This article focuses on multilevel governance applied to health organizations inQuébec (Canada). The objective is to understand the action levers thatfacilitate the adaptation of the services toward migrant populations. This typeof population establishes itself as an excellent tracer case to analyze theadaptation process, its fractalization and its involvement with the Environment.The dynamics between the actors and their self-organization takes part in thedevelopment of a multilevel governance. Interactions with the Environment—bothinternal and external—highlight the development of networks that emerge from thefield and are then implemented at strategic levels in the organizations. Thepresence of connectivity actors within the organization and the Environment isestablished. The context, the bonds of trust between the actors and thecredibility of the policymakers are reflected as important factors. However,connectivity actors cannot be successful without the support and contribution ofthe more “hierarchical” actors. Eight action levers are revealed by theanalysis. We categorized them in 3 functions: administrative, enabling, andemerging. The levers of the administrative and emerging functions require thatthe levers of the enabling function be credible and legitimate and be able tosupport them for the adaptation to spread throughout the healthcareorganization, regardless of the scope or policymaking level. The fractalfunction facilitates this process, by combining connectivity actors with theimplementation of connectivity structures. Therefore, one of the possibilities for managers,decision-makers and health professionals to give more meaning to their actions is tostay connected to their environment  and to manage the tensionswithin the institution, service or network. One possible approach for managing thesetensions could be, for example, to promote diversity within theorganization.2When it comes to organization theory, stability is traditionally a sign of successand sustainability. This also applies to managers’ vision in healthorganizations.3 Depending onthe context  and the bonds of trust that may exist between theactors, the proximity between the different levels—like the vertical interactions—isalso important when challenges emerge from the field, such as those related toimmigration and service adaptation. While primary actors such as nurses andcommunity organizers are connectivity actors, they cannot besuccessful without the support and the contribution of more “hierarchical” actors.To make this happen, the needs emerging from the field must be known andacknowledged.In a previous article, we showed that the interactions between the actors often occurwithin the same hierarchical level—like through horizontal interactions.Through this article, we set out “to identify the action levers, within a multilevelgovernance, that may or may not facilitate the adaptation of the services tomigrants and vulnerable persons.”10 when primary health care is considered from the perspectiveof complexity sciences, the focus is more on the quality of the relationshipsbetween the actors  than on the actors themselves. There exists somesensitivity to the fact that relationships between the various actors are non-linearand dynamical, and consequently, give rise to high levels of surprise anduncertainty. When it comes to knowledge, the preoccupation is based more oncontinued learning and reflexivity, than on knowledge as an end. It is acknowledgedthat there exists some interdependency between the formal and the informalorganization. It should be noted that it is indeed more important to understand theinformal organization than to try (in vain) to underestimate it to the benefit ofthe sole formal organization. The coevolution between the system and the Environmentrequires special attention. It is not sufficient to only observe how the systemadapts itself to the Environment, one must go beyond and understand the duality ofthis relation.For Stroebel et al.,46 It is necessary to leverage thediversity that exists between the various actors to promote learning, instead oftrying to minimize its effect, or—even worse—to deny it completely.The concept of diversity is at the core of the theories of complexity, just like itis at the core of health organizations, with the primary care as the entry door tothe system, for most of the population.In our research, diversity refers to the plurality of actors within the healthorganization  but alsowithin the society, particularly in terms of migration. The types of patientstargeted by our research are culturally diverse and there is a wide variety ofplaces of origin .8It is recognized that all managers, professionals, patients, and citizens are partsof the actual system,9 and not external observers or manipulators of the system. Byconsidering primary health organizations from this angle, the authors are suggestingthat the way they are traditionally seen should be changed from linear entitiesconsisting of a juxtaposition of unique or processual non-related events, to a“pattern, interrelated processes and relationship” orientedthinking (p. 440).10 This notion of relationships between the actors is sharedby other authors who refer to it as “generativerelationship”.11 Indeed, establishingrelationships with organizations that represent or provide services to migrantpopulations and/or newcomers  could influence healthorganizations’ will to adapt their services to this type of patients.12 In turn, thiswill facilitate—within the self-eco-organization & co-evolutionprocesses—the overall consideration of this issue by all the actors who play anactive part in this process, especially in the governance.14Social relationships are also numerous within health organizations; whether binomial(doctor-patient) or collective (team meetings), they promote sense-making, learning,improvisation and other functions that require some interaction between theactors.After presenting the study’s framework and methodology, the results are split into 3parts: (1) the levers of administrative functions, (2) the levers of emergingfunctions, and (3) the levers of enabling functions. The proposal is to regroup allthese levers to implicate them in an adaptation framework suited to a fractalorganization.1517 the model focuses on acomplex organization’s multilevel governance.1820 It embeds the determiningelements of health organizations in accordance with internal actions(self-organization and feedbacks) and external actions(self-eco-organization and coevolution.) This model setsout to situate the characteristics of an organization whose adaptation isfractal, that is, is at all levels of the organization, through connectivity andinterdependence mechanisms that support the multilevel governance. Each sphereis subdivided in 3 distinct scopes:Leveraging the theoretical framework developed in a previous articles,operational scope represents all of the primaryprofessionals fulfilling a clinical practice, and involved in each case.Under the term “clinical practice,” we include “all clients supportprocesses implying an inherent uncertainty that requires adequateprofessional judgment”21 (p. 170).Clinical activities conducted by primary professionals rely on thedegree of adaptation that can be attained in order to sustain andimprove the quality, safety, and fairness of the care provided to allpatients, including migrants.The tactical scope refers to actors from the administrationand management domains. From a multilevel governance perspective, thisscope conveys the strategic orientations to the operational level, andtransmits the actions undertaken by the operational level up to thestrategic level. By being the junction point between the heterogeneousself-organization of the multiple actors (from the organization and fromthe Environment), it allows the institution to self-eco-organizeitself.The strategic scope represents the “hierarchical”policymaking entity where the health institution’s senior executives andleaders are situated . Partof the strategic scope’s responsibility is to bring together and tosustain collective, coherent, unifying and homogenous schemata, whilepromoting coevolution with the Environment.The Environment actors are the health organization’s external partners. They mayinclude Community Organizations working with migrants (CO), Regional HealthAgency, Health and Immigration Ministries, etc.22 The choice to focus on 2 Health Centers (HC) in theMonteregian region rather than in Montreal imposed itself, since we were mostinterested in the adaptation process of those establishments that are “lessexperienced” in terms of international immigration and cultural mix combined tovulnerability. The study of 2 territories—one urban, one semi-urban—aims to bestreflect this reality, consistent with the policies currently implemented inQuebec with regards to immigrant settlement. A regionalization policy being ineffect in Quebec,23 we set out to better understand how the context caninfluence health organizations and their willingness to adapt to newphenomena.The selected strategy is a synthetic research through multiple case studies )—with integrated analysis levels , in accordance with a qualitativeapproach.24The analysis units (the cases) are the 2 HCs (HC1 and HC2) known for being thepopulation’s access points to health and social services—this includes migrantpersons.The study focused particularly on 3 clinical programs: family-children-youth(FCY) (Program A), physical health (Program B), and public health &community action (Program C). We selected them because of the importance of thecontacts with migrant persons, and the challenges associated. These 3 programsare useful in this research like “observation units” but not like analysisunits.Several administrative services were also retained, in addition to 2 communityorganizations  that are very present in Montérégie region and in theHC territories subjected to the study. Lastly, an actor from the regional branchof the Immigration Ministry (MICC) was interviewed. In total, 43 semi-directiveinterviews were conducted between November 2010 and February 2011 inclusively.Six (6) final interviews  were realized inApril 2012. We made the deliberate choice to wait for the progression of theanalysis of the first 43 interviews, which allowed us to dive deeper on selecttopics with the actors