the requirements for the degree of ... Dr. Mark Williams, Graduate Coordinator ... action risk on attitudes towards and behavioral intentions to get the HPV vaccine ...
THE EFFECT OF MESSAGE FRAMING AND PERCEIVED ACTION RISK ON YOUNG WOMEN’S ATTITUDES TOWARD AND INTENTIONS TO GET THE HUMAN PAPILLOMAVIRUS (HPV) VACCINE
Jessica C. Russell B.A., California State University, Sacramento, 2006
THESIS
Submitted in partial satisfaction of the requirements for the degree of
MASTER OF ARTS
in
COMMUNICATION STUDIES
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
FALL 2009
© 2009 Jessica C. Russell ALL RIGHTS RESERVED ii
THE EFFECT OF MESSAGE FRAMING AND PERCEIVED ACTION RISK ON YOUNG WOMEN’S ATTITUDES TOWARD AND INTENTIONS TO GET THE HUMAN PAPILLOMAVIRUS (HPV) VACCINE
A Thesis
by
Jessica C. Russell
Approved by:
__________________________________, Committee Chair Dr. James K. Ah Yun
__________________________________, Second Reader Dr. Lisa L. Massi Lindsey
__________________________________, Third Reader Dr. Carmen Stitt
__________________________________, Fourth Reader Dr. Elaine Gale
Date:_____________________________ iii
Student: Jessica C. Russell
I certify that this student has met the requirements for format contained in the University format manual, and that this thesis is suitable for shelving in the Library and credit is to be awarded for the thesis.
_______________________________________________ Dr. Mark Williams, Graduate Coordinator Department of Communication Studies
iv
__________________ Date
Abstract of THE EFFECT OF MESSAGE FRAMING AND PERCEIVED ACTION RISK ON YOUNG WOMEN’S ATTITUDES TOWARD AND INTENTIONS TO GET THE HUMAN PAPILLOMAVIRUS (HPV) VACCINE by Jessica C. Russell The human papillomavirus (HPV) is the most prevalent sexually transmitted disease (STD) in the United States. In June of 2006, a vaccine aimed to protect young women against major strands of the HPV virus was licensed. Although the vaccine is widely available, an insufficient number of young women have taken the necessary steps to get the vaccine so that they might protect their health. One strategy to increase the number of young women getting the vaccine is to engage in a persuasive message campaign. Message framing is one persuasive strategy that health communication scholars have found to be effective in positively changing health behavior attitudes and intentions. The current thesis examined the potential interaction effect between message framing (loss vs. gain) and perceived action risk (low vs. high), on attitudes towards and behavioral intentions to get the HPV vaccine. This study utilized a 2x2 factorial experimental design in which message framing (loss vs. gain) and perceived action risk (low vs. high), were manipulated. In addition to the four experimental conditions, a no message control group was utilized as a baseline comparison. Participants consisted of 475 female students, of which 373 fulfilled the screening requirements and were included in the main experiment. These data indicate no interaction effect between message framing and perceived action risk on attitudes towards and behavioral intentions to get the HPV vaccine. Furthermore, no main effect for message framing was revealed. However, a main effect for perceived action risk was found with each of the outcome variables. Limitations and implications of these findings are discussed.
__________________________________, Committee Chair Dr. James K. Ah Yun ____________________ Date v
ACKNOWLEDGEMENTS This thesis would not have been possible without the support of many individuals. To Nana and Daddad, you taught me the importance and value of an education from a young age. I am so appreciative of all your support in making these dreams come true. I hope you can see the manifestation of your efforts from heaven. I love you both. To Kimo, as promised, I dedicate this thesis to you, the giver of light and all that is good. Without you there is only darkness. I am so grateful to have you in my life as a mentor and a friend. Thank you for everything. Here is to the next step. You are not off the hook yet. To Lisa, thank you for being absolutely incredible. No big deal. I hope to follow in your footsteps, or at the very least, not ruin your reputation at MSU. Let’s face it; Kimo’s reputation is already shot out. Go green, go white. To Carmen and Elaine, thank you for your support throughout this process and the lack of “bus” attacks. To Jarrett, you will always be hakuna matata in my eyes. Thank you for being there to emphasize what is really important in life. While we are the same in the face, I have so much to learn from you. You are the greatest brother and best friend I could ever ask for. To Dad, you are an incredible human being. Your positive “Yoda” perspectives on life are inspirational. Thank you for all your support during this process and always. To Mom, although done in unconventional ways, you have made me the person I am today. For this, I am grateful. Without you, I would not have the drive to have come this far. Two degrees down, one to go! To Ali, you are the greatest cheerleader. Thanks for providing ample amounts of sarcastic and comedic relief. Hold the California fort down while I am gone.
