Message Framing Strategies to Promote the Uptake of PrEP: Results from Formative Research with Diverse Adult Populations in the United States.

There are no evidence-based recommendations for communicating about pre-exposure prophylaxis (PrEP) as part of a broader HIV-prevention messaging approach. To inform future message development related to PrEP uptake, we interviewed 235 individuals across ten locations in the U.S. to explore their understanding and perceptions of draft HIV prevention messages and assess their overall preferences for a broad or PrEP-focused messaging approach. Participants responded favorably to and related to both draft messages. Participants who were not aware of PrEP were more likely to say the broad HIV-prevention message was personally relevant than those aware of PrEP. There were no significant differences in perceived personal relevance for the PrEP-focused message. Qualitative findings suggest that HIV prevention messages should use specific well-defined terms, include links to additional information, and use choice-enhancing language that emphasizes personal agency and frames the call to action as an informed decision among an array of effective prevention options.

RESUMEN: No existen recommendaciones basadas en evidencia para comunicar sobre la profilaxis prexposición (PrEP) como parte de un efoque más amplio de mensajes de prevención del VIH. Para informar el desarrollo de mansajes relacionados con el consumo de la PrEP, entrevistamos a 235 personas en 10 ubicaciones en los EE.UU. para explorar su comprensión y percepciones de los borradores de mensajes de prevención del VIH y evaluar sus preferencias generales por un enfoque de mensajeria amplio o centrado en la PrEP. Los participantes respondieron favorablemente y relacionadoscon ambos barradores de mensajes. Los participantes que no conocían la PrEP tenían más probabilidades de decir que el mansaje general de prevención amplia de VIH era personalmente relevent que aquellos que conocían la PrEP. No existe differencias significativas en la relevancia personal percibida para el mensaje centrado en la PrEP. Los hallazgos cualitativos sugieren que los mensajes de prevención del VIH deben utilizar términos especificos bien definidos, incluir enlaces a información adicional y utilizar un lenguaje que mejore las opciones, que enfatice la agencia personal y enmarque el llamado a la acción como una decisión informada entre una variedad de opciones de prevención efectivas.

HIV information needs of transgender people and their healthcare providers.

Despite the disproportionate burden of HIV among transgender people in the United States, few HIV-related communication materials exist for transgender people or their healthcare providers. Our goal was to understand the barriers and facilitators transgender people face in accessing HIV prevention, testing, and care services and the potential implications for message development and dissemination. We reviewed the literature and interviewed nine key informants representing healthcare and service providers, researchers, and transgender advocates. Healthcare providers who care for transgender patients often demonstrate a lack of transgender competent care strategies. In addition, transgender people face many barriers to accessing HIV services. Although communication materials cannot address many of these barriers, materials specifically developed for transgender people and their healthcare providers would fill a gap and may increase uptake of HIV services. Materials for transgender people should include gender-affirming messaging and imagery, be framed in terms of resiliency, and present HIV information tailored to the needs of transgender people. Materials for healthcare providers should provide basic information to increase transgender competency and provision of comprehensive healthcare for transgender patients, inclusive of gender-affirming and HIV prevention, testing and care services. Channels for disseminating materials to transgender people and healthcare providers are described.

An Interrupted Time Series Evaluation of the Testing Makes Us Stronger HIV Campaign for Black Gay and Bisexual Men in the United States.

Black gay, bisexual, and other men who have sex with men (BMSM) are the subpopulation most disproportionately affected by HIV in the United States. Testing Makes Us Stronger (TMUS), a communication campaign designed to increase HIV testing rates among BMSM ages 18 to 44, was implemented in the United States from December 2011 through September 2015. We used interrupted time series analysis (ITSA) to compare pre- and post-campaign trends in monthly HIV testing events among the priority audience in six of the implementation cities from January 2011 through December 2014. In the 11 months prior to the launch of TMUS, HIV testing events among BMSM in the six campaign implementation cities decreased by nearly 35 tests per month (p = .021). After the introduction of TMUS, the number of HIV testing events among BMSM in the same cities increased by more than 6 tests per month (p = .002). ITSA represents a quasi-experimental technique for investigating campaign effects beyond underlying time trends when serial outcome data are available. Future evaluations can be further strengthened by incorporating a comparison group to account for the effects of history and maturation on pre- and post-campaign trends.

