filippo quattrone

nicola bellé

paola cantarelli

English

Archivio della ricerca della Scuola Superiore Sant'Anna

Vaccine 39 (2021) 5732–5736Contents lists available at ScienceDirectVaccinejournal homepage: www.elsevier .com/locate /vacc ineShort communicationNudging influenza vaccination among health care workershttps://doi.org/10.1016/j.vaccine.2021.08.0400264-410X/ 2021 Elsevier Ltd. All rights reserved.⇑ Corresponding author.E-mail addresses: paola.cantarelli@santannapisa.it (P. Cantarelli), nicola.belle@-santannapisa.it (N. Belle), filippo.quattrone@santannapisa.it (F. Quattrone).1 All authors contributed equally.Paola Cantarelli a,⇑,1, Nicola Belle a,1, Filippo Quattrone b,1aManagement and Healthcare Laboratory, Institute of Management and Department EMbeDS, Scuola Superiore Sant’Anna, Pisa, Italyb Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy and Management and Healthcare Laboratory, Institute of Management and Department EMbeDS, ScuolaSuperiore Sant’Anna, Pisa, Italya r t i c l e i n f o a b s t r a c tArticle history:Received 11 September 2020Received in revised form 11 June 2021Accepted 10 August 2021Available online 1 September 2021Keywords:Nudge theoryInfluenza vaccinationHealth care workersSocial normsBeneficiary impactDefaultsOur online randomized controlled trial on 6230 healthcare workers (HCWs) tests the impact that threenudges – social norms, reminding the impact on beneficiaries, and defaults – have on the intention tovaccinate against seasonal influenza across job families. Willingness to get a flu shot was higher amongsubjects invited to imagine themselves working at the local health authority (LHA) with the greatestimmunization coverage within their region relative to their counterparts prompted to imagine workingat the LHA with the lowest coverage. Reminding the impact of flu vaccination on beneficiaries had differ-ent effects across job families, with physicians caring more benefits for themselves, nurses about patients’benefits, and technicians about family and friends. Default responses anchoring toward a high rather thana low vaccination intention increased the willingness to immunize among all HCW except physicians.Targeted nudges can be considered in developing interventions to promote influenza vaccination amongHCWs. 2021 Elsevier Ltd. All rights reserved.1. IntroductionThe World Health Organization and other national and interna-tional agencies strongly recommend that all healthcare workers(HCWs) receive an annual influenza vaccination to minimize flu-generated morbidity and mortality among professionals, preventpotential nosocomial outbreaks, and limit absenteeism and conse-quent disruption of medical services [1–3]. Although flu immu-nization is the most effective public health intervention tomitigate and prevent seasonal influenza [3], influenza causes upto 650,000 deaths per year worldwide [4] and vaccination ratesamong HCWs remains largely suboptimal [5–7]. Encouraging fluvaccination uptake among HCWs seems even more relevant andurgent as the world navigates through the COVID-19 pandemic [8].In the absence of mandatory influenza vaccination and relatedethical issues in its implementation [9,10], the Nudge Theory[11] illuminates our understanding of how low-powered incen-tives are predictably effective in gearing high-stake behaviorstoward individual and societal good. Our work is among the pio-neers in employing a randomized controlled trial (RCT) design totest the impact of three nudges – namely social norms, remindersof beneficiary impact, and defaults – on the intention to vaccinateagainst seasonal influenza among 6,230 HCWs. Nudging-inspiredinterventions seem promising in complementing other strategiesthat have been proposed to increase flu vaccination uptake – suchas removal of administrative barriers, on–site vaccination, educa-tional campaigns, participation of senior personnel or opinion lead-ers as role models, vaccinate-or-mask policies, and requirement ofdeclination forms.At their core, ‘‘nudges are supposedly irrelevant factors thatinfluence our choices in ways that make us better off” [12]. Thosewho design the environment in which individuals make decisions,thus, are warned that small variations in said context can greatlyinfluence final decisions. Nudges are particularly useful when sub-jects make a difficult or rare decision, make a choice for which theydo not get immediate or direct enough feedback, and when someaspects of the situation are difficult to understand