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TABLE OF CONTENTS Page Acknowledgements ............................................................................................................ vi List of Tables ...................................................................................................................... x Chapter 1. INTRODUCTION ........................................................................................................ 1 HPV and Cervical Cancer ....................................................................................... 1 HPV Prevention ...................................................................................................... 2 HPV Vaccine Recommendations ............................................................................ 3 Key Audience.......................................................................................................... 3 Knowledge and Awareness ..................................................................................... 4 The Role of Communication................................................................................... 5 Message Framing .................................................................................................... 5 Prospect Theory ...................................................................................................... 6 Current Study .......................................................................................................... 7 2. LITERATURE REVIEW ............................................................................................. 8 3. METHOD ................................................................................................................... 21 Induction Check .................................................................................................... 21 Participants ................................................................................................ 21 vii
Procedure .................................................................................................. 22 Independent Variables .............................................................................. 22 Measures ................................................................................................... 24 Check for Potential Confounding Variables ............................................. 24 Data Analysis ............................................................................................ 25 Main Experiment .................................................................................................. 28 Participants ................................................................................................ 28 Design ....................................................................................................... 29 Procedure .................................................................................................. 29 Instrumentation ......................................................................................... 30 Measures ................................................................................................... 30 Additional Measures of Risk .................................................................... 31 Confound Check ....................................................................................... 33 Outcome Measures.................................................................................... 34 4. RESULTS ................................................................................................................... 37 5. DISCUSSION ............................................................................................................. 41 Limitations ............................................................................................................ 45 Directions for Future Research ............................................................................. 45
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Appendices ........................................................................................................................ 48 Appendix A. Scenarios ..................................................................................................... 49 Appendix B. Framing Items .............................................................................................. 51 Appendix C. Perceived Action Risk Items ....................................................................... 52 Appendix D. Message Clarity Items ................................................................................. 53 Appendix E. Message Processing Effort Items................................................................. 54 Appendix F. HPV Perceived Susceptibility Items ............................................................ 55 Appendix G. Cervical Cancer Perceived Susceptibility Items ......................................... 56 Appendix H. Attitude Items .............................................................................................. 57 Appendix I. Behavioral Intention Items............................................................................ 58 References ......................................................................................................................... 63
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LIST OF TABLES Page 1.
Table 1 Perceived Action Risk by Frame on Attitudes......................................... 59
2.
Table 2 Perceived Action Risk by Frame on Behavioral Intention ...................... 60
3.
Table 3 Perceived Action Risk by Frame on Perceived Susceptibility to HPV ... 61
4.
Table 4 Perceived Action Risk by Frame on Perceived Susceptibility to Cervical Cancer ................................................................................................................... 62
x
1 Chapter 1 INTRODUCTION The human papillomavirus (HPV) is the most prevalent sexually transmitted disease (STD) in the United States. It is estimated that 20 million Americans are infected and an additional 6.2 million individuals become infected annually (Weinstock, Berman, & Cates, 2004). Spread through skin-to-skin contact during sexual activity, it is estimated that more than 50 percent of sexually active individuals will contract HPV at some point during their lives, though most will never be aware of it (Koutsky, 1997). HPV and Cervical Cancer Over 100 types of HPV exist, 40 of which infect the genital area (Koutsky & Kiviat, 1999). Genital HPV types are categorized by risk level. The majority of these infections has no symptoms and goes away without clinical treatment (Friedman & Shepeard, 2006; Koutsky, 1997). However, low-risk types of infections (e.g., types 6 and 11) can cause nonmalignant or low-grade cervical cell changes and genital warts. Highrisk HPV types (e.g., 16 and 18) can cause low-grade and high-grade cervical cell abnormalities that may serve as precursors to cervical cancer and other anogenital cancers (Gerberding, 2004; Markowitz, Dunne, Saraiva, Lawson, Chesson, & Unger, 2007). High-risk HPV types are present in 99.7% of cervical cancers worldwide (Walboomers et al., 1999). Of these cervical cancer cases, 70% are caused by HPV types 16 and 18 (Bosch & Sanjose, 2003). Cervical cancer mortality rates in the United States are in decline due to widespread Papanicolaou (Pap) testing (Helms & Melnikow, 1999). Despite the
2 downward trend, in 2007, over 11,000 new cases of cervical cancer were diagnosed and estimates indicate that nearly 4,000 of these women will die annually from cervical cancer (Markowitz et al., 2007). Although, Pap testing has contributed to the decline in the cervical cancer mortality rate, even under regular optimal use, the Pap test only detects 90% of cervical cancers. Additionally, of women in the United States, 40% do not engage in regular screening (Hoover, Carfioli, & Moench, 2000). The HPV progression into cervical cancer is a slow process, at times taking over 20 years from the time of initial infection. Most HPV infections occur during the teenage years or early twenties, whereas cervical cancer is more common among women over the age of 35 (Hoover, Carfioli, & Moench, 2000). Cervical cancer is the most serious outcome of HPV infection, yet is highly preventable with routine screening and followup (Gerberding, 2004). HPV Prevention HPV does not have a cure, only treatment for abnormalities that result from HPV, thus preventive measures are paramount. The only way to prevent HPV is abstinence from sexual activity. Sexually active individuals can use condoms to lower the risk of getting HPV. However, because HPV is spread through skin to skin contact instead of bodily fluids, any area not covered by a condom is unprotected (Koutsky, 1997; Manhart & Koutsky, 2002). Additionally, due to the subclinical and asymptomatic nature of many HPV types, transmission is not abated by abstaining from sexual activity during active breakouts (Hoover, Carfioli, & Moench, 2000).
