Framing of nutrition education messages in persuading consumers of the advantages of a healthy diet

The "Planning Health in School" Programme (PHS-pro) to Improve Healthy Eating and Physical Activity: Design, Methodology, and Process Evaluation

Few interventions have successfully promoted healthy eating and active living among children with effective changes in anthropometric health outcomes. Well-designed interventions involving multiple strategies to convert the knowledge already available into action are needed for preventing childhood obesity. In this study, an educational programme called "Planning Health in School" (PHS-pro) was designed, implemented and evaluated to contribute to the prevention of obesity in childhood. The PHS-pro aimed at improving the eating behaviours and lifestyles of Portuguese grade-6 children towards healthier nutritional status. This paper describes and evaluates the PHS-pro concerning: (i) the research design within the theoretical framework grounded on "The Transtheoretical Model" and the stages of change; (ii) the educational components and the application of the participatory methodology to engage children to meet their needs, as active participants in their change process; and (iii) the process evaluation of the intervention. The implementation of the PHS-pro took into account the views and inputs of the participants for evaluating the educational components that should be considered in the designing of interventions aiming to be effective strategies. From the health promotion perspective, this study is important because it examines new approaches and pathways to effectively prevent overweight and obesity in children.

Health gains through loss frames: Testing the effectiveness of message framing on citizens' use of nutritional warnings

The aim of the present work was twofold: (i) to evaluate the effect of nutritional warnings and health-related packaging cues (nutrient claim and images of natural foods) on consumers' food choices, and (ii) to evaluate the influence of two types of messages (gain-framed and loss-framed) aimed at encouraging the use of such warnings and packaging cues on food choices. A total of 510 participants were recruited using an advertisement on Facebook and Instagram targeted at Uruguayan adult users. Participants were randomly allocated to one of three experimental groups: control (n = 167), loss-framed messages (n = 177) and gain-framed messages (n = 166). Then, they completed a choice-conjoint task involving packages of crackers differing in three variables: nutritional warnings (present vs. absent), nutrient claim (present vs. absent) and images of seeds and wheat (present vs. absent). Warnings were the most relevant package element driving choices, even when participants were not exposed to any type of message. Exposure to loss-framed messages led to changes in the relative importance attached to the package characteristics, whereas gain-framed messages did not. Graphic pieces conveying messages encouraging the use of nutritional warnings by stressing the negative consequences of excessive consumption of sugar, fat, and sodium increased the relative importance attached to nutritional warnings and decreased the relative importance attached to health-related cues (nutrient claims and images of seeds and wheat). These results suggest that public awareness campaigns aimed at encouraging citizens to use nutritional warnings should emphasize the negative health consequences of excessive intake of sugar, fat, and sodium.

Developing and refining behaviour-change messages based on the Brazilian dietary guidelines: use of a sequential, mixed-methods approach

Background

Dietary Guidelines are an important tool for population health promotion efforts. However, current surveillance data suggest that only a small minority of the population meet the 2014 Brazilian Dietary Guidelines (BDG) recommendations. Translating recommendations into practice may not be immediately clear and behavior-change messages guiding the behaviors that need to be changed and identifying substitute practices to meet a specific recommendation, are required. This study details the methods undertaken to develop and refine messages supporting the adoption of healthy dietary choices and behaviors in adults, as outlined in the BDG.

Methods

A sequential, five-step, mixed-methods approach, determined a priori, was followed for designing and refining messages. These included: (1) content extraction; (2) audience analysis; (3) input from an expert review panel; (4) message development and message refinement; and a (5) test of content validity.

Results

The content extraction process led to the identification of 63 excerpts from the BDG, organized into themes. The audience analysis highlighted barriers to healthy eating that included lack of time (to eat, to cook), difficulty in accessing healthy food, the convenience and the ubiquitous marketing of ultra-processed foods. Twenty of the 63 DG excerpts reviewed by the expert panel were identified as being a priority for message development and total of 111 messages were developed. Messages were short, structured to be one-sided, conveyed the most important information at the beginning (anticlimactic), used simple language and were explicit in the information they relayed. They were positive and gain-framed and used an empathetic, solution- or substitution-based tone and were presented in the active voice. The messages focused on goals and skill development, behavior regulation, incentivized positive practices as time and/or cost saving. Content validity testing helped further messages and reduced the number of messages from 111 to 40.

