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In October 2021, Emergency Use Authorization of Coronavirus Disease 2019 (COVID-19) vaccines was granted for children aged 5-11. To ensure vaccine uptake in children upon approval, California will implement a state-wide executive order mandating COVID-19 vaccination for school children following full US FDA approval. This study uses survey data collected between November 6th, 2020 and December 14th, 2020 (n = 2091) to identify how sociodemographic characteristics and attitudes towards childhood vaccines among California parents were associated with their intentions to vaccinate their child against COVID-19. About one quarter (26 %) of surveyed California parents did not intend to vaccinate their child, suggesting skepticism towards the COVID-19 vaccine for children and the potential for pushback to a COVID-19 vaccine school-entry mandate. However, 17 % were unsure of their decision, suggesting the potential for public health messaging to make a positive impact on COVID-19 vaccine confidence and uptake. This study identifies characteristics of hesitant parents in California to prioritize for research and outreach. These data also provide a baseline for parental attitudes towards vaccinating children against COVID-19 in California, which will be useful for characterizing changes in attitudes towards childhood COVID-19 vaccination over time.

To evaluate the impact of a peer-referral and clinic welcome programme for reducing barriers to adolescents' uptake of family planning services in Uganda.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.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.A behavioural change intervention designed to target identified barriers can increase adolescents' uptake of family planning counselling and services.Évaluer dans quelle mesure un programme d'accueil clinique basé sur l'orientation confraternelle peut contribuer à surmonter les obstacles à l'adoption des services de planification familiale chez les adolescents en Ouganda.Nous avons mis au point une intervention en nous aidant du design comportemental, puis avons mené une évaluation randomisée contrôlée et stratifiée de cette intervention chez les jeunes filles âgées de 15 à 19 ans. Plusieurs cliniques de santé sexuelle et reproductive ont été réparties aléatoirement dans un groupe de contrôle (56 cliniques) ou d'intervention (60 cliniques). Toutes les cliniques appartenant au second groupe ont reçu l'intervention de base (des ressources servant à créer un environnement adapté aux adolescents, ainsi que des cartes de référence à distribuer autour d'eux), tandis qu'un sous-groupe de cliniques a suivi une formation spécialisée dans la prise en charge des jeunes. Nous avons récolté les données courantes des cliniques relatives au nombre mensuel de visites effectuées par des adultes et adolescents sur une période initiale de 15 mois et une période d'intervention de 6 mois, entre 2018 et 2020.L'analyse de régression multivariée nous a permis de constater que le programme avait d'importantes répercussions sur les résultats primaires au sein du groupe d'intervention par rapport au groupe de contrôle. Le nombre mensuel moyen de visites effectuées par des adolescents a augmenté de 45% (rapport de taux d'incidence, RTI: 1,45; intervalle de confiance de 95%, IC: 1,14–1,85), l'équivalent d'au moins cinq patients adolescents supplémentaires par clinique chaque mois. Le pourcentage moyen d'adolescents sur l'ensemble des patients a connu une hausse de 5,3 points de pourcentage (IC de 95%: 0,02–0,09). Dans le groupe d'intervention, les cliniques ayant suivi une formation spécialisée dans la prise en charge des jeunes ont enregistré une progression spectaculaire de 62% (RTI: 1,62; IC de 95%: 1,21–2,17) auprès des patients adolescents, ce qui signifie que chaque clinique a accueilli au moins sept adolescents supplémentaires par mois, par rapport au groupe de contrôle.Une intervention induisant un changement de comportement, conçue dans le but de déjouer des obstacles clairement identifiés, peut favoriser l'adoption des services et consultations de planification familiale chez les adolescents.Evaluar el impacto de un programa de acogida en clínicas y de referencia entre pares para reducir las barreras que impiden adoptar los servicios de planificación familiar entre los adolescentes en Uganda.Se desarrolló una intervención mediante un diseño conductual y se llevó a cabo una evaluación aleatorizada, controlada y estratificada de la intervención en mujeres de 15 a 19 años. Las clínicas de salud sexual y reproductiva se dividieron de manera aleatoria en grupos de referencia (56 clínicas) y de intervención (60 clínicas). Todas las clínicas de intervención recibieron la intervención principal (materiales para crear un entorno amigable con los adolescentes y tarjetas de referencia para entregar a los amigos), mientras que un subconjunto de clínicas recibió además formación en la prestación de servicios adaptados a las necesidades de los jóvenes. Se recopilaron los datos rutinarios de las clínicas sobre el número de visitas mensuales de adultos y adolescentes durante un periodo basal de 15 meses y un periodo de intervención de 6 meses entre 2018 y 2020.En el análisis de regresión multivariante se encontraron efectos significativos de la intervención sobre los resultados primarios en el grupo de intervención agrupado en comparación con el de referencia. La media de visitas mensuales de los adolescentes aumentó en un 45 % (razón de tasas de incidencia, IRR: 1,45; intervalo de confianza del 95 %: IC: 1,14-1,85), es decir, más de cinco clientes adolescentes adicionales por clínica al mes. El porcentaje medio de adolescentes sobre el total de clientes mejoró en 5,3 puntos porcentuales (IC del 95 %: 0,02-0,09). Dentro de los grupos de tratamiento, las clínicas que recibieron la formación en la prestación de servicios adaptados a las necesidades de los jóvenes mostraron los efectos más fuertes: un aumento del 62 % (IRR: 1,62; IC del 95 %: 1,21-2,17) en los clientes adolescentes, es decir, más de siete adolescentes adicionales por clínica al mes, en relación con el grupo de referencia.Una intervención orientada al cambio de conducta, diseñada para abordar las barreras identificadas, puede hacer que los adolescentes acepten el asesoramiento y los servicios de planificación familiar.الغرض تقييم تأثير إحالة الأقران، وبرنامج الترحيب بالعيادة، لتقليل الحواجز التي تحول دون استيعاب المراهقين لخدمات تنظيم الأسرة في أوغندا. الطريقة قمنا بتطوير تدخل باستخدام التصميم السلوكي، وتنفيذ تقييم تدريجي عشوائي خاضع للتحكم للتدخل لدى الفتيات اللاتي تتراوح أعمارهن بين 15 و19 عامًا. تم ترتيب عيادات الصحة الجنسية والإنجابية بشكل عشوائي إلى مجموعة خاضعة للتحكم (56 عيادة)، ومجموعات للتدخل (60 عيادة). جميع عيادات التدخل تلقت التدخل الأساسي (مواد لإنشاء بيئة صديقة للمراهقين وبطاقات إحالة لمنحها للأصدقاء)، بينما تلقت مجموعة فرعية من العيادات بالإضافة إلى ذلك تدريباً على تقديم خدمة صديقة للشباب. قمنا بجمع البيانات الروتينية للعيادات حول الأعداد الشهرية للزيارات التي يقوم بها البالغون والمراهقون على مدى 15 شهرًا، وفترة تدخل مدتها 6 أشهر، خلال الفترة من 2018 إلى 2020. النتائج في تحليل للتحوف متعدد المتغيرات، وجدنا تأثيرات ملموسة للتدخل على النتائج الأولية في مجموعة التدخل المجمعة، مقارنةً بمجموعة التحكم. زاد متوسط الزيارات الشهرية بواسطة المراهقين بنسبة 45% (نسبة معدل وقوع الحالة (IRR): 1.45؛ وبفاصل ثقة مقداره 95%: 1.14 إلى 1.85)، أو أكثر من خمسة عملاء مراهقين إضافيين لكل عيادة شهريًا. تحسن متوسط نسبة المراهقين من إجمالي العملاء بمقدار 5.3 نقطة مئوية (وبفاصل ثقة مقداره 95%: 0.02 إلى 0.09). ضمن أذرع العلاج، أظهرت العيادات التي تتلقى التدريب في تقديم الخدمات الصديقة للشباب أقوى التأثيرات: زيادة بنسبة 62% (نسبة معدل وقوع الحالة IRR): 1.62)؛ ‏بفاصل ثقة 95%: 1.21 إلى 2.17) في العملاء المراهقين، أو أكثر من سبعة مراهقين إضافيين لكل عيادة شهريًا، بالنسبة لمجموعة التحكم. الاستنتاج يمكن أن يؤدي تدخل التغيير السلوكي، المصمم لاستهداف العوائق المحددة، إلى زيادة استيعاب المراهقين لاستشارات وخدمات تنظيم الأسرة.旨在评估为乌干达青少年接受计划生育服务减少障碍而施行的同行转诊和“诊所欢迎计划”的影响。.我们使用行为设计开发了一项干预措施，并对 15-19 岁女孩的干预措施进行分层、随机对照评估。将性健康与生殖健康诊所随机分为对照组（56 个诊所）和干预组（60 个诊所）。所有干预组诊所都接受了核心干预（创建青少年友好环境的资料和可赠送朋友的转诊卡），同时一部分诊所还接受了青少年友好服务的培训。我们收集了 2018 至 2020 年 15 个月基线和 6 个月干预期间成人和青少年每月就诊次数的诊所常规数据。.在多元回归分析中，我们发现与对照组相比，汇总后干预组的干预对主要结果有显著影响。青少年每月平均就诊次数增加了 45%（发生率比值，IRR：1.45；95% 置信区间：CI: 1.14–1.85)，或每月每个诊所增加超过五个青少年客户。总客户中青少年的平均比例提高了 5.3 个百分比（95% CI: 0.02–0.09）。在治疗组中，接受青少年友好服务培训的诊所显示出最显著的效果：青少年客户增加 62% (IRR: 1.62; 95% CI: 1.21–2.17)，或相比于对照组，每月每个诊所增加超过七个青少年。.针对已识别的障碍实施行为变化干预可以增加青少年接受计划生育咨询和服务的程度。.Оценить влияние программы по обращению к специалистам по принципу «сверстник-сверстнику» и ознакомлению с клиникой для уменьшения препятствий, мешающих подросткам пользоваться услугами по планированию семьи в Уганде.Авторы разработали мероприятие с использованием поведенческого дизайна и провели стратифицированную рандомизированную контролируемую оценку данного мероприятия среди девушек в возрасте 15–19 лет. Клиники сексуального и репродуктивного здоровья были рандомизированы на контрольные (56 клиник) и экспериментальные (60 клиник). Все экспериментальные клиники получили основные средства (материалы для создания благоприятной для подростков среды и направления к специалисту для распространения среди друзей), а отдельная подгруппа клиник дополнительно прошла обучение по оказанию услуг, учитывающих потребности молодежи. Мы собрали стандартные данные клиник о ежемесячном количестве посещений взрослых и подростков в течение 15-месячного исходного и 6-месячного экспериментального периода, 2018–2020 гг.Во время многомерного регрессионного анализа мы обнаружили значительное влияние мероприятия на первичные исходы в объединенной экспериментальной группе по сравнению с контрольной группой. Среднее ежемесячное посещение подростками увеличилось на 45% (отношение частоты случаев, ОЧС: 1,45; 95%-й доверительный интервал: ДИ: 1,14–1,85) или более чем на пять дополнительных клиентов-подростков на клинику в месяц. Средняя доля подростков в общем числе клиентов увеличилась на 5,3 процентных пункта (95% ДИ: 0,02–0,09). Среди групп воздействия клиники, прошедшие обучение по оказанию услуг, учитывающих потребности молодежи, показали самое сильное воздействие: рост на 62% (ОЧС: 1,62; 95% ДИ: 1,21–2,17) среди клиентов-подростков, или более семи дополнительных подростков на клинику в месяц по сравнению с контрольной группой.Мероприятие по изменению поведения, направленное на устранение выявленных препятствий, может повысить интерес подростков к консультированию и услугам по планированию семьи.

