterns, nutritional perceptions, and ecological attitudes, emerged as determinants in shaping consumers' food choices. While health-related messages exhibit marked influence, the nuanced landscape of diverse drivers and barriers necessitates judicious communication strategies. These insights bear significance for policymakers, health professionals, and marketers, offering guidance for interventions that effectively influence consumer behaviour toward more sustainable and healthier food practices.

Using the Australian Dietary Guidelines 2&5 education message in supermarket shopping trolleys to nudge shoppers to purchase more fruit and vegetables: A feasibility study using an intervention design.

Fruit and vegetable (F&V) consumption is associated with a reduced risk of developing chronic diseases; however, only one in 16 Australian adults consume F&Vs at the recommended two servings of fruit and five servings of vegetables per day. What and how much people eat is influenced by their social and physical environments. Supermarkets are a key setting influencing food purchases, and as such, they can shape consumption patterns of F&Vs. Implementing effective strategies to increase F&V intake is crucial. The objective of this research was to test the feasibility of modifying shopper purchasing behaviour to purchase more F&Vs using the Australian Dietary Guidelines 2&5 education message covering one-half of the base of shopping trolleys. Placards giving the message that eating 2 fruits and 5 vegetables every day for good health were placed at the base of shopping trolleys as an educational nudge. Applying an intervention research design, 30 out of ~100 trolleys were fitted with the placards and shopper purchases were measured by collecting paper sales receipts to measure the weight (kg), total spending and F&V-specific spending (Australian dollars) for intervention versus control trolleys for one Saturday. We also conducted a short intercept survey that was administered independently from the research study day on non-trial shoppers. Shoppers who selected trolleys with the 2&5 education nudge placards (n = 101) purchased 1.66 kg less weight of F&Vs (Intervention: mean = 3.89 kg, SD = 3.40 kg, 95% CI = 3.21 kg, 4.56 kg, vs. Control: mean 5.55 kg, SD = 4.16 kg, 95% CI = 4.73 kg, 6.37 kg, p = 0.002) and spent less on F&Vs compared to shoppers in the control group (n = 102; Intervention: mean = $26.00, SD = $21.60, 95% CI = $21.78, $30.32 vs. Control: mean $36.00, SD = $27.00, 95% CI = $30.72, $42.36, p = 0.004). Intervention group shoppers also spent less in total spending between groups (Intervention: mean = $115.40, SD = $68.30, 95% CI = $101.95, $128.95 vs. Control: mean $151.30, SD = $79.40, 95% CI = $135.73, $166.93, p = 0.001). The 2&5 education nudge placard had the opposite effect as intended on shoppers' purchases to buy more F&Vs, although there may have been other differences between the intervention and the control groups since they were not randomised. Larger studies are required to elucidate and confirm these findings over the longer term.

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.

Stimulating Preconception Care Uptake by Women With a Vulnerable Health Status Through a Mobile Health App (Pregnant Faster): Pilot Feasibility Study.

BACKGROUND: A low socioeconomic status is associated with a vulnerable health status (VHS) through the accumulation of health-related risk factors, such as poor lifestyle behaviors (eg, inadequate nutrition, chronic stress, and impaired health literacy). For pregnant women, a VHS translates into a high incidence of adverse pregnancy outcomes and therefore pregnancy-related inequity. We hypothesize that stimulating adequate pregnancy preparation, targeting lifestyle behaviors and preconception care (PCC) uptake, can reduce these inequities and improve the pregnancy outcomes of women with a VHS. A nudge is a behavioral intervention aimed at making healthy choices easier and more attractive and may therefore be a feasible way to stimulate engagement in pregnancy preparation and PCC uptake, especially in women with a VHS. To support adequate pregnancy preparation, we designed a mobile health (mHealth) app, Pregnant Faster, that fits the preferences of women with a VHS and uses nudging to encourage PCC consultation visits and engagement in education on healthy lifestyle behaviors. OBJECTIVE: This study aimed to test the feasibility of Pregnant Faster by determining usability and user satisfaction, the number of visited PCC consultations, and the course of practical study conduction. METHODS: Women aged 18-45 years, with low-to-intermediate educational attainment, who were trying to become pregnant within 12 months were included in this open cohort. Recruitment took place through social media, health care professionals, and distribution of flyers and posters from September 2021 until June 2022. Participants used Pregnant Faster daily for 4 weeks, earning coins by reading blogs on pregnancy preparation, filling out a daily questionnaire on healthy lifestyle choices, and registering for a PCC consultation with a midwife. Earned coins could be spent on rewards, such as fruit, mascara, and baby products. Evaluation took place through the mHealth App Usability Questionnaire (MAUQ), an additional interview or questionnaire, and assessment of overall study conduction. RESULTS: Due to limited inclusions, the inclusion criterion "living in a deprived neighborhood" was dropped. This resulted in the inclusion of 47 women, of whom 39 (83%) completed the intervention. In total, 16 (41%) of 39 participants visited a PCC consultation, with their main motivation being obtaining personalized information. The majority of participants agreed with 16 (88.9%) of 18 statements of the MAUQ, indicating high user satisfaction. The mean rating was 7.7 (SD 1.0) out of 10. Points of improvement included recruitment of the target group, simplification of the log-in system, and automation of manual tasks. CONCLUSIONS: Nudging women through Pregnant Faster to stimulate pregnancy preparation and PCC uptake has proven feasible, but the inclusion criteria must be revised. A substantial number of PCC consultations were conducted, and this study will therefore be continued with an open cohort of 400 women, aiming to establish the (cost-)effectiveness of an updated version, named Pregnant Faster 2. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/45293.