from the Environment. All interviews were conducted bythe same researcher.stratified samplingwas applied to the 2 Health Centers, and “snowball sampling”was applied to the actors from the Environment.25 Stratified samplingwas completed with the help of a key informer in each one of the HC, byselecting respondents within each of the 3 scopes. Additionally, the keyinformer role allowed us to target—within the 3 programs—persons who workedmore frequently with migrant patients and newcomers. This especially appliedto the operational scope. However, to limit any selection bias, we also didtarget stakeholders with less exposure to this type of patients. Theobjective was to develop a better understanding of the circumstances inwhich a “less expert” practice, applied to cultural diversity, isexperienced by operational actors.Regarding the selection of our respondents, operational scoperepresents all the health professionals who practice in clinics, and who aredirectly exposed to the patients  The tactical scope represents themanagerial part of the organization . Finally, thestrategic scope represents the hierarchical andpolicymaking area, consisting of directors and chief administrators .Basing ourselves on Mintzberg’s work (1989),26 we identified 3 scopes:operational, tactical and strategic. The 27These 3 scopes are separated between 2 spheres: clinical and administrative.The clinical sphere focuses on phenomena related to the clinical aspects,while managing the interface with the administrative sphere. Theadministrative sphere focuses on organizational phenomena in interface withthe clinical sphere, which it is dedicated to serve.Actors from the Environment belonged to one of the following 3 types oforganizations: (1) 2 community organizations (CO) that were unanimouslymentioned by all the HC interviewees, (2) the regional health authority, and(3) the Ministry of Immigration . Out of the 57 interviewsinitially planned, only 8 respondents were not available. It should be notedthat it is mostly the respondents from the operational scope of HC1 whorefused to participate. In any case, the participation rate for the studywas 86%, which is very satisfactory. Frequently, during the interviewscheduling phase, respondents would spontaneously get in touch with theresearcher, offering to contribute. Actors showed a strong interest for thesubject matter addressed by this study.28 Atopic was retained if at least 3 respondents (regardless of their level)mentioned it.Data analysis was completed based on the interview transcripts. We conducteda coding analysis by classifying the codes according to the topics andsub-topics obtained through our theoretical framework and through the dataitself when the topic was recurrent (Miles and Huberman.Two sources of data were leveraged as part of this research effort: 1-Document sources (N = 21) and 2- individual interviews (n = 49).Document sources were used to situate the challengeof migration and health service adaptation at the level ofgovernment archives, ministerial archives, and regional agencies,but also at a local level like at the level of HCs and partnercommunity organizations operating and interacting with migrantpersons. These documents were minutes of strategic, tactical, oroperational meetings such as board meetings, clinical-administrativemeetings. These documents were also newspaper articles, minutes ofmeetings between health organizations and departmental or communitypartners. Finally, there were also immigration and health policies.This comprehensive documentation search allowed us to enrich theresources provided by the interviewees. For instance, thesedocumentary sources allowed us to better grasp exactly what theEnvironment is seeking from each one of the studied HC.Semi-directive interviews (N = 49) were conducted withprofessionals , managers  andadministrators (strategic scopes) . We asked the various actors to share ideas or strategiesthat—from their point of view—could benefit the service adaptation process.To facilitate transcription, interviews were recorded, with theparticipants’ consent. scopes) . For thefield bookinventorying precise details of the research process .31 Thisallowed us to retrace all the activities completed by the researcher, whichis a valuable input to the final redaction.Finally, throughout this fieldwork, we kept a “summary sheet” was completed for eachinterview.28 Each summary sheet was transmitted to therespondents from HC1 so that they could validate and confirm its contents.Because all summary sheets were compliant for all respondents, we postulatedthat the same approach was not needed with HC 2. HC 1 was selected forpractical reasons: interviews were conducted first with HC 1. Moreover,interviews with the Regional Agency and Community Organization 1 wereconducted from September to December of 2011. Several respondents from bothHCs attended, either in person or through videoconference. The analysis andthe preliminary results of the research were presented. Discussions ensued,and the respondent’s expressed satisfaction with regards to the implementedapproach. Throughout the study, these restitution checkpoints facilitatedinformation feedback and transparency with the respondents, thus reinforcingthe study’s internal validity andcredibility.25 Finally, in March2010, the research protocol successfully met all the criteria set by 2Ethical committees.A 32—wasused to capture the data and facilitate the analysis. Output data werereduced , whichpermitted the development of assumptions that could be verified based on thedata already collected, and the data still being collected.33The analysis and data gathering activities were performed simultaneously;they included some iterative aspects with regards to coding andcategorization, which allowed us to adjust the interview grids. Once theinterviews were transcribed, the QDA Miner software—version 3.2internalcase analysis, by focused on each Health Center. The aim was toregroup and synthesize the models to draw a clear picture of the dynamicsand processes within the health center regarding the adaptation of theservices to migrant persons.The analysis was completed in 2 steps: the first step was an 22 Interpretations were verified with actors fromdifferent scopes to meet the criterion for credibility .A deep analysis of each case allowed us to achieve strong internalvalidity.Moreover, the validation of both the analysis and the interpretations was thesubject of several conversations between the research directors and thedoctoral candidate.transverse case analysis,which allowed us to compare the 2 HCs to expand observations on researchproposition. In doing so, we have favored the investigation of explanatorylinks in order to uncover the mechanisms behind the adaptation process, theinteraction between different actors and different levels ofgovernance.25The second step consisted of a Schemata.34 Fouradditional ones were highlighted through the coding and interview analysis:“Communication,” “Knowledge,” “Coupling” also known as degree of influence, and“Connectivity.” In the end, 8 action levers are available to test the researchproposal , it appears that theofficial designation of a case owner or reference person for the“adaptation & migration” topic is a major thing. Indeed, toeveryone, there usually exists a natural interlocutor. It is importantthat this actor—or this group of actors (such as program C forinstance)—have the necessary credibility, through their knowledge of thesubject, through their network with the Environment and through theirinterest for the challenge at stake. Built upon the credibilitydeveloped, legitimacy is made possible by the recognition of the role bythe hierarchical actors.While “Like I am saying. . . Having a case owner, let’s saythat, for me, around here, for HC2, it is a person you canrefer others to. Actually, we know it, it is her who hasaccess to the bank, in case we need interpreters, in case wehave an issue with a family, and it’s sort of like that. Inorder for it to work, it takes a case owner, who is easilyaccessible, who has relationships with the people thatmatter in the community, who works with thecommunity”“It is necessary to have an owner (for the case), aminimum of resources, and accountability. It also takeswillingness; it takes a responsible person. It also takescontracts”As far as Health Center 1 is concerned, the case owner is a collectiveone. We are talking about programs A and C, via their common programdirector. However, while the liaisons with the strategic actors aregoing through him, all the activities—including managing the internalCommittee—are delegated to an operational actor recognized as “very muchinvolved” with migrant persons. The “owner” role is shared between thestrategic actor and the operational actor, each involved in his ownscope of influence. From an internal perspective, as well as from theEnvironment’s perspective, the operational actor gives credibility tothe topic. Meanwhile the strategic actor brings legitimacy via hishierarchical position. In doing so, he facilitates direct access to theclinical and administrative directions.In administrative terms—in addition to the associated symbolism—thedemand from cultural and migrant communities to be represented at theAdministrative Board is deemed an interesting lever by severalrespondents. In Health Center 1, this lever is part of the action planemanating from the internal migration Committee. In Health Center 2,many respondents identified this type of lever as a tangibledemonstration of the efforts made by an organization to get adapted andto include people with an immigrant background. However, severalstakeholders mentioned that a lot of work is left to be done to bringsuch an action to completion.