The effects of message framing and healthcare provider recommendation on adult hepatitis B vaccination: A randomized controlled trial.

Many adults in the U.S. do not receive recommended vaccines, and the research literature remains inconclusive on the best communication strategies for increasing this behavior. This study examined the association of message framing (gained-framed vs. loss-framed vs. control), and healthcare provider (HCP) recommendation (offered vs. recommended) on uptake of adult hepatitis B virus (HBV) vaccination in a high risk population using a 3 × 2 block design randomized controlled trial. Fear of shots, fear of vaccines, and perceived message framing were examined in secondary analyses. Of the 1747 participants, 47.7% (n = 833) received 0 doses of HBV vaccine, 27.8% (n = 485) received 1 dose, 10.4% received 2 doses, and 14.1% received all 3 recommended doses. There was not a significant interaction between message framing and HCP recommendation (p = .59). Mean number of doses received by the gain-framed group (m = 0.96) was not significantly different from the loss-framed group (m = 0.97, RR = 0.99, 95% CI = 0.88-1.12). However, those receiving any framing message received significantly more doses (m = 0.96) than those in the control condition (m = 0.81, RR = 1.17, 95%CI = 1.06-1.31). Participants who received a HCP recommendation received significantly more vaccine doses (m = 0.95) than those in the vaccine-offered condition (mean = 0.82, RR = 1.16, 95%CI = 1.05-1.28). These results suggest there is no difference in vaccine uptake between gain-frame and loss-frame messages, but both are better than a control message. These results also support advising HCP to provide a strong recommendation for vaccinations beyond merely offering it to patients. This study has implications for vaccine uptake beyond HBV, and can inform future research on effective vaccine communication research. Clinicaltrials.gov Identifier: NCT00739752. Registration date: August 20, 2008.

Behavior and health beliefs as predictors of HIV testing among women: a prospective study of observed HIV testing.

Much of the research examining predictors of HIV testing has used retrospective self-report to assess HIV testing. FINDINGS: therefore, may be subject to recall bias and to difficulties determining the direction of associations. In this prospective study, we administered surveys to women in community clinics to identify predictors of subsequent observed HIV testing, overcoming these limitations. Eighty-three percent were tested. In the adjusted multivariable model, being born in the U.S., perceived benefits of testing, worries about being infected with HIV, having had more than 15 lifetime sexual partners, and having had one or more casual sexual partners in the previous three months predicted acceptance of testing. Perceived obstacles to testing predicted non-acceptance. Those who had never been tested for HIV and those tested two to five years previously had greater odds of test acceptance than those who had been tested within the last year. The findings from this study with observed testing as the outcome, confirm some of the results from retrospective, self-report studies. Participants made largely rational decisions about testing, reflecting assessments of their risk and their history of HIV testing. Health beliefs are potentially modifiable through behavioral intervention, and such interventions might result in greater acceptance of testing. ABBREVIATIONS: HIV: human immunodeficiency virus; AIDS: acquired immune deficiency syndrome; CDC: Centers for Disease Control and Prevention; ACASI: audio computer-assisted self-interview; TRA: theory of reasoned action; HBM: Health Belief Model; STI: sexually transmitted infection; STD: Sexually Transmitted Disease; AOR: adjusted odds ratio; CI: confidence interval.

The effects of HIV testing advocacy messages on test acceptance: a randomized clinical trial.

