Treating people with information: an analysis and review of approaches to communicating health risk information.

The communication of risk information is a fundamental aspect of nearly all health promotion interventions. However, no consensus exists regarding the most effective way to provide people with risk information. We will review and evaluate the relative merits of two approaches to risk communication. One approach relies on the presentation of numerical information regarding the probability of a health problem occurring, whereas the other relies on the presentation of information about the antecedents and consequences of a health problem. Because people have considerable difficulty understanding and using quantitative information, the effectiveness of interventions that rely solely on numerical probability information has been limited. Interventions that provide people with a broader informational context in which to think about a health problem have had greater success systematically influencing perceptions of personal risk but have several important limitations. However, before any final conclusions can be drawn regarding the relative merits of different communication strategies, investigators must agree on the specific criteria that should be used to identify an effective intervention.

Shaping perceptions to motivate healthy behavior: the role of message framing.

Health-relevant communications can be framed in terms of the benefits (gains) or costs (losses) associated with a particular behavior, and the framing of such persuasive messages influences health decision making. Although to ask people to consider a health issue in terms of associated costs is considered an effective way to motivate behavior, empirical findings are inconsistent. In evaluating the effectiveness of framed health messages, investigators must appreciate the context in which health-related decisions are made. The influence of framed information on decision making is contingent on people, first, internalizing the advocated frame and, then, on the degree to which performing a health behavior is perceived as risky. The relative effectiveness of gain-framed or loss-framed appeals depends, in part, on whether a behavior serves an illness-detecting or a health-affirming function. Finally, the authors discuss the cognitive and affective processes that may mediate the influence of framed information on judgment and behavior.

Attributions of responsibility and persuasion: increasing mammography utilization among women over 40 with an internally oriented message.

One hundred ninety-seven women over 40 years old and not adhering to national guidelines for screening mammography viewed persuasive messages varying in attributional emphasis (internal, external, or information-only). Internal attributions of responsibility for health-promoting behavior were expected to motivate the greatest change in women's attitudes and behaviors in relation to breast cancer and mammography. Attitudes about breast cancer and mammography were measured immediately and 6 months after the presentation. Twelve months later, women who viewed the internal message were more likely to have obtained a screening mammogram than women assigned to the other 2 conditions. The attributions of responsibility encouraged by the persuasive messages were associated with whether viewing the presentation led to behavior change.

Stage of change as a predictor of success in weight control in adult women.

Weight change over 3 years was examined in a large and heterogeneous sample of women as a function of stage of change for weight control. Women were classified into Precontemplation, Contemplation, Preparation, and Action stages on the basis of reports of current and past weight control behaviors and future intentions. Stage of change did not predict success in weight control. Mean weight changes over 3 years were 1.1 kg, 1.0 kg, 2.1 kg, and 2.3 kg for Precontemplation, Contemplation, Preparation, and Action stages, respectively. The findings call into question the generality of the stages-of-change classification system across behavioral domains.

Stage theories of health behavior: conceptual and methodological issues.

Despite growing interest in stage theories of health behavior, there is considerable confusion in the literature concerning the essential characteristics of stage theories and the manner in which such theories should be tested. In this article, the 4 key characteristics of a stage theory-a category system, an ordering of categories, similar barriers to change within categories, and different barriers to change between categories--are discussed in detail. Examples of stage models of health behavior also are described. Four major types of research designs that might be used for testing stage theories are examined, including examples from the empirical literature. The most commonly used design, which involves cross-sectional comparisons of people believed to be in different stages, is shown to have only limited value for testing whether behavior change follows a stage process.

The effects of message framing on mammography utilization.

This experiment compared the effectiveness of gain-versus loss-framed messages to persuade women to obtain mammography screening. One hundred and thirty-three women 40 years and older and not adhering to current guidelines for obtaining mammography screening were assigned randomly to view either gain-framed (emphasizing the benefits of obtaining mammography) or loss-framed (emphasizing the risks of not obtaining mammography) persuasive videos that were factually equivalent. Attitudes and beliefs were measured before and immediately following the intervention. Mammography utilization was assessed 6 and 12 months later. Consistent with predictions based on prospect theory, women who viewed the loss-framed message were more likely to have obtained a mammogram within 12 months of the intervention. These findings suggest that loss-framed messages may have an advantage in the promotion of detection behaviors such as mammography.