“Like I said, there could be a reserved spot in theadministrative boards of the establishments, for a delegaterepresenting the population, one or two delegates forimmigrant populations, why not. So we reserve spots toensure that they are well represented (. . .) Take thepulse, and have their own weight in the decisions”The involvement of the Regional Agency—specifically on the topic ofimmigration—is highlighted in several ways. The involvement could, likethe Montreal regional bank of interpreters, go through a Monteregianbank relying on what is already existing at the local level, whilecoordinating the whole thing so that all time slots for accessing theseservices are expanded. Currently, it is the community organizations thatcompensate for the lack of interpreters in both the Health Centersstudied. At Agency level, the regional vision for the bank ofinterpreters did not appear to be a priority; this is justified by aweak critical mass of migrant persons and by the fact that local healthcenters have a responsibility to provide interpreters to patients whospeak neither French nor English. However, it is important to mentionthat several people were mixing up the health centers’ internalbanks—which are more informal; the regional bank—which does not exist;and the banks from the local Community Organizations.“Yes, I am aware of the bank of interpreters. . . It isorganized by the regional agency. . . But I wonder if eveninternally, we don’t have a small system. . . I am not surewhether this is a formal thing. . . In the field, it is adifferent story since people know each other, and then, forexample. . . if we have a nurse from China. . .., we knowit, we leverage her”“And those, these banks of interpreters are usuallymanaged by community organizations. . . In the Montérégie.This could be different in a region as large as Montrealwhere some establishments have among their staff people fromvarious communities, who sometimes do offer this kind ofservices, while doing something else. This is probably notthe case in Montérégie”“But the establishments that have those communities ontheir territory, they have the duty to adapt or to dosomething to reach out to this clientele and to create theconditions for accessible services for those clients. . .And even to help people. . . through interpreters forinstance, when they are in need of care or services. Andthis, this is a preoccupation that must be very. . ., thatis very local”Additionally, the regional Agency had implemented a regional Committeefor Health and Social service accessibility by ethno-culturalcommunities. However, this committee is no longer active for severalyears. Yet, according to several respondents—including some from theAgency itself—it is the most important lever at regional level.“The Regional Committee should be reactivated; this isreally important. For the Agency itself, this committee isvery important and informs the CEO. The simple fact offormulating, addressing this question with the communities,and developing the CEO’s position, thisalready stimulates the action”Lastly, the leadership of the Agency is directly put in question by someof the respondents. According to them, the Agency’s role is tocentralize socio-economical, demographic, and socio-sanitary informationto establish—in collaboration with local stakeholders—the primary needsof the populations on those territories. The lack of informationregarding migrants and newcomers is raised repeatedly in manyinterviews.“When it comes to program implementation (. . .) therehas to be some leadership from the Agency, because part ofits role is to better understand the needs of its populationand its region, this is why they are here, they are here forconsultation, needs (. . .) They have to have someleadership, for me, this is squarely part of theirjob”“Within our network, we have very little informationregarding the ethno-cultural clientele. We don’t recordtheir background; this is not in the regular databases thatwe use. (. . .) But at the Agency, we are not aware, and wedon’t have it”connectivity actors attached to this program aretrying to educate network actors on this responsibility, while insistingon the importance of sharing this responsibility. By“Connectivity actors”, we refer to the actors fromthe multilevel governance who are involved in the establishment’sadaptation process. Most of time, these actors are from the operationaland tactical scopes. In our study, nurses, community organizers andclinical advisors were identified as “connectivityactors.” For all of the actors interviewed, regardless oftheir origin , it is clear that the Health Center cannot bear thisresponsibility alone. Additionally, some actors from the Environmentperceive this as an interference from the Health Center, and not as anacknowledgment of their expertise, experience and independence. Thesetensions are regularly voiced with community organizers, during theMICC’s “Table des Partenaires en Immigration” (Immigration PartnersRoundtable meetings) for instance. However, this remains a strong lever.In Health Center 2, it is thanks to the pooling facilitated by the“Table de la Petite Enfance” (Early Childhood Roundtable) that resourceswere identified, and a liaison officer position created.The concept of population-based responsibility was highlighted in severalinterviews. In both Health Centers, program C is especially supportingthis challenge inside and outside the organization. The“With the early childhood consultation roundtable, wecreated a liaison agent position between the families thatcome in. Very often, they are refugee families with manychildren (. . .) and it works”In Health Center 1, when the topic of immigration comes up,population-based responsibility and network implementation arematerialized through the internal Immigration Committee, and through theHealth Center’s increased participation in the various adaptation andimmigration roundtables and committees. Moreover, this is an interestinglever since it also influences the actors’ schemata versus the network;their ability to share; and the pooling of individual experiences.“We live in the same territories, how do we adapt, andin the same time, what are the contributions, thereciprocity, what is available in the community to help uswith that, to accompany us and so on. The population-basedapproach has changed things around, in a way we go back tothe early stages of when the LCSC were created: LocalCommunity Service Center. There you go. . . look, there is adifference of vision between: « this is what we have andthis guy has to fit in » and « There is this, and us, whatare we doing to deliver. . . and to adapt”reach-out actions, or of sustainableadvanced strategies, is identified as a powerful lever when it comes toservice adaptation and vulnerable populations such as somemigrants.38Combined with population-based responsibility and networks, thedevelopment of “An organization that reaches out, that is able to goand meet people. . . in their environments, to go. . ., tonot simply wait that, that people come ask for help whensomething is turning, turning bad or. . . It would beproactive to really have, to say “OK, so, where are ourmigrant populations?”. . . To have, to establish the needsin a more precise way, maybe in our public healthcare plan,well. I think it needs to be clearly defined”EthnicMatching, it is acknowledged by several contributors thatthe influence of persons with an immigrant background is beneficial tothe whole staff, as it facilitates openness as well as the realizationthat some obstacles do exist, be they cultural, linguistic, orother.In terms of human resources, the lever most people referred to is theadequacy between the background of the persons employed by the healthorganization, and the persons treated and followed by the healthorganization. Without going into systematic “I could tell you . . . the story of a. . . lady. . . ofMuslim background, anyways, of. . . Muslim confession, whorefused to receive care from a male nurse, because accordingto her religion. . . she could not denude her arm in orderfor the male nurse to give her the injection. And. . . Atthis time. . . we had to intervene for, well, well, therewasn’t any, no one else was. . ., no one else was available,so by telling the lady: « Listen, no one else than me orthis male nurse is available to provide this service ». Atthat point she was able to agree to be treated by him. Thisis just an example. But there. . ., I learned from thisexample because. . . the nurse, as for him, was upset, hispoint was. . .: « She shouldn’t have to. . ., well, if shedoesn’t want to be cared for by me, then let her go » andall that, and I think this is a good example that shows thatwe should go beyond the resistance, beyond, and try tounderstand why, and also adapt our response”minimal variability.2In order to reduce the distance between the Environment and theorganization, it is important to increase the variability in theorganization, in adequacy with the Environment’s variability: Zimmermanand Hurst call that When it comes to resources and knowledge, the lack of training wasdispraised by all the interviewed actors. They all agree to put anemphasis on the need for knowledge, be it for operational actors, whointeract directly with migrant persons, or for tactical and strategicactors, who need to have at least a basic awareness of the challengesassociated with this type of patients.“I think it would be good to. . . Could we not. . . It’sdifficult to say. . . Go get people from differentminorities. Look I know, lately I was asked to go to McGillto attend a recruiting event. There were a couple of peoplefrom different backgrounds who were [. . .] (32.10): « sendme your resume, I want to do a follow-up ». For sure I wantto be certain that they have the right skills, but Isaid. . . there was a young woman from Arabic background,who speaks English, French and Arabic, and I said she livesin the neighborhood, she knows the area, me I’d like, if sheis competent, I’d like her to be part of the team”The financial resources lever was highlighted in all the interviews asbeing at the foundation of any possible action. The current budgetaryrestrictions are limiting service adaptations. Moreover, Bill 100restrained access to training, which penalizes « long term » learningsuch as multiethnic trainings.