BACKGROUND: Nearly 1 in 5 people living with HIV in the United States are unaware they are infected. Therefore, it is important to develop and evaluate health communication messages that clinicians can use to encourage HIV testing. METHODS: The objective was to evaluate health communication messages designed to increase HIV testing rates among women and evaluate possible moderators of message effect. We used a randomized four-arm clinical trial conducted at urban community outpatient health clinics involving 1,919 female patients, 18 to 64 years old. The four health message intervention groups were: i) information-only control; ii) one-sided message describing the advantages of HIV testing; iii) two-sided message acknowledging a superficial objection to testing (i.e., a 20 minute wait for results) followed by a description of the advantages of testing; and iv) two-sided message acknowledging a serious objection (i.e., fear of testing positive for HIV) followed by a description of the advantages of testing. The main outcome was acceptance of an oral rapid HIV test. RESULTS: Participants were randomized to receive the control message (n = 483), one-sided message (n = 480), two-sided message with a superficial objection (n = 481), or two-sided message with a serious objection (n = 475). The overall rate of HIV test acceptance was 83%. The two-sided message groups were not significantly different from the controls. The one-sided message group, however, had a lower rate of testing (80%) than the controls (86%) (OR, 0.66; 95% CI, 0.47-0.93; P = 0.018). "Perceived obstacles to HIV testing" moderated this effect, indicating that the decrease in HIV test acceptance for the one-sided message group was only statistically significant for those who had reported high levels of obstacles to HIV testing (OR, 0.36; 95% CI, 0.19-0.67; P = 0.001). CONCLUSIONS: None of the messages increased test acceptance. The one-sided message decreased acceptance and this effect was particularly true for women with greater perceived obstacles to testing, the very group one would most want to persuade. This finding suggests that efforts to persuade those who are reluctant to get tested, in some circumstances, may have unanticipated negative effects. Other approaches to messaging around HIV testing should be investigated, particularly with diverse, behaviorally high-risk populations. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT00771537. Registration date: October 10. 2008.

Use of drawings to explore U.S. women's perspectives on why people might decline HIV testing.

The purpose of this research is to explore through drawings and verbal descriptions women's perspectives about reasons why persons might decline human immunodeficiency virus (HIV) testing. We asked 30 participants to draw a person that would NOT get tested for HIV and then explain drawings. Using qualitative content analysis, we extracted seven themes. We found apprehension about knowing the result of an HIV test to be the most commonly identified theme in women's explanations of those who would not get tested. This technique was well received and its use is extended to HIV issues.

The Centers for Disease Control and Prevention revised recommendations for HIV testing: reactions of women attending community health clinics.

The purpose of this study was to examine reactions to the Centers for Disease Control and Prevention revised recommendations for HIV testing by women attending community health clinics. A total of 30 women attending three community clinics completed semistructured individual interviews containing three questions about the recommendations. Thematic content analysis of responses was conducted. Results were that all agreed with the recommendation for universal testing. Most viewed opt-out screening as an acceptable approach to HIV testing. Many emphasized the importance of provision of explicit verbal informed consent. The majority strongly opposed the elimination of the requirement for pretest prevention counseling and spontaneously talked about the ongoing importance of posttest counseling. The conclusion was that there was strong support for universal testing of all persons 13 to 64 years old but scant support for the elimination of pretest prevention counseling. In general, respondents believed that verbal informed consent for testing as well as provision of HIV-related information before and after testing were crucial.

Does perceived risk influence the effects of message framing? Revisiting the link between prospect theory and message framing.

Health-promoting messages can be framed in terms of the beneficial consequences of healthy behaviour (gain-framed messages) or the detrimental consequences of unhealthy behaviour (loss-framed messages). An influential notion holds that the perceived risk associated with the recommended behaviour determines the relative persuasiveness of gain- and loss-framed messages. This 'risk-framing hypothesis', which was derived from prospect theory, has been central to health message-framing research for the better part of two decades and has enduring appeal to researchers and practitioners. It has found its way into several health communication handbooks and is communicated to the general public. The present article examines the validity of the risk-framing hypothesis anew by providing a review of the health message-framing literature. In spite of its ongoing appeal, we conclude that the hypothesis has severe theoretical flaws. In addition, we find that the empirical evidence in favour of the hypothesis is weak and inconsistent. It seems that, in applying prospect theory's tenets to a health-promotion context, some of the theory's key aspects have been lost in translation. At the close of the article, we offer a research agenda for the future, arguing that, above all, new methodology is needed to bring the message-framing literature further.