Daily antiretroviral therapy (ART) suppresses viral replication, rendering HIV undetectable through viral load (VL) testing. People living with HIV (PLWH) who have an undetectable VL cannot transmit HIV to sexual partners or through giving birth, a message commonly referred to as U = U (undetectable equals untransmittable). To increase knowledge and understanding of U = U among men, who have poorer HIV testing and treatment outcomes than women, we engaged men from high HIV burden communities in Cape Town in two interactive human-centered design cocreation workshops to develop local U = U messaging for men. Two trained workshop facilitators, explained the U = U message to 39 adult men (in two separate workshops), and asked them how to effectively communicate U = U to other men in the local language (isiXhosa). Participant-designed messages sought to inform men about U = U to help assuage fears of testing HIV positive (by removing the stigma of living with HIV and being a vector of disease), and to explain that ART enables PLWH to live normal healthy lives, making HIV "untransmittable" to sex partners. Participants' messages emphasized that when virally suppressed, "

Workplace mandates are a highly effective strategy for increasing COVID-19 vaccination rates, and their adoption by United States employers grew throughout 2021. Still, public opinion on these mandates has remained starkly polarized. Drawing from the widespread use of analogies in health communication during the pandemic, we investigated whether analogies to widely-accepted workplace safety rules could affect attitudes toward vaccination mandates. In a survey experiment conducted in September-October 2021, 1194 respondents were randomized to one of three messages about workplace COVID-19 vaccination mandates that included (1) no analogy; (2) an analogy to workplace hard hat policies; or (3) an analogy to workplace smoking bans. Only the smoking analogy increased support for (b = 0.41; p < .001) and perceived effectiveness of (b = 0.20; p = .037) workplace vaccination mandates. Moreover, the smoking analogy’s effect on perceived effectiveness was greater for unvaccinated respondents (b = 0.54; p = .015 for interaction) and was mediated via the perceived strength of mandate enforcement (indirect effect = 0.05; 95% confidence interval = [0.01, 0.10]; P = .006). Our results demonstrate that policymakers and administrators may use a simple analogy to boost public opinion on workplace mandates for COVID-19 vaccination.

Widespread SARS-CoV-2 vaccine uptake will be critical to resolution of the COVID-19 pandemic. Politicians have the potential to impact vaccine sentiment and uptake through vaccine-related communication with the public. We used tweets (n = 6,201), abstracted from Quorum, a public affairs software platform, to examine changes in the frequency of vaccine-related communication by legislators on the social media platform, Twitter. We found an increase in vaccine-related tweets by legislators following the arrival of SARS-CoV-2 in the United States. In the pre-COVID-19 era the majority of vaccine-related tweets were generated by Democrat and state senators. The increase in tweets following the arrival of COVID-19, however, was greater among Republican and federal legislators than Democrat or state legislators. This suggests that legislators who were previously less engaged in public discussion of vaccination, became engaged following the arrival of SARS-CoV-2, which may have implications for COVID-19 vaccine uptake among their followers.