How do opt-in versus opt-out settings nudge patients toward electronic health record adoption? An exploratory study of facilitators and barriers in Austria and France.

BACKGROUND: Electronic health records (EHR) are becoming an integral part of the health system in many developed countries, though implementations and settings vary across countries. Some countries have adopted an opt-out policy, in which patients are enrolled in the EHR system following a default nudge, while others have applied an opt-in policy, where patients have to take action to opt into the system. While opt-in systems may exhibit lower levels of active user requests for access, this contrasts with opt-out systems where a notable percentage of users may passively retain access. Thus, our research endeavor aims to explore facilitators and barriers that contribute to explaining EHR usage (i.e., actively accessing the EHR system) in two countries with either an opt-in or opt-out setting, exemplified by France and Austria. METHODS: A qualitative exploratory approach using a semi-structured interview guideline was undertaken in both countries: 1) In Austria, with four homogenously composed group discussions, and 2) in France, with 19 single patient interviews. The data were collected from October 2020 to January 2021. RESULTS: Influencing factors were categorized into twelve subcategories. Patients have similar experiences in both countries with regard to all facilitating categories, for instance, the role of health providers, awareness of EHR and social norms. However, we highlighted important differences between the two systems regarding hurdles impeding EHR usage, namely, a lack of communication as well as transparency or information security about EHR. CONCLUSION: Implementing additional safeguards to enhance privacy protection and supporting patients to improve their digital ability may help to diminish the perception of EHR-induced barriers and improve patients' health and commitment in the long term. PRACTICAL IMPLICATIONS: Understanding the differences and similarities will help to develop practical implications to tackle the problem of low EHR usage rates in the long run. This problem is prevalent in countries with both types of EHR default settings.

Hand hygiene compliance in nursing home wards: The effects of feedback with lights on alcohol-based hand rub dispensers.

BACKGROUND: Hand hygiene (HH) among health care workers (HCWs) is crucial in preventing infections in nursing homes. However, HH compliance (HHC) among HCWs remains low. This study aimed to investigate the effect of feedback lights on HCWs' HHC. METHODS: A 5-month interventional study was conducted in 3 wards in a nursing home in Denmark. During the intervention period, a green light with a smiley appeared on the alcohol-based hand rub (ABHR) dispensers when HCWs used the ABHR, acknowledging HCWs for using the ABHR. HHC was monitored using an automatic HH monitoring system (AHHMS). RESULTS: A total of 64 HCWs were enrolled. The AHHMS collected 23,696 HH opportunities in apartments and dirty utility rooms. Overall, HHC in the apartments increased from 50% at baseline (95% CI: 48, 53) to 56% (95% CI: 54, 58) during the intervention. However, the increased HHC level was not sustained during follow-up. CONCLUSIONS: The AHHMS enabled the assessment of the intervention. We found a significant effect of light-guided feedback in the apartments. However, the increased HHC was not sustained after the light was switched off.

How does the frame of communication affect cancer patients' decisions?-from a behavioral economics point of view.