Conclusions

This study provides the blue-print for the phase-wise development of messages that synthesize the key recommendations of the food-based BDG and communicate the adoption of behaviors and goals that are consistent with it’s message. It details methods which could be adapted and replicated for message development in other contexts.

Impact of a Mobile Phone App to Increase Vegetable Consumption and Variety in Adults: Large-Scale Community Cohort Study

Background

Large-scale initiatives to improve diet quality through increased vegetable consumption have had small to moderate success. Digital technologies have features that are appealing for health-related behavior change interventions.

Objective

This study aimed to describe the implementation and evaluation of a mobile phone app called VegEze, which aims to increase vegetable intake among Australian adults.

Methods

To capture the impact of this app in a real-world setting, the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was utilized. An uncontrolled, quantitative cohort study was conducted, with evaluations after 21 and 90 days. The app was available in the Apple App Store and was accompanied by television, radio, and social media promotion. Evaluation surveys were embedded into the app using ResearchKit. The primary outcomes were vegetable intake (servings per day) and vegetable variety (types per day). Psychological variables (attitudes, intentions, self-efficacy, and action planning) and app usage were also assessed. Descriptive statistics and multiple linear regression were used to describe the impact of the app on vegetable intake and to determine the characteristics associated with the increased intake.

Results

Data were available from 5062 participants who completed the baseline survey; 1224 participants completed the 21-day survey, and 273 completed the 90-day survey. The participants resided across Australia and were mostly women (4265/5062, 84.3%) with a mean age of 48.2 years (SD 14.1). The mean increase in intake was 0.48 servings, from 3.06 servings at baseline to 3.54 servings at the end of the 21-day challenge (t₁₂₂₃=8.71; P<.001). The variety of vegetables consumed also increased by 0.35 types per day (t₁₁₂₃=9.59; P<.001). No changes in intake and variety were found from day 21 to the 90-day follow-up. Participants with the highest app usage increased their vegetable intake by 0.63 (SD 2.02) servings per day compared with 0.32 (SD 1.69) servings per day for those with the lowest app usage. On the basis of multiple linear regression, gender; age; BMI; psychological variables of self-efficacy, attitudes, intentions, and action planning specific to vegetable intake; baseline vegetable intake; and active days of app usage accounted for 23.3% of the variance associated with the change in intake (F_9,1208=42.09; P<.001). Baseline vegetable intake was the strongest predictor of change in intake (beta=−.495; P<.001), with lower baseline intake associated with a greater change in intake. Self-efficacy (beta=.116; P<.001), action planning (beta=.066; P=.02), BMI (beta=.070; P=.01), and app usage (beta=.081; P=.002) were all significant predictors of the change in intake.

Conclusions

The VegEze app was able to increase intake by half a serving in a large sample of Australian adults. Testing the app in a real-world setting and embedding the consent process allowed for greater reach and an efficient, robust evaluation. Further work to improve engagement is warranted.

Consumer Understanding, Perception and Interpretation of Serving Size Information on Food Labels: A Scoping Review

