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ORIGINAL ARTICLE
Behavioral Frequency Moderates the Effects of Message
Framing on HPV Vaccine Acceptability
Mary A. Gere nd, Ph.D. & Janet E. Shepherd, M.D. &
Kara A. Monday, B.S.
Published online: 12 March 2008
#
The Society of Behavioral Medicine 2008
Abstract
Background Research suggests that gain-framed messages
are generally more effective than loss-framed messages at
promoting preventive health behaviors. Virtually all previ-
ous studies, howe ver, have examined prevention behaviors
that require regular and repeated action to be effective.
Little is known about the utility of message framing for
promoting low-frequency prevention behaviors such as
vaccination. Moreover, few studies have identified media-
tors of framing effects.
Purpose We investigated whether behaviora l frequency
(operationalized as the number of shots required) moderated
the effect of framed health messages on women’s intentions
to receive the human papillomavirus (HPV) vaccine. We
also sought to identify mediators of framing effects.
Method Undergraduate women (N=237) were randomly
assigned to read an HPV vaccination booklet that varied by
message frame (gain vs. loss) and behavioral frequency
(one shot vs. six shots).
Results We observed a frame-by-frequency interaction
such that the loss-framed message led to greater vaccination
intentions than did the g ain-framed message but only
among participants in the one-shot condition. Perceived
susceptibility to HPV infection mediated the observed
framing effects.
Conclusions This study provides an important exception to
the commonly observed gain-framed advantage for preven-
tive health behaviors. Loss-framed appeals appear to be
particularly effective in promoting interest in low-frequency
prevention behaviors such as HPV vaccination.
Keywords Message framing
.
Human papillomavirus (HPV) vaccine
.
Mediators of framing effects
Introduction
Message framing —providing equiva lent health information
in terms of either gains or losses—has proven to be an
effective strategy for promoting behavior change across a
wide range of health practices [1]. Several previous studies
suggest that loss-framed messages tend to be most effective
in promoting disease-detection behaviors (e.g., mammog-
raphy, HIV testing), whereas gain-framed messages tend to
be most effective in promoting prevent ive health behaviors
(e.g., sunscreen use, exercise) [1–6]. Virtually all studies
demonstrating an advantage of gain-framed messages,
however, have focused on preventive health behaviors that
require regular and repeated action to be effective. Thus,
little is known about the utility of mess age framing for
ann. behav. med. (2008) 35:221–229
DOI 10.1007/s12160-008-9024-0
Portions of this article were presented at the annual meeting of the
Society of Behavioral Medicine, San Francisco, March 2005.
M. A. Gerend (*)
Department of Medical Humanities and Social Sciences,
Florida State University College of Medicine,
1115 West Call Street,
Tallahassee, FL 32306-4300, USA
e-mail: mary.gerend@med.fsu.edu
J. E. Shepherd
Department of Clinical Sciences,
Florida State University College of Medicine,
1115 West Call Street,
Tallahassee, FL 32306-4300, USA
K. A. Monday
Florida State University College of Medicine,
1115 West Call Street,
Tallahassee, FL 32306-4300, USA
promoting low-frequency or one-time prevention behaviors
such as vaccination.
Effects of framed health messages on vaccination may be
different from those typically observed for other preventive
health behaviors. Moreover, there is reason to suspect that this
difference may be due, at least in part, to the low behavioral
frequency associated with vaccination as opposed to most
other prevention behaviors. The primary purpose of the
present study was to investigate the role behavioral frequency
plays in shaping the effects of framed health messages on
women’s willingness to get vaccinated against human
papillomavirus (HPV). HPV is a sexually transmitted infec-
tion that causes genital warts and cervical cancer [7]. The
second goal of this study was to identify potential mediators
of message-framing effects, as relatively few studies have
successfully identified the psychological mechanisms under-
lying the influence of framed health messages.