3 One strategy to reduce the spread of HPV, and thus prevent cervical cancer, is to increase the number of individuals who get vaccinated. In June 2006, an HPV vaccine was licensed for women between the ages of nine and 26. It is delivered in a series of three doses over a period of six months. The vaccine protects against four major types of HPV (6, 11, 16, and 18). Types 16 and 18 are the cause of 70% of cervical cancers and types 6 and 11 are the cause of 90% of genital warts (Markowitz et al., 2007). HPV Vaccine Recommendations Due to the prevalence of HPV, health professionals recommend getting the vaccine prior to becoming sexually active. Although the suggested age for vaccination is between 11 and 12 years of age, catch-up vaccines are available through the age of 26. Individuals that receive the vaccine prior to initial sexual activity are inoculated against the four major types of HPV. Individuals that receive the vaccine after becoming sexually active will only be protected from the types of HPV they have not yet contracted (Markowitz et al., 2007). Key Audience Among those at highest risk for HPV infection are sexually active females under the age of 25 (Ho, Bierman, Beardsley, Chang, & Burk, 1998; Koutsky, 1997; Myers, McCrory, Nanda, Bastian, & Matchar, 2000; Trottier & Franco, 2006). Annually there is an estimated 6.2 million new cases of HPV infection reported, of which 74% occur among those between the ages of 15-24 (Markowitz et al., 2007). HPV is the most common sexually transmitted disease with estimated prevalence rates ranging between 19-90% (Ho et al. 1998; Ley, Bauer, Reingold, Schiffman, Chambers, Tashiro, & Manos,
4 1991; Markowitz et al., 2007; Myers et al., 2000; Peyton, Gravitt, Hunt, Hundley, Zhao, Apple, & Wheeler, 2001) with infection rates decreasing markedly with increasing age (Garner, 2003). Ho et al., (1998) conducted a longitudinal study that examined prevalence rates of HPV. Although only 26% of the participants were reported HPV positive at the baseline, 60% were infected at some time during the three year period of the study. This study highlights the difficulty of determining an exact prevalence rate due to the subclinical nature of many cases of HPV, potentially causing prevalence to be underestimated. Barriers in addressing HPV extend beyond the difficulty in identifying prevalence rates. Knowledge and Awareness Despite the prevalence and complications associated with HPV, several studies have demonstrated significant knowledge deficits about HPV (Holcomb, Baily, Crawford, & Ruffin, 2004; Ramirez, Ramos, Clayton, Kanowitz, & Moscicki, 1997; Waller, McCaffery, Forrest, Szarewski, Cadman, & Wardle, 2003; Yacobi, Tennant, Ferrante, Naazneen, & Roetzheim, 1999). In one study, Ramirez et al. (1997) found that 28% of survey respondents had never heard of HPV. Among respondents that had heard of HPV, 73% did not know that HPV could be asymptomatic, 56% were unaware of the link between HPV and cervical cancer, and 53% did not know HPV was associated with Pap abnormalities (Ramirez et al., 1997). Similarly, a study conducted by Yacobi et al. (1999), found that 38% of college student respondents had never heard of HPV prior to the study. Among those that had been diagnosed with HPV, 62% had no existing knowledge of HPV prior to diagnosis. When Yacobi et al. assessed how knowledge of
5 HPV compared with other sexually transmitted diseases (STDs), they found that of the seven STD’s examined, HPV was the disease that participants indicated they knew the least about. The Role of Communication Cervical cancer is largely a preventable disease (Markowitz et al., 2007). With health care screening advances and the new HPV vaccine, there is the potential to drastically reduce the incidence of HPV, and thus greatly reduce the risk of cervical cancer. HPV awareness is increasingly important with the availability of preventable measures. Deficits exist when high prevalence rates are paired with low levels of HPV understanding. Given the need to explore ways to get women vaccinated, communication scholars should be interested in methods to increase the number of women who get the HPV vaccine. One persuasive strategy that could be used is message framing. Message Framing Framing is a persuasive approach that is used to influence individuals to engage in attitude and behavioral change. Messages can be framed in ways that emphasize either the positive or negative outcomes of engaging or failing to engage in a given behavior (Rothman & Salovey, 1997). The framing of health information can call attention to the benefits of engaging in a behavior (i.e., the potential gains) or the costs of not taking action (i.e., the potential losses). Health messages using gain-framing emphasize positive outcomes that are possible as a result of the target behavior. In contrast, health messages using loss-framing emphasize the detriments of not taking action (e.g. Meyerowitz & Chaiken, 1987; Rothman & Salovey, 1997; Rothman, Bartels, Wlaschin, & Salovey,
6 2006). For example, a campaign on exercising using gain-framed messages might emphasize the health benefits afforded by exercising such as increased energy, heightened mobility, and a more fit physique. In contrast, a campaign on exercising using loss-framing messages might emphasize the health losses of not exercising such as decreased energy, loss of mobility, and a less fit physique. Prospect Theory Prospect theory (Kahneman & Tversky, 1979; Kahneman & Tversky, 1981) provides a framework that addresses the conditions under which gain- or loss-frame messages are most effective in garnering behavior change (Rothman et al., 2006). Framing effectiveness is dependent upon the type of behavior targeted and individuals’ perceived risks of engaging in the proposed behavior (Rothman & Salovey, 1997). Health communication research surrounding perceived risk has focused on different types of risk. One type of risk focuses on susceptibility, or the belief that one is vulnerable to a disease (Rimal & Real, 2003). Susceptibility concerns the risk that one might fall prey to an illness or disease based on factors such as behavior, lifestyle, and family history. Another form of risk commonly examined, especially with regard to message framing research, is detection risk. This form of risk concerns recommended disease detection behaviors such as colonoscopies, mammograms, or HIV testing. By engaging in these behaviors, individuals face the risk of discovering they have an illness or disease. A final type of risk is action risk, which is the risk that a behavioral change to minimize a threat might have undesirable side effects. For example, a person might have cancer and subsequently chooses to undergo chemotherapy treatment. In this example,