Implementing an SMS-based intervention for persons living with human immunodeficiency virus.

This article describes a process evaluation conducted as part of a proof-of-concept study to develop, implement, and test a text messaging program to promote medication and appointment adherence, sexual and substance use risk reduction, general health and well-being, social support, and patient involvement. The text-messaging program was implemented in Chicago, Illinois, at an outpatient medical clinic that promotes the well-being of gay, lesbian, bisexual, and transgender persons. We collected and analyzed qualitative data from patients, providers, and research staff to answer the following questions: (1) What factors of the organizational context were important for implementation? (2) How are implementation policies and practices, organizational climate, and perceptions of implementation effectiveness described by intervention stakeholders? (3) What types of issues related to fidelity occurred during implementation? (4) What recommendations for improvement do stakeholders suggest? The study coordinator, providers, and the patients themselves confirmed that patients liked the messages and program overall. The program was implemented with high fidelity. The primary recommendations for improvements were to enhance confidentiality and implement strategies to lessen message fatigue. The findings from this process evaluation demonstrate the feasibility and acceptability of the intervention from the perspectives of patients, providers, and research staff. A larger-scale intervention study that incorporates these stakeholders' suggestions for improvement is warranted.

Beyond reminders: a conceptual framework for using short message service to promote prevention and improve healthcare quality and clinical outcomes for people living with HIV.

The availability of effective antiretroviral therapy has altered HIV from being an acute disease to being a chronic, manageable condition for many people living with HIV (PLWH). Because of their ubiquity and flexibility, mobile phones with short message service (SMS) offer a unique opportunity to enhance treatment and prevention for people managing HIV. To date, very few US studies using SMS for HIV self-management have been published. In this article, we review the published SMS-based intervention research that aimed to improve healthcare quality and outcomes for PLWH and other chronic health conditions, and propose a conceptual model that integrates the communication functionality of SMS with important psychosocial factors that could mediate the impact of SMS on health outcomes. We posit that an SMS-based intervention that incorporates the elements of interactivity, frequency, timing, and tailoring of messages could be implemented to encourage greater medication adherence as well as impact other mutually reinforcing behaviors and factors (e.g., increasing patient involvement and social support, reducing risk behaviors, and promoting general health and well-being) to support better healthcare quality and clinical outcomes for PLWH. We recommend that future studies explore the potential linkages between variations in SMS characteristics and these mediating factors to determine if and how they influence the larger outcomes.

Addressing HIV knowledge, risk reduction, social support, and patient involvement using SMS: results of a proof-of-concept study.

Men who have sex with men continue to be severely and disproportionately affected by the HIV/AIDS epidemic in the United States. Effective antiretroviral therapy has altered the HIV epidemic from being an acute disease to a chronic, manageable condition for many people living with HIV. The pervasiveness, low cost, and convenience of short message service suggests its potential suitability for supporting the treatment of conditions that must be managed over an extended period. The purpose of this proof-of-concept study was to develop, implement, and test a tailored short message service-based intervention for HIV-positive men who have sex with men. The messages focused on reducing risk-taking behaviors and enhancing HIV knowledge, social support, and patient involvement. Participants reported strong receptivity to the messages and the intervention. The authors detected a statistically significant increase in HIV knowledge and social support from baseline to follow-up. Among participants who received sexual risk reduction messages, the authors also detected a statistically significant reduction in reported risk behaviors from baseline to follow-up. Results confirm the feasibility of a tailored, short message service-based intervention designed to provide ongoing behavioral reinforcement for HIV-positive men who have sex with men. Future research should include a larger sample, a control group, multiple sites, younger participants, and longer term follow-up.