Review of Message-Fram ing Research
Most persuasive health communications can be framed in
terms of either gains or losses. A gain-framed message
highlights the benefits of engaging in a health-protective
behavior or avoiding a risky behavior, whereas a loss-
framed message highlights the costs of not engaging in a
health-protective behavior or engagi ng in a risky behav-
ior. For example, when encouraging an individual to
engage in physical activity, one could highlight the ben-
efits of exercising with a gain-framed message (“Exer-
cising regularly can help you feel energized and improve
your health.”) or the costs of not exercising with a loss-
framed message (“Failing to exercise regularly can make
you feel lethargic and impair your health.”). Message
framing is grounded in prospect theory [8, 9], which
suggests that people respond differently to information
highlighting gains vs. losses. Specifically, prospect theory
holds that individuals are generally more willing to take risks
when considering losses, but are more risk-averse when
considering gains.
Drawing on prospect theory, Rothman and Salovey [10]
proposed that whether a gain- or loss-framed appeal is more
effective depends largely upon whether the recommended
behavior is percei ved to involve risk or uncertainty. The
degree of risk associated with a given behavior is often
signaled by its purpose, for example, whether it is aimed at
detecting or preventing disease. Because the purpose of a
detection or screening behavior (e.g., mammography,
colonoscopy) is to reveal a potentially life-threatening
disease, engaging in these behaviors could be viewed as
risky (at least in the proximate psychological sense because
they could reveal an unpleasant outcome, such as cancer).
In contrast, because the purpose of a preventive health
behavior (e.g., using sunscreen, eating fruits and vegeta-
bles) is to thwart disease, engaging in these behaviors is
typically viewed as relatively safe and certain.
Linking this framework to prospect theory, Rothman and
Salovey [10] proposed that because people are relatively
open to taking risks when faced with potential losses, loss-
framed appeals shoul d be most effective in promoting
disease detect ion behaviors—behaviors that signal potential
risk. However, because people tend to avoid risks in the
face of potential gains, gain-framed appeals should be most
effective in promoting preventive health behaviors—behav-
iors general ly associated with low risk and relative
certainty. Empirical support for this conceptual framework
has been accumulating [1–6, 11], although inconsistent
findings have also been noted [12–14].
Message Framing and Vaccination
Whether gain- or loss-framed messages are more effective
for prom oting immunization is largely unknown. The
framework outlined by Rothman and Salovey would suggest
that, because vaccination is a preventive health behavior,
messages highlighting the benefits of getting vaccinated (a
gain frame) should be more effective than messages
highlighting the costs of not getting vaccinated (a loss
frame). Yet, evidence for this prediction has not materialized
[15, 16
]. In fact, a recent framing study targeting vaccination
found the reverse, such that among some individuals, a loss-
framed appeal promoted greater intentions to receive the
HPV vaccine than did a gain-framed appeal [17].
One possible explanation is that the relative efficacy of
gain- vs. loss-framed messages depends on the frequency
required to perform the behavior. Indeed, vaccination is
unlike most other preventive health behaviors, which
require regular repeated action to be maximally effective.
To achieve the optimal health benefits of sunscreen, for
example, it must be worn every time one is exposed to the
sun. Likewise, to reap the benefits of exercise, it shoul d be
done on a regular basis— ideally, every day. Vaccination, in
contrast, is typically a low-frequency (often one-shot)
event. With the exception of an occasi onal booster, many
vaccinations are completed in a single visit.
Virtually all studies demonstrating an advantage of gain-
framed over loss-framed messages in promoting prevention
behaviors have focused on effortful, high-frequency pre-
ventive health behaviors such as exercise [5], oral hygiene
[16, 18], safe driving behavior [19], and sun protection [4,
20], thus obscuring the potential importance of behavioral
frequency. Rothman and Salovey [10] suggested that loss-
framed messages may be more effective than gain-framed
messages in motivating low effort, one-time preventive
health behaviors such as vaccin ation. That is, the pattern
implied by prospect theory might flip when a preventive
health behavior involves a singl e, “one-shot” behavior.