7 action risk is the degree to which a person believes that the chemotherapy will negatively affect their health. Current Study Following the framing postulate of prospect theory, loss-framed messages are preferred when advocating a detection behavior and gain-framed messages are preferred when the target behavior is preventative in nature due to the varying levels of perceived risk (Rothman & Salovey, 1997; Rothman et al., 2006). The current study applies gainand loss-framed messages and perceived action risk to the target behavior of HPV vaccination. It is predicted that message framing interacts with perceived action risk to engaging in the desired behavior to impact an individual’s attitudes and behavioral intentions. The next chapter provides an in-depth discussion of prospect theory, message framing, important message outcome variables, and presents the formal research hypotheses tested in this study.
8 Chapter 2 LITERATURE REVIEW The theoretical foundation of message framing was drawn from prospect theory (Kahneman & Tversky, 1979; Kahneman & Tversky, 1981). Originally used to explain decision making under risk, prospect theory posits that individuals encode information regarding potentially risky decisions in terms of potential gains or losses in comparison to a neutral reference point such as current wealth or health status. According to prospect theory, individuals react differently to messages depending on how these messages are framed (Tversky & Kahneman, 1981). Different presentations of factually equivalent information may change the location of the reference point, ultimately, influencing people’s behavioral intentions, especially with regard to perceived risk (Kahneman & Tversky, 1979). For example, consider a situation in which a person has a reference point for their current health. They perceive their physical mobility to be at a certain state. A loss-framed message would suggest that the individual would lose mobility in comparison to their current reference point, whereas, a gain-framed messages would emphasize that the individual would acquire mobility in comparison to their current health state. It does not matter that individuals may have varying reference points, what matters is that a loss-framed message emphasizes a detraction from a current reference point while a gain-framed message emphasizes the ability to improve upon a reference point. Prospect theory proposes that individuals are loss-sensitive. Consistent with this idea, gain-framed messages encourage individuals to be risk-aversive and loss-framed
9 messages encourage individuals to be more risk-seeking. When given a prospect of avoiding a loss, individuals are likely to take it, even if their decision runs them the risk of an even greater loss. Conversely, if given a prospect of a potential gain, individuals are less likely to engage for fear of losing what they have already acquired. In a seminal study illustrating the effects of framing, Tversky and Kahneman (1981) presented participants with a scenario and factually equivalent choices framed in different ways. The scenario described a situation in which 600 lives were at stake due to a disease outbreak. Participants were asked to pick a proposed program to implement as a response. First, participants were given the choice between an option framed in terms of the number of lives that would be saved (i.e. “If program A is adopted, 200 people will be saved”) or an option with less certainty regarding the number of lives saved (i.e. “If Program B is adopted, there is 1/3 probability that 600 people will be saved, and 2/3 probability that no people will be saved”). Of the two program choices with potential gains, the participants preferred Program A, the more certain, risk averse option, even though the risky alternative had a potential of saving a greater number of lives. The second group of participants was provided the same scenario and two differently formulated proposed programs to choose from. The program options were framed in terms of lives lost (i.e. “If Program C is adopted 400 people will die. If Program D is adopted there is a 1/3 probability that nobody will die, and a 2/3 probability that 600 people will die”). Of the two choices with potential loses, participants were more willing to choose Program D, the more risk-taking option to the program option with the certain number of lives lost. Even though the loss and gain program options provided the
10 equivalent disease combatant (i.e. offered to save 200 lives and lose 400 lives vs. the probability of either saving or losing all 600 lives), participants decisions varied based on whether the framing emphasized lives saved or lives lost. The responses illustrated by the study are consistent with prospect theory in that gain-framing encourages individuals to be risk averse, while loss-framing promotes more risk-seeking behaviors. Prospect theory has also been applied to the study of health communication. With regard to health, individuals are faced with a variety of decisions. There are often costs and benefits to weigh in on whether or not to engage in certain behaviors. How the information regarding these health decisions and their potential outcomes are framed, can impact behavioral uptake (Rothman & Salovey, 1997). Prospect theory proposes that the framing of health information can either emphasize the benefits of taking action (i.e., the potential gains) or the costs of not taking action (i.e., the potential losses). For example, Umprey (2003) examined the effects of message framing on performing testicular selfexaminations (TSE). The gain-framed message explained: By doing a monthly TSE, you will know what your normal, healthy testicle feels like and will be able to recognize any changes. Research clearly shows that men who do the TSE increase their chances of detecting a lump early, when it is smaller and has not spread. Ultimately by engaging in TSE you may be increasing your chances of surviving cancer. The earlier the detection the more likely you will have a favorable prognosis and successful treatment. This knowledge you will gain by doing TSE can only help you. Remember, early detection can save your life (p. 105).