Effectiveness of asking anticipated regret in increasing HPV vaccination intention in mothers.

OBJECTIVE: To determine the effectiveness of asking Anticipated Regret Questions (ARQ) and risk presentation format on enhancing attitudes and behavioral intentions of mothers to have their daughters receive the HPV vaccine. DESIGN: The study used a 2 × 2 between-subjects factorial design with a no message control, involving 2 anticipated regret conditions (asked or not asked) and HPV risk presentation format (text only or graphical presentation of risk). Data were collected from a national sample of 320 mothers of girls ages 11-16. MAIN OUTCOME VARIABLES: The primary outcome variable was mothers' intention to vaccinate their daughters with all 3 doses of the HPV shots. Message involvement, perceived ease of message comprehension, and health beliefs regarding HPV infection and the HPV vaccine were also measured. RESULTS AND CONCLUSIONS: Results indicated there was a significant interactive effect of asking anticipated regret and risk presentation format on message involvement and behavioral intention. ARQ positively influenced behavioral intention only among mothers exposed to the graphical presentation of HPV-related statistics. This effect was mediated by message involvement. Thus, the combined effect of the graphical message and anticipated-regret questions on behavioral intentions was mediated by increased emotional involvement with the information concerning cervical cancer and HPV vaccination. These findings are consistent with the view that the formation of health-behavior intentions often involves the interplay of both affective and cognitive processing.

Trust and transparency: patient perceptions of physicians' financial relationships with pharmaceutical companies.

Financial ties between physicians and pharmaceutical companies are pervasive and controversial. However, little is known about how patients perceive such ties. This paper describes an experiment examining how a national sample of U.S. adults perceived a variety of financial relationships between physicians and drug companies. Each respondent read a single scenario about a hypothetical physician and his financial ties to the pharmaceutical industry; scenarios varied in terms of payment type of (e.g., payment for meals vs. consulting fees) and amount. Respondents then evaluated the physician on several dimensions (e.g., expertise, trustworthiness, knowledge of new treatments, moral character, focus on patients' interests). Findings revealed that perceptions of the physician were more strongly influenced by payment type than by payment amount. Specifically, respondents were quite critical of doctors who owned drug company stock or received industry payments for meals and lodging, but were more forgiving of physicians who received free drug samples (which were perceived as benefiting patients) or consulting fees (which were seen as signaling physician expertise). Interestingly, physicians who received no payments, while seen as honest, were also viewed by some respondents as inexperienced or uninformed about new treatments. Implications for public policy and future research are discussed.

Does perceived risk influence the effects of message framing? A new investigation of a widely held notion.

Health-promoting messages can be framed in terms of the beneficial consequences of healthy behaviour (gain-framed messages) or the detrimental consequences of unhealthy behaviour (loss-framed messages). An influential notion holds that the perceived risk associated with the recommended behaviour determines the relative persuasiveness of gain- and loss-framed messages. This 'risk-framing hypothesis', as we call it, was derived from prospect theory, has been central to health message framing research for the last two decades, and does not cease to appeal to researchers. The present paper examines the validity of the risk-framing hypothesis. We performed six empirical studies on the interaction between perceived risk and message framing. These studies were conducted in two different countries and employed framed messages targeting skin cancer prevention and detection, physical activity, breast self-examination and vaccination behaviour. Behavioural intention served as the outcome measure. None of these studies found evidence in support of the risk-framing hypothesis. We conclude that the empirical evidence in favour of the hypothesis is weak and discuss the ramifications of this for future message framing research.

Can self-prediction overcome barriers to Hepatitis B vaccination? A randomized controlled trial.