222 ann. behav. med. (2008) 35:221–229
Why might framing effects depend on the frequency of the
prevention behavior being promoted? Preventive health
behaviors that require regular, repeated action are likely to
engender a sense of familiarity and certainty regarding both
the nature of the behavior and its consequences. For example,
exercising nearly every day is likely to promote a sense of
certainty and safety regarding the proximate experience of
exercise and its health-related consequences. Conversely,
single-event prevention behaviors such as vaccination tend to
be associated with more uncertainty because of their novelty
and lack of familiarity . Indeed, there is evidence that people
often view vaccination procedures as relatively uncertain in
terms of their consequences and effectiveness [21–23]. As
described earlier, prospect theory as applied to message
framing implies that behaviors associated with perceptions of
uncertainty should be most responsive to loss-framed
messages. Thus, when contempl atin g a low-frequenc y
prevention behavior (e.g., one-shot vaccination), people
might be expected to respond more favorably to a loss-
framed message than to a gain-framed message.
The current study tested the potential moderating role of
behavioral frequency on framed health messages promoting
HPV vaccination. In addition to manipulating the frame of
the health message, we manipulated the number of shots
required for immuniz ation against HPV infection. Partic-
ipants were told that they would have to receive either one
shot or six shots of the vaccine. When vaccination involved
a one-time behavior, we predicted that a loss-framed
message would outperform a gain-framed message. When
vaccination involved repeated action (i.e., multiple visits
over time), however, we expected the advantage of the loss-
framed message to disappear.
Mediators of Message-Framing Effects
The second goal of this study was to identify potential
mediators of framing effects. Although several studies have
attempted to uncover the cognitive and affective mecha-
nisms underlying the effects of framed health messages on
behavior, relativel y few studies have been successful [3, 4,
6, 20]. Across these studies, several putative mediators have
been investigated—namely, common predictors of health
behavior such as healt h beliefs (e.g., perceived susceptibil-
ity to the health threat, perceived severity of the healt h
threat, self-efficacy to engage in the recommended behav-
ior), attitudes toward the recommended behavior, behavior-
al intentions, and affective factors (e.g., negative affect
associated with exposure to the message).
Only a few studies have found evidence of mediation [16,
24]. Meyerowitz and Chaiken [24] found that self-efficacy
beliefs partially mediated the effect of a framed message on
breast self-examination (BSE). Exposure to a loss-framed
message increased perceptions of self-efficacy for
performing BSE which, in turn, led to higher rates of BSE.
In a study demonstrating that gain frames work best for pro-
moting prevention behaviors whereas loss frames work best
for promoting detection behaviors, Rothman and colleagues
[16] reported that attitudes, favorable thoughts about the
message, and behavioral intentions partially mediated the
observed framing effects. Nevertheless, to date, a clear
pattern of mediating variables has been difficult to discern.
Perceptions of risk or susceptibility to the health threat
portrayed in the message have been proposed to mediate
loss-framed effects [20]. As the aim of a loss-framed
message is to highlight risk and uncertainty, it follows that
exposure to a loss frame might increase risk perceptions.
Indeed, several studies have shown that, relative to a gain-
framed message, exposure to a loss-framed message leads
to increased concern a nd worry about the health threat,
elevated perceptions of risk, and higher levels of negative
affect [16 , 20]. Moreover, much research has shown that
risk percept ions predict health behavior [25, 26], including
vaccination [23, 27, 28]. No studies, however, have
demonstrated the presence of a mediational pathway in
which exposure to a loss-framed message increased
perceived susceptibility, and higher perceptions of suscep -
tibility, in turn, predicted greater intentions or behavior.
In the present study, we tested the hypothesis that
exposure to a loss-framed, low-frequency message would
lead women to feel more susceptible to HPV infection
which, in turn, would increase their intentions to receive the
HPV vaccine. In addition, we explored other variables from
the Health Belief Model (HBM; perceived severity, benefits,
barriers, and self-efficacy) as potential mediators—variables
that have been shown to predict a broad range of health-
related behaviors [25, 26]. As these analyses were explor-
atory, we had no a priori mediation hypotheses for variables
other than perceived susceptibility.
The Present Study
We examined the influence of framed health messages on
college-aged women’s willingness to receive the HPV
vaccine. HPV is a sexually transmitted infection that is
most prevalent among individuals under age 25 [29].