Background The COVID-19 pandemic was accompanied by an “infodemic”–an overwhelming excess of accurate, inaccurate, and uncertain information. The social media-based science communication campaign Dear Pandemic was established to address the COVID-19 infodemic, in part by soliciting submissions from readers to an online question box. Our study characterized the information needs of Dear Pandemic’s readers by identifying themes and longitudinal trends among question box submissions. Methods We conducted a retrospective analysis of questions submitted from August 24, 2020, to August 24, 2021. We used Latent Dirichlet Allocation topic modeling to identify 25 topics among the submissions, then used thematic analysis to interpret the topics based on their top words and submissions. We used t-Distributed Stochastic Neighbor Embedding to visualize the relationship between topics, and we used generalized additive models to describe trends in topic prevalence over time. Results We analyzed 3839 submissions, 90% from United States-based readers. We classified the 25 topics into 6 overarching themes: ‘Scientific and Medical Basis of COVID-19,’ ‘COVID-19 Vaccine,’ ‘COVID-19 Mitigation Strategies,’ ‘Society and Institutions,’ ‘Family and Personal Relationships,’ and ‘Navigating the COVID-19 Infodemic.’ Trends in topics about viral variants, vaccination, COVID-19 mitigation strategies, and children aligned with the news cycle and reflected the anticipation of future events. Over time, vaccine-related submissions became increasingly related to those surrounding social interaction. Conclusions Question box submissions represented distinct themes that varied in prominence over time. Dear Pandemic’s readers sought information that would not only clarify novel scientific concepts, but would also be timely and practical to their personal lives. Our question box format and topic modeling approach offers science communicators a robust methodology for tracking, understanding, and responding to the information needs of online audiences.

IntroductionCOVID-19 vaccination coverage in South Africa (RSA) remains low despite increased access to vaccines. On 1 November 2021, RSA introduced the Vooma Voucher programme which provided a small guaranteed financial incentive, a Vooma Voucher redeemable at grocery stores, for COVID-19 vaccination among older adults, a population most vulnerable to serious illness, hospitalisation and death. However, the association of financial incentives with vaccination coverage remains unclear.MethodsWe evaluated the association of the conditional economic incentive programme with first-dose vaccination rates among adults (aged ≥60 years) through a quasi-experimental cohort study. The Vooma Voucher programme was a nationwide vaccination incentive programme implemented for adults aged ≥60 years from 1 November 2021 to 28 February 2022. We ran ITS models to evaluate the Vooma Voucher programme at national and provincial levels. We used data between 1 October 2021 and 27 November 2021 in models estimated at the daily level. Individuals who received their first vaccine dose received a text message to access a ZAR100 ($~7) voucher that was redeemable at grocery stores.ResultsThe Vooma Voucher programme was associated with a 7.15%–12.01% increase in daily first-dose vaccinations in November 2021 compared with late October 2021. Overall, the incentive accounted for 6476–10 874 additional first vaccine doses from 1 November to 27 November 2021, or 8.31%–13.95% of all doses administered to those aged ≥60 years during that period. This result is robust to the inclusion of controls for the number of active vaccine delivery sites and for the nationwide Vooma vaccination weekend initiative (12 November to 14 November), both of which also increased vaccinations through expanded access to vaccines and demand creation activities.ConclusionsFinancial incentives for COVID-19 vaccination led to a modest increase in first-dose vaccinations among older adults in RSA. Financial incentives and expanded access to vaccines may result in higher vaccination coverage.Trial registration number (SANCTR)DOH-27-012022-9116.

IntroductionCOVID-19 vaccination coverage in South Africa (RSA) remains low despite increased access to vaccines. On November 1, 2021, RSA introduced the Vooma Voucher program which provided a small guaranteed financial incentive, a Vooma Voucher redeemable at grocery stores, for COVID-19 vaccination among older adults, a population most vulnerable to serious illness, hospitalization, and death. However, the association of financial incentives with vaccination coverage remains unclear.MethodsWe evaluated the association of the conditional economic incentive program with first-dose vaccination rates among adults (aged ≥60 years) through a quasi-experimental cohort study. The Vooma Voucher program was a nationwide vaccination incentive program implemented for adults aged ≥60 years from November 1, 2021 to February 28, 2022. We ran interrupted time series models to evaluate the Vooma Voucher program at national and provincial levels. We used data between October 1, 2021 and November 27, 2021 in models estimated at the daily level. Individuals who received their first vaccine dose received a text message to access a ZAR100 ($∼7) voucher that was redeemable at grocery stores.ResultsThe Vooma Voucher program was associated with a 7.15-12.01% increase in daily first-dose vaccinations in November 2021 compared to late October 2021. Overall, the incentive accounted for 6,476-10,874 additional first vaccine doses from November 1-27, 2021, or 8.31-13.95% of all doses administered to those aged ≥60 years during that period. This result is robust to the inclusion of controls for the number of active vaccine delivery sites and for the nationwide Vooma vaccination weekend initiative (November 12-14), both of which also increased vaccinations through expanded access to vaccines and demand creation activities.ConclusionsFinancial incentives for COVID-19 vaccination led to a modest increase in first dose vaccinations among older adults in RSA. Financial incentives and expanded access to vaccines may result in higher vaccination coverage.Trial registration number (SANCTR)DOH-27-012022-9116Key points (3-5 sentences)What is already known about this topic?There is a lack of evidence on whether financial incentives for COVID-19 vaccinations are effective in low- and middle-income countries.What does this study add?We found that a ZAR100 (∼US$7) incentive for adults aged ≥60 years increased additional first vaccine doses between November 1-27, 2021 to those aged ≥60 years during that period.How this study might affect research, practice or policy?Small guaranteed financial incentives may be an effective strategy to increase vaccine demand among older adults in low- and middle-income countries.

The World Health Organization has identified excessive COVID-19 pandemic-related information as a public health crisis, calling it an "infodemic." Social media allows misinformation to spread quickly and outcompete scientifically grounded information delivered via other methods.

Purpose To investigate partisanship in COVID-19 attitudes, and assess partisan or scientific messaging effects on COVID-19 vaccination intentions. Design Two-wave survey with two-arm randomized experiment. Setting Recruited Pennsylvania residents online. Sample 2037 (May 2020) and 1577 (October 2020) Pennsylvania residents, aged 18–94 years. Intervention Respondents saw messaging that presented either President Trump or scientists endorsing the vaccine, then reported their vaccination intentions. Measures Likert scale items measuring COVID-19 attitudes (May), including mask wearing and vaccination intentions (May and October). Analysis Partisan differences in attitudes were analyzed by chi-square; differences in support for mask wearing and vaccination intentions were also analyzed by Mann–Whitney U. The messaging experiment was analyzed by chi-square, Mann–Whitney U, and survey-weighted multivariate logistic regression. Results Significant partisan differences were found in all attitudes. The partisan split in support for mask wearing increased from May to October, whereas the split in vaccination intentions decreased. Compared to partisan messaging, scientific messaging increased overall odds of intending to vaccinate by 32% in May (adjusted odds ratio [AOR]=1.32, 95% confidence interval [CI] = 1.06-1.65), and increased odds among Democrats by 142% in October (AOR = 2.42, CI = 1.29-4.55). Scientific messaging had no significant effect on independents or Republicans. Conclusion Partisan COVID-19 attitudes were widespread and persistent. Partisan endorsement of the vaccine positively influenced those with congruent beliefs, while scientific messaging produced consistent effects across political affiliation.

We present the case of a child of color diagnosed with autism spectrum disorder (ASD) at 67 months of age. Drawing from behavioral economics, we used this case to explore errors in decision-making by clinicians and family members and structural factors that may have delayed ASD diagnosis well beyond the national average.