OBJECTIVE: Hepatitis B virus (HBV) infection remains a serious public health problem, due in part to low vaccination rates among high-risk adults, many of whom decline vaccination because of barriers such as perceived inconvenience or discomfort. This study evaluates the efficacy of a self-prediction intervention to increase HBV vaccination rates among high-risk adults. METHOD: Randomized controlled trial of 1,175 adults recruited from three sexually transmitted disease clinics in the United States over 28 months. Participants completed an audio-computer-assisted self-interview, which presented information about HBV infection and vaccination, and measured relevant beliefs, behaviors, and demographics. Half of participants were assigned randomly to a "self-prediction" intervention, asking them to predict their future acceptance of HBV vaccination. The main outcome measure was subsequent vaccination behavior. Other measures included perceived barriers to HBV vaccination, measured prior to the intervention. RESULTS: There was a significant interaction between the intervention and vaccination barriers, indicating the effect of the intervention differed depending on perceived vaccination barriers. Among high-barriers patients, the intervention significantly increased vaccination acceptance. Among low-barriers patients, the intervention did not influence vaccination acceptance. CONCLUSIONS: The self-prediction intervention significantly increased vaccination acceptance among "high-barriers" patients, who typically have very low vaccination rates. This brief intervention could be a useful tool in increasing vaccine uptake among high-barriers patients.

Behavioral interventions to increase HPV vaccination acceptability among mothers of young girls.

OBJECTIVE: To determine the most effective ways to present human papillomavirus (HPV) vaccine risk and benefit information to mothers in Hispanic, African American, and White communities, to increase mothers' intentions to vaccinate their daughters against HPV. DESIGN: The study used a 3 x 2 between-subjects factorial design, involving 3 different risk presentation formats (graphical HPV statistics, nongraphical HPV statistics, or no-statistics control) and the presence or absence of rhetorical questions (RQ). Data were collected from a national sample of 471 mothers of girls ages 11-16. MAIN OUTCOME VARIABLES: The primary outcome variable was mothers' intention to vaccinate their daughters against HPV. Secondary outcomes included mothers' self-reported message comprehension and perceptions of daughters' vulnerability to HPV infection, infection severity, vaccine efficacy, and obstacles to immunization. RESULTS AND CONCLUSION: Results showed that both risk presentation format and RQs had an overall positive effect on mothers' intention to vaccinate their daughters. However, the interventions appear to be more effective when used separately than when used in combination. Each of these interventions is brief and could easily be implemented by health care providers as well as in patient health communication literature.

Vaginal microbicide preferences among midwestern urban adolescent women.

PURPOSE: The purpose of this study was to assess adolescent women's preferences for specific microbicide characteristics including pregnancy prevention, timing of application, potential for side effects, and whether it targeted human immunodeficiency virus (HIV) or other sexually transmitted infections (STI). Potential differences in microbicide preferences by adolescent age group and behavioral patterns including engaging in sexual intercourse and use of hormonal contraception were examined, as it was hypothesized that as adolescents progress into adulthood and gain sexual experience their preferences in microbicide characteristics may shift. METHOD: Adolescent and young women (N = 405, 56.0% African American; 24.0% Euro-American) between the ages of 14 and 20 (mean = 17.0, SD = 1.8) were recruited from urban community-based clinics. Video-Audio Computer-Assisted Self-Interviews were conducted with the young women, during which they were asked about their preferences regarding the characteristics of hypothetical vaginal microbicides. Conjoint analysis was utilized to determine adolescent women's relative preferences for each microbicide characteristic and intent-to-purchase microbicides based upon a combination of the selected properties. RESULTS: Overall, the results suggest adolescent and young women had an ordered preference for a microbicide with (1) no side effects, (2) pregnancy prevention, (3) postcoital application, and (4) protection against HIV. Age and behavioral group conjoint analyses resulted in the same pattern of preferences as those reported for the entire group. However, women having sex and not using hormonal contraception had a stronger preference for postcoital application. CONCLUSION: The findings suggest that young women's ratings of microbicides were sensitive to characteristics such as side effects, pregnancy prevention, and timing of application and should be considered in microbicide development. The conjoint analysis approach is useful in understanding microbicide preferences, and should be utilized with other populations to assess preferences for specific microbicide characteristics.