Infection with low-risk types of HPV can cause genital
warts, while persistent infection with certain high-risk HPV
types can progress to cervical cancer [30 ]. Because HPV is
such a common virus, many individuals become infected
shortly after initiating sexual activity [29]. A vaccine
(Gardasil) for preventing infection by the four types of
HPV that cause most cases of genital warts and cervical
cancer was approved for females ages 9 to 26 in June 2006
by the Food and Drug Administration [7]. Ideal ly, females
should rece ive the vaccine before involvement in any
sexual activity; however, sexually active women are still
ann. behav. med. (2008) 35:221–229 223223
encouraged to get vaccinated to receive protection against
those types they have not acquired [7].
The present study tested whether behavioral frequency
(operationalized as the number of shots required for
vaccination) moderated the effect of framed health messages
on women’s intentions to receive the HPV vaccine. We
predicted that a loss-framed message would outperform a
gain-framed message when vaccination was achieved with a
one-time behavior. When six shots were required, however,
no differences in intentions were expected among women
exposed to the gain- and loss-framed messages. Perceived
susceptibility was hypothesized to mediate the interactive
effect of frame and frequency on HPV vaccination intentions.
Method
Participants
Female undergraduate students (n=243) recruited from a
large southeastern university participated for course credit.
Women who reported a previous HPV diagnosis (n=6)
were excluded from analysis, resulting in a final sample of
237 women. Mean age was 18.6 years (SD=1.1; range, 18–
26). The majority of the sample was white (76%; 13%
black or African American; 2% Asian or Asian American;
<1% Native Hawaiian or Pacific Islander; 8% mixed or
other). Eight percent were of Hispanic or Latino decent.
Three-quarters of the sample were college freshman. Sixty-
eight percent (n=161) reported that they had engaged in
sexual intercourse at least once in their lifetime and most
(99%) were heterosexual. Of those who had ever had sex,
68% (n=109) were sexually activ e at the time of data
collection. The average number of lifetime sexual partners
for the full sample was 2.73 (SD=3.65; range, 0–25).
Procedure, Experimental Design, and Materials
Experimental sessions were conducted in groups of two to
ten individuals. During the session, participants (a) complet-
ed a pre-manipulation survey, (b) read a two-page booklet on
HPV infection and the HPV vaccine, and then (c) completed
a post-manipulation survey. Participants were randomly
assigned to read either a gain- or loss-framed message about
a vaccination procedure involving one or six shots. They
were given 5 min to read the information. Participants were
told to review the material carefully because they would be
quizzed on it later. The booklet provided information about
HPV infection (its prevalence, transmission, consequences,
diagnosis, treatment, risk factors, and association with
cervical cancer) and the HPV vaccine (Gardasil).
We used a two (message frame: gain vs. loss)-by-two
(behavioral frequency: one shot vs. six shots) between-
subjects design. Identical information about the HPV
vaccine was presented across conditions; only the frame
of the message and number of shots required for immuni-
zation differed. We manipulated the frame of the message
by highlighting either the benefits of getting vaccinated
(gain frame) or the costs of not getting vaccinated (loss
frame). For example, the gain-framed message read: “There
are many benefits you may experience if you get the genital
HPV vaccine. First, if you decide to get the vaccine you
may decrease your chances of contracting genital HPV.” In
contrast, the loss-framed message read: “There are many
risks you may experience if you don’t get the genital HPV
vaccine. First, if you decide not to get the vaccine you may
increase your chances of contracting genital HPV.” See
Gerend and Shepherd [17] for more details related to
message-frame content.
We manipulated behavioral frequency by indicating that
HPV vaccination required either one shot of the vaccine or
six shots of the vaccine. The one-shot condition read as
follows: “Getting the vaccine requires very little effort.
You’ll need to go to the Student Health Center just one time
to get vaccinated. At the visit, a technician will inject a dose
of the vaccine.” The high-frequency condition read as
follows: “Getting the vaccine requires substantial effort.
You’ll ne ed to go to the Student Health Center 6 separate
times within a six-month period to get vaccinated (that is,
you’ll have to go to the clinic 6 times in half a year). At each
visit, a technician will inject a dose of the vaccine.”
Measures
Demographic and sexual history information were collected
on the pre-manipulation survey. All other variables were
assessed on the post-manipulation survey after participa nts
read the information booklet.