11 Conversely, the loss-framed message highlighted: By not doing a monthly TSE, you will not know what your normal, healthy testicle feels like and will be unaware of any changes. Research clearly shows that men who do not perform the TSE increase their chances of discovering a lump when it’s too late, when it is larger and may have spread to other parts of the body. Ultimately by not engaging in TSE you may be increasing your chances of dying from cancer. The later the detection the more likely you will have an unfavorable prognosis and unsuccessful treatment. This lack of knowledge can only hurt you. Remember, late detection can end your life prematurely (p. 105). The gain-framed message emphasized a series of statements describing the health benefits afforded by TSE, whereas, the loss-framed message emphasized the potential costs of not engaging in TSE. Early message framing research revealed inconsistent reporting of the benefits of one frame over another (Rothman & Salovey, 1997). Increased target health behaviors had been observed after both exposures to loss- and gain-framed messages. Although some research maintains that loss-framed messages are better, other research suggests that gain-framed messages are better. For example, Meyerowitz and Chaiken (1987) assessed loss- and gain-framed message impact on breast self-examinations (BSE). Participants were randomly assigned to brochures regarding BSE framed in loss, gain, or neutral language. The gain-framed brochure emphasized the benefits of performing BSE (i.e. increased chance of finding a tumor in the early, more treatable stages of disease) while the loss-framed brochure focused on the costs of not performing BSE (i.e.
12 decreased chance of finding a tumor in the early, more treatable stages of disease). In a four month follow-up, participants who read a loss-framed message manifested more positive BSE attitudes, behaviors, and intentions in comparison to those who read a gainframed message (Meyerowitz & Chaiken, 1987). Alternatively, research has also identified cases in which gain-framed messages are more effective. For instance, a loss- and gain-framed message intervention with the preventative health behavior of sunscreen application was conducted (Detweiler, Bedell, Salovey, Pronin, & Rothman, 1999). Participants at a beach were given either a loss- or gain-framed message concerning the use of sunscreen and then asked to report their attitudes and behavioral intention to use sunscreen in a questionnaire. After participants completed the questionnaire they were given a coupon to redeem for a free sample of sunscreen later that day. Participants in the loss- and gain-framed conditions were subsequently compared. Results revealed that participants exposed to the gain-framed message were more likely to request and repeatedly apply sunscreen than those exposed to the loss-framed message while at the beach (Detweiler et al., 1999). In attempt to uncover a unifying explanation that showed consistency in the framing research, Rothman and Salovey (1997) conducted an analysis of prospect theory’s application to health messages. They found that the effectiveness of the loss- or gain-frame message hinges on perceptions of risk and is dependent upon whether the recommended behavior is prevention or detection. Detection behaviors are performed to discover early signs of a disease so that treatment effectiveness and prognosis may be optimized. Engaging in health detection behavior poses potential risk for unpleasant
13 outcomes (Rothman, Martino, Bedell, Detweiler, & Salovey, 1999). For example, individuals engaging in mammogram screenings pose detection risks of identifying an abnormality that could be cancerous. Although detection behaviors often provide longterm health benefits, the short-term potential of informing an individual that they have a health problem categorizes them as risky (e.g. Meyerowitz & Chaiken, 1987). Alternatively, prevention behaviors are performed to preclude the onset of a health problem. They aid in affording the opportunity to maintain healthy lifestyles and minimize the risks of illness and include practices such as engaging in physical exercise and eating a balanced diet. Prevention behaviors are associated with low levels of risk, where oftentimes the only perceived risk is not taking action (Rothman et al., 1999). Given that health behaviors vary on their level of perceived risk, it follows that the type of framing would differ depending upon the type of behavior promoted. For example, it is likely that individuals have a much lower perceived risk of protection behaviors such as putting on sunscreen, wearing seatbelts, and taking multivitamins in comparison to detection behaviors such as breast and testicular self-examinations, colonoscopies, and blood tests, behaviors in both detection risks and action risks might exist. The important distinction between the functions of detection and prevention behaviors is the level of perceived uncertainty and risk involved (Detweiler et al., 1999). As prospect theory suggests, risk avoidance options are preferred in the domain of gains and more risky options are preferred in the domain of losses, it follows that prevention behaviors, those with a relatively certain outcomes and low levels of risk, would be more persuasive when accompanied by a gain-framed message. Conversely,
14 detection behaviors, those associated with higher perceived risk or uncertainty of outcomes, would be more persuasive when accompanied by a loss-framed message (Rothman & Salovey, 1997; Rothman et al., 2006). Therefore, the distinct findings of the Meyerowitz and Chaiken (1987) study and the Detweiler et al. (1999) are explained by the different health behavior functions. Meyerowitz and Chaiken (1987) focused on breast self-examinations (BSE). Results are consistent with Rothman and Salovey’s (1997) addition to prospect theory in incorporating health behavior outcomes, in that BSE is a detection (i.e. more risky) behavior and therefore, loss-framed messages were more effective. Conversely, the Detweiler et al. (1999) study examined intentions to use sunscreen. Given the preventative, and therefore, less risky nature of sunscreen application, the effectiveness of the gain-frame messages was consistent with prospect theory. Additional research surrounding framing and detection behaviors have focused primarily on cancer screening including mammography (Banks et al., 1995), breast selfexaminations (Meyerowitz & Chaiken, 1987), testicular self-examinations (Umphrey, 2003), and colorectal cancer screening (Myers et al., 1991), but have also included behaviors such as blood-cholesterol screenings (Maheswaran & Myers-Levy, 1990), and HIV testing (Apanovitch, McCarthy, & Salovey, 2003). Research concerning message framing and preventative health include behaviors such as wearing sunscreen (Detweiler et al., 1999; Rothman, Salovey, Antone, Keough, & Martin, 1993), engaging in physical exercise (Jones, Sinclair, & Courneya, 2003), and safe driving practices (Millar & Millar, 2000).
