Brent I. Fox, Pharm.D., Ph.D., is an associate professor in the Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University
Brent I. Fox, Pharm.D., Ph.D.

ComputerTalk readers have likely seen the reports that childhood vaccination rates dropped dramatically during 2020. The latest reports indicate a substantial drop-off during the early part of the pandemic. The good news is that weekly vaccination rates approached pre-pandemic levels by fall 2020 among all age groups examined (less than 24 months, 4–6 years, 11–13 years, and 16 years). However, vaccination rates and the proportion of children who are up to date on vaccinations remain below 2019 levels.

Vaccine hesitancy was the focus of this column in the July/August issue. Vaccine hesitancy was discussed in the context of individuals’ reluctance to receive the COVID-19 vaccine. In terms of childhood vaccination rates during the early months of the pandemic, the issue was not vaccine hesitancy. The issue was access and demand, as providers were encouraged to delay routine vaccinations to maximize social distancing and to minimize potential exposures to COVID. These same concerns led parents to not bring their children in for routine vaccinations. Reports like the one identified above highlight the results of those decisions to delay routine vaccinations. In that July/August issue, incentives, assistance programs, and general information were identified as methods to help address patients’ vaccine hesitancy. Messages delivered via SMS (short message service) were identified as a conduit to share information about these methods to address vaccine hesitancy.

Using Nudges

Recently, reports have highlighted the core components of SMS messages to nudge people to receive the COVID vaccine.

My focus here, however, is not the COVID vaccine. Instead, I want to focus on SMS “nudges” and health behaviors in general. To be fair, the domain of health behaviors is very broad. In essence, health behaviors are actions that an individual takes (or chooses not to take) that influence health or mortality. Common examples include exercising, smoking, sleep habits, medication adherence, health-seeking activities, and diet choices. In the context of health behaviors, the term nudge represents an approach to influencing decision-making through how choices are presented to patients and how the various presentation methods can impact actual decision-making.

Think of your patients who have considered stopping smoking. The health benefits of changing this health behavior (behaviors can be positive and, in this case, negative) are irrefutable. That reality doesn’t make it any easier to stop. Patients have a variety of resources to help, from nicotine replacement to apps and support groups. Or what about patients who want to improve their adherence to prescribed medication? Reminders are a common method of improving adherence, ranging from sticky notes to apps. Medication synchronization is another popular tool. You can think of a host of other health behaviors and behavioral change approaches that have and have not worked.

Underlying the use of these tools are the mental processes that a patient goes through to make decisions. This is an extremely active area of research and provides many insights into programs and services pharmacies can implement to support their patients’ efforts for healthier lifestyles. This is where nudges enter the conversation. Dr. BJ Fogg is one of the leaders in this area (although he is not a fan of the term nudge, because he believes it is ambiguous). According to his model, nudges must include three primary components for success: motivation, ability, and a prompt.

Without getting too deep in the weeds, let’s quickly look at the core components of Dr. Fogg’s behavioral model. He believes there are three primary motivators, each having positive and negative sides: sensation, anticipation, and belonging. In terms of ability, there are three ways to improve someone’s ability to perform a behavior: training, providing a tool, or simplifying the behavior. Lastly, prompts in Dr. Fogg’s behavioral model can take three forms: signals, facilitators, or sparks.

So how does this apply to SMS for health behaviors at your pharmacy? Let’s circle back to the COVID report linked above. Including a link to schedule a vaccine appointment in SMS reminder messages increased vaccination rates. This link is an example of a prompt — specifically, a facilitator — in Dr. Fogg’s model. The presence of the link prompts the behavior, making it easy for the recipient to perform the target behavior, which is signing up for the vaccine. In that same report, terminology was used to create a sense of ownership for the vaccine. Specifically, the use of phrases indicating that the vaccine had “just been made available to you,” and to “claim your dose,” was found to increase vaccination rates.

But what about other health behaviors? The Pew Research Center indicates that 97% of American adults own a cellphone of some kind, meaning that most adults in the United States have SMS capability. While variations exist in desire and capacity to send SMS messages, this remains one of the most efficient methods to reach patients and support their health behaviors. One recent review looked at nudges for health behaviors among patients with diabetes. Behaviors of interest included medication adherence, physical activity, diet, blood glucose monitoring, and several others. This report found that nudges that included reminders and gamification were most likely to lead to the desired health behaviors.

How does this translate to your practice? First, you are not expected to be an expert in behavioral models. There are many, and while each has its proponents, no one model has been labeled the model. The discussion here is intended to illustrate a few points. One, research provides support for the notion that simple interventions delivered via SMS messages can have a positive impact on helping change patient health behaviors. Two, patients may respond differently to the same nudge, and similarly, a nudge that is effective for one behavior may be less effective for other behaviors. This is where relationships enter the discussion. Your relationship with your patients can provide the entry point for discussions about the nudges that work best for them. Similarly, as you explore SMS-based strategies to promote your patients’ desired health behaviors, your pharmacy management system vendor will be an important partner. Your comments regarding successful and unsuccessful nudges are welcome. CT

Brent I. Fox, Pharm.D., Ph.D., is an associate professor in the Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University.
He can be reached at