The increase in packaged food and beverage portion sizes has been identified as a potential factor implicated in the rise of the prevalence of obesity. In this context, the objective of this systematic scoping review was to investigate how healthy adults perceive and interpret serving size information on food packages and how this influences product perception and consumption. Such knowledge is needed to improve food labelling understanding and guide consumers toward healthier portion size choices. A search of seven databases (2010 to April 2019) provided the records for title and abstract screening, with relevant articles assessed for eligibility in the full-text. Fourteen articles met the inclusion criteria, with relevant data extracted by one reviewer and checked for consistency by a second reviewer. Twelve studies were conducted in North America, where the government regulates serving size information. Several studies reported a poor understanding of serving size labelling. Indeed, consumers interpreted the labelled serving size as a recommended serving for dietary guidelines for healthy eating rather than a typical consumption unit, which is set by the manufacturer or regulated in some countries such as in the U.S. and Canada. Not all studies assessed consumption; however, larger labelled serving sizes resulted in larger self-selected portion sizes in three studies. However, another study performed on confectionary reported the opposite effect, with larger labelled serving sizes leading to reduced consumption. The limited number of included studies showed that labelled serving size affects portion size selection and consumption, and that any labelled serving size format changes may result in increased portion size selection, energy intake and thus contribute to the rise of the prevalence of overweight and obesity. Research to test cross-continentally labelled serving size format changes within experimental and natural settings (e.g., at home) are needed. In addition, tailored, comprehensive and serving-size-specific food literacy initiatives need to be evaluated to provide recommendations for effective serving size labelling. This is required to ensure the correct understanding of nutritional content, as well as informing food choices and consumption, for both core foods and discretionary foods.

Does message framing matter for promoting the use of nutritional warnings in decision making?

Objective:

To evaluate the impact of message framing on attitudes towards messages aimed at promoting the use of nutritional warnings, behavioural intention and actual behaviour, evaluated through visual attention to nutritional warnings and the choice of a snack product during a real choice task.

Design:

Following a between-subjects design, participants were exposed to loss-framed nutrition messages, gain-framed nutrition messages or non-nutrition-related messages (control group). After evaluating the messages, participants were asked to select a snack product as a compensation for their participation. The experiment was conducted using an eye tracker.

Setting:

Montevideo (Uruguay).

Participants:

Convenience sample of 201 people (18–51 years old, 58 % female).

Results:

The average percentage of participants who fixated their gaze on the nutritional warnings during the choice task was slightly but significantly higher for participants who attended to nutrition messages (regardless of their framing) compared with the control group. Participants who attended to loss-framed messages fixated their gaze on the warnings for the longest period of time. In addition, the healthfulness of the snack choices was higher for participants exposed to nutrition-related messages compared with the control group.

Conclusions:

Results from the present work suggest that nutrition messages aimed at increasing awareness of nutritional warnings may increase consumers’ visual attention and encourage more heathful choices. The framing of the messages only had a minor effect on their efficacy.

The Development of VegEze: Smartphone App to Increase Vegetable Consumption in Australian Adults

Background

Poor-quality dietary patterns are often characterized by inadequate consumption of fruits and vegetables. Changing dietary behavior is difficult, and although it is often clear what needs to change, how to enact change is more difficult. Smartphones have characteristics that may support the complexity of changing dietary behavior.

Objective

This paper describes the iterative process of developing a theory-based smartphone app called VegEze that aimed to increase vegetable consumption.

Methods

To upscale, reach target users, and create a user-friendly end product, a collaborative research-industry partnership was formed to build the app over a 20-week period. The Integrate, Design, Assess, and Share framework was used as a scientific basis to guide the development. The behavior change wheel was also used as a theoretical grounding in combination with other theory-based strategies, such as self-monitoring, social comparison, and gamification—which have all been shown to be successful in dietary change or digital health interventions. We conducted 1 consumer survey (N=1068), 1 usability testing session (N=11), and a pilot effectiveness and usability trial (N=283) to inform the design of the app.

Results

The target behavior for the app was defined as having 3 different types of vegetables at dinner. The perceived achievability of this target behavior was high; 93% of respondents (993/1068 users) felt they were likely or very likely to be able to regularly achieve the behavior. App features that users wanted included the following: recipes and meal ideas (876/1068, 82% of users), functionality to track their intake (662/1068, 62%), and information on how to prepare vegetables (545/1068, 51%). On the basis of importance of self-monitoring as a behavior change technique (BCT) and its rating by users, the vegetable tracker was a core feature of the app and was designed to be quick and simple to use. Daily feedback messages for logging intake and communicating progress were designed to be engaging and fun, using friendly, positive language and emoji icons. Daily and weekly feedback on vegetable consumption was designed to be simple, informative, and reinforce monitoring. A creative team was engaged to assist in the branding of the app to ensure it had an identity that reflected the fun and simple nature of the underlying behavior. The app included 16 BCTs, most of which were from the goals and planning subsection of the BCT taxonomy.