15 Some health behaviors might be perceived as having both a prevention and detection purpose (Rivers, Pizarro, Schneider, Pizarro, & Salovey, 2005; Rothman et al., 1999). For example, Pap tests may be perceived as either preventing the possibility of developing cervical cancer or detecting abnormal cervical cells. In this case, the prevention and detection functions are interrelated. In order to prevent the development of cervical cancer regular check-ups to detect any abnormal cells are emphasized. Rivers et al. (2005) tested the effectiveness of loss- and gain-framing on a video emphasizing different function of the Pap test. Results indicated that when the detection function of Pap tests was highlighted, loss-framed messages were most effective, whereas when the prevention function of Pap tests was highlighted, the gain-framed message was most persuasive (Rivers et al., 2005). Similar results were found in another study focusing on mouthwash and gum disease. Participants were either informed of a mouthwash that prevents gum disease (i.e. inhibits plaque from developing) or of mouthwash which functions to detect gum disease (i.e. indicates where plaque has accumulated and indicates the areas of risk). Gain-framed messages were more persuasive with the preventative mouthwash, whereas the loss-framed messages were more persuasive with the gum disease detecting mouthwash (Rothman et al., 1999). Results of these studies emphasize the need to consider health behavior functions when considering the message framing. For health behaviors that may have dual purposes, either real or perceived, it is important to emphasize one function while framing the behavior using the matched message (Rivers et al., 2005; Rothman et al., 1999).
16 Although the categorical taxonomy that detection and prevention behaviors aided in clarifying the mixed results of prior studies, it has limitations (O’Keefe & Jensen, 2007). Generally speaking, when applying the framing postulate of prospect theory to health behaviors it has been hypothesized that loss-framed messages are more effective in persuading individuals to engage in detection behaviors associated with a degree of risk and that gain-framed messages are more effective in persuading people to engage in prevention behaviors associated with little risk (Rothman & Salovey, 1997). Following this line of reasoning, all preventative behaviors are similar in their levels of perceived risks whether it is the probability of attaining an uncertain outcome or dangers associated with engaging in the behavior. However, perceived risk has been introduced as a subjective perception of a behavior (Rothman et al., 2006). Given the subjective nature of perceived risk, there may be variability in how certain prevention behaviors are construed (O’Keefe & Jensen, 2007). To illustrate the point of variance within the prevention category, the behaviors of dental hygiene and flu vaccination were compared. Individuals are likely to associate dental hygiene behaviors with a certain low action risk outcome given the absence of uncertain outcomes or dangerous side effects, thus resulting in a condition in which gainframed messages might be most effective. Conversely, a flu-shot, although still a preventative behavior, may be perceived as having more action risk with some uncertain outcomes, given potential side effects (O’Keefe & Jensen, 2007). Given that the flu shot may be perceived as a risky behavior by some, a loss-framed message might be more effective.