or makeconcrete.Extant scholarship suggests that social norms, reminders ofbeneficiary impact, and default options qualify as viable nudginginterventions [11]. Firstly, social norms [13] may increase theuptake of a desirable behavior by triggering conformity. More pre-cisely, as individuals like to conform to others rather than beingoutcasts [11,14], informing individuals that the majority of othersare engaging in a positive conduct generate a virtuous cycle. Thismechanism holds in the negative domain also, whereby subjectsconform to undesirable conduct when that is what the majorityTable 1Percentage distribution of HCWs in our sample by job family, work setting, gender,and age group (n = 6230).n %Job familyAdministrative staff 827 13Nurses 3881 62Physicians 922 15Technicians 600 10Work settingHospital 3919 63Ambulatory 1415 23Teaching hospital 874 14n.a. 22 –GenderFemale 4346 70Male 1862 30n.a. 22 –Age group<25 35 125–34 1050 1735–44 1492 2445–54 2299 37>54 1349 21n.a. 5 –P. Cantarelli, N. Belle and F. Quattrone Vaccine 39 (2021) 5732–5736of others do. Secondly, messages that focus decision makers’ atten-tion on the positive impact of vaccination on beneficiaries mayincrease vaccine uptake by leveraging on individuals’ motivationto make a prosocial difference [15]. Being ‘‘the people and groupsof people whom employees believe their actions at work havethe potential to positively affect” [15], HCWs’ beneficiaries includethemselves, their family and friends, and their patients. Thirdly,using default settings for priming professionals to think in termsof a high rather than a low probability of vaccinating may encour-age immunization because decision makers have a strong tendencyto anchor on defaults when making subsequent judgments [16,17].2. Materials and methodsOur study consists of a large-scale online RCT with 6230 HCWs.Subjects were recruited among the respondents to an employeeviewpoint survey that was administered in March and April 2019to all the employees of the public healthcare system of an ItalianRegion. At the end of the employee viewpoint survey, participantswere invited to click on a link that would redirect them to a web-page to complete our online RCT. Participation was voluntary andresponses were anonymous. The survey was developed and admin-istered through Qualtrics.Our RCT aims at investigating the main effect of each of thethree nudges on the intention to vaccinate against the seasonalinfluenza across different categories of employees – namely,administrative staff, nurses, physicians, and technicians. Wemanipulated the three experimental factors at 2, 4 and 2treatment-levels, respectively. The resulting factorial design fea-tured 16 (i.e. 2*4*2) experimental conditions. Each respondentwas presented with one vignette that was selected randomly fromthe pool of 16 and then asked about the probability of getting a flushot in the upcoming influenza season. Respondents moved thecursor on a slider ranging from 0 to 100 percent probability.3. Experimental manipulation of social normsHCWs were shown a bar graph displaying the 2017 seasonalinfluenza vaccination rates among the employees of the nine LHAsin their Region. Immunization coverage percentages referred to themost recent available data and varied from 13% to 69%. Profession-als were asked to imagine working for the LHA highlighted in thebar chart, which was the one with lowest immunization rate (i.e.13%) for a random half of respondents and the one with highestimmunization rate (i.e. 69%) for the other half of participants.The rationale behind this manipulation was to set two differentsocial norms, whereby the majority of colleagues either get vacci-nated or do not vaccinate against influenza.4. Experimental manipulation of beneficiary impactHCWs in the control condition (Ctrl) were asked to state theirintention to get a flu shot during the next flu season without beingreminded about the positive impact that this behavior may have ononeself or others. Their counterparts in the three treatments wereexposed to a message reminding them about the potential benefitsof flu immunization on three categories of beneficiaries: oneself,family and friends, or patients.5. Experimental manipulation of defaultsThe slider was preset at 20 for a random half of respondents andat 80 for the remainder of participants. The rationale behind thismanipulation was to prime subjects with either a low or a highdefault probability of getting immunized.57336. ResultsTable 1 displays