Now or Future? Analyzing the Effects of Message Frame and Format in Motivating Chinese Females to Get HPV Vaccines for Their Children

"[I]t is of critical importance to identify optimal and customized communication messages that motivate parents to vaccinate their kids against HPV infection, especially in a developing nation where such knowledge may be limited..."

Considering that, as of this writing, human papillomavirus (HPV) vaccines had only recently become available in China (Cervarix and Gardasil were both approved in late 2017), Chinese parents are likely to scrutinise the benefits and costs of HPV vaccines. This is particularly the case in the context of that country's traditional patriarchal culture and contemporary one-child policy, meaning that Chinese parents, especially mothers, tend to be more dominant and protective in issues related to children's well-being. In order to identify the optimal strategies to promote HPV vaccine among Chinese mothers, this study aims to explore the persuasive effects of 3 commonly used health communication message formats: gain-framed, loss-framed, and narrative. Understanding the effectiveness of different types of promotion messages could help healthcare providers and communication practitioners design messages to increase awareness and persuade Chinese mothers to vaccinate their children against HPV at an appropriate age.

The comparative effectiveness of gain and loss frames has been studied in health communication research, yielding guidelines for health practitioners in designing health promotion campaigns. Although it is reasonable to expect that gain-framed messages highlighting the benefits of vaccination would be more persuasive than loss-framed messages stressing the costs of not getting vaccinated, some people, especially those concerned about vaccine safety, may consider HPV vaccination as a risky behaviour. In addition, a childhood vaccine scandal in China may have further deterred parents from getting non-mandatary vaccines for their children.  As such, the first hypothesis (H1) is: Compared to the gain-framed message, the loss-framed message will lead to greater intentions to get HPV vaccines for their children among Chinese women.

In addition to message framing, which focuses on presenting different aspects of the same information without altering the format of a message, recent research has also begun to recognise the effectiveness of narrative, a story-based message format, in health promotion. Narrative stories persuade audiences by transporting them into an imaginary world where they can actively take the characters' perspectives and learn from their experiences. As such, the second hypothesis (H2) is: Compared to both the gain- and loss-framed messages, the narrative message will lead to greater intentions among Chinese women to get HPV vaccines for their children.

Many health communication scholars have incorporated time orientation in their research. Research has found that future-oriented individuals are more likely to engage in health behaviours, while present-minded people often delay actions due to different valuation of future consequences and immediate costs. As such, the third hypothesis (H3) is: Future-mindedness is positively related to Chinese women's intention to get the HPV vaccines for their children. Time orientation could also moderate the impact of message framing on vaccination intention. Thus, the fourth hypothesis (H4) is: The gain-framed message will be more persuasive for future-minded people, and the loss-framed message will be more persuasive for present-minded people. In addition, time orientation may influence their responses to narrative messages. Readers of a narrative on HPV vaccination may be transported into the story and evaluate the consequences of HPV vaccination from the identified character's perspective, which also effectively renders both costs and benefits as their immediate considerations. Therefore, the fifth hypothesis (H5) is: Present-minded individuals will be more persuaded by the narrative message.

From January 10 to January 17 2018, an online survey experiment was conducted among Chinese women (parents and non-parents) aged 18-45. Participants were randomly assigned to one of 3 conditions: gain (n=145) vs. loss (n=140) vs. narrative (n=146) messages. Stimuli articles were presented as newsletters. Information about HPV and HPV vaccines was adopted from the United States (US) Centers for Disease Control and Prevention (CDC) website and a HPV prevention training programme in China held by Project HOPE, a non-governmental organisation (NGO). With identical wording, the prevalence of HPV and its consequences was first addressed, followed by information of HPV vaccines' availability and efficacy. In the last section, the gain-framed message articulated the benefits of getting HPV vaccine (e.g., lower chance of contracting cervical cancer and genital warts), while the loss-framed message stressed the dangers of not getting it (e.g., higher chance of contracting cervical cancer and genital warts). In the narrative condition, participants read a first-person narrative centring on a young mother's story related to HPV and HPV vaccine. Consistent with the non-narrative messages, the prevalence and negative consequences of HPV infection were presented as conversations between a physician and the main character who was diagnosed with cervical cancer caused by HPV. Through dialogues and reflection, the character recognises the necessity of getting the HPV vaccines, especially for her daughter.

To test message effects on vaccination intention, a one-way analysis of covariance (ANCOVA) was conducted with demographics and time orientation as covariates. Results indicate no main effect for conditions on participants' intention to get their children vaccinated. Therefore, neither H1 nor H2 was supported.

Results of the regression model with time orientation (consideration of future consequences, or CFC) and demographics as predictors indicate that future-mindedness is positively related to vaccination intention, supporting H3.

Loss-framed message and its interaction term with time orientation were not statistically significant predictors of vaccination intentions. Thus, H4 was not supported.

Results of the regression analysis show significant interaction between narrative condition and time orientation (CFC). Specifically, after controlling for individual characteristics, participants in the narrative condition show stronger intention to get their children vaccinated against HPV, but this effect diminishes among the more future-oriented participants. Therefore, H5 was supported.

It was observed that present-minded participants (scored at 1 standard deviation below the mean) were in general most persuaded by the narrative message and least persuaded by the gain-framed message. Differently, future-minded individuals were most persuaded by the loss-framed message, while least motivated by the narrative message. Integration of message frames (gain vs. loss) and message type (narrative vs. non-narrative) is recommended for future research.

As present-minded individuals in general indicated lower intention to get their children vaccinated, the findings also call for health communication practitioners and clinicians to pay more attention to this group. The former may consider developing health communication campaigns for this group based on formative research, while the latter may interview their patients using some of the items from the CFC scale to rapidly identify the optimal strategy in motivating them to get vaccination either for themselves or for their children.

Considering practice implications, the researchers conclude: "Healthcare providers may consider interviewing patients to gain insights into their trait time-orientation and provide counselling accordingly. Health communication practitioners should also consider incorporating narrative messages in campaigns designed to promote the HPV vaccines, especially when appealing to more present-minded audiences....By vividly presenting the outcomes of different health decisions, narrative could potentially bring the discussion to message receivers' immediacy and thus achieve stronger persuasion."