Exposure and Vulnerability of California Kindergarteners to Intentionally Unvaccinated Children

Widespread vaccination coverage among children is responsible for reducing or eliminating 14 serious childhood diseases in the United States. Despite this success, some parents remain concerned about the health effects of vaccines, and choose to keep their children unvaccinated. When population rates of vaccinations remain high enough, even unvaccinated children are protected because everyone around them is immune (so-called “herd immunity”). But clusters of unvaccinated children may threaten herd immunity and lead to increasing outbreaks of preventable diseases. This Issue Brief summarizes a new study that investigates the extent of such clustering, and quantifies the exposure of all California kindergartners to their intentionally unvaccinated schoolmates

Impact evaluation of school feeding programs in Lao PDR

Despite the popularity and widespread implementation of school feeding programs, evidence on the impact of school feeding on school participation and nutritional status is mixed. This study evaluates school feeding programs in three northern districts of the Lao People's Democratic Republic (Lao PDR). Feeding modalities included on-site feeding, take-home rations, and a combination. District-level implementation of the intervention sites and selective take-up present considerable evaluation challenges. To address these limitations, the authors use difference-in-difference estimators with propensity-score weighting to construct two plausible counterfactuals. They find minimal evidence that the school feeding schemes increased enrollment or improved children’s nutritional status. Several robustness checks and possible explanations for null findings are presented.Education For All,Youth and Governance,Nutrition,Primary Education,Food&Beverage Industry

Equitable Allocation of COVID-19 Vaccines: An Analysis of the Initial Allocation Plans of CDC\u27s Jurisdictions with Implications for Disparate Impact Monitoring

Major global and national vaccine allocation guidelines urge planners to allocate vaccines in ways that recognize, and ideally reduce, existing societal inequities within countries. However, allocation plans of the US will be determined individually by each of the CDC’s 64 jurisdictions (states, the District of Columbia, five cities, and territories). We analyzed whether jurisdictions have incorporated novel approaches to reduce inequity, based on plans published by the CDC in early November 2020 (63 summaries [98% of all jurisdictions] and 47 full guidance documents [73% of all, including all 50 states]). Eighteen states adopted a novel proposal to use a disadvantage index to allocate vaccines more equitably, for five types of equity goals: 1) to prioritize disadvantaged groups directly, 2) to define priority groups in phased systems, 3) to plan tailored outreach and communication, 4) to plan the location of dispensing sites and 5) to monitor uptake. Yet just over a third of all states, and only half of the 16 states with the largest shares of disadvantaged populations—where reducing inequity would be most urgent—pursue such goals. While allocation frameworks are still evolving, the plans we analyzed mark important historical and practical benchmarks, and could become firm policy when COVID-19 vaccines are authorized and delivered. Vaccine roll-out poses unprecedented logistical and practical challenges. To minimize the risk that ethics and social justice falls by the wayside in the busy months to come, planners at the federal, state and local levels should carefully consider on what grounds they decline to adopt equity measures that other planners deem important and feasible for defining priority populations, designing allocation quotas, and just as critical, enabling, and monitoring, uptake

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

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

Is Participation Contagious? Evidence From a Household Vector Control Campaign in Urban Peru

Objective: High rates of household participation are critical to the success of door-to-door vector control campaigns. We used the Health Belief Model to assess determinants of participation, including neighbour participation as a cue to action, in a Chagas disease vector control campaign in Peru. Methods: We evaluated clustering of participation among neighbours; estimated participation as a function of household infestation status, neighbourhood type and number of participating neighbours; and described the reported reasons for refusal to participate in a district of 2911 households. Results: We observed significant clustering of participation along city blocks (p\u3c0.0001). Participation was significantly higher for households in new versus established neighbourhoods, for infested households, and for households with more participating neighbours. The effect of neighbour participation was greater in new neighbourhoods. Conclusions: Results support a ‘contagion’ model of participation, highlighting the possibility that one or two participating households can tip a block towards full participation. Future campaigns can leverage these findings by making participation more visible, by addressing stigma associated with spraying, and by employing group incentives to spray

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

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

Study protocol for a type III hybrid effectiveness-implementation trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care

BACKGROUND: Insights from behavioral economics, or how individuals\u27 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? METHODS: The 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\u27 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 receive S.A.F.E. Firearm materials, 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 the S.A.F.E Firearm program. 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. DISCUSSION: The 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 REGISTRATION: ClinicalTrials.gov, NCT04844021 . Registered 14 April 2021

Implementing nudges for suicide prevention in real-world environments: project INSPIRE study protocol

Background: Suicide is a global health issue. There are a number of evidence-based practices for suicide screening, assessment, and intervention that are not routinely deployed in usual care settings. The goal of this study is to develop and test implementation strategies to facilitate evidence-based suicide screening, assessment, and intervention in two settings where individuals at risk for suicide are especially likely to present: primary care and specialty mental health care. We will leverage methods from behavioral economics, which involves understanding the many factors that influence human decision making, to inform strategy development. Methods: We will identify key mechanisms that limit implementation of evidence-based suicide screening, assessment, and intervention practices in primary care and specialty mental health through contextual inquiry involving behavioral health and primary care clinicians. Second, we will use contextual inquiry results to systematically design a menu of behavioral economics-informed implementation strategies that cut across settings, in collaboration with an advisory board composed of key stakeholders (i.e., behavioral economists, clinicians, implementation scientists, and suicide prevention experts). Finally, we will conduct rapid-cycle trials to test and refine the menu of implementation strategies. Primary outcomes include clinician-reported feasibility and acceptability of the implementation strategies. Discussion: Findings will elucidate ways to address common and unique barriers to evidence-based suicide screening, assessment, and intervention practices in primary care and specialty mental health care. Results will yield refined, pragmatically tested strategies that can inform larger confirmatory trials to combat the growing public health crisis of suicide

Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke

Background Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. Methods A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or “nudges”) promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. Discussion This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. Trial registration Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021

Behavioral economic implementation strategies to improve serious illness communication between clinicians and high-risk patients with cancer: protocol for a cluster randomized pragmatic trial

Background Serious illness conversations (SICs) are an evidence-based approach to eliciting patients’ values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics (“nudges”) that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion—either alone or in combination with clinician nudges that additionally compare performance relative to peers—may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer. Methods We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity. Discussion This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies. Trial registration ClinicalTrials.gov , NCT04867850 . Registered on April 30, 2021. Funding National Cancer Institute P50CA24469