Background

Evidence-based health information (EBHI) and decision aids (DA) are key components for
improving health care by enabling more people to make informed decisions. However,
despite their overall effectiveness, there is a risk that only certain groups of the
population will benefit from them. Because although they are target group oriented, the
factors that lead to inequality in terms of shared and informed decision-making have not
yet been sufficiently taken into account in their development process. For example, there
are many patient-oriented materials written at an advanced level, which makes the
materials less accessible to people with reading difficulties, lower education, health
literacy or socioeconomic status (SES).

Evidence-based fact boxes have been shown to support informed decision-making. However,
few studies have analysed how the boxes support decision-making in different social
groups. Further, it is unclear whether fact boxes promote informed and shared decision
making equally when implemented by health educators (HE) in different settings. Hence,
there is a risk that fact boxes will only help less disadvantaged people to make informed
health decisions.

Objective

In a Multi-center, cluster-randomised, cross-sectional study, the effectiveness of
evidence-based fact boxes (intervention) compared with usual health education/care
(control) on outcomes relevant to the decision to vaccinate will be investigated in
people from different backgrounds in Germany.

Fact boxes on COVID-19 and influenza vaccination have been adapted in several steps to
meet the information needs and requirements of the population. This included feedback
from various public health stakeholders on a COVID-19 fact box implemented in Germany in
January 2021 by a national Public Health institute, the identification of information
needs and requirements of the population in Germany based on secondary data analyses, and
testing of COVID-19 fact boxes in pre-studies in population-wide surveys with N=1,942 to
N=6,056 respondents in Germany. The data basis and individual studies have been described
in detail elsewhere.

The Influenza vaccination fact box was updated in 2021 based on current evidence and is
available on the Harding Center website for older people (65 years and older) and for
people aged 16 to 65. During cognitive interviews, simplified COVID-19 and Influenza
vaccination fact boxes were first piloted with German-speaking laypeople and adapted
based on their feedback. Visualized COVID-19 fact boxes were also piloted with Arabic-,
Turkish- and Russian-speaking laypeople from disadvantaged neighbourhoods in Berlin. A
visualized flu fact box is currently being piloted by the University of Erfurt with
German-speaking lay people.

Main research question

Do disadvantaged people benefit to the same extent as non-disadvantaged people in terms
of informed and shared decision-making from receiving COVID-19 and influenza vaccination
fact boxes as opposed to standard vaccination communication in medical practices and
outreach work (field settings)?

Research questions (RQ) and main hypotheses (HYP)

RQ1 Is the use of fact boxes more effective than standard vaccine communication (control
condition) in the field?

Primary HYP

1. Compared to standard vaccine communication, fact boxes will lead to higher
vaccination knowledge.

2. Compared to standard vaccine communication, fact boxes will lead to more vaccination
intentions that are in line with attitudes and vaccination knowledge (informed
vaccination intentions; operationalised based on the multidimensional construct of
informed choice by Marteau et al. 2001).

Secondary HYP

1. Compared to standard vaccine communication, fact boxes will improve risk perception.

2. Compared to standard vaccine communication, fact boxes will increase patient
involvement in medical decision making.

3. Compared to standard vaccine communication, fact boxes will decrease decisional
conflict.

RQ2 Are fact boxes as effective for people with disadvantaging factors as for those
without factors associated with disadvantages?

Primary HYP

Compared to standard vaccine communication, fact boxes will lead to a greater alignment
of knowledge, informed vaccination intentions, and accuracy of risk perception between:

1. People with low and high education through fact boxes compared to usual care.

2. People with problematic or inadequate and excellent or sufficient level of health
literacy through fact boxes compared to usual care.

3. Non-native (Arabic, Turkish and Russian speaking participants, only with low German
skills) and native German speakers (including non-native speakers with high German
skills), because the investigators not only provide information in the native
language, but also tested it with these target groups.

4. People with low and high reading literacy in different languages, because fact boxes
are a complexity-reduced format of health information and the investigators tried to
address accessibility through pilot testing with different groups.

RQ3 Does the use of fact boxes in outreach work promote more shared and informed
decision-making than in regular health care settings?

HYP

a) Compared to standard vaccine communication fact boxes will more likely lead to more
informed vaccination intentions and shared decisions in outreach work than in regular
health care settings.

Explorative analyses

1. The investigators will analyse the effect of fact boxes on knowledge, vaccination
intentions, accuracy of risk perception between people with low and medium or high
SSS through fact boxes compared to usual care.

2. The investigators will analyse the effect of fact boxes on vaccination intentions,
knowledge, risk perception, patient involvement, and decisional conflict among
people with migration-related indicators (e.g., residential status, length of stay
in Germany) compared to usual care, controlling for other factors describing the
social situation (e.g., education, health literacy).