“We have zero money for that. We get orders from theministry: you must offer such and such services. But getorganized with the resources you currently have. It isextremely difficult to implement because we just don’t havethe resources”“We are in a context of cost cutting when it comes totraining, you have to prioritize. So in the teams, people,they don’t really prioritize because they don’t see it as aneed. Because it is not the priority for their clientele. Sowhen you have to prioritize between trainings like. . . Forthe SIPPE [NDLR: The integrated services and early childhoodprogram] feeding sessions for instance, because there is aneed, because if you want to be certified as“Baby-friendly”, we are going to put this as a priority, andnot the multiethnic approach”schemata andcoupling. Three main levers were highlighted in theanalysis.The emerging function, as far as it is concerned, regroups the more informallevers, those related to Actors from the Environment are seen by the actors from the Health Center assources of information and immigration experts. In this context, the Healthcenter does not act as a “decision making” entity, but rather as aninstitutional actor who participates and contributes to a wider network. Asthe actors from the Environment and those from the Health Center influenceeach other, a coevolution develops between them. However, Health Centersclearly rely on Community Organizations when it comes to knowledge,networking, information, and population monitoring.“CO 2 is the organization, par excellence, that we refer to.We collaborate a lot with them. If at any point we are in needof information, or if we’re not sure about something, wecommunicate with CO 2”“For CO 1, the mission is to implement some levers that willfacilitate the adaptation of immigrants to their new country.When it comes to health, integrating immigrants in the healthcare system is not an end in itself but a stepping stone. It isthe institution par excellence for integrating all citizens, notonly immigrants. This network, at the beginning, must beleveraged for integrating all immigrants, since they areprobably excluded from the other networks, especially uponarrival”[Actor CO 1]“There are things, that are not up to us, be we still haveto be able to lead. . . When it’s us, in my opinion, at alltimes we must be able to offer high quality services,accessibility, continuity in the care, accessibility when itcomes to prevention, healing, supporting. This is what we do,community development, we also work with the groups. We doinclusion; we do citizen participation, this is what wedo”“lobbying” power from theorganizations that support migrant persons on their territory. On the otherhand, most of the interviewed nurses working in a Health Center did notindicate that they lacked any knowledge about the resources specialized inmigration. On the contrary, they identify them well, know them and most ofthe time, use them. This highlights the lack of connectivity between thephysicians and their Environment as well as the need to join them to getthem involved. The monetary aspect was discussed several times, which tendsto show that financial arrangements would facilitate greater cooperationfrom physicians. However, data analysis tends to show that other levers—suchas the communication lever—would be just as appropriate. The imbrication ofthe administrative, emerging, and enabling functions would facilitatephysicians’ involvement and would benefit the adaptation of theorganization.When it comes to medical practice, meetings between physicians and communityorganizations prove to be necessary: physicians often complain that they donot know what the available resources are which raises the question of thelack of visibility and On the other hand, a readjustment of the Agency’s Regional Committee wouldgive a “formal” voice to the challenge of adapting the region’s health andsocial services, and at the same time, permit a contextualization of theactions for each one of the impacted Health Centers.“Like I said, activating the Regional Committee is our onlyhook; there is no other lever available to the Agency. As itstands, it is a structure that was developed by the Agency, notall the Agencies have it, and even Montreal doesn’t have it! Thequestion was posed of whether this service, uh. . . thisstructure should be abandoned, but in terms of governance, theAgency decided to maintain the advisory committee to the CEO,it’s still something. So we need to leverage this”For tactical and strategic actors, considering the feedback provided byoperational actors is a way to rapidly gain legitimacy and respect fromoperational actors. This also facilitates a more patient-oriented caredelivery, which proves to be an important thing in the eyes of theoperational actors. This type of lever can influence the development of moreadministrative levers, such as the representation of migrant populations onthe establishment’s Administrative Board, for instance.“Ideally, this is how it would be done: we all convergetowards the same direction, if we are clientele-oriented, wemaximize accessibility, we listen to the issues, we identify allthat, we find possible solutions, and then we go at it. I thinkthis would be showing true openness”“When a solution is introduced, it is also evaluated by thewhole team (. . .) every six weeks, we meet, and this is how weidentify some issues, and this is also how we found somesolutions. Indeed, when saying “look at you, you’re from Haiti,this is great what you did that last time”. We give ourselvesthis way to do things, we hear about these things, fromeverybody, when we have a client who’s from Haiti, it can bedifficult. . . We do it like that, we all worktogether”As for Health Center 2, it is the needs coming directly from the field thatled several actors to develop an informal Committee about service adaptationwith migrant patients.“Following difficulties that were met, a small committeedeveloped, sort of informally, for service adaptation, and soonwe will formalize this approach and gather all the requiredinterlocutors to improve access to services to migrantpersons”coupling.The resonance of the needs and actions from the operational scope permits tocreate awareness with the tactical and strategic actors on day-to-dayclinical operations, and, at the same time, permits to import thesechallenges in the different scopes so that the willingness to adapt is feltat all levels. It should be noted that in the case of HC2, this processrealized itself within the clinical sphere only. Regarding these challenges,the connection with the administrative sphere is more difficult to develop.However, it is acknowledged that some strategic actors would be decisive interms of “I can assure you that identifying the influential actors inthe organizations is a big question mark. The financial directorhas a lot of influence, physicians, money, physicians; all thishas a lot, a lot of influence”Their involvement level would then vary according to their schemata. This isnot a time for developing and financing innovative programs or actions. Thisis a time for cost tracking and budget restrictions, and it does notencourage the actors from these departments to get involved in immigrationrelated committees or projects.“If we are on a HC territory where there is a strongimmigrant population, but no immigrant clients are coming, maybethen we should talk about performance, maybe we are not doing sowell. It could be part of our performance indicators, todocument for instance the number of immigrants, the number ofpeople coming from another country vs. the number of clientsreached by the establishment, and then we could see whether ornot we reach vulnerable populations (. . .) Me, I have nothingagainst performance, I am for performance, I am a manager, thepoint is to have efficient and reliable services, but efficientand reliable, it also means that we reach the righttargets”Each Health Center has levers of the administrative kind, and of the emergingkind. Levers of the enabling function permit the creation of links between theemerging and administrative functions. They gather communication, knowledge andconnectivity. Four main levers were highlighted by our analysis.“know those people”  while referring to migrants and newcomers.The influence of the communication board is a known lever. However, despitethe limited means of this board and despite low involvement from strategicactors in this lever, several of the actors interviewed did highlight thisspecific lever as critical, provided it is implemented adequately. To borrowa Rugby oriented metaphor, just like a try can be converted into additionalpoints, the levers of the emerging functions need to be “converted” by thelevers of the enabling function for the adaptation to fractalize and extendthrough the whole health establishment. Indeed, the winning strategy,according to many stakeholders, leverages the communication lever, be itinter-individuals, inter-program, inter-scope or inter-sphere. It also seemsimportant to break the silos and open the organizations to Environmentactors and to the communities. It wasn’t rare for respondents to say thatthey didn’t “Since the strategy permits the adaptation, there is nodiscussion channel (. . .) creating a dialogue between immigrantpopulations and us, well it can happen through coordinationcommittees, consultation roundtables, but none of it isreally. . . Anyways, it doesn’t come to me. The communityorganizer, well she takes some action, but it doesn’t stick, itdoesn’t spread that much through the organization”Based on public health concerns and community actions, the communityorganizer can facilitate the transmission of the needs from the field to thestrategic actors or to the actors from the administrative sphere.