the distribution of the 6,230 HCWs in our sam-ple in terms of their job family (i.e. administrative staff, nurses,physicians, and technicians), work setting (i.e. hospital, ambula-tory, teaching hospital), gender, and age group.Fig. 1 shows the average probability of vaccinating against theseasonal influenza by social norm and job family. A series of anal-yses of variance (ANOVAs) demonstrate that, across HCWs job fam-ily, the probability of immunizing against seasonal influenza ishigher among those randomly assigned to the high-coverage con-dition - in which the majority of colleagues vaccinated - as com-pared to their peers randomly assigned to the low-coveragecondition - in which the majority of colleagues did not vaccinate.More precisely, the difference in the probability of getting a flushot between the high- and low-coverage groups is 5.56 percent-age points (p = .048) among administrative personnel, 6.75(p < .0005) among nurses, 8.03 among physicians (p < .0005), and9.23 percentage points (p = .005) among technicians.Fig. 2 displays the mean probability of getting a flu shot by ben-eficiary prime and job family. A series of ANOVAs reveal that theeffect of messages emphasizing the potential positive impact ofvaccinating on different categories of beneficiaries vary acrossHCWs. Among administrative staff, the intentions to get a flu shotdid not significantly vary across the four experimental conditions(p = .515). In the case of nurses, reminding benefits for patientsincreased the probability of vaccinating by 4.80 percentage points(p = .068) as compared to a message that emphasized the personalbenefits of immunization. Among physicians, the probability ofvaccinating against seasonal influenza was 9.25 percentage pointhigher among those reminded about the personal benefits of vac-cinating as compared to the control group (p = .057). Priming tech-nicians about the benefits of getting vaccinated against theseasonal influenza for family and friends increased the stated prob-ability of getting a flu shot by 15.05 percentage points as comparedto the control group (p = .014) and by 13.23 percentage points rel-ative to the personal benefit message (p = .043).Fig. 3 reports the average probability of immunizing againstseasonal influenza by default and job family. ANOVAs find that set-ting the default probability of vaccinating at 80 rather than at 20 inthe response scale encourage vaccination among all HCWs butFig. 1. Mean percentage probability of vaccinating against seasonal influenza, by social norm, by HCW (n = 6230).P. Cantarelli, N. Belle and F. Quattrone Vaccine 39 (2021) 5732–5736physicians (p = .609). In particular, the size of that increase is 9.78percentage points among administrative staff (p < .0005), 5.15 per-centage points among nursing personnel (p < .0005), and 7.90 per-centage points among technical staff (p = .016).A series of tests for the equality of means across randomizedtreatments show that medical doctors tend to show a propensityto immunize against seasonal influenza that is about 24 percentagepoints higher relative to all other HCWs (physicians: n = 922,M = 74.32, SD = 34.48; administrative staff: n = 827, M = 49.93,Fig. 2. Mean percentage probability of vaccinating against seasona5734SD = 40.43; nurses: n = 3,881, M = 49.60, SD = 39.63; technicians:n = 600, M = 50.02, SD = 40.95, p < .0005).7. DiscussionOur large-scale randomized study aimed at exploring the maineffect of three nudges on the intent to get a flu shot in four differentgroups of HCWs. Firstly, the positive and negative impact of socialnorms hold across administrative staff, nurses, physicians, andl influenza, by type of beneficiary group, by HCW (n = 6230).Fig. 3. Mean percentage probability of vaccinating against seasonal influenza, by default probability, by HCW (n = 6230).P. Cantarelli, N. Belle and F. Quattrone Vaccine 39 (2021) 5732–5736technical personnel. In particular, the probability of undertaking adesired behavior – namely vaccinating against the seasonal influ-enza – was greatly enhanced by a social norm emphasizing thatthe majority of colleagues engage in that same behavior. To thecontrary, we found a sizably smaller probability of vaccinatingfor the random half of participants informed that most of theircolleagues did not get a flu shot. Secondly, the effect of messagesreminding the positive impact that one can have on oneself andon others by getting vaccinated tended to be conditional on theprofessional group. A prompt