BACKGROUND: It has been said that physicians should provide their patients with accurate evidence in terms of information on treatment options. However, in some cases, although the physician provides accurate and sufficient information, the patient still chooses the medically not-recommended treatment. The purpose of this research is to clarify how patients' decisions differ when a physician changes the frame of an explanation when he/she provides information about cancer treatment. METHODS: An online questionnaire survey was conducted in March 2017. Through the aid of a survey company, we emailed questionnaires to 1,360 cancer patients who received treatment within the last 2 years. We randomly assigned participants to 6 hypotheticals scenario of a terminal cancer patient, and presented hypothetical evidence in different ways. Subsequently, we asked survey participants whether they would choose to receive additional anti-cancer treatment. RESULTS: Although there was no statistically significant difference between scenarios, the "social burden" groups showed a lower rate of patients who preferred to continue a medically ineffective anti-cancer treatment than the control group, at a 10% significance level. The scenario significantly affected the patients' sense of abandonment [F(5, 1,354)=5.680, P<0.001], sense of distress [F(5, 1,354)=3.920, P=0.002], and necessity of improvement [F(5, 1,354)=2.783, P=0.017]. CONCLUSIONS: Nudges were not shown to be effective in situations where discontinuation of anticancer treatment was being considered. On the other hand, some nudges were found to be invasive and should be used with caution.

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.

Anti-Herpes Zoster Vaccination of Fragile Patients in Hospital Setting: A Nudge Intervention in Italy.

BACKGROUND: A nudge intervention against Herpes Zoster, created and implemented in Italy, is presented in order to administer the Shingrix vaccine on a sample of frail patients, as required by the National Prevention Plan. Individual and contextual factors associated with vaccine adherence were investigated. METHOD: 300 frail adult subjects underwent a full vaccine cycle with recombinant-Shingrix vaccine (RZV vaccine). Hospital Presidia of the Salerno University Hospital Authority, a Hospital Presidium of the Salerno Local Health Authority, and the Public Health Laboratory of the University of Salerno (Campania) participated in the intervention. An ad hoc questionnaire was administered with the following scales: EQ-5D, PSS-10, MSPSS, and representations of HZ and its consequences. RESULTS: Some variables, such as peer support, doctor-patient relationship, level of education, and perception of health, are important in vaccine adherence and information processing. The following factors emerged from the factor analysis: Trust in collective knowledge and collective responsibility (F1); beliefs about virus risk and vaccine function (F2); information about virus and symptomatology (F3); and vaccine distrust (F4). Factor 4 correlates negatively with social support indices (R = -0.363; p < 0.001). There is a significant relationship between factor 3 and satisfaction with national information campaigns (F = 3.376; gdl = 5; p-value = 0.006). CONCLUSIONS: Future vaccination campaigns should be built with the aim of personalizing information and developing contextualized strategies, starting from understanding the stakeholders involved, cultural contexts, and organizational settings.

Tailored Prompting to Improve Adherence to Image-Based Dietary Assessment: Mixed Methods Study.

Background: Accurately assessing an individual's diet is vital in the management of personal nutrition and in the study of the effect of diet on health. Despite its importance, the tools available for dietary assessment remain either too imprecise, expensive, or burdensome for clinical or research use. Image-based methods offer a potential new tool to improve the reliability and accessibility of dietary assessment. Though promising, image-based methods are sensitive to adherence, as images cannot be captured from meals that have already been consumed. Adherence to image-based methods may be improved with appropriately timed prompting via text message. Objective: This study aimed to quantitatively examine the effect of prompt timing on adherence to an image-based dietary record and qualitatively explore the participant experience of dietary assessment in order to inform the design of a novel image-based dietary assessment tool. Methods: This study used a randomized crossover design to examine the intraindividual effect of 3 prompt settings on the number of images captured in an image-based dietary record. The prompt settings were control, where no prompts were sent; standard, where prompts were sent at 7:15 AM, 11:15 AM, and 5:15 PM for every participant; and tailored, where prompt timing was tailored to habitual meal times for each participant. Participants completed a text-based dietary record at baseline to determine the timing of tailored prompts. Participants were randomized to 1 of 6 study sequences, each with a unique order of the 3 prompt settings, with each 3-day image-based dietary record separated by a washout period of at least 7 days. The qualitative component comprised semistructured interviews and questionnaires exploring the experience of dietary assessment. Results: A total of 37 people were recruited, and 30 participants (11 male, 19 female; mean age 30, SD 10.8 years), completed all image-based dietary records. The image rate increased by 0.83 images per day in the standard setting compared to control (P=.23) and increased by 1.78 images per day in the tailored setting compared to control (P≤.001). We found that 13/21 (62%) of participants preferred to use the image-based dietary record versus the text-based dietary record but reported method-specific challenges with each method, particularly the inability to record via an image after a meal had been consumed. Conclusions: Tailored prompting improves adherence to image-based dietary assessment. Future image-based dietary assessment tools should use tailored prompting and offer both image-based and written input options to improve record completeness.