Nurturing, Nudging and Navigating the Increasingly Precarious Nature of Cooperation in Public Health: The Cases of Vaccination and Organ Donation

"Nudging and nurturing cooperation while navigating the turbulent political and social storms and societal polarisation requires a concerted effort."

Many public health initiatives encouraging positive health behaviours require citizens' cooperation in the face of perceived costs and health risks. A growing environment of mis- and disinformation, along with volatile individual and group emotions, beliefs, and ideologies, all threaten our cooperative nature. This article investigates the dynamics of cooperation through the lens of two health interventions that depend on cooperation: vaccination and organ transplantation. Both can be viewed as social dilemmas because individuals have incentives not to cooperate but everyone in the population ends up better off if everyone cooperates (accepts vaccinations or offers organ donation) than if everyone defects. The article also explores policy incentives that have encouraged cooperation with these positive health behaviours.

First, the article outlines the costs, benefits, and motivators regarding cooperation in each of the cases of vaccination and organ donation. For example, despite the significant health benefits conferred by vaccines, the past decade has seen a growing amount of questioning and hesitancy around vaccination, with the perceived risks of vaccination often exaggerated by social media. This same prism of risk distortion can be seen in organ donation, where external nudges and support are needed to sustain cooperation through the multiple processes involved in achieving the public good of an organ supply for those needing transplantation to save or prolong their lives.

In the face of these various perceived and real benefits and costs, what motivates cooperation? The researchers find that appeals to kinship (e.g., in the case of living donor transplantation), reciprocity (i.e., a perpetual cycle of exchanges), reputation (i.e., being observed by others), and morality (e.g., perception of fairness) are important behavioural predictors of cooperation. Alongside the various individual incentives that have been used to prompt cooperation, a variety of external incentives and structural interventions - ranging from tangible rewards to public recognition - play key roles in achieving and sustaining cooperation.

Per the researchers, there is a tension between voluntary and involuntary behaviours in the context of cooperation around transplantation and vaccination. Whereas transplantation is always voluntary and involves a supportive process with coordinators who help individuals and their families navigate the various stages of the process in the preparation for transplantation, vaccination is sometimes mandated, which risks undermining individual trust and wider cooperative efforts.

The article describes cooperation as a fragile state, vulnerable to the individual's risk perceptions, as well as external social, cultural, and political forces, such as social media-disseminated misinformation, which can sway attitudes to health behaviours, including cooperation. Like rumours or false narratives, fears incited by rare adverse events - in the context of either vaccination or transplantation - are powerful emotions that can be deliberately sensationalised by factions opposed to cooperation. Personal stories and emotionally relatable details can be more convincing than the evidence. In short, the precarious nature of cooperation and the importance of continually nurturing trust over time is a key lesson from both transplantation and vaccination.

The researchers conclude by calling for a nuanced understanding of cooperation in a number of policy recommendations. Notably, they propose that:

• Reputation, anticipated reciprocity, morality, emotion, altruism ,and trust are intangible levers of cooperation and are not based on reason. They can be volatile and fragile. Social policies must take these forces into account to support positive cooperation.
• Cooperation is fragile and needs to be monitored and nurtured over time to be sustained. Being alert to changes and nimble in policy responses is crucial.
• Repeated mandates or restrictive policies across multiple issues will exhaust the goodwill and cooperative spirit of a population. Leaders must prioritise and use compulsory measures selectively.
• Opt-out vaccination policies should be made difficult to encourage compliance and cooperation with positive health behaviours that support a public good.
• Short-term wins, such as some of the pandemic restrictions, may result in long-term losses, particularly in public trust and cooperation.
• Social policies need to be culturally tailored and locally relevant/relatable.
• Community-level forces - including trust, familiarity, fairness, and a sense of belonging - are all important levers for cooperation, and policies should account for community nuances whenever possible.
• Positive emotions, such as hope and empathy, need to be nurtured and supported for sustained cooperation.
• Acting for the public good should be celebrated. Compliments and praise are free. Similarly, appropriate peer pressure from within the group locally can be a positive lever.

In conclusion: "We are living in a dramatically changing world on multiple fronts, including rising political polarisation and anti-globalisation movements, the increasing frequency of disease outbreaks and extreme weather events, and a rapidly changing technology landscape. We must learn how to navigate these changes to support cooperation but recognise and address significant challenges around human behaviour."