Increases in vaccine hesitancy and vaccine-preventable disease outbreaks have focused attention on state laws governing school-entry vaccine mandates and the allowable exemptions (medical and nonmedical) from those mandates. There is substantial variation in the type of exemptions available in each state, and states with more rigorous or burdensome exemption requirements generally have lower exemption rates. States have little evidence, however, about how vaccine-hesitant parents respond to different requirements. Despite recent efforts to formulate "model legislation" templates for states to follow, policy evidence about optimal exemption regimes is limited to observational studies in states that have changed exemption laws. We conducted two online experiments to explore how parental attitudes and intentions responded to different school-entry vaccine mandate exemption requirements. We randomly assigned online participants to one of four hypothetical vaccine exemption application scenarios: parental signature only, a checklist of vaccines for which an exemption is requested, a lengthy (10-30+ min) video-based vaccine education module, and a requirement to write a statement justifying the exemption. Among parents with high vaccine hesitancy, a required vaccine education module led to significant decreases in vaccine hesitancy, while checklist and justification requirements increased vaccine hesitancy slightly. Among parents with low vaccine hesitancy, we observed a potential backfire effect when parents were required to write a justification statement. Our findings warrant replication in a larger, fully-powered trial to accelerate knowledge about how parents across the vaccine hesitancy spectrum respond to exemption regimes.

In 2015, California passed Senate Bill No. 277 (SB 277) and became the first state in more than 30 years to eliminate nonmedical exemptions to mandatory childhood immunizations for school entry. One concern that emerged was that the law created an incentive for parents to remove children from brick-and-mortar schools to bypass the immunization requirements.To assess the trends in homeschooling rates after the elimination of nonmedical exemptions to the requirement of childhood immunizations for school entry.This preintervention-postintervention cross-sectional study calculated homeschooling rates as the number of students in kindergarten through grade 8 (K-8) enrolled through each of California's 3 homeschooling mechanisms (independent study program, private school affidavit, and private school satellite program) divided by all K-8 students enrolled in the same academic year. Data on homeschooling rates were obtained from the California Department of Education. Interrupted time series analyses were conducted using a linear regression model in which the outcome variable was the percentage of students enrolled in a homeschool program before and after SB 277. Data were collected and analyzed from October 3, 2012, to October 2, 2019.Passage of SB 277, which eliminated nonmedical exemptions to childhood immunizations for school entry.Homeschooling rates for K-8 students.Among the students included in the analysis, the homeschooling enrollment for K-8 students in California increased from 35 122 students (0.8%) during the 2012-2013 school year to 86 574 students (1.9%) during the 2019-2020 school year; however, the implementation of SB 277 was not associated with an increase in the percentage of students enrolled in homeschooling programs in California beyond the secular trend. The increase in homeschooling was greatest for the lower grade levels: kindergarten homeschooling enrollment increased from 2068 students (0.4%) in the 2012-2013 school year to 10 553 students (1.9%) in the 2019-2020 school year, whereas the grade 8 homeschool enrollment rate increased from 5146 students (1.0%) in the 2012-2013 school year to 10 485 students (2.0%) in the 2019-2020 school year. Independent study programs accounted for 20 149 students (45.3%) of homeschooling enrollment, private school affidavits accounted for 19 333 students (43.5%), and private school satellite programs accounted for 4935 students (11.1%) during the 2015-2016 school year.The findings of this study suggest that legislative action to limit nonmedical exemptions for compulsory vaccination for school entry is not associated with removal of students from classroom-based instruction in brick-and-mortar institutions.

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.

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.

BACKGROUND: In 2018, Facebook introduced Ad Archive as a platform to improve transparency in advertisements related to politics and “issues of national importance.” Vaccine-related Facebook advertising is publicly available for the first time. After measles outbreaks in the US brought renewed attention to the possible role of Facebook advertising in the spread of vaccine-related misinformation, Facebook announced steps to limit vaccine-related misinformation. This study serves as a baseline of advertising before new policies went into effect. METHODS: Using the keyword ‘vaccine’, we searched Ad Archive on December 13, 2018 and again on February 22, 2019. We exported data for 505 advertisements. A team of annotators sorted advertisements by content: pro-vaccine, anti-vaccine, not relevant. We also conducted a thematic analysis of major advertising themes. We ran Mann-Whitney U tests to compare ad performance metrics. RESULTS: 309 advertisements were included in analysis with 163 (53%) pro-vaccine advertisements and 145 (47%) anti-vaccine advertisements. Despite a similar number of advertisements, the median number of ads per buyer was significantly higher for anti-vaccine ads. First time buyers are less likely to complete disclosure information and risk ad removal. Thematically, anti-vaccine advertising messages are relatively uniform and emphasize vaccine harms (55%). In contrast, pro-vaccine advertisements come from a diverse set of buyers (83 unique) with varied goals including promoting vaccination (49%), vaccine related philanthropy (15%), and vaccine related policy (14%). CONCLUSIONS: A small set of anti-vaccine advertisement buyers have leveraged Facebook advertisements to reach targeted audiences. By deeming all vaccine-related content an issue of “national importance,” Facebook has further the politicized vaccines. The implementation of a blanket disclosure policy also limits which ads can successfully run on Facebook. Under current policies, improving transparency and limiting misinformation are not separate goals. Public health communication efforts should consider the impact on Facebook users’ vaccine attitudes and behaviors.

Lotteries have been shown to motivate behavior change in many settings. However, the value of large-scale, geographically-targeted lotteries as a policy tool for changing the behaviors of entire populations is a matter of heated debate. In mid-2021, we implemented a pre-registered, city-wide experiment in Philadelphia to test the effects of three, high-payoff (up to $50,000) geographically-targeted lotteries designed to motivate adult residents of Philadelphia to get vaccinated against COVID-19. All Philadelphia residents ages 18 and older were eligible for inclusion in each drawing but, if selected, could not accept a prize unless they had received at least one dose of a COVID-19 vaccine. In each drawing, residents of a randomly selected “treatment” zip code received half of the 12 lottery prizes (boosting their chances of a win to 50-100x those of other Philadelphians). This experimental design makes possible a causal estimate of the impact of vastly increasing people’s odds of winning a vaccine lottery. We estimate that the first treated zip code, which drew considerable media attention, may have experienced a small bump in vaccinations compared to control zip codes: vaccinations rose by an estimated 61 per 100,000 people (an 11% increase). Pooling results from all three zip codes treated over the course of our six-week experiment, however, we do not detect any overall benefits. This unsustained effect may be because media attention waned, salience of the lottery declined, or attitudes about vaccination became increasingly entrenched over time. Further, our 95% confidence interval provides an upper bound on the overall benefits of treatment in our study of 9%. Given that lotteries of this scale cost hundreds of thousands of dollars to implement, the lack of a substantial benefit from this experiment strengthens the policy case for other, more impactful ways to encourage health behavior change.

STRUCUTRED ABSTRACTIntroductionIn 2015 California passed Senate Bill No. 277 (SB 277) and became the first state in over 30 years to eliminate nonmedical exemptions to mandatory childhood immunizations for school entry. One concern that emerged was that the law created an incentive for parents to remove children from brick-and-mortar schools to bypass the immunization requirements.ObjectiveTo assess the impact of eliminating nonmedical exemptions to childhood immunizations on homeschooling rates.DesignPre-Post Intervention study. We calculated homeschooling rates as the number of K-8 students enrolled through each of California’s three homeschooling mechanisms (Independent Study Program, Private School Affidavit, and Private School Satellite Program) divided by all K-8 students enrolled in the same academic year. Data on homeschooling rates was obtained from the California Department of Education. We then conducted an interrupted time series analyses in which the outcome variable was percent of students enrolled in a homeschool program pre- and post-SB 277.SettingCalifornia homeschoolsParticipantsK-8 students enrolled through each of the state’s three homeschooling mechanisms (Independent Study Program, Private School Affidavit, and Private School Satellite Program)InterventionPassage of SB 277 which eliminated nonmedical exemptions to childhood immunizations for school entryMain OutcomeK-8 homeschooling ratesResultsThe homeschooling enrollment for K-8 students in California increased from 0.8% (35,122 students) during SY 2012-13 to 1.9% (86,574 students) during SY 2019-20; however, we found no significant increase in the percent of students enrolled in homeschooling programs in California following the implementation of SB 277 beyond the secular trend.Conclusions and RelevanceLegislative action to limit nonmedical exemptions to compulsory vaccination for school entry is not associated with removal from classroom-based instruction in brick- and-mortar institutions.KEY POINTSQuestionWhat is effect of California Senate Bill No. 277, which eliminated nonmedical exemptions to childhood immunizations for school entry, on the homeschooling rates?FindingWe found no evidence that elimination of nonmedical exemptions to mandatory childhood immunizations for school entry was associated with an increase in homeschooling rates for K-8 in California.MeaningLegislative action to limit nonmedical exemptions to compulsory vaccination for school entry is not associated with removal from classroom-based instruction in brick-and-mortar institutions.