Efficacy of an HIV testing campaign's messages for African American women.

We conducted a Web-based randomized controlled experiment to test the efficacy of the Take Charge. Take the Test. (TCTT) campaign messages. The experiment had two conditions: (a) exposure to campaign messages and (b) no exposure. Participants completed a baseline assessment, exposure condition participants were exposed to campaign materials for 2 weeks, and all participants completed a follow-up survey at 2- and 6-weeks postbaseline. Multivariate results indicate that exposure to TCTT messages was associated with increases in key knowledge items targeted by the campaign, intentions to get tested for HIV, and increases in peer-to-peer communication about getting an HIV test.

Engagement marketing for social good: Application to the All of Us Research Program.

Engagement marketing, when applied to increasing the social good, involves making a deliberate effort to engage communities with an organization's brand that might not have otherwise happened organically. Organizations that typically focus on increasing the social good include non-profits, community organizations, public health departments, and federal, state, and local agencies. Engagement marketing builds relationships, gives a voice to, and fosters collaboration with community members to transform their insights into impactful experiences that motivate and empower them to act to increase the social good. These actions may include making an informed decision, changing a health or prosocial behavior, or joining an effort that promotes or increases social good. In this paper, we translate the commercial engagement marketing approach, typically used, and studied widely to increase profits, to one that uses engagement marketing to increase prosocial outcomes. We propose a new definition of engagement marketing applied to the social good, a multi-level conceptual framework that integrates individual, social, community and macro-level processes and outcomes, and illustrates an example applying this translated model to co-create digital engagement experiences using a human centered design approach for the All of Us Research Program. This model can also guide research and practice related to DNA-based population screening.

Multilevel communication to improve well-being during a pandemic.

The COVID-19 pandemic has highlighted existing crises and introduced new stressors for various populations. We suggest that a multilevel ecological perspective, one that researchers and practitioners have used to address some of public health's most intransigent challenges, will be necessary to address emotional distress and mental health problems resulting from the COVID-19 pandemic. Multiple levels of influence (individual, interpersonal, organizational, community, and policy) each contribute (individually and in combination) to population health and individual well-being. We use the convergence strategy to illustrate how multilevel communication strategies designed to raise awareness, educate, or motivate informed decision-making or behavior change can address various sources of information surrounding a person to synergistically affect mental health outcomes. Looking ahead, dissemination and implementation researchers and practitioners will likely need to coordinate organizations and networks to speak in complementary and resonant ways to enhance understanding of complex information related to the pandemic, mitigate unnecessary anxiety, and motivate healthy behavior to support population mental health. Plain language abstract: The current COVID-19 pandemic has threatened the mental health and well-being of various populations. The pandemic also has compounded health disparities experienced by communities of color and magnified the vast treatment gaps they experience related to behavioral health and substance use treatment access. A multilevel approach to future communication interventions focused on mental health likely will be useful, as we need to know about and address interactions with health care professionals, mass media information sources, social networks, and community influences rather than solely trying to reach people with carefully crafted videos or advertisements. Implementation researchers and practitioners likely will need to coordinate organizations and networks to speak in complementary and resonant ways to support population mental health.

Effectively Communicating About HIV and Other Health Disparities: Findings From a Literature Review and Future Directions.

Despite significant progress in the prevention and treatment of HIV, disparities in rates of infection remain among key groups in the United States, including blacks and African Americans; Hispanics/Latinos; and men who have sex with men (MSM). The U.S. Department of Health and Human Services' initiative, Ending the HIV Epidemic: A Plan for America, calls for addressing HIV-related disparities and reducing stigma and discrimination associated with HIV. The goal of this literature review was to identify approaches for effectively communicating about health disparities across the HIV care continuum. We reviewed the literature to investigate strategies used to communicate health disparities and to identify potential unintended adverse effects resulting from this messaging. Messages about health disparities often target subgroups at higher risk and can be framed in a variety of ways (e.g., social comparison, progress, impact, etiological). Studies have examined the effects of message framing on the risk perceptions, emotional reactions, and behaviors of individuals exposed to the messaging. The evidence points to several potential unintended adverse effects of using social comparison framing and individual responsibility framing to communicate about health disparities, and visual images and exemplars to target messages to higher-risk subgroups. There is not yet a clear evidence-based approach for communicating about health disparities and avoiding potential unintended effects. However, we offer recommendations for communicating about HIV-related disparities based on our findings. Because we found limited literature that addressed our research questions in the context of HIV, we propose a research agenda to build an evidence base for developing effective messages about HIV-related disparities.

