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Table 4 Behavioural insights informed changes to the flu invitation letter and rationale

From: Can uptake of childhood influenza immunisation through schools and GP practices be increased through behaviourally-informed invitation letters and reminders: two pragmatic randomized controlled trials

Changes to letter

Behavioural rationale

Formatting

Reduced in length and made simpler.

Simplification: Reduces the cognitive effort required to process the information and identify the action required [25].

We have formatted text to highlight the key points of note/ actions required.

Salience: Reduces cognitive effort to identify action required [26,27,28].

Provider letterhead plus NHS logo

Messenger effect: NHS is a trusted brand when it comes to medical/ health issues. (BCT 9.1 Credible Source [24])

Phrasing

Your child’s annual flu vaccination is now due

Stating ‘due’ creates a sense of urgency.

This vaccination programme is in place to help protect your child against flu.

Gain-framed message: evidence indicates gain-framed messages may be more effective than loss-framed for preventative behaviours (BCT 13.2 Framing [24])

Flu can be an unpleasant illness and sometimes causes serious complications.

Information about Health Consequences and Salience of Consequences: highlighting the negative effects of flu (BCT 5.1 Information about Health Consequences and 5.2 Salience of consequences [24])

Please complete the enclosed consent form (one for each child) and return to the school [by/ within] [INSERT DATE or TIME FRAME]

Action orientated: providing clear action focused instruction including telephone number to make the behaviour easy to perform and providing child’s name to increase personal salience (BCT 4.1 Instruction on how to perform a behaviour [24])

The vaccination is free …

Framing/ Reducing friction: to perform the behaviour: Reduces friction costs by eliminating the barrier of cost since there is anecdotal evidence that parents do not realise it is free or annual. Note: the evidence on use of ‘free’ is mixed as this can be deemed as less valuable, particularly by some cultures. (BCT 13.2 Framing, 6.3 Information about others’ approval [24])

… and will be given by a quick and simple spray up the nose

Framing effect: Encouraging uptake of this method because it is appealing and not painful (compared to traditional ideas of a vaccination being an invasive injection) (BCT 13.2 Framing [24])

Last year, most children offered the vaccine in schools had the immunisation.

Social norms (BCT 6.2 Social comparison [24])