Lotteries have been shown to motivate behaviour change in many settings, but their value as a policy tool is relatively untested. We implemented a pre-registered, citywide experiment to test the effects of three high-pay-off, geographically targeted lotteries designed to motivate adult Philadelphians to get their COVID-19 vaccine. In each drawing, the residents of a randomly selected 'treatment' zip code received half the lottery prizes, boosting their chances of winning to 50×-100× those of other Philadelphians. The first treated zip code, which drew considerable media attention, may have experienced a small bump in vaccinations compared with the control zip codes: average weekly vaccinations rose by an estimated 61 per 100,000 people per week (+11%). After pooling the results from all three zip codes treated during our six-week experiment, however, we do not detect evidence of any overall benefits. Furthermore, our 95% confidence interval provides a 9% upper bound on the net benefits of treatment in our study.

We identified common and unique barriers and facilitators of evidence-based suicide prevention practices across primary care practices with integrated behavioral health services and specialty mental health settings to identify generalizable strategies for enhancing future implementation efforts.Twenty-six clinicians and practice leaders from behavioral health (There were a number of similar themes associated with implementation of suicide prevention practices across settings and clinician types, such as the benefits of inter-professional collaboration and uncertainties about managing suicidality once risk was disclosed. Clinicians also highlighted barriers unique to their settings. For primary care settings, time constraints and competing demands were consistently described as barriers. For specialty mental health settings, difficulties coordinating care with schools and other providers in the community made implementation of suicide prevention practices challenging.Findings can inform the development and testing of implementation strategies that are generalizable across primary care and specialty mental health settings, as well as those tailored for unique site needs, to enhance use of evidence-based suicide prevention practices in settings where individuals at risk for suicide are especially likely to present.HIGHLIGHTSWe examined barriers and facilitators to suicide prevention across health settings.Common and unique barriers and facilitators across health-care settings emerged.Findings can enhance suicide prevention implementation across health-care settings.

Background Online platforms are used to manage aspects of our lives including health outside clinical settings. Little is known about the effectiveness of using online platforms to manage hypertension. We assessed effects of tweeting/retweeting cardiovascular health content by individuals with poorly controlled hypertension on systolic blood pressure (SBP) and patient activation. Methods and Results We conducted this 2‐arm randomized controlled trial. Eligibility included diagnosis of hypertension; SBP >140 mm Hg; and an existing Twitter account or willingness to create one to follow study Twitter account. Intervention arm was asked to tweet/retweet health content 2×/week using a specific hashtag for study duration (6 months). The main measures include primary outcome change in SBP; secondary outcome point change in Patient Activation Measure (PAM). We remotely recruited and enrolled 611 participants, mean age 52 (SD, 11.7). Mean baseline SBP for the intervention group was 155.8 and for control was 155.6. At 6 months, mean SBP for intervention group was 137.6 and for control was 135.7. Mean change in SBP from baseline to 6 months for the intervention group was −18.5 and for control was −19.8 (P =0.48). Mean PAM at baseline for the intervention group was 70.3 for control was 72.7. At 6 months, mean PAM scores were 71.1 (intervention) and 75.6 (control). Mean change in PAM score for the intervention group was 0.0 and for control was 3.3 ( P =0.12). Conclusions Recruiting and engaging patients and collecting outcome measures remotely are feasible using Twitter. Encouraging patients with poorly controlled hypertension to tweet or retweet health content on Twitter did not improve SBP or PAM score at 6 months. Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02622256.

BackgroundInsights from behavioral economics, or how individuals’ decisions and behaviors are shaped by finite cognitive resources (e.g., time, attention) and mental heuristics, have been underutilized in efforts to increase the use of evidence-based practices in implementation science. Using the example of firearm safety promotion in pediatric primary care, which addresses an evidence-to-practice gap in universal suicide prevention, we aim to determine: is a less costly and more scalable behavioral economic-informed implementation strategy (i.e., “Nudge”) powerful enough to change clinician behavior or is a more intensive and expensive facilitation strategy needed to overcome implementation barriers?MethodsThe Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) hybrid type III effectiveness-implementation trial uses a longitudinal cluster randomized design. We will test the comparative effectiveness of two implementation strategies to support clinicians’ use of an evidence-based firearm safety practice,S.A.F.E. Firearm, in 32 pediatric practices across two health systems. All pediatric practices in the two health systems will receiveS.A.F.E. Firearmmaterials, including training and cable locks. Half of the practices (k= 16) will be randomized to receive Nudge; the other half (k= 16) will be randomized to receive Nudge plus 1 year of facilitation to target additional practice and clinician implementation barriers (Nudge+). The primary implementation outcome is parent-reported clinician fidelity to theS.A.F.E Firearmprogram. Secondary implementation outcomes include reach and cost. To understand how the implementation strategies work, the primary mechanism to be tested is practice adaptive reserve, a self-report practice-level measure that includes relationship infrastructure, facilitative leadership, sense-making, teamwork, work environment, and culture of learning.DiscussionThe ASPIRE trial will integrate implementation science and behavioral economic approaches to advance our understanding of methods for implementing evidence-based firearm safety promotion practices in pediatric primary care. The study answers a question at the heart of many practice change efforts: which strategies are sufficient to support change, and why? Results of the trial will offer valuable insights into how best to implement evidence-based practices that address sensitive health matters in pediatric primary care.Trial registrationClinicalTrials.gov,NCT04844021. Registered 14 April 2021.

Reporting of HIV self-test results to encourage linkage to HIV care for those who receive a positive test result is a common challenge faced by HIV self-testing programs. The impact of self-testing programs is diminished if individuals who obtain a self-test do not use the test or seek confirmatory testing and initiate HIV treatment following a positive result. We conducted a cluster randomized trial of two interventions designed to increase reporting of HIV self-test results: a “plan and commit” intervention that leveraged insights from behavioral economics, and an enhanced usual care version of the standard HIV self-test community distribution protocol that promoted the importance of reporting results. The trial was conducted at community distribution sites for HIV self-tests in Tshwane Metropolitan Municipality, Gauteng Province, South Africa. The primary outcome was reporting of self-test results via a WhatsApp messaging system. We recruited 1,478 participants at 13 distribution sites over 24 days. In the plan and commit condition, 63/731 participants (8.7%) reported their test results via WhatsApp, compared to 59/747 participants (7.9%) in the enhanced usual care condition (n.s., p = 0.61). During the study period, 101/3,199 individuals (3.1%) who received a self-test under the standard protocol reported test results via WhatsApp, a significant difference across the three arms (p < .00001). Our results suggest that boosting the reporting of self-test results can be done solely through increasing the salience of the importance of reporting and a clear explanation of the procedure for reporting results. Trial Registration: ClinicalTrials.gov: NCT03898557.