Testing Makes Us Stronger™: Evaluating the correlation between exposure and intermediate outcomes targeted by the campaign's messages.

OBJECTIVES: To examine whether self-reported exposure to Testing Makes Us Stronger™ (TMUS), an HIV testing health communication campaign for black gay, bisexual, and other men who have sex with men (BMSM), was associated with key intermediate outcomes targeted by the campaign's messages. METHODS: Data from sexually active, HIV-negative or unknown status BMSM aged 18-44 (N = 590) were collected through an anonymous Web-based survey that measured sociodemographics, campaign exposure, attitudinal beliefs, normative beliefs, self-efficacy, and HIV testing intentions, among other variables. The association between exposure to TMUS and intermediate outcomes was evaluated using propensity-score weight adjusted correlations. RESULTS: Exposure to TMUS was high (43%) among the priority audience. Exposure to the campaign was correlated with 8 of 11 intermediate outcomes measured, including key attitudinal beliefs about the accessibility of the test and benefits to the individual, injunctive norms, self-efficacy, and HIV testing intention. CONCLUSION: Adhering to principles of effective campaign design, such as using theory as a conceptual foundation for message design, can increase a campaign's chances for successfully meeting its goals and objectives. PRACTICE IMPLICATIONS: Findings from this study can be used to inform message design for other communication efforts to promote HIV testing among BMSM.

Do content and format affect older consumers' use of comparative information in a Medicare health plan choice? Results from a controlled experiment.

We assessed the efficacy of materials that integrated comparative information on cost, benefits, and quality for employer-based retiree health plans and Medicare Advantage plans in a randomized experiment to test the impact of content and format. Results indicate that older consumers who received the intervention materials found the materials easier to use, gained greater knowledge about Medicare from them, were more likely to value comparative quality information, were more likely to select higher quality plans, and were more likely to choose a plan that reflected the dimensions they found most important compared to older consumers receiving the control materials.

Measures and predictors of Medicare knowledge: a review of the literature.

As the Medicare Program evolves, adding new insurance options like regional preferred provider organizations (PPOs) and prescription drug benefits, beneficiaries have an even greater need to understand the program. However, past research suggests that many beneficiaries have limited understanding of Medicare and related health insurance options. While improvements in beneficiary understanding of Medicare may be feasible, driven by new and varied efforts to provide the Medicare population with educational opportunities, is there evidence of factors that predict knowledge limitations? This article seeks to address this question by a thorough review of the literature on the measures and factors that influence beneficiary knowledge.

Bundling of STDs and HIV in Prevention Messages.

PURPOSE ­: This study aims to explore peoples cognitive perceptions of HIV and other sexually transmitted diseases (STDs) to inform decisions on message development with regard to message bundling, with limited research on the concept of bundling-related prevention messages and no studies that consider the bundling of HIV and other STD prevention messages. DESIGN/METHODOLOGY/APPROACH ­: Individual and small-group interviews were conducted with 158 African American men and women to explore perceptions of STDs and communication preferences. Open-ended questions and a pile-sort exercise were used to elicit individuals' judgments on similarities of 12 STDs, including HIV. Interview data were coded and analyzed for themes and patterns; pile sort data were analyzed using multidimensional scaling (MDS) and cluster analysis to visualize the set of relations identified from the piles. FINDINGS ­: STDs and HIV are associated with stigma, risk behaviors and personal responsibility. The card sorting activity revealed two primary dimensions by which people organized STDs: seriousness and curability. Potential clusters of STDs that correspond to participants described sorting strategies were identified and they may have implications for message bundling. Disaggregation of the data by sex and age revealed slight variations in the relationships of HIV and human papillomavirus (HPV) to other STDs. ORIGINALITY/VALUE ­: By identifying a set of cognitive attributes people use in organizing the overall semantic domain of STDs, ideas can be generated for how best to combine STD and HIV messages to meet public health communication goals.