Conclusions

Combining a theoretical framework with an industry perspective and input resulted in an app that was developed in a timely manner while retaining its evidence-base. VegEze is an iOS app currently available in the App Store, and the overall impact of the VegEze app will be evaluated in an uncontrolled, quantitative study.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000481279; http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=ACTRN12618000481279 (Archived by WebCite: at http://www.webcitation.org/769oG9EaA)

Comparing mortality risk reduction, life expectancy gains, and probability of achieving full life span, as alternatives for presenting CVD mortality risk reduction: A discrete choice study of framing risk and health behaviour change

The growing rate of obesity has recently required governments to divert considerable resources in the promotion of healthy lifestyles. We explored the relative effectiveness in inducing healthy behaviour change of three different communication strategies about the benefits of an intervention that reduces the mortality risks of cardiovascular disease (CVD) and encourages respondents to embrace healthier lifestyles. We designed a Discrete Choice Experiments questionnaire to analyse the trade-off between lifestyles, defined in terms of diet and exercise, and reduction in cardiovascular disease (CVD) mortality risk. We set three ways of framing an identical benefit: (A) as a reduction in mortality risk from cardiovascular disease, (B) as an increase in months of life expectancy, and (C) as an increase in the probability of reaching an individual's full lifespan. The experiment was tailored for each subject in the sample according to his/her individual's baseline information on diet and physical activity. During the period February 2010-July 2011, we interviewed 1008 individuals in Northern Ireland, split randomly into three samples for the three CVD risk reduction frames. Considering the models' goodness of fit and significance, we conclude that the most effective way of communicating these CVD health benefits is using an increase in life expectancy, since with this frame individuals are more inclined to state that they would change to a healthier lifestyle.

Does message framing affect changes in behavioural intentions in people with psoriasis? A randomized exploratory study examining health risk communication

Message framing is important in health communication research to encourage behaviour change. Psoriasis, a long-term inflammatory skin condition, has additional comorbidities including high levels of anxiety and cardiovascular disease (CVD), making message framing particularly important. This experimental study aimed to: (1) identify whether health messages about psoriasis presented as either gain- or loss-framed were more effective for prompting changes in behavioural intentions (BI), (2) examine whether BI were driven by a desire to improve psoriasis or reduce CVD risk; (3) examine emotional reactions to message frame; and (4) examine predictors of BI. A two by two experiment examined the effects on BI of message frame (loss vs. gain) and message focus (psoriasis symptom reduction vs. CVD risk reduction). Participants with psoriasis (n = 217) were randomly allocated to one of four evidence-based health messages related to either smoking, alcohol, diet or physical activity, using an online questionnaire. BI was the primary outcome. Analysis of variance tests and hierarchical multiple regression analyses were conducted. A significant frame by focus interaction was found for BI to reduce alcohol intake (p = .023); loss-framed messages were more effective for CVD risk reduction information, whilst gain-framed messages were more effective for psoriasis symptom reduction information. Message framing effects were not found for BI for increased physical activity and improving diet. High CVD risk was a significant predictor  of increased BI for both alcohol reduction (β = .290, p < .01) and increased physical activity (β = -.231, p < .001). Message framing may be an important factor to consider depending on the health benefit emphasised (disease symptom reduction or CVD risk reduction) and patient-stated priorities. Condition-specific health messages in psoriasis populations may increase the likelihood of message effectiveness for alcohol reduction.

Vending Machines: A Narrative Review of Factors Influencing Items Purchased

Vending machines are a ubiquitous part of our food environments. Unfortunately, items found in vending machines tend to be processed foods and beverages high in salt, sugar, and/or fat. The purpose of this review is to describe intervention and case studies designed to promote healthier vending purchases by consumers and identify which manipulations are most effective