17 It is suggested that the degree of perceived action risk be considered at the level of the individual given that they might vary in their perceptions of risk, specifically concerning associated feelings of anxiety and distress regarding the target behavior (Latimer, Salovey, & Rothman, 2007; Rothman et al., 2006). Considering the degree to which the individual perceives action risk in engaging in the behavior, may serve to better understand which message framing will be maximally effective. For example, with respect to the flu-shot example, some individuals perceive getting the flu shot as a risky behavior to engage in, for fear that the live strains of the virus in the vaccine will make them sick. Other individuals may perceive the only action risk associated with getting a flu shot is not getting one. The variability of individual perceptions regarding health behaviors is likely to impact the effectiveness of the loss- and gain-framed messages (Latimer et al., 2007; O’Keefe & Jensen, 2007). The idea that there is perceived risk action variability associated with health based persuasive appeals is especially important with the examination of the HPV vaccine. Although the HPV vaccine is a preventative behavior, and therefore, traditionally associated with low levels of action risk, variation in individual perceptions likely exists. Typically, individuals have a degree of comfort regarding vaccination, ranging from welcomed acceptance to outright opposition (Poland & Jacobson, 2001; Zimet, 2005; Zimmerman et al., 2005). With the recent FDA approval of the HPV vaccine, the longterm knowledge of potential side effects may be limited (Saul & Pollack, 2007). Despite the protection that it provides, there may be those individuals that perceive getting the HPV vaccine as a risky behavior. Therefore, the current study tests the interaction
18 between message framing and perceived action risk of engaging in the proposed behavior on attitudes towards, and behavioral intentions to get, the HPV vaccine. One of the most frequently examined outcomes with regard to health related behavior change is attitudes. The concept of attitude plays a central role in explaining communication phenomena, specifically concerning the effects of persuasive messages (Kim & Hunter, 1993a). Attitudes toward the behavior refer to a person’s evaluation of performing the behavior in question (Ajzen, 1988). It is also thought that attitudes exert a strong influence on behavior (O’Keefe, 2002). If an individual has an overall positive evaluation they will be more likely to engage in the behavior in comparison to an individual that has an overall negative evaluation (Ajzen, 1991). A meta-analysis of 138 studies resulted in uniformly positive correlations between relevant attitudes and behavior (r = .79) when methodological artifacts were eliminated. Thus, suggesting that theoretical utility of attitudes should be a fundamental condition when trying to predict overt behavior (Kim & Hunter, 1993a). As attitudes are thought to be predictors of behavior it should be expected that participants with more favorable attitudes towards the HPV vaccine will be more likely to get vaccinated. Given the argument made above to predict a differential effect of loss- and gain-framed messages, depending on whether a target perceives the action risk of engaging the in the behavior to be low or high, the following hypothesis is posed: H1: Message framing and perceived action risk will interact such that the most positive attitudes towards the HPV vaccine will be in the gain-framed condition, when perceived action risk of engaging in the behavior is low and the loss-framed
19 condition when perceived action risk of engaging in the behavior is high and that these two conditions will not differ from one another. Furthermore, the gainframed, high-risk condition and the loss-framed, low-risk condition, will have the least positive attitudes towards the HPV vaccine, and these conditions will also not differ from each other. In addition to attitudes, behavioral intention, which is the degree to which a target intends to engage in a behavior, is another antecedent of behavior that is commonly examined in persuasion research. Behavioral intention depicts the motivational factors that influence behavior and incorporates both willingness of an individual to work hard as well as the effort they are planning to exert in order to perform a given behavior (Ajzen, 1991). A meta-analysis of studies concerning attitudes, behavioral intention, and behaviors showed a consistent view that behavioral intention serves as a mediator in attitude-behavior relationships (Kim & Hunter, 1993b). Thus, understanding behavioral intentions is crucial for predicting behavior from attitudes. As behavioral intention is thought to be a predictor of behavior it should be expected that participants with more favorable intentions towards the HPV vaccine will be more likely to get vaccinated. Given the argument made above to predict a differential effect of loss- and gain-framed messages, depending on whether a target perceives the action risk of engaging in the behavior to be low or high, the following hypothesis is posed: H2: Message framing and perceived action risk will interact such that the most positive behavioral intentions towards getting the HPV vaccine will be in the gain-framed condition, when perceived action risk of engaging in the behavior is
20 low and the loss-framed condition when perceived action risk of engaging in the behavior is high and that these two conditions will not differ from one another. Furthermore, the gain-framed, high-risk condition and the loss-framed, low-risk condition, will have the least positive behavioral intentions to get the HPV vaccine, and these conditions will also not differ from each other. This chapter reviewed existing literature surrounding decision making under risk and message framing. Additionally, the chapter presented explanations for the potential interaction effect between message framing and perceived action risk on the outcome variables attitude and behavioral intention. The following chapter presents the methodology that was utilized in the current study.