reminding benefits onto others (i.e.,family and friends and patients) increased technicians’ and nurses’propensity to vaccinate, respectively. Messages highlighting per-sonal benefits, instead, encouraged vaccination intent amongphysicians. Thirdly, setting a high rather than low default probabil-ity of getting a flu shot increased intentions to vaccinate for allHCWs with the only exception of physicians.Our novel experimental evidence provides three main generalcontributions to efforts aimed at enhancing the uptake of flu vacci-nation among Italian HCWs [18] in the absence of mandatoryimmunization [19,20]. A nudging intervention may prove moreeffective than another. For instance, emphasizing social normswhereby the majority undertake a desirable behavior may be moreeffective than other nudges. Nudges, however, can backfire. Forexample, our results tend to discourage the use of data about vac-cination coverage in organizations where most employees engagein negative conduct such that avoiding immunization. Then, theeffect of any given nudge may differ across groups of HCWs. Thus,administrative personnel, nursing staff, physicians, and techniciansmay react differently to the same intervention. In short, our studyputs an unprecedented accent on the fact that one-nudge-does-not-fit-all.Results from our study should be used with caution in light oftwo main limitations that pave the way for future research pro-jects. On the one hand, although RCTs are the gold standard inunveiling cause-effect links and estimating the magnitude of theaverage treatment effect, they fall short in explaining the mecha-nism through which the impact plays out. On the other hand, thegeneralizability of findings to naturally occurring settings is yet5735to be tested. In fact, the intention to vaccinate does not correspondto vaccination. In our context, only 31.7 percent of healthcareworkers and technicians actually got vaccinated in 2017 in theRegion considered in the study.In the wake of recent Nobel Prizes awarded to Richard Thalerand Esther Duflo, combining behavioral science insights and exper-imental methodologies seems to be a viable tool to improve deci-sions about public health. Our large-scale RCT with real HCWsmay provide valuable implications for scholars and practitionersalike as health care organizations around the world fight toincreasing the uptake of seasonal influenza vaccination amongtheir employees under the not-yet fully understood threats ofCOVID-19.Declaration of Competing InterestThe authors declare that they have no known competing finan-cial interests or personal relationships that could have appearedto influence the work reported in this paper.AcknowledgmentsThis study is part of a joined research project with the ItalianRegione del Veneto – Azienda Zero.References[1] How to implement seasonal influenza vaccination of health workers. Geneva:World Health organisation; 2019.[2] Advisory Committee on Immunization Practices, Centers for Disease Controland Prevention (CDC). Immunization of health-care personnel:recommendations of the Advisory Committee on Immunization Practices(ACIP). MMWR Recomm Rep Morb Mortal Wkly Rep Recomm Rep. 2011 Nov25;60(RR-7):1–45.[3] Bossuyt N, Damme PV, Grammens T, Nadezhda V, Filipova R, Kaić B, et al.Seasonal influenza vaccination and antiviral use in EU/EEA Member States –Overview of vaccine recommendations for 2017–2018 and vaccinationcoverage rates for 2015–2016 and 2016–2017 influenza seasons; 54.[4] OECD. Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019.P. Cantarelli, N. Belle and F. Quattrone Vaccine 39 (2021) 5732–5736[5] To KW, Lai A, Lee KCK, Koh D, Lee SS. Increasing the coverage of influenzavaccination in healthcare workers: review of challenges and solutions. J HospInfect 2016;94(2):133–42.[6] Dini G, Toletone A, Sticchi L, Orsi A, Bragazzi NL, Durando P. Influenzavaccination in healthcare workers: acomprehensive critical appraisal of theliterature. Hum Vaccines Immunother. 2018;04(14(3)):772–89.[7] Tavoschi Lara, Quattrone Filippo, Agodi Antonella, Lopalco Pier L. 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Nudging influenza vaccination among health care workers

https://www.iris.sssup.it/bitstream/11382/539692/5/CantarelliBelleQuattrone_2021_%20Nudging%20influenza%20vaccination%20among%20health%20care%20workers.pdf

Nudging influenza vaccination among health care workers

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Archivio della ricerca della Scuola Superiore Sant'Anna