Background The COVID-19 era has been characterized by the politicization of health-related topics. This is especially concerning given evidence that politicized discussion of vaccination may contribute to vaccine hesitancy. No research, however, has examined the content and politicization of legislator communication with the public about vaccination during the COVID-19 era. Objective The aim of this study was to examine vaccine-related tweets produced by state and federal legislators during the COVID-19 era to (1) describe the content of vaccine-related tweets; (2) examine the differences in vaccine-related tweet content between Democrats and Republicans; and (3) quantify (and describe trends over time in) partisan differences in vaccine-related communication. Methods We abstracted all vaccine-related tweets produced by state and federal legislators between February 01, 2020, and December 11, 2020. We used latent Dirichlet allocation to define the tweet topics and used descriptive statistics to describe differences by party in the use of topics and changes in political polarization over time. Results We included 14,519 tweets generated by 1463 state legislators and 521 federal legislators. Republicans were more likely to use words (eg, “record time,” “launched,” and “innovation”) and topics (eg, Operation Warp Speed success) that were focused on the successful development of a SARS-CoV-2 vaccine. Democrats used a broader range of words (eg, “anti-vaxxers,” “flu,” and “free”) and topics (eg, vaccine prioritization, influenza, and antivaxxers) that were more aligned with public health messaging related to the vaccine. Polarization increased over most of the study period. Conclusions Republican and Democratic legislators used different language in their Twitter conversations about vaccination during the COVID-19 era, leading to increased political polarization of vaccine-related tweets. These communication patterns have the potential to contribute to vaccine hesitancy.

BACKGROUND The COVID-19 era has been characterized by the politicization of health-related topics. This is especially concerning given evidence that politicized discussion of vaccination may contribute to vaccine hesitancy. No research, however, has examined the content and politicization of legislator communication with the public about vaccination during the COVID-19 era. OBJECTIVE The aim of this study was to examine vaccine-related tweets produced by state and federal legislators during the COVID-19 era to (1) describe the content of vaccine-related tweets; (2) examine the differences in vaccine-related tweet content between Democrats and Republicans; and (3) quantify (and describe trends over time in) partisan differences in vaccine-related communication. METHODS We abstracted all vaccine-related tweets produced by state and federal legislators between February 01, 2020, and December 11, 2020. We used latent Dirichlet allocation to define the tweet topics and used descriptive statistics to describe differences by party in the use of topics and changes in political polarization over time. RESULTS We included 14,519 tweets generated by 1463 state legislators and 521 federal legislators. Republicans were more likely to use words (eg, “record time,” “launched,” and “innovation”) and topics (eg, Operation Warp Speed success) that were focused on the successful development of a SARS-CoV-2 vaccine. Democrats used a broader range of words (eg, “anti-vaxxers,” “flu,” and “free”) and topics (eg, vaccine prioritization, influenza, and antivaxxers) that were more aligned with public health messaging related to the vaccine. Polarization increased over most of the study period. CONCLUSIONS Republican and Democratic legislators used different language in their Twitter conversations about vaccination during the COVID-19 era, leading to increased political polarization of vaccine-related tweets. These communication patterns have the potential to contribute to vaccine hesitancy.

Background California’s Senate Bill 277 (SB-277) law eliminated the personal belief exemption to school immunization requirements. A potential consequence may be that parents choose homeschooling to avoid immunization. Vaccine attitudes and behaviors have not been well studied among the home-schooling population. This study explored the effect of SB-277 and vaccine decision-making among California home schoolers. Methods Purposive and snowball sampling were used recruit home-schooling parents through home-schooling Facebook groups based on home school type in high-exemption regions in California for in-depth interviews. Participants had to have a child in a legalized form of homeschooling in California in grades kindergarten-twelfth grade. Results Twenty-four mothers were interviewed. Participants were categorized based on self-reported vaccine attitudes and behavior into three groups: Confident and Accepting, Hesitant and Accepting, and Skeptical and Refusing. All reported the belief that SB-277 is an infringement on parental rights but was not currently impacting them. Confident and Accepting mothers (n = 10) generally believed vaccinations were safe, effective, and posed a lower risk than vaccine preventable disease (VPD). Hesitant and Accepting mothers (n = 5) expressed varying confidence levels in the belief that vaccinations were safe and effective, were not confident in the belief that vaccination posed lower risks than VPD risk, and risk perception affected vaccine decision-making. Skeptical and Refusing mothers (n = 9) generally believed that vaccinations were unsafe and ineffective, refused select vaccines, believed that vaccination posed a more serious risk than VPD risks, and belief of vaccine harm was a salient factor in vaccine decision-making. Conclusion Home-schooling mothers were concerned about SB-277 but did not report that it was directly impacting their children, their vaccine decisions, or reason to home school. Vaccine attitudes and beliefs among homeschooling mothers broadly fell into categories similar to parents of non-home-schooled children. Future quantitative studies should measure vaccine hesitancy and refusal prevalence and potential confounders.

IntroductionTaking daily ART eliminates sufficient virus so that HIV is undetectable via viral load (VL) testing within 24 weeks. HIV-positive individuals with an undetectable VL cannot transmit HIV to sexual partners or through giving birth, a message commonly referred to as U=U (undetectable equals untransmittable). Since South African men have poorer HIV outcomes than women, we used interactive human centred design co-creation workshops to ask men from high HIV burden communities in Cape Town, South Africa to create a U=U message aimed at increasing HIV testing and ART uptake in men.MethodsTwo facilitators explained the U=U message to the men (n =39) attending the workshop and asked them how to effectively communicate the message. Participants designed messages to assuage fears of testing HIV positive, explaining that ART enables HIV positive people to live normally and makes the virus “untransmittable” to their sexual partners.ResultsParticipants developed three insights for the U=U message; 1) “Introduce” the modern antiretroviral pill, 2) positively redefine the man for whom the pill is intended, and 3) simplify the benefits of ART for men. Participants’ messages emphasised 1) “you cannot spread the virus (HIV) to the other person” 2) and “(the pill) keeps on killing the virus so I can live a normal life for the rest of my life.”DiscussionMen in the workshops co-created a simple U=U message to address fears of testing HIV positive, emphasising the pill’s positive effects. Co-created, tailored messaging may improve the uptake of HIV services for South African men.

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.

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 randomized trial with individual mobile clinic days as unit of randomization.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=1.59, 95% CI=0.98-2.57).Tailored, peer-delivered messages that explain the benefits of HIV treatment in reducing HIV transmission can increase men’s HIV testing uptake.

The speed at which social media is propagating COVID-19 misinformation and its potential reach and impact is growing, yet little work has focused on the potential applications of these data for informing public health communication about COVID-19 vaccines. We used Twitter to access a random sample of over 78 million vaccine-related tweets posted between December 1, 2020 and February 28, 2021 to describe the geographical and temporal variation in COVID-19 vaccine discourse. Urban suburbs posted about equitable distribution in communities, college towns talked about in-clinic vaccinations near universities, evangelical hubs posted about operation warp speed and thanking God, exurbs posted about the 2020 election, Hispanic centers posted about concerns around food and water, and counties in the ACP African American South posted about issues of trust, hesitancy, and history. The graying America ACP community posted about the federal government's failures; rural middle American counties posted about news press conferences. Topics related to allergic and adverse reactions, misinformation around Bill Gates and China, and issues of trust among Black Americans in the healthcare system were more prevalent in December, topics related to questions about mask wearing, reaching herd immunity and natural infection, and concerns about nursing home residents and workers increased in January, and themes around access to black communities, waiting for appointments, keeping family safe by vaccinating and fighting online misinformation campaigns were more prevalent in February. Twitter discourse around COVID-19 vaccines in the United States varied significantly across different communities and changed over time; these insights could inform targeted messaging and mitigation strategies.