Manipulation Checks
To assess the effectiveness of the framing manipulation, par-
ticipants rated the booklet’s relative emphasis on the benefits
of getting the vaccine vs. the costs of not getting the vaccine (1
=costs of not getting the vaccine to 6=benefits of getting the
vaccine). To assess the effectiveness of the behavioral
frequency manipulation, participants rated (a) how effortful
(1=not much effort to 6=a great deal of effort)and(b)how
time consuming (1=not at all to 6=extremely) it would be to
get vaccinated for HPV. The two behavioral-frequency items
were averaged to create a composite (α=0.87).
Booklet Evaluations
To assess their impressions of the booklet, participants rated
their agreement with the following statements: I learned a
224 ann. behav. med. (2008) 35:221–229
lot from readi ng the booklet; The booklet was informative
(1=disagree strongly to 6=agree strongly).
Behavioral Intentions
As the HPV vaccine was not yet available at the time of
data collection (November 2005), we assessed women’s
intentions to obtain the HPV vaccine using five items from
previous research [17]: How likely is it that you will: (a) try
to get more information about, (b) consider getting, (c) try
to get, and (d) actually get the HPV vaccine once it is
available. Participants also rated (e) the likelihood they will
get the HPV vaccine if a healt h care provider offered it to
them in the next 3 years (1=very unlikely to 6=very likely).
The average of these five items was computed to create a
composite representing intentions to obtain the HPV
vaccine (α=0.97).
Putative Mediating Variables
Five constructs from the HBM were assessed with items
based on previous research [17, 31]. Perceived susceptibil-
ity to HPV infection was assessed with two items: How
likely is it that you’ll get genital HPV in the future? How
likely is it that you’ll get genital HPV in the next 10 years?
(1=very unlikely to 6=very likely; α=0.94). Perceived
severity of HPV infection was assessed with four items:
Having genital HPV would be disruptive to my (a) social
life; (b) physical health; (c) romantic relationships; and (d)
life overall (1=strongly disagree to 6=strongly agree; α=
0.90). Perceived benefits of the HPV vaccine were assessed
with three items: Getting the HPV vaccine in the future
may help me stay healthier; The benefits of getting the
HPV vaccine outweigh the potential risks; Getting the HPV
vaccine in the future may be a good thing to do for my
health (1=strongly disagree to 6=strongly agree; α=0.86).
Perceived barriers to receiving the HPV vaccine were
assessed with two items: How much would the follo wing
factors prevent or keep you from getting vaccinated against
genital HPV in the future? (a) If it took a lot of effort to get
the vaccine; (b) If it was hard to get the vaccine (1=not at
all to 6=very much ; α=0.90). Self-efficacy to obtain the
HPV vaccine was assessed with two items: I am confident
in my ability to get the vaccine once it’s available; I think I
will be able to get the vaccine once it’s available (1=
strongly disagree to 6=strongly agree; α=0.94). Items for
each construct were averaged to create a composite.
Data Analysis Plan
We used multivariate regression to assess the effects of
message frame (gain vs. loss), behavioral frequency (one shot
vs. six shots), and the frame-by-frequency interaction on the
manipulation check variables, booklet evaluations, and
intentions to receive the HPV vaccine. All predictor variables
were centered prior to analysis [32]. Significant interactions
were probed by examining the simple effect of message
frame on the dependent variable for the one-shot and six-
shot conditions. Mediation analyses were conducted with
multiple regression following Baron and Kenny [33]. To
identify potential mediating variables, we first predicted each
putative mediator (perceived susceptibility, perceived sever-
ity, perceived benefits, perceived barriers, and self-efficacy)
from frame, frequency, and the frame-by-frequency interac-
tion. Candidates for mediation included any variable for
which a significant frame-by-frequency interaction was
observed. Those variables were then entered as simultaneous
predictors in a multiple regression analysis predicting HPV
vaccination intentions, along with the primary predictors of
frame, frequency, and the frame-by-frequency interaction.