Message framing and sunscreen use: gain-framed messages motivate beach-goers.

Prospect theory suggests that people respond differentially to factually equivalent messages depending on how these messages are framed (A. Tversky & D. Kahneman, 1981). A. J. Rothman and P. Salovey (1997) relied on prospect theory to predict that messages highlighting potential "gains" should promote prevention behaviors such as sunscreen use best. This experiment compared the effectiveness of 4 differently framed messages (2 highlighting gains, 2 highlighting losses) to persuade 217 beach-goers to obtain and use sunscreen. Attitudes and intentions were measured before and immediately following the delivery of the framed information, and after completing the questionnaire participants were given a coupon redeemable for a small bottle of sunscreen later that same day. People who read either of the 2 gain-framed brochures, compared with those who read either of the 2 loss-framed brochures, were significantly more likely to (a) request sunscreen, (b) intend to repeatedly apply sunscreen while at the beach, and (c) intend to use sunscreen with a sun protection factor of 15 or higher.

The effects of message framing and ethnic targeting on mammography use among low-income women.

The authors examined the effects that differently framed and targeted health messages have on persuading low-income women to obtain screening mammograms. The authors recruited 752 women over 40 years of age from community health clinics and public housing developments and assigned the women randomly to view videos that were either gain or loss framed and either targeted specifically to their ethnic groups or multicultural. Loss-framed, multicultural messages were most persuasive. The advantage of loss-framed, multicultural messages was especially apparent for Anglo women and Latinas but not for African American women. These effects were stronger after 6 months than after 12 months.

Emotional states and physical health.

Positive emotional states may promote healthy perceptions, beliefs, and physical well-being itself. To explore potential mechanisms linking pleasant feelings and good health, the authors consider several lines of research, including (a) direct effects of positive affect on physiology, especially the immune system, (b) the information value of emotional experiences, (c) the psychological resources engendered by positive feeling states, (d) the ways in which mood can motivate health-relevant behaviors, and (e) the elicitation of social support. As anticipated by the Greek physician Hippocrates, positive emotions and healthy outcomes may be linked through multiple pathways.

Toward a theory-based analysis of behavioral maintenance.

Intervention strategies that can produce successful rates of long-term behavior change have proven elusive and indicate the need for new approaches to this vexing problem. However, the development of new intervention strategies is constrained by our current conceptualization of behavioral maintenance. This article reviews how the dominant models of health behavior change have operationalized the psychological processes that guide the initiation and maintenance of a new pattern of behavior. In light of this review, an alternative framework is proposed based on the premise that the decision criteria that lead people to initiate a change in their behavior are different from those that lead them to maintain that behavior. Decisions regarding behavioral initiation are predicted to depend on favorable expectations regarding future outcomes, whereas decisions regarding behavioral maintenance are predicted to depend on perceived satisfaction with received outcomes. The implications of this framework for behavioral interventions are addressed.

The Challenge study: theory-based interventions for smoking and weight loss.

Both smokers and overweight persons report frequent efforts to change their behavior. Long-term success, however, is achieved by few. Interventions are needed to improve long-term success in smoking cessation and weight loss. Our research program is designed to address this need and to test a novel conceptualization of health behavior change that is based on the premise that the initiation and the maintenance of behavior change involve different decision processes. Positive expectations about the consequences of behavior change are thought to guide decisions to initiate behavior change, whereas satisfaction with the outcomes afforded by one's behavior guides decisions about maintenance. In the first phase of our research program, we are evaluating the effect people's expectations about the benefits of behavior change have on immediate and long-term behavioral outcomes. Specifically, participants are assigned to either an 'optimistic' treatment condition that emphasizes positive expectations for outcomes or a 'balanced' treatment condition that gives equal weight to the benefits and costs associated with behavior change. The impact of manipulating people's expectations about behavior change will be examined in the areas of smoking cessation and weight loss. Results of these studies will advance research on health behavior change by informing practical and theoretical understanding of the factors that control decisions to initiate a new pattern of behavior and to maintain it.