“I think we can act as a sort of catalyst. We are well positionedbecause of our community mandates, we know the community well, andwe know the organizations well, like [NGO2]. A privileged role inthat we can put a name on those realities, and become familiar withthem, and bring them to the attention of those other parts of theorganization that are less close, and that won’t be confronted tothem until a case presents itself”“Community organizers, they can be influential, because theysee things, they can say to us: « Hey listen. Think about suchand such”“connectivityactors” by directly influencing clinical practice with theoperational actors; they also indirectly influence organizational practicesby providing information on the needs from the field to the tactical andstrategic actors.However, the community organizer role—by itself—is not sufficient to raiseawareness in the organization on the challenges associated with immigrationand adaptation. Therefore, the clinical advisor role also becomes anoutstanding source of information and knowledge. They make it easier todevelop links between the different programs, and they share informationwith advisors from other establishments. They act as “The specialized care advisors for instance, they areoutstanding resources to provide guidance to the teams. Indeed,I am certain that if anything exists, good practices, data,these people can go get that. So I am certain that we are wellequipped to address that, and then go fetch what we need to getbetter tools”“What I say is. . . The advisors, the clinical advisors, they walkaround, they (. . .) because the mandate of the advisor is toestablish best practices, define what the best practices are. Shegoes around, she must show openness; consider all avenues toidentify the best possibility, and always in relation to the need –at field level, at the level of the clientele. So this is not comingfrom the top based on what we know, unidirectional, that’s how itis. . .”connectivity role toward the strategic actors who thenmay or may not promote this challenge to the various boards.The community organizer and clinical nurse advisor roles have a level ofinfluence that is recognized by all the other actors. They manage to reachall actors, inside and outside of the organization. Later, at policymakinglevel, any gap will be filled by transmission and relay from the; a formal structure is alsobeing implemented, with its official meetings, common objectives and avision going in the same direction: one consisting of adapting the healthorganization, at each individual level.Based on the levers of the emerging function, an informal initiative—carriedby one of the community organizers and backed from the beginning by one ofthe strategic actors—consisted of developing a “Migration” committee withinHC1. This initiative was successful, and the committee now involves actorsfrom all 3 fields and both spheres of HC1. Actors from the environment,including community organization 1, also show some involvement. Inter-sphereand inter-scope communication channels materialize, and concrete actions aredeveloped connectivity actor, regardless of the scope sheor he belongs to. The level of connectivity, combined with the group’scommon schemata and combined with the legitimacy of the formal structurethat developed from the Committee, promotes the amplification of thechallenge throughout the organization and its various scopes: theconnectivity actors contribute to the development ofconnectivity structures.However, it should be recognized that Health Center 1 is not affected by theactions of this Committee, this is especially true for the administrativesphere. On the other hand, each of the actors represented in this Committeebecomes a “Me, I used to tell myself, if only I was able to plant avirus within each board, so that they become aware of a globalvision, it would make me happy. Even more than that, we aremoving towards a work plan. (. . .) The date [of the nextmeeting] was picked and we are going to hold it at [NGO1] sothat we are straight in the right setting, get out of oursurroundings, in the end the assessment turned out to beinteresting. There is willingness, it’s more than what Ithought, I think that the field was maybe. . . Maybe the righttiming (. . .) So when we highlighted it, our objective was notto make them a clientele that you have to study with a spyglass,and put aside, but to come to the realization that this is animportant part of the population that must be taken intoaccount, so, as leaders and managers, we have some work to do inorder to iron out biases, to send a clear sign within theorganization that immigration is a priority, then. . .”“Migrantfriendly” program, which favors adaptation.39Clinical and organizational practice adaptation becomes an objective that isshared by all actors—clinical or administrative—via certification proceduresthat are recognized and valorized: the connectivitystructures are now established.Besides, knowledge of existing resources and monitoring trainings are a keyaction lever. Through efficient inter-level and inter-sphere communication,the knowledge levers allow the affected actors to consolidate theirexpertise, and in the same time, facilitate continuous improvements in thequality of the care delivered to migrant and newcomer patients. From thispoint on, structures such as Health Promoting Institutions (HPI) can openthemselves to specific certification programs such as the “Let us get certified as « immigration supportiveenvironment » you see? We are « Baby friendly » certified,everyone is trained at different levels: the direct player isgoing to get a three-day training, the one who is remotelyinvolved in this, the janitor is probably going to get ahalf-hour session, we don’t have a choice. Everybody, here,we’re all going to be certified”“We are currently implementing the « Health Promoting »concept, in which we can find for instance, the standardsrelated to patient care (and) we could adapt them to Anglophoneclientele or clienteles who don’t speak French orEnglish”It is recognized by several actors that stronger commitment from physicianswould be a favorable lever to the adaptation of the organization and to theadaptation of the clinical services. The lack of interest on the part ofthese actors—together with the shortage of physicians and the peak workloadsthey are faced with—are some of the factors may explain the low involvementlevels.In this regard, actors from both Health Centers and from the regional Agencydid point out again that there exists a paradox between the Health Center’spopulation-oriented responsibility and the physicians’ professionalresponsibility. While the Health Center is, by law, accountable for thehealth and well-being of the population on its territory, physicians—as forthem—are accountable for their patients, and they are not required to takemore patients that they can or wish to take. According to severalrespondents, this paradox involves schemata levers and at the same timeconnectivity and resource levers. The shortage of physicians and healthprofessionals has a negative impact on the levels of involvement with themore vulnerable patients who require more time and knowledge. This knowledgeresides directly within the network of partners that physicians may or maynot have developed. The more partnerships physicians will entertain with theEnvironment and with the Health Centers, the more support they will get whendelivering treatments and the easier it will for them to access the wholerange of services offered. Contrariwise the smaller the network, the moreisolated physicians will be in their practice, and they will have to supportnew types of patients by themselves. This, in turn, will not encourage themto get more involved with this type of patient.“It’s just that if you want to raise awareness on a specificclientele, you need to couple that with some support tophysicians. When you don’t have that, the door shuts itself.It’s like: « Look, I can’t do any more than this, this is it. ».So, it’s too bad, but that’s the way it is. So, if you want tosay to them: « Well, there is such and such clientele that weneed to pay special attention to because they have let’s say,one, two, three, four, five, eight particular needs, we needyour help », yes, but for such and such things, you need to bemore precise, then. . . you will have access to this and thatand this and that. Without it, it’s just too heavy”“With the labor shortage and the time we. . ., I mean thisis the thing we lack the most: time, I don’t think that they areso welcome. We are going to do it if they are sick, but youknow, saying: « Yes, I will be your family doctor ». . ., we arenot going to rush to say that I think”coupling.).The doctor’s symbolic role should also be considered. They hold stronginfluence and credibility with the actors from the Environment, with thepatients, and with the actors from the Health Center. Their commitment in aprocess like an organization’s adaptation to migrant patients’ treatmentgears up the other actors, which facilitates policymaking and action there could bea sort of patient assessment service for migrant populationswithin the HCs. This should exist, things would be much easier.And physicians would then be more prone to accepting to followtheir medical issues”[Strategic Actor - Agency]The paradox opposing population-based responsibility versus the medical orpatient responsibility was raised by several respondents; it probably comesfrom the fact that physicians do not have an obligation to adapt to theirEnvironment. Neither do they have an obligation to get more involved withvulnerable patients like migrants or newcomers. Nevertheless, they are anessential actor of the health system and of its adaptation. In both thecases studied, physicians’ involvement is a key lever, especially in termsof health service accessibility for migrants and newcomers. For example,when a refugee health clinic is created, it is only because there arephysicians—in addition to the other health professionals—who agree to seeand to follow refugees for a given period.The various governance levels, as tools to fractalize the adaptation of thehealth organization.