21 Chapter 3 METHOD The current study utilized a 2x2 factorial experimental design in which message framing (loss vs. gain) and perceived action risk (low vs. high) was induced. The dependent variables of attitude and behavioral intention were used. Furthermore, perceived susceptibility for both HPV and cervical cancer was measured. The current study occurred in two phases: an induction check followed by the main experiment. The induction check was designed to ensure that the stimuli elicited the desired responses. In addition to ensuring the stimuli elicited the desired responses, the induction check also tested whether or not the stimuli induced unintended effects. Thus, perceived message clarity and message processing effort were also measured to assess if the stimuli also impacted these outcomes. Once adequate inductions of the key variables were established, the main experiment tested the extent to which there was an interaction between framing and perceived action risk on attitudes and behavioral intentions. Induction Check Participants. Participants included 73 female undergraduate students enrolled in a Western state university. Participants ranged in age from 19 to 25 years old (M = 21.07, SD = 1.02). The majority of students identified themselves as juniors (49.3%), the rest identified as seniors (46.6%), and sophomores (4.1%). The majority of the participants identified themselves as Caucasian (53.4%), followed by Asian (34.2%), Hispanic
22 (4.1%), and other (8.2%). The respondents used in the induction check were not part of the main experiment. Procedure. Respondents were notified that participation was voluntary and were informed prior to volunteering that all provided information was confidential. Participants were assigned randomly to one of four written scenarios in which framing (loss vs. gain) and perceived action risk (low vs. high) had been manipulated (see Appendix A for each scenario) and subsequently were asked to complete a semantic-differential scale measuring framing and perceived action risk of engaging in the behavior based on the scenario. Participants were also asked to complete semantic differential scales concerning the potential confound variables of message clarity and effort required to process the message. Independent variables. Framing. Two types of framing (loss vs. gain) were manipulated across four written stimulus scenarios. Participants exposed to the loss-framed message read: By not getting the HPV vaccine, you have a great deal to lose. You may lose any protection against genital warts, which have no known cure, as well as the potential to have children. You can also lose protection to your cervix. This loss in protection makes you more prone to getting cervical cancer and can cost you your life. Ultimately, not getting this vaccine can lead to significant unnecessary damages to your health. In contrast, participants exposed to the gain-framed message read:
23 By getting this vaccine, you have a great deal to gain. You gain protection against genital warts as well as your reproductive health. You also gain protection to your cervix. This protection makes you less prone to getting cervical cancer and can save you your life. Ultimately, getting this vaccine can benefit you by preventing unnecessary damages to your health. Perceived action risk. Perceived action risk refers to the potential negative side effects of engaging in the target behavior. Two levels of perceived action risk (low vs. high) were created. Participants exposed to the low action risk message read: The HPV vaccine is low risk. The safety of the vaccine was tested in clinical trials before it was licensed. Side effects are very minor and include redness and itching where the shot was given. These symptoms do not last long and go away on their own. Whereas, participants exposed to the high action risk message read: Although the HPV vaccine offers protection against the contraction of cervical cancer, the HPV vaccine poses other potentially serious risks to your health. The safety of the vaccine has been tested; however, some of the vaccine’s reported side effects include suicidal thoughts, appendicitis, liver damage, paralysis, and in some cases, death. No research has been done to rule out these side effects as a risk of getting the HPV vaccine.
24 Measures. To ensure that the scenarios induced loss- and gain-framing and low- and highperceived action risk, participants after reading one of the four scenarios completed a series of questions. Framing. In order to ensure that the message framing manipulation adequately induced the intended effect, a five-item, 7-point semantic differential scale was created to measure perceived loss- and gain-framing (see Appendix B). The scale was scored such that higher scores represented greater perceptions of gain-framing. Based on the message, participants were asked to indicate the number that corresponds to the word that best describes their perception of the message’s frame. The scale included items such as “loss/gain” and “disadvantages/advantages.” Perceived action risk. The perceived action risk of getting the HPV vaccine was assessed using a five-item, 7-point semantic differential scale that was scored such that higher scores represented greater perceptions of action risk (see Appendix C). Based on the message, participants were asked to indicate the number that corresponds to the word that best describes their perception of the effects associated with the vaccine. The scale included items such as “safe/risky” and “harmless/harmful.” Check for potential confounding variables. An effective induction should be limited to influencing only the variable that is intended to be induced. For this study, in addition to the stimuli inducing the intended effect (inducing message frame and perceived action risk), it might have induced unintended effects. Specifically, these messages may differ in perceptions of how clear
25 they are as well as how much effort is required to process them. Given these potential differences, the outcome measures of message clarity and message processing effort were also assessed. Message clarity. Clarity of the message was measured using a five-item, 7-point semantic differential scale that was scored such that higher scores represented greater perceptions of clarity (see Appendix D). Based on the message, participants were asked to indicate the number that corresponded to the word that best described their perception of the clarity of the message’s content. With respect to the clarity of the message’s content, the scale included items such as “unclear/clear” and “confusing/not confusing.” Message processing effort. Message processing effort was measured using a fiveitem, 7-point semantic differential scale that was scored such that higher scores represented greater perceptions of effort to process the message (see Appendix E). Based on the message, participants were asked to indicate the number that corresponds to the word that best described their perception of the message processing effort. The scale included items such as “easy to read/hard to read” and “not difficult to process/difficult to process.” Data Analysis. Given that specific items are specified a priori to measure only one factor, confirmatory factor analysis was performed for all scales to test both internal consistency and parallelism (Anderson, Gerbing, & Hunter, 1987; Hunter & Gerbing, 1982; Levine, 2005). To test the measurement model, the current study examined the magnitude of the errors between the predicted and obtained correlations, calculated the Root Mean Square
26 error for each variable for tests of internal consistency and parallelism, and assessed reliability analysis. Reliability was assessed using Chronbach’s alpha. A confirmatory factor analysis (CFA) was conducted on the five message framing items to test the hypothesis that they measured a single construct. The test for internal consistency (RMSE = .07) and parallelism (RMSE = .05) revealed small errors. A review of the individual errors revealed they were generally small and flat. Given the small errors in the check for internal consistency and parallelism, none of the items were removed. A reliability check of these items indicated that the scale was highly reliable (α = .95). Given the factor analysis and reliability findings, these items were summed to form a composite score (M = 4.31, SD = 1.70). As predicted, participants in the gainframed condition (M = 5.12, SD = 1.36) indicated a more gain emphasized message than participants in the loss-framed condition (M = 3.63, SD = 1.67). The differences between the gain- and loss-framed conditions were significant and in the expected direction, t(71) = 4.11, p