Testing the effect of quality reports on the health plan choices of Medicare beneficiaries.

This article describes a laboratory experiment that used a convenience sample of 225 Medicare beneficiaries to test the effects of comparative quality information on plan choice. Providing information about quality did not significantly influence the choice between Original Medicare and a health maintenance organization (HMO), but did affect the choice of HMO. Results from this experiment suggest that information about plan quality may not be effective in encouraging beneficiaries to leave Original Medicare and join HMOs that are rated high in quality. Furthermore, beneficiaries choosing among HMOs were not inclined to select a low-cost HMO, even when it was rated higher in quality. Implications for policy are discussed.

Tailored text messaging intervention for HIV adherence: a proof-of-concept study.

OBJECTIVE: This study sought to determine if dynamically tailored medication messages delivered to people living with HIV (PLWH) via text messaging would be well received and enhance adherence and clinical outcomes. METHODS: A preexperimental proof-of-concept study with 52 men who have sex with men (MSM) recruited from a health clinic focused on promoting the well-being of gay, lesbian, bisexual, and transgender people. Inclusion criteria were being an English speaking HIV-positive MSM, aged 25 or older. Participants also had to agree to allow access to their medical records, have a cell phone, and be able to receive text messages over the 3-month intervention period. Participants completed baseline surveys that assessed various demographic, social, and health questions; received text messages over 3 months; answered weekly adherence questions via two-way messaging; and completed a follow-up survey at the end of the intervention period. Clinical outcomes were abstracted from participants' medical records at baseline and follow-up. Self-reported medication adherence and clinical outcomes, including CD4 counts and viral load. RESULTS: Participants were receptive to the text messaging intervention, and reported reading and liking the messages. Self-reported medication adherence significantly improved among participants who began the study as nonadherent and received tailored medication reminders. Overall viral load significantly decreased and CD4 count significantly increased from baseline to follow-up. CONCLUSIONS: The results demonstrate that using two-way text messaging to dynamically tailor adherence messages may enhance adherence and improve important clinical outcomes for PLWH.

Technical Implementation of a Multi-Component, Text Message-Based Intervention for Persons Living with HIV.

BACKGROUND: Men who have sex with men (MSM) continue to be severely and disproportionately affected by the HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome) epidemic in the United States. Effective antiretroviral therapy has altered the HIV epidemic from being an acute disease to a chronic, manageable condition for many people living with HIV. The pervasiveness, low cost, and convenience of Short Message Service (SMS) suggests its potential suitability for supporting the treatment of conditions that must be managed over an extended period. OBJECTIVE: The purpose of this proof-of-concept study was to develop, implement, and test a tailored SMS-based intervention for HIV-positive MSM. Prior studies do not routinely provide sufficiently detailed descriptions of their technical implementations, restricting the ability of subsequent efforts to reproduce successful interventions. This article attempts to fill this gap by providing a detailed description of the implementation of an SMS-based intervention to provide tailored health communication messages for HIV-positive MSM. METHODS: We used archives from the SMS system, including participant responses to messages and questions sent via SMS, as the data sources for results reported in this article. Consistent with the purpose of this article, our analysis was limited to basic descriptive statistics, including frequency distributions, means and standard deviations. RESULTS: During the implementation period, we sent a total of 7,194 messages to study participants, received 705 SMS responses to our two-way SMS questions of participants, and 317 unprompted SMS message acknowledgements from participants. Ninety two percent of participants on antiretroviral therapy (ART) responded to at least one of the weekly medication adherence questions administered via SMS, and 27% of those had their medication adherence messages changed over the course of the study based on their answers to the weekly questions. Participants who responded to items administered via SMS to assess satisfaction with and use of the messages reported generally positive perceptions, although response rates were low overall. CONCLUSIONS: Results confirm the technical feasibility of deploying a dynamically tailored, SMS-based intervention designed to provide ongoing behavioral reinforcement for HIV-positive MSM. Lessons learned related to text programming, message delivery and study logistics will be helpful to others planning and implementing similar interventions.

