Decades of promotion of the Pap test have fallen short in persuading vulnerable women to get screened for cervical cancer. Human papillomavirus (HPV) testing provides an additional screening tool, and the task for cancer control is to promote understanding of the test and encourage its use. Ogden and colleagues investigated the effect of message framing on increasing knowledge and intention to receive HPV testing. Although both messages increased knowledge and intention, no differences were found between gain- and loss-framed messages. We explore implications of this finding and discuss needed research to expand upon and contextualize this important formative research.

See related article, p. 839

Human papillomavirus (HPV) testing has developed into a primary strategy for early detection of cervical cancer (1). As described in the paper by Ogden and colleagues appearing in this issue of Cancer Prevention Research, numerous national guidelines have evolved to including HPV testing as a recommended or preferred screening option. As recent updates to screening guidelines support the value of HPV testing as a tool for cervical cancer prevention and early detection (1), the challenge to cancer control is to promote this new strategy to the public and particularly for those at high risk. Promotion includes increasing knowledge to prepare women for interactions when their provider recommends HPV testing and developing interventions that increase intention to follow through and obtain the test.

As a primary cervical cancer–prevention strategy, promotion of HPV testing to the intended audiences is critical to widespread adoption. For context, cancer control professionals have decades of experience with promotion of cancer prevention strategies with the Pap test and mammography and more recent experience with screening for colorectal and lung cancer. Traditionally, both mass and small media have been used in a variety of settings to promote screening (2). These appeals have been developed with guidance from relevant health behavior models and theories such as the Health Belief Model (HBM; ref. 3) and Social Cognitive Theory (SCT; ref. 4). The HBM was initially developed from observation of participation in screening for tuberculosis by chest x-ray and provided insight into factors that were associated with having the x-ray such as perceived seriousness of the disease (Tuberculosis) and perceived efficacy of screening. The SCT, on the other hand, is a broad theory that focuses attention on the social context of behavior as well as processes within the individual that are associated with participation in new experiences such as screening. The study by Ogden and colleagues employed prospect theory, a conceptualization of decision-making that focuses on risk and uncertainty (5). The theory posits that people's reactions to health communication messages are often different depending on how the consequences of a particular behavior are framed, i.e., showcasing something that might be gained (gain-framed) or as something that might be lost (loss-framed). Health behavior researchers have suggested that behaviors that promote health are best served by gain-framed messages, whereas behaviors that help people avoid illness are more effective when matched to loss-framed messages (6). By this logic, screening and early detection messages, such as for HPV testing, are generally considered to be most effective when loss-framed (6).

Guided by this fundamental tenet of prospect theory, Ogden and colleagues tested the effect of messages promoting HPV testing as a means of gaining health (i.e., gain-framed) versus messages that promoting HPV testing as a means of avoiding loss of health (i.e., loss-framed). Participants were recruited through Amazon Mechanical Turk (MTurk), an online crowdsourcing tool, and randomized to receive gain- or loss-framed messages advocating HPV testing. Participants were tested on HPV screening knowledge before and after viewing the message, with a primary outcome of stated intention to obtain HPV testing. The study's results indicated that intention to obtain HPV testing increased among all participants and that there was no significant difference between those receiving gain- or loss-framed messages. An apparent basic conclusion from the results is that providing a message about HPV testing increases knowledge and intention to obtain the test and that the presence of any sort of message is more important than the framing of the message. Ultimately, these results confirm what has been documented in numerous settings: that providing information about a new topic can increase knowledge and intention to change behavior.

Nevertheless, when interpreting these findings, it is important to note that actual behavior change is seldom, if ever, observed, and intention alone is rarely a strong predictor of behavior change (7). While Ogden and colleagues' present study cannot make inferences about behavior, further research is necessary to determine the actual behavioral impact of these messages beyond the scope of a 25-minute health-communication intervention. Perhaps message framing does not impact behavioral intentions, but does it impact actual screening behaviors?

Ogden and colleagues' work represents strong formative research in health communication to increase HPV screening rates. Several aspects of the Ogden study, however, should be considered when interpreting the findings and assessing generalizability. The randomized design of the Ogden study is an important strength, but the lack of a control or comparison condition where no information about HPV testing was provided is a potential limitation. A second area of potential concern is with the study population and recruitment. MTurk is a crowdsourcing tool commonly used by businesses to develop marketing strategies, though it has also been used frequently in the social sciences in recent years.

Whereas use of MTurk is an efficient recruitment strategy, studies comparing it with other nationally representative data sets (e.g., BRFSS, NHANES) have suggested that MTurk “workers” are not a generalizable population regarding health status and behaviors (8, 9). Studies have suggested that results from the 40 to 59–year-old age group might be most generalizable, but that generalizability decreases with other age groups, racial/ethnic minorities, and those with lower educational attainment. In this study, respondents were overwhelmingly white (nearly three fourths of the sample), with at least one post-secondary degree (cumulatively about two thirds), and over half were outside of the above-listed age range. In other words, it is possible that the findings from this study do not accurately capture the effects of framed messages in “real world” settings and might not be applicable to the population of women needing HPV testing.

With regard to the gain- and loss-framed messages, it is unclear whether or how the gain/loss/neutral framing of the messages was calibrated and assessed. The report provides little detail on the format or detailed content of the messages and other features such as inclusion of illustrations or logos (10). The authors state that messages were refined for clarity, burden, and comprehension followed by pilot testing, but no information on the pilot testing is provided. In other words, who reviewed the materials (e.g., public health colleagues, members of the intended audience, or both)? Similarly, did a subset of MTurk users help with pilot refinement? Pilot message testing has been shown to be effective in developing materials that are reflective of the values and beliefs of the intended audience. These considerations are important when contextualizing Ogden and colleagues' findings.

Ultimately, we are left with a finding that confirms what we have known since the testing of the HBM in the 1950s: that the presence of health-related messages has potential to increase one's intention to act to prevent disease – in this case, cervical cancer. Although this study suggests that framing the messages in terms of gain or loss is less important than the presence of the message in any form, more longitudinal research is necessary to determine whether message framing truly affects actual behavioral change.

No disclosures were reported.

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