“The adaptation of the clinical and administrative spheres of ahealth organization, and the scopes that compose them operate a convergencethrough various action levers that facilitate the integration – in a consistentfashion – of the clinical and administrative practices between theprofessionals, the managers, the administrators and theEnvironment.”The origin of this article was about identifying the levers of a multilevelgovernance that may facilitate the adaptation of an organization’s primary healthservices toward migrant populations. To do so, we set out to verify the followingproposal: Based on the conceptual framework proposed in a previous article, the analysis of thedata obtained through a case study focusing on 2 Health Centers and their local,regional, and national Environment allowed us to validate our research proposal.The different actors, from the 2 Health Centers and from the Environment, leverageseveral action levers that we grouped in 8 categories . To bettThis imbrication allows the fractal function to realize itself through the differentlevels of an organization’s governance, while coevolving with the Environmentactors, first on a local scale then on a global scale. Lastly, the adaptationprocess is not a “finite” process: over time, retroactions allow for a questioningof the actions that are deemed less appropriate for the programs, for theinterventions or for the targeted services. Through these retroactions, it ispossible to review the processes, to contextualize them and to learn bothindividually and collectively.connectivity actors, thanks to the information andcommunication levers, facilitate the development of connectivitystructures, on which the legitimacy of adaptive actions unequallydeveloped, will then be founded in each scope and each sphere of the organization.The proposal of an adaptation plan, accompanied by structural measures such asrepresenting migrant persons on the user Board of users, can be a demonstration ofthis fact. This is an enabling lever since it allows the escalation, through thespheres and the scopes, of the needs expressed by the patients or operational actorsfrom the Environment and the Health Center.These 3 functions—that assemble the different levers, themselves paired with theinfluence of the connectivity actors residing at the different levels of the HealthCenter—facilitate, even partially, the fractalization of the adaptation within thehealth organization. It expands over time as actions are taken. TheThe relationships between the Health Centers and the Environment actors play animportant part in the adaptation process, and in its fractalization. For example,Health Center 1 relates to several Environment actors, which facilitates thedevelopment of partnerships, even more so since HC1’s board was recently replaced.Strategic actors, such as Direction Committees’ members, would like to see HC1 takea more central place within the local health network, since they are eager tooperationalize the concept of population-oriented responsibility.connectivity actors like inCentre 1. While community organizers and nurses, at the operational level, arerecognized as connectivity actors, their actions are limited tothis level and don’t typically move up to the tactical and strategic levels.Moreover, physicians’ involvement is perceived as weak, yet they represent a majorlever especially when it comes to service accessibility. In this configuration, theconditions are not met for the creation of connectivity structures.According to some respondents, political and organizational will regarding thischallenge is lacking and is too weak to initiate a fractalization of the adaptation.Indeed, it stays at the same scale. Stakeholders’ case-by-case approach and thetrial-and-error learning are the most used methods in default of a more homogenousadaptation through all of the scopes and spheres of the governance.In HC2, the action levers—whether emerging, administrative, or enabling—are notpromoted to multiple levels by the While the traditional hierarchical channels are more present in Health Center 2, theoperational actors’ decision-making authority is limited in both the organizationsstudied. The needs from the field seem more and more remote from the strategicactors and are less and less reflected in their concerns. Tactical actors havetrouble bridging the gaps between the 2 other scopes.coupling and schemata levers, thecommunication board could act as an information distributor within the HealthCenter. It would enjoin the strategic actors—who care about the image of theorganization—to get more involved in their organization’s adaptation with migrantand newcomer populations. Nurse advisors, since they reside at the tactical level,are connectivity actors capable of creating inter-levels andinter-sphere relationships. They hold a wide array of knowledge as well as acontinuously developing network, spreading inside and outside of the Health Centervia—among other things—the collaboration they entertain with community organizers. Abalance could be developed to facilitate the development of the fractal function andwould trigger a multilevel adaptation process comprised of continuous supportbetween the different actors and establishments.However, solutions are being considered when it comes to enabling levers: because itis leveraging 41 This does not permit morethan a heterogeneous, case-by-case adaptation, with limited individual andcollective learning.The fractalization of an organization’s adaptation allows the necessary adjustmentsto be achieved in a coordinated fashion, while avoiding redundancy between thedifferent scopes and the different spheres. Because the clinical governance tends toleverage the emerging levers while the administrative governance tends to leveragethe administrative ones, a junction point is possible, provided the enablingfunction is applied to the multilevel property of the organization’s governance. Ifnot, there is a significant risk to become stagnant within one scope without answerfor wicked problem or global crisis.connectivity actors in the differentscopes of the organization; (2) administrative and emerging levers exist and arerelayed by enabling levers, which allows them to be tied together to realizeconcrete actions at different levels within the organization; (3) a network-basedorganization interacting with diverse Environment actors. However, a uniqueactor-partner like in the case of Health Center 2 presents a risk of monopolizingthe attention and the tension between this organization and the operational actors,to the detriment of the recognition of the challenge, and of a hierarchical andorganizational support.42 (4) Lastly, support from the Environment actors at theregional and national levels appears to be important to facilitate the globalizationof the challenge as well as a more systemic approach.To Fractalize a health organization’s adaptation is to bring together severalnecessary characteristics: (1) connectivity structures, who arethemselves facilitated by the presence and the involvement of connectivityactors. This pleads for a new approach to adaptation processes, wherepriority would be given first to the actors, and second to the structures.In a nutshell, the adaptation of a health organization is « fractalized » through theimplementation of action levers that make it more visible and present at eachgovernance level, thanks to We address here the limits. There are 3 of them. The first concerns the choice wehad to make for reasons of feasibility. Indeed, in addition to obtaining thepoint of view of the actors of the health organization and the environment, wewould have liked to collect the point of view of migrant people who had or hadnot had access to health services. However, we were careful to take into accountthe literature and the reports of community organizations so as not to excludemore community than institutional points of view.The second limitation concerns internal validity: the views of some professionalsmay have been “diminished” due to less participation in interviews.The third limitation is that our case study was conducted, like many researchstudies, over a 4-year period (2010-2014). This allows for the collection ofactors’ positions at a given time, in addition to historically tracing thedifferent stages of the organization via their memories and the administrativedocuments consulted. However, since our fieldwork, several major transformationshave taken place, such as a major reform of the Quebec health system in2015.At the end of this article, we wish to highlight 3 major points arising from ourresults:The first concerns a point raised by many of the actors we met: the lack ofvisibility of migrant patients (and their representatives) within the governingbodies of health organizations such as boards of directors (BoDs) and usercouncils.The second concerns the politicization of issues related to immigration and theintegration of people of immigrant background into the host society. Thisaffects the health care environment and can play a negative role for those withreal needs, whether they are migrants or not. This contributes to the emphasison the health care system as an “integrating” system for “non-integrated”populations, posing “problems” because it does not respond to the law of themajority. This type of reasoning and vision frequently serves parts of thepopulation that do not have the capital, at the appropriate time, to take theirplace in the social debate. Thus, in the perspective of a just and equitablesociety, and without talking about depoliticizing the health system, it would beimportant to maintain, at all costs, a “safety net” for people in precarious andvulnerable situations, whether economic, social, or material. In terms ofmigration, for example, mental health services, especially for “refugee”migrants, pose major problems (and questions): indeed, their care isinsufficient, with many breaks in follow-up, and even refusals of care.The third concerns the context favorable to the establishment and emergence ofnetworks: indeed, a tendency toward adapted governance in networks, like morebalanced to respond to the ambiguity of adaptation in complex organizations, hasbeen revealed. Indeed, within the 2 health organizations studied, and theirrespective environments, we were able to observe on several occasions that theconcept of population responsibility is increasingly integrated by the differentactors.There is therefore a dynamic that calls for a strengthening of the concept ofpopulation responsibility, while pluralizing it to all the actors involved, andnot simply defining it as the preserve of the targeted health centers. Thesetypes of networks, as we have seen, go beyond the health system alone andtherefore cannot be limited to typically “health” coordination.The presence of connectivity actors within the organization and the environment isrevealed. The context, the bonds of trust forged between actors and the credibilityof decision-makers appear to be important levers.But the connectivity actors cannot achieve this without the support and contributionof the more “hierarchical” actors. Eight levers for action emerged from theanalysis. We have classified them into 3 functions: administrative, enabling, andemergent.Through the “connectivity actors” emerge the needs of the field. If they are heardand understood by the strategic actors, the structures in turn become “connectivitystructures.The levers of the administrative and emerging functions require that the levers ofthe enabling function be credible and legitimate and be able to support them for theadaptation to spread throughout the healthcare organization, regardless of the scopeor policymaking level. The fractal function facilitates this process, by combiningconnectivity actors with the implementation of connectivity structures.