Audience reactions and receptivity to HIV prevention message concepts for people living with HIV.

This study measured audience reactions and receptivity to five draft HIV prevention messages developed for people living with HIV (PLWH) to inform future HIV message choice and audience targeting decisions. Our premise was that message concepts that receive wide audience appeal constitute a strong starting point for designing future HIV prevention messages, program activities, and health communication and marketing campaigns for PLWH. The majority of participants indicated agreement with evaluative statements that expressed favorable attitudes toward all five of the message concepts we evaluated. Participants gave the lowest approval to the message promoting sero-sorting. Sociodemographic characteristics played less of a role in predicting differences in message perceptions than attitudes, beliefs and sexual behavior. The general appeal for these messages is encouraging given that messages were expressed in plain text without the support of other creative elements that are commonly used in message execution. These results confirm the utility of systematic efforts to generate and screen message concepts prior to large-scale testing.

The "choose with care system" - development of education materials to support informed Medicare health plan choices.

People aging into Medicare need to choose a health plan. Several challenges exist for consumers in choosing a Medicare health plan, including limited knowledge of Medicare, limited experience in using comparative health plan quality information, and limited experience and ability to pull together and use plan information from different sources like employers and the Medicare program. The Choose with Care System was developed to help consumers aging into Medicare make informed Medicare health plan choices. Choose with Care is an innovative decision support tool for employers to use to assist people approaching age 65 to learn about their Medicare health plan options and how to incorporate information on the quality of care and services offered by health plans into their choices. Employers are the targeted channel for distributing the Choose with Care materials because they are one of the most recognized and accessible formal intermediaries for information about health insurance. We used multiple methods to test the Choose with Care products. Product testing showed that the Choose with Care materials increase older consumers' knowledge of Medicare and how it relates to retiree health insurance and improves their comprehension and use of comparative quality information when choosing a health plan.

Beneficiary knowledge of original Medicare and Medicare managed care.

BACKGROUND: Previous research on beneficiary knowledge of the Medicare program has shown that the beneficiary population is not well informed about Medicare. The Centers for Medicare & Medicaid Services (CMS) implemented the National Medicare Education Program in 1998 to educate Medicare beneficiaries about program benefits; choices, rights, responsibilities and protections, and health behaviors. OBJECTIVES: We sought to measure beneficiary knowledge of the Medicare program and to assess how knowledge varies by beneficiary subgroups and topic areas. RESEARCH DESIGN: We conducted psychometric analyses of survey data from Round 36 of the Medicare Current Beneficiary Survey to construct knowledge indices and estimated regression models with each knowledge index as the dependent variable, controlling for sociodemographic characteristics, self-reported health status, and insurance. SUBJECTS: The study sample included 2634 noninstitutionalized Medicare beneficiaries. MEASURES: There were 2 separate knowledge indices representing the 2 primary avenues for receiving Medicare benefits: Original Medicare and Medicare managed care. RESULTS: Beneficiaries ages 75 or older, nonwhite, with lower incomes, lower education levels, and public insurance had lower levels of knowledge on both indices. Enrollment in Medicare managed care was positively associated with knowledge about Medicare managed care but negatively associated with knowledge about Original Medicare. Areas of low program knowledge included coverage and benefits, enrollment/disenrollment, and plan choice. CONCLUSIONS: Our findings suggest the need to develop educational campaigns targeting vulnerable beneficiaries who have continued to demonstrate low levels of Medicare program knowledge.