Sobel tests [34] were then conducted to identify significant
mediating variables. Sobel statistics were calculated as a
joint function of (a) the magnitude of the relationship
between the interaction effect and the putative mediator;
and (b) the magnitude of the unique relationship between
each of the putative mediators and vaccine intentions, while
controlling for the frame-by-frequency interaction (as well as
the main effects). All analyses were conducted using two-
tailed tests with a critical alpha of 0.05. Partial correlations
areprovidedasanestimateofeffectsize.
Results
Manipulation Checks and Booklet Evaluations
Manipulation checks confirmed the effectiveness of the
framing and frequency manipulations. Compared to partic-
ipants in the loss-framed condition (M=3.44; SD=1.79),
participants in the gain-framed condition (M=4.84; SD=
1.40) were more likely to report that the booklet focused on
the benefits of getting the vaccine, β=−0.40, t(229)=−6.70,
p<.001, p artial r=− 0.41. Neither frequency, β=−0.06,
t(229)=−0.95, p=.34, partial r=−0.06, nor the frame-by-
frequency interaction, β=− 0.03, t(229)=− 0.57, p=.57,
partial r= −0.04, predicted responses on this measure.
Participants in the six-shot condition (M=4.13; SD=1.27)
reported that getting vaccinated for HPV was more effortful
and time consuming than p articipants in the one-shot
condition ( M=1.61; SD=0.73), β =0.77, t(231)=18.59,
p<.001, partial r
=0.77. Neither frame, β=−0.01, t(231)=
−0.29, p=.77, partial r=−0.02, nor the frame-by-frequency
interaction, β=0.001, t(231)=0.04, p=.97, partial r=0.002,
predicted responses on this measure. Participants in the four
conditions rated the booklet similarly on the extent to
ann. behav. med. (2008) 35:221–229 225225
which it was informative and educational (no main effects
or interactions; all values of p>.05).
Effects of Message Frame and Frequency on Vaccination
Intentions
We observed a significant main effect of frame on
intentions to receive the HPV vaccine, β=0.14, t(231)=
2.12, p=.04, partial r=0.14. Higher vaccination intentions
were reported by participants exposed to the loss-framed
message than by participants exposed to the gain-framed
message. However, as predicted, this main effect was
qualified by a significant frame-by-frequency interaction, β=
−0.20, t(231)=−3.19, p=.002, partial r=−0.21 (see Fig. 1).
No main effect of behavioral frequency was observed, β=
−0.09, t(231)=−1.34, p=.18, partial r=−0.09.
To interpret the interaction, we tested the simple effects
of message frame on HPV v accina tion intentions for
participants in the one-shot and six-shot conditions. In the
one-shot condition, the loss-framed message (M=4.65; SD=
1.32) led to significantly higher vaccination intentions than
did the gain-framed message (M=3.60; SD=1.55); β=0.34,
t(231)=3.75, p<.001, partial r=0.24. However, in the six-
shot condition, there were no differential effects of the
gain- (M=3.96; SD=1.54) vs. loss-framed message on
vaccination intentions (M=3.74; SD=1.72), β=−0.07, t(2 31)=
−0. 76, p=.45, partial r=−0.05.
Mediation Analyses
In an initial set of analyses, we examined the extent to
which the interactive effect of message frame and frequen-
cy was observed for each of the five putative mediators. We
observed significant (or marginally significant) interactions
for perceived susceptibility to HPV infection [β=−0.15,
t(231)=−2.24, p
=.03, partial r=−0.15], perceived benefits
oftheHPVvaccine[β=−0. 15 , t(231)=−2.39, p =.02,
partial r=− 0.16], and self-efficacy to get vaccinated for
HPV [β=−0.11, t(232)=−1.79, p=.08, partial r=−0.12].
Simple effects tests revealed that, compared to women in
the other three conditions, women exposed to the loss-
framed, low-frequency message reported significantly
higher perceptions of susceptibi lity, perceived benefits,
and self-efficacy (all values of p<.05). No interaction was
found between frame and frequency in predicting percei ved
barriers or perceived severity (both values of p>.70). Thus,
three potential candidates for mediation were identified:
perceived susceptibility, perceived benefits, and self-efficacy.