Many vaccine rationing guidelines urge planners to recognize, and ideally reduce, inequities. In the United States, allocation frameworks are determined by each of the Centers for Disease Control and Prevention's 64 jurisdictions (50 states, the District of Columbia, five cities and eight territories). In this study, we analyzed vaccine allocation plans published by 8 November 2020, tracking updates through to 30 March 2021. We evaluated whether jurisdictions adopted proposals to reduce inequity using disadvantage indices and related place-based measures. By 30 March 2021, 14 jurisdictions had prioritized specific zip codes in combination with metrics such as COVID-19 incidence, and 37 jurisdictions (including 34 states) had adopted disadvantage indices, compared to 19 jurisdictions in November 2020. Uptake of indices doubled from 7 to 14 among the jurisdictions with the largest shares of disadvantaged communities. Five applications were distinguished: (1) prioritizing disadvantaged groups through increased shares of vaccines or vaccination appointments; (2) defining priority groups or areas; (3) tailoring outreach and communication; (4) planning the location of dispensing sites; and (5) monitoring receipt. To ensure that equity features centrally in allocation plans, policymakers at the federal, state and local levels should universalize the uptake of disadvantage indices and related place-based measures.

BACKGROUND Smoking rates among low-income individuals, including those eligible for Medicaid, have not shown the same decrease that is observed among high-income individuals. The rate of smoking among pregnant women enrolled in Medicaid is almost twice that among privately insured women, which leads to significant disparities in birth outcomes and a disproportionate cost burden placed on Medicaid. Several states have identified maternal smoking as a key target for improving birth outcomes and reducing health care expenditures; however, efficacious, cost-effective, and feasible cessation programs have been elusive. OBJECTIVE This study aims to examine the feasibility, acceptability, and effectiveness of a smartwatch-enabled, incentive-based smoking cessation program for Medicaid-eligible pregnant smokers. METHODS Pilot 1 included a randomized pilot study of smartwatch-enabled remote monitoring versus no remote monitoring for 12 weeks. Those in the intervention group also received the SmokeBeat program. Pilot 2 included a randomized pilot study of pay-to-wear versus pay-to-quit for 4 weeks. Those in a pay-to-wear program could earn daily incentives for wearing the smartwatch, whereas those in pay-to-quit program could earn daily incentives if they wore the smartwatch and abstained from smoking. Pilot 3, similar to pilot 2, had higher incentives and a duration of 3 weeks. RESULTS For pilot 1 (N=27), self-reported cigarettes per week among the intervention group declined by 15.1 (SD 27) cigarettes over the study; a similar reduction was observed in the control group with a decrease of 17.2 (SD 19) cigarettes. For pilot 2 (N=8), self-reported cigarettes per week among the pay-to-wear group decreased by 43 cigarettes (SD 12.6); a similar reduction was seen in the pay-to-quit group, with an average of 31 (SD 45.6) fewer cigarettes smoked per week. For pilot 3 (N=4), one participant in the pay-to-quit group abstained from smoking for the full study duration and received full incentives. CONCLUSIONS Decreases in smoking were observed in both the control and intervention groups during all pilots. The use of the SmokeBeat program did not significantly improve cessation. The SmokeBeat program, remote cotinine testing, and remote delivery of financial incentives were considered feasible and acceptable. Implementation challenges remain for providing evidence-based cessation incentives to low-income pregnant smokers. The feasibility and acceptability of the SmokeBeat program were moderately high. Moreover, the feasibility and acceptability of remote cotinine testing and the remotely delivered contingent financial incentives were successful. CLINICALTRIAL ClinicalTrials.gov NCT03209557; https://clinicaltrials.gov/ct2/show/NCT03209557.

Background Smoking rates among low-income individuals, including those eligible for Medicaid, have not shown the same decrease that is observed among high-income individuals. The rate of smoking among pregnant women enrolled in Medicaid is almost twice that among privately insured women, which leads to significant disparities in birth outcomes and a disproportionate cost burden placed on Medicaid. Several states have identified maternal smoking as a key target for improving birth outcomes and reducing health care expenditures; however, efficacious, cost-effective, and feasible cessation programs have been elusive. Objective This study aims to examine the feasibility, acceptability, and effectiveness of a smartwatch-enabled, incentive-based smoking cessation program for Medicaid-eligible pregnant smokers. Methods Pilot 1 included a randomized pilot study of smartwatch-enabled remote monitoring versus no remote monitoring for 12 weeks. Those in the intervention group also received the SmokeBeat program. Pilot 2 included a randomized pilot study of pay-to-wear versus pay-to-quit for 4 weeks. Those in a pay-to-wear program could earn daily incentives for wearing the smartwatch, whereas those in pay-to-quit program could earn daily incentives if they wore the smartwatch and abstained from smoking. Pilot 3, similar to pilot 2, had higher incentives and a duration of 3 weeks. Results For pilot 1 (N=27), self-reported cigarettes per week among the intervention group declined by 15.1 (SD 27) cigarettes over the study; a similar reduction was observed in the control group with a decrease of 17.2 (SD 19) cigarettes. For pilot 2 (N=8), self-reported cigarettes per week among the pay-to-wear group decreased by 43 cigarettes (SD 12.6); a similar reduction was seen in the pay-to-quit group, with an average of 31 (SD 45.6) fewer cigarettes smoked per week. For pilot 3 (N=4), one participant in the pay-to-quit group abstained from smoking for the full study duration and received full incentives. Conclusions Decreases in smoking were observed in both the control and intervention groups during all pilots. The use of the SmokeBeat program did not significantly improve cessation. The SmokeBeat program, remote cotinine testing, and remote delivery of financial incentives were considered feasible and acceptable. Implementation challenges remain for providing evidence-based cessation incentives to low-income pregnant smokers. The feasibility and acceptability of the SmokeBeat program were moderately high. Moreover, the feasibility and acceptability of remote cotinine testing and the remotely delivered contingent financial incentives were successful. Trial Registration ClinicalTrials.gov NCT03209557; https://clinicaltrials.gov/ct2/show/NCT03209557.

In 2015, California passed Senate Bill 277 eliminating all nonmedical exemptions to school vaccinations. We aimed to explore school-level modes of SB277 enforcement, characterize vaccination knowledge, attitudes, and beliefs of school officials, and identify whether school vaccination policies are associated with medical exemptions being granted. Surveys were mailed to a stratified random sample of 1,450 schools in California. School personnel (n = 752) reported their medical training, vaccination beliefs, enforcement of vaccination policies, and school rates of medical exemptions. Multiple logistic regression was used to assess whether school policies are associated with the likelihood of medical exemption requests being granted. Nurses were more likely than non-nurses to hold beliefs recognizing the importance of vaccination. A school where the survey respondent was a nurse was more likely to have granted a medical exemption request compared to a school where the respondent was not a nurse (OR 2.11, 95% CI 1.34–3.36). The training of school officials and school-level practices may impact the enforcement of medical exemptions. Equipping school officials as competent sources of vaccine information for concerned parents will be valuable in improving parental vaccine uptake.

The US needs a national strategy for promotion of COVID-19 vaccines that unites the urgency and commitment of Operation Warp Speed with innovative behavioral science and social marketing approaches to increase COVID-19 vaccine confidence and acceptance in diverse populations Core to any successful strategy is to rebuild trust in the rigor of vaccine trials and the integrity of the approval process Make the vaccine free and easily accessible, make access to valued settings conditional on getting vaccinated, use public endorsements from trusted leaders to increase uptake, provide priority access to people who sign up to get vaccinated before vaccines are widely available, and transform individual vaccination decisions into a public act (PsycInfo Database Record (c) 2021 APA, all rights reserved)

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 P 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.

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.