Accuracy prompts, nudges that make accuracy salient, typically decrease the sharing of fake news, while having little effect on real news. Here, we introduce a new accuracy prompt that is more effective than previous prompts, because it does not only reduce fake news sharing, but it also increases real news sharing. We report four preregistered studies showing that an “endorsing accuracy” prompt (“I think this news is accurate”), placed into the sharing button, decreases fake news sharing, increases real news sharing, and keeps overall engagement constant. We also explore the mechanism through which the intervention works. The key results are specific to endorsing accuracy, rather than accuracy salience, and endorsing accuracy does not simply make participants apply a “source heuristic.” Finally, we use Pennycook et al.’s limited-attention model to argue that endorsing accuracy may work by making people more carefully consider their sharing decisions. Fake news—fabricated news stories presented as if they were real —can haveAlthough fake news is not a modern phenomenon, it is becoming especially concerning in recent years because of the emergence of social media as a source of news content. As of 2020, 57% of millennials in the United States report using social media for news on a daily basis; similar percentages can be found in the United Kingdom, France, and the Netherlands, whereas they are even higher in Kenya, South Africa, and Bulgaria, where 70% of the adult population get news content from social media . Social A set of interventions that is receiving considerable attention is rooted in the observation that some users do not share false content because they are confused or lack the knowledge or the competence to discern false headlines from true ones, but because they do not even think about whether a given news headline might be fake . Indeed,In the last few years, there have been several studies testing the effect of accuracy prompts. Most prompts decrease intentions to share fake news, while keeping intentions to share real news unaffected . See PenWe introduce a new form of accuracy prompt that is more effective than previous prompts because it both decreases intentions to share fake news and increases intentions to share real news.We begin with a study testing two potential interventions, one that alerts participants that the headline they are reading can be fake (“Remember that it could be fake news”), and one that makes participants endorse the accuracy of the news headline (“I think this news is accurate”). On one hand, based on previous work, we expect the “fake alert” condition to decrease intentions to share fake news, while keeping intentions to share real news unaffected. On the other hand, we reasoned that endorsing accuracy might not only decrease intentions to share fake news, but also increase sharing intentions of real news, because endorsing accuracy may make people more carefully consider their sharing decisions: if you believe that a headline is accurate, then you may consider sharing it. In line with this idea, Study 1 finds that endorsing accuracy decreases intentions to share fake news and increases intentions to share real news. Moreover, it also keeps overall sharing constant. The subsequent studies are then devoted to increasing the ecological validity of Study 1 and to exploring the mechanisms through which the intervention works. Specifically, Study 2 replicates the results of Study 1 in a context where people make their sharing decisions in an environment that more closely resembles a social media newsfeed. Study 3 compares the endorsing accuracy intervention with an accuracy salience intervention that uses a wording that is very similar to the one used in the endorsing accuracy condition  and shows that the key findings are, again, specific to endorsing accuracy. Study 4 replicates the main results in a context where news sources are not displayed on the news headlines, thus suggesting that the intervention works by making people pay more attention to each news headline, rather than to the source of news more generally. Finally, we use the limited-attention model of content sharing introduced by The aim of Study 1 is to test the effectiveness of two messages, one that alerts participants that the headline they are reading can be fake, and one that makes participants endorse the accuracy of the headline.f = 0.129 with an α of 0.05 and power of 0.80.We recruited 550 U.S.-based participants on Amazon Mechanical Turk AMT; . A sensibaseline, participants were asked to report their intention to share each of 24 headlines  in Facebook format, in random order. In this and in the next studies, we used fake news collected from three news sources—dailibuzzlive.com, now8news.com, and realnewsrightnow.com—that have been classified by Supplementary Material (SM), we show that our key results are not significantly moderated by type of news. For each headline, participants were asked: “If you were to see the above article on Facebook, would you consider sharing it?” (yes/no). The fake alert condition differed from the baseline in that the button with the “Yes answer” to the question whether they would consider sharing the headline, contained the message: “Remember that it could be fake news”  and condition . reveals that the interaction between the real news dummy and the accuracy endorsement condition dummy is significant  while the interaction between the real news dummy and the fake alert condition dummy is not significant . Moreover, the coefficients of the two interactions  are statistically different, F = 36.76, p < .001. Regression tables can be found in the SM, accuracy endorsement condition tend to share more real news compared with both the baseline and the fake alert conditions , whereas there is no difference between the sharing intentions of real news in the baseline vs. the fake alert condition, b = −0.002, p = .937. Participants in the accuracy endorsement condition tend to share less fake news compared with both the baseline and the fake alert conditions , while there is no difference between the sharing intentions of fake news in the baseline vs. the fake alert condition, b = −0.028, p = .336. Regarding overall sharing , we find that there is no difference between the sharing intentions in the accuracy endorsement condition and the baseline , and between the fake alert condition and the baseline , while there is a marginally significant difference between the accuracy endorsement condition and the fake alert condition  . In the SM, A linear regression with robust standard errors clustered on participants and headlinesIn sum, Study 1 reveals that endorsing accuracy decreases intentions to share fake news, increases intentions to share real news, and keeps overall sharing constant. For these reasons, it seems to be a far more promising intervention than the fake alert message.Study 2 aims at increasing the ecological validity of the previous study.N = 558 participants were recruited on AMT. A sensitivity analysis showed that 558 participants are sufficient to detect an effect size of f = 0.125 with an α of 0.05 and power of 0.80.baseline, fake alert, and accuracy endorsement.The design was similar to Study 1, but participants, instead of being asked to report the intention to share one news headline at a time, one for each screen, could scroll through the news headlines in a similar fashion as they do in social media such as Facebook or Twitter. Moreover, instead of being asked, for each news headline, whether they would consider sharing it, below each news headline, we included two buttons: a “like button” and a “share button.” Responses were not forced, and multiple answers were allowed. In other words, participants were free to scroll through the newsfeed and, for each headline, they could like it, share it, do both, or neither see . As in SBefore leaving the survey, participants were asked about their gender, age, and level of education.real vs. fake) and condition .real news dummy and the two condition dummies are both significant . Regression tables can be found in the SM, Table S2. The coefficients of the two interactions  are statistically different, F = 18.48, p < .001. Post hoc analyses find that participants in the accuracy endorsement condition tend to share more real news compared with both the baseline and the fake alert conditions , whereas there is no difference between the sharing intentions of real news in the baseline vs. the fake alert condition, b = −0.001, p = .975. Participants tend to share less fake news, compared with the baseline, both in the fake alert and in the accuracy endorsement conditions ; there is a marginally significant difference between the sharing of fake news in the accuracy endorsement condition with respect to the fake alert condition, b = −0.039, p = .089. Regarding overall  sharing, we find no difference across treatments . Finally, we compare the overall engagement, that we define as the total number of reactions (number of likes plus number of shares) divided by the number of news headlines, across conditions. We find that there is no difference in the overall engagement across treatments   see . In the In sum, Study 2 confirms the broad finding of Study 1 that endorsing accuracy is a promising intervention, as it decreases intentions to share fake news, increases intentions to share real news, while keeping overall sharing and overall engagement (likes + shares) constant.endorsing accuracy, but to the way in which the concept of accuracy is made salient. To address this point, in Study 3 we compare the endorsing accuracy condition with an accuracy salience condition that uses a message that is very similar to the one used in the endorsing accuracy condition.One limitation of the first two studies is that the endorsing accuracy condition differs from the fake alert condition in dimensions other than the act of endorsing. Specifically, the endorsing accuracy condition explicitly uses the term “accuracy,” while the fake alert condition uses the term “fake news.” Therefore, it is possible that the effects of endorsing accuracy