Next, we predicted vaccination intentions from per-
ceived susceptibility, perceived benefits, and self-efficacy
while including the framing manipulation, frequency
manipulation, and the frame-by-frequency interaction. The
three putative medi ators were included as simultaneous
predictors to provide a more conservative and rigorous test
of mediation (i.e., we evaluated the unique relations hip
between each mediating variable and intentions while
controlling for the other putative mediators). Perceived
susceptibility [β=0.25, t(225)=4.78, p<.001, partial r=
0.30] and self-efficacy [β=0.45, t(225)=6.69, p<.001,
partial r=0.41] uniquely predicted vaccination intentions.
Perceived benefits did not predict intentions [β=0.09, t(225 )=
1.35, p=.18, partial r=0.09].
We followed this analysis with Sobel tests to evaluate
the possibility that perceived susceptibility and self-efficacy
mediated the intera ctive effect of message frame and
frequency on vaccination intentions. Results suggested that
the interaction was partially mediated by incre ases in
perceived susceptibility, z =2.03, p =.04. In addition,
increases in self-efficacy also appeared to have so me
mediational effect, although this test did not reach statistical
significance, z=1.72, p=.08.
Discussion
Findings from the present study suggest that behavioral
freque ncy plays an important role in message-framing
effects. Participants reported greater intentions to recei ve
the HPV vaccine when they were exposed to the costs of
not getting vaccinated (a loss-framed message), as opposed
to the benefits of getting vaccinated (a gain-framed
message). As predicted, however, the loss-frame advantage
was evident only when the frequency required for vaccina-
tion was low, that is, when immunization was achieved
with a single shot. When vaccination required six shots,
equivalent intentions were observed among participa nts
3.00
3.50
4.00
4.50
5.00
2.50
One Shot
Six Shots
Behavioral Frequenc
y
HPV Vaccination Intentions
Gain Frame
Loss Frame
3.00
3.50
4.00
4.50
5.00
2.50
One Shot
Six Shots
Behavioral Frequenc
y
HPV Vaccination Intentions
Gain Frame
Loss Frame
Fig. 1 Mean HPV vaccination intentions as a function of message
frame and behavioral frequency with 95% confidence intervals. In the
one-shot condition, exposure to the loss-framed message led to greater
intentions than did exposure to the gain-framed message. In the six-
shot condition, message framing had no effect on intentions
226 ann. behav. med. (2008) 35:221–229
exposed to the loss- vs. the gain-framed message. Findings
are consistent with Rothman and Salovey [10]who
suggested that a loss-framed appeal might outperform a
gain-framed appeal in persuading individuals to engage in a
one-time prevention behavior like vaccination.
Results suggest that the differential effects of message
framing for vaccination vs. other preventive health behav-
iors may be attributable, at least in part, to differences in the
behavioral regularity associated with these behaviors. The
current findings are consistent with the noti on that, because
low-frequency behaviors are more likely than regular,
repeated behaviors t o be associated with feelings of
uncertainty, such behaviors may be more responsive to
loss-framed messages than to gain-framed messages.
Indeed, previous studies have shown that people’s willing-
ness to engage in behaviors associated with risk or
uncertainty is enhanced by exposure to loss-framed
messages [1]. In contrast, when vaccination was described
as a more regular and frequent behavior (by requiring six
shots rather than one), the advantage of the loss frame
disappeared. The presen t study makes an important theo-
retical contribution to a growing body of research demon-
strating the utility of framed health communications.
A worthwhile point to consider is why a crossover
interaction was not observed—that is, why was a gain-
frame advantage not observed when vaccination required
six shots? We suspect that we did not observe this reverse
framing effect because having to receive six shots may have
been considered only moderately frequent. Performing a
behavior six times is certainly more often than performing
it only once, but it is hardly as frequent as most other
preventive behaviors, which should occur on a daily or
weekly basis for extended perio ds of time. Indeed,
manipulation-check data suggest that the six-shot condition
was viewed as only moderately effortful and time consum-
ing (only a bit above 4 on a six-point scale). One might
speculate that the crossover interaction between message
frame and behavi oral frequency would be observed if a
broader range of frequencies was represented, although this
remains an empirical question.