In 2015, California passed Senate Bill 277 and became the third state in the United States to ban all nonmedical exemptions from school immunization requirements, effectively prohibiting religious and personal belief exemptions. This attracted grassroots opposition and considerable debate among vaccine hesitant factions online. This mixed-methods study used quantitative linguistic analysis, semantic network analysis, and content analysis techniques to examine 2424 online documents drawn from newspapers, blogs, health websites, government information pages, web forums, personal websites, Facebook groups, among others. The study examined which words and phrases were used most frequently by vaccine skeptics, vaccine defenders, and more neutral media accounts to illuminate how groups with different attitudes towards vaccination discuss and disseminate information about vaccines and vaccine policy online. We proposed an innovative methodology for examining online discourse surrounding vaccine hesitance, as well as for studying the online dissemination of misinformation about vaccines. Our findings highlighted discrepancies in the narratives between what vaccine supporters believe causes vaccine skepticism and the issues that vaccine skeptics actually discuss within their own digital spaces. For example, in these exchanges, the importance of parental rights overshadowed that of children's rights; supporters of vaccines brought up autism in more distinct documents than skeptics do; distrust of government regulators and researchers seemed to unite vaccine skeptics and defenders; and politicians, doctors, and even celebrities often served as proxies in heated exchanges about factual evidence, believability, and the importance of expertise in public discourse.

Behavioral economics applies key principles from psychology and economics to address obstacles to behavior change. The important topic of pediatric firearm injuries has not yet been explored through a behavioral economic lens. Pediatric firearm-related injuries are a significant public health problem in the United States. Despite American Academy of Pediatrics guidelines advising that firearms be stored unloaded, in a locked box or with a locking device, and separate from ammunition, estimates suggest that ∼4.6 million children live in homes with at least 1 loaded and unlocked firearm. In this article, we use behavioral economic theory to identify specific cognitive biases (ie, present bias; in-group, out-group bias; and the availability heuristic) that may influence parental decision-making around firearm storage. We illustrate situations in which these biases may occur and highlight implementation prompts, in-group messengers, and increased salience as behaviorally informed strategies that may counter these biases and subsequently enhance safe firearm storage. We also describe other opportunities to leverage the behavioral economic tool kit. By better understanding the individual behavioral levers that may impact decision-making around firearm storage, behavioral scientists, pediatric providers, and public health practitioners can partner to design and test tailored interventions aimed at decreasing pediatric firearm injuries. Further empirical study is warranted to identify the presence of specific biases and heuristics and determine the most effective behavior change strategies for different subpopulations.

A canine rabies epidemic started in early 2015 in Arequipa, Peru and the rabies virus continues to circulate in the dog population. Some city residents who suffer dog bites do not seek care or do not complete indicated post-exposure prophylaxis (PEP) regimens, increasing the risk of human rabies. The objectives of our study are to qualitatively assess knowledge about rabies, and preventive practices, such as rabies vaccine administration, following a dog bite. We conduct eight focus group discussions in peri-urban and urban communities with 70 total participants. In our results, we observe low awareness of rabies severity and fatality, and different practices following a dog bite, depending on the community type: for example, whereas participants in the urban communities report cleaning the wound with hydrogen peroxide rather than soap and water, participants in peri-urban areas cover the wound with herbs and hair from the dog that bit them. Misconceptions about rabies vaccines and mistreatment at health centers also commonly prevent initiating or completing PEP. We identify important behavioral and structural barriers and knowledge gaps that limit evidence-based preventive strategies against rabies and may threaten successful prevention of dog-mediated human rabies in this setting., Author summary The city of Arequipa, Peru has been experiencing an outbreak of dog rabies since 2015. The Peruvian Ministry of Health has implemented measures to prevent human infection, including no-cost rabies vaccinations for people bitten by dogs, but health posts report that many people do not utilize the service or complete treatment. We conduct focus groups in urban and peri-urban areas of Arequipa to examine community perceptions and attitudes towards PEP, and organizational and behavioral barriers to initiate and complete the PEP regimen. We observe low awareness of rabies severity, and different practices following a dog bite depending on the community type. Misconceptions about rabies vaccines and mistreatment at health centers also commonly prevent participants from initiating or completing PEP. We identify important behavioral and structural barriers and knowledge gaps that limit preventive strategies against rabies and may threaten successful prevention of dog-mediated human rabies in this setting. Finally, disparate landscapes and topography seem to have different effects on urban and peri-urban participants’ use of healthcare resources. Thus, strategies should target the specific needs of each population.

Recent measles and pertussis outbreaks in the US have focused national attention on state laws governing exemptions from mandatory vaccines for school entry. After several years of increases in nonmedical exemptions in California, the state assembly passed Assembly Bill 2109 in 2012, making nonmedical exemptions more difficult to obtain by requiring parents to obtain a signature from a health care provider. We used data from the California Department of Public Health to describe changes in the overall prevalence of personal belief exemptions and compositional changes in immunization status for the school years 2012–2013 through 2015–2016. Following the implementation of Assembly Bill 2109, the statewide exemption rate declined from 3.1% in 2013 to 2.5% in 2014 and then to 2.3% in 2015, representing a 25% reduction from the 2013 peak. Continued surveillance of exemption rates and vaccine refusal are needed to monitor and protect herd immunity against vaccine-preventable diseases.

Objective: The majority of U.S. teens admit to handheld cellphone use while driving, an increasingly common cause of crashes. Attitudes toward novel cellphone applications and settings that block use while driving are poorly understood, potentially limiting uptake. We examined teens’ willingness to reduce cellphone use while driving and perceptions of potential strategies to limit this behavior. Methods: Teen drivers (n = 153) aged 16–17 who owned smartphones and admitted to texting while driving completed an online survey. Survey instruments measured willingness to give up cellphone use and perceptions of technological and behavioral economic strategies to reduce cellphone use while driving. We used chi-square tests to test the hypothesis that willingness to give up certain types of cellphone use while driving and the perceptions of strategies to reduce cellphone use while driving would differ by self-reported frequency of texting while driving in the past 30 days (low [1–5 days] vs. high [6 or more days]). Results: Most teens were willing or somewhat willing to give up reading texts (90%), sending texts (95%), and social media (99%) while driving. However, they were not willing to give up navigation (59%) and music applications (43%). Those who engaged in high-frequency texting while driving were more likely to say that they were not willing to give up navigation applications (73 vs. 44%, P P P =.029). Overall, the following strategies where rated as likely to be very effective for reducing texting while driving: gain-framed financial incentives (75%), loss-framed financial incentives (63%), group-based financial incentives (58%), insurance discounts (53%), automatic phone locking while driving (54%), e-mail notifications to parents (47%), automated responses to incoming texts (42%), peer concern (18%), and parental concern (15%). Those who engaged in high-frequency texting while driving were less likely to say that following strategies would be very effective: automated responses to incoming texts (33 vs. 53%, P =.016), peer concern (9 vs. 29%, P =.002), and parental concern (9 vs. 22%, P =.025). The strongest perceived benefit of cellphone blocking apps was decreasing distraction (86%). The predominant reason for not wanting to use this technology was not wanting parents to monitor their behavior (60%). Conclusions: Promising strategies for increasing acceptance of cellphone blocking technology among teen drivers include automated screen locking and permitting hands-free navigation and music combined with behavioral economic incentives to sustain engagement.

Psychiatric disorders account for more years lived with disability globally than any other disease category. Currently, effective mental health treatments are variably deployed in community practice and patient outcomes are less robust than clinical trials. A major frontier in psychiatry is to develop strategies that increase the use of evidence-based assessment, prevention, and intervention approaches, galvanizing the new field of implementation science. In this Viewpoint, we argue that we must bring concepts from behavioral economics to implementation science to accelerate the reach and impact of psychiatric treatments.