are not due to the act of N = 550 participants were recruited on AMT. A sensitivity analysis showed that 550 participants are sufficient to detect an effect size of f = 0.129 with an α of 0.05 and power of 0.80.baseline, accuracy salience, and accuracy endorsement. The baseline and the accuracy endorsement conditions were identical to those of Study 2; the accuracy salience condition was similar to the accuracy endorsement condition, but the message displayed into the sharing button was: “Think if this news is accurate.” As in Study 2, participants could scroll through the news headlines and, for each of them, they could like it, share it, do both, or neither. We also slightly changed the visualization of the available answers to eliminate the “squares” in the “like” and “share” buttons in Study 2  and condition .real news dummy and the two condition dummies are both significant . Regression tables can be found in the SM, Table S4. The coefficients of the two interactions  are statistically different, F = 12.23, p < .001. Post hoc analyses reveal that participants in the accuracy endorsement condition tend to share more real news compared with both the baseline and the accuracy salience conditions—although the difference between the accuracy endorsement condition and the baseline was, this time, marginally significant —whereas there is no difference between the sharing intentions of real news in the baseline vs. the accuracy salience condition, b = 0.002, p = .948. Participants tend to share less fake news, compared with the baseline, both in the accuracy salience and in the accuracy endorsement conditions , whereas there is no difference in the sharing intentions of fake news between the accuracy endorsement condition and the accuracy salience condition, b = −0.036, p = .110. Regarding overall sharing, we find that in the accuracy endorsement condition this was not different from the overall sharing in the baseline , while the overall sharing in the accuracy salience condition was marginally significantly smaller than in the baseline , although not significantly different from the accuracy endorsement condition, b = 0.012, p = .591. Finally, we find that there is no difference in the overall engagement across conditions   see . In the In sum, Study 3 replicates the broad finding of Studies 1 and 2 that endorsing accuracy decreases intentions to share fake news, increases intentions to share real news, while keeping overall sharing and overall engagement constant. Moreover, it shows that a message similar to the endorsing accuracy message, but which only makes accuracy salient, without endorsing it, fails to increase intentions to share real news, suggesting that it is the act of endorsing that increases intentions to share real news, and not accuracy salience per se.In the previous studies, the source of news was displayed on the news headline. We made this design choice to present headlines in the same format as they are presented on social media. However, this raises a theoretical question regarding the channel through which endorsing accuracy works: does endorsing accuracy make people pay more attention to the accuracy of the headlines, or does it make them more likely to apply a more general “source heuristic” to determine which news to share ? In this study, we answer this question.N = 372 participants were recruited on AMT. A sensitivity analysis showed that this sample size is sufficient to detect an effect size of f = 0.140 with an α of 0.05 and power of 0.80.baseline and accuracy endorsement. The baseline and the accuracy endorsement conditions were identical to those of the previous studies, but the source of news was removed from the news headlines  and condition (baseline vs. accuracy endorsement).real news dummy and the condition dummy is significant . Regression tables can be found in the SM, Table S6. Participants in the accuracy endorsement condition tend to share more real news  and less fake news  compared with the baseline. Regarding overall sharing and overall engagement, we find no difference between conditions   see . In the In sum, Study 4 replicates the broad finding of the previous studies—that endorsing accuracy increases real news sharing, decreases fake news sharing, while having little effect on overall sharing and overall engagement—in a context in which news sources are not displayed, thus suggesting that endorsing accuracy makes people pay attention to the accuracy of each headline, rather than making them apply a general source heuristic to decide which headline to share.In this section, we show that the effect of endorsing accuracy can be explained by the “limited-attention” model of content sharing introduced by Pennycook and colleagues (2021). Specifically, we make formal our interpretation that “endorsing accuracy may work by making people more carefully consider their sharing decisions,” and we test one of its predictions using the utility function proposed by Pennycook and colleagues.x through a utility function U(x) = −a1b1F(x) + a2b2C2(x) kbkCk+ . . . + a, where F represents whether the content is fake, C2, . . ., kC are other dimensions that might be important at the moment of sharing , the ia’s are context-dependent parameters that represent whether dimension i is salient (ia = 1) or not (ia = 0) at the moment of sharing, and the ib’s are individual, context-independent parameters representing the weight a person assigns to dimension i. In standard utility theory, ia = 1, for all i. Pennycook and colleagues’ “limited-attention” model assumes that people have cognitive constraints that make them unable to consider all the dimensions together; that is, not all ia’s are equal to 1. However, a given dimension can be made salient using nudges. In particular, the role of accuracy salience is to turn a1 = 1. Then, participants share x with some probability p(U(x)), which is an increasing function of U(x). Ideally, p would be a stepwise function such that (assuming that the utility of non-sharing is zero) a participant shares any piece of content that gives them positive utility. However, in more realistic situations, p could be a logistic function: p(share) = (1 + e-θ(U(x)-µ))-1, where μ represents the value of U(x) at which the person is equally likely to share and to not share, and θ represents the steepness of the transition from sharing to not sharing  = b1(−F(x)), obtained from the Pennycook et al.’s utility function, assuming (a) a1 = 1, because the concept of accuracy is salient in the fake alert, the accuracy salience, and the endorsing accuracy conditions; (b) the role played by the other dimensions C2,k. . ., C does not change across conditions, because the headlines are the same across conditions, and these dimensions are not related to accuracy. Note that −F(x) is the real news dummy, so, to estimate θ and μ, we need to run, for each of the relevant conditions, a logistic regression predicting sharing intentions as a function of the real dummy: the coefficient of the real news dummy will be equal to θ, while μ will be equal to minus the coefficient of the constant divided by the coefficient of the real dummy. In Studies 1 and 2, we compare the estimates in the fake alert condition with those in the endorsing accuracy condition, while in Study 3 we compare the estimates in the accuracy salience condition with those in the endorsing accuracy condition. To do so, we consider the utility function We tested three potential interventions to fight the spread of fake news on social media: (a) an alert into the sharing button, with written “Remember that it could be fake news,” decreased intentions to share fake news in Study 2, but not in Study 1, and left intentions to share real news unaffected in both studies; (b) an accuracy endorsement into the sharing button, “I think this news is accurate,” decreased intentions to share fake news, increased intentions to share real news, and kept overall sharing and engagement (likes + shares) unaffected; (c) an accuracy prompt into the sharing button, “Think if this news is accurate,” decreased intentions to share fake news, while keeping intentions to share real news unaffected.These results suggest that adding a short message into the sharing button on social media, which makes users endorse the accuracy of the corresponding headline, can decrease fake news sharing and increase real news sharing, while having little effect on overall sharing and engagement. This intervention has several positive sides. It is as invasive as other interventions already in use on social media; indeed, Facebook and Twitter have already implemented interventions that tag each news headline regarding vaccines with a message and a link, or with pop-ups that alert users who are sharing without reading . FurtherIn Studies 2 to 4, we also explored whether our accuracy prompts affect liking intentions. We found no effect. To the best of our knowledge, there is only work exploring the effect of accuracy prompts on liking intentions: Recently, scholars have stressed the importance of clarifying by which mechanism an intervention works . From a Our results have some limitations. First, we measured only intentions to share (Study 1) or sharing decisions in an environment that simulated a social media newsfeed (Studies 2–4). Although this is an improvement with respect to previous research, which typically measured only sharing intentions, it is still limited; for example, our simulated newsfeed is not visually identical to the Facebook newsfeed; moreover, we only added the “like” button and not the other reactions. However, we believe that this is not a major limitation, as previous work found that sharing intentions collected on AMT are correlated to actual sharing decisions on Twitter  and becaDespite these limitations, our results show that endorsing accuracy may decrease fake news sharing and increase real news sharing. Therefore, endorsing accuracy could be a promising intervention for increasing the quality of information on social media.Click here for additional data file.Supplemental material, sj-docx-1-psp-10.1177_01461672221117691 for “I Think This News Is Accurate”: Endorsing Accuracy Decreases the Sharing of Fake News and Increases the Sharing of Real News by Valerio Capraro and Tatiana Celadin in Personality and Social Psychology Bulletin