The presen t study begins to shed light on the psycho-
logical processes that mediate message framing effects—
processes that have been elusive in the majority of previous
framing studies. Data were consistent with a model in
which exposure to the loss-framed, low-frequency message
resulted in increased perceptions of susceptibility to HPV
infection which, in turn, promoted greater intentions to
receive the HPV vaccine. These findings are consistent with
previous studies showing that (a) relative to a gain-framed
appeal, loss-framed appeals elevate perceptions of suscep-
tibility to the health threat addres sed in the message [16,
20] and (b) perceived risk is an important predictor of many
health behaviors, including vaccin ation [23, 27, 28]. Why
perceived susceptibility emerged as a mediator of framing
effects in the present study but not in previous studies [6,
24] is unclear. There are several unique aspects of the
current investigation that could explain our ability to
identify the mediating effect. Perhaps the mediating effect
of perceived susceptibility is especially strong for unfamil-
iar, single-event behaviors, for which perceptions of
uncertainty are particularly salient. In addition, it is possible
that perceived susceptibility for sexually transmitted infec-
tions (STIs) is easy to manipulate in a college-aged
population for which STIs are especially relevant.
Bolstered perceptions of self-efficacy also seemed to
have some mediational effect on the observed framing
effects, although this test of mediation was only marginally
significant. It is less clear as to why the loss-framed, low-
frequency message, relative to the other three conditions,
promoted greater self-efficacy be liefs. The behavioral
regularity required for HPV vaccination may have been
partially responsible for this finding. It is plausible that
having to engage in a health behavior only once (relative to
multiple times) might increase people’s confidence in their
ability to perform the behavior. Another possibility was
suggested by Meyerowitz and Chaiken [24], who proposed
that heightened perceptions of self -efficacy may be serve to
lower perceptions of risk produced by a loss-framed
message. While additional studies are needed to further
clarify the mechanisms underlying message-framing
effects, the present study reflects an important step in this
direction and begins to fill a central gap in the message-
framing literature.
Limitations of this study should be noted. We did not
include a no-information control group. Without such a
control group, it is difficult to know whether framing is
increasing or decreasing intentions, relative to receiving no
information at all. Another limitation is that neither one
shot nor six shots represents the actual dosing schedule of
the HPV vaccine. Vaccination for HPV with Gardasil is
achieved with a three-dose series administered at months 0,
2, and 6 [7]. Although manipulating the dosing schedule
was essential for testing hypotheses pertaining to the
interactive effects of message framing and behavioral
frequency, it nevertheless limits the practical implications
that can be draw n from the present study. Notably, Gerend
and Shepherd [17] suggested a loss-frame advantage when
participants were informed of the actual dosing schedule of
the HPV vaccine. Findings are also limited to behav ioral
intentions. Because the HPV vaccine was not available at
the time of data collection, we could not assess the effect of
framed health messages on actual receipt of the vaccine.
Whether framing effects found in the present study extend
to HPV vaccination behavior should be explored in future
research. Another limitation is that we examined the effects
of message framing for only one of many vaccines. Future
ann. behav. med. (2008) 35:221–229 227227
research should assess the extent to which these findings
generalize to other vaccination contexts. Finally, it is not
clear whether the current findings regarding mediation
would extend to other health behaviors; further research is
necessary.
In conclusion, a growing literature suggests that message
framing is an effective, theoretically based strategy for
motivating individuals to engage in healthy behavior. This
study demonstrates that behavioral frequency plays an
important role in shaping the effects of framed health
appeals. Previous studies have shown that gain-framed
messages are more effective than loss-framed messages at
promoting preventive health behaviors. Findings from the
present study suggest an important exception to this pattern:
messages promoting preventive health behaviors that
involve relatively low beh avioral frequency, suc h as
vaccination, appear to garner greater acceptability when
they focus on potential losses rather than potential gains.
Furthermore, findings suggest that increased perceptions of
risk to the health threat may be responsible for the efficacy
of loss-framed messages in promoting vaccine accept-
ability. This study serves as a vital springboard for
additional research exploring the utility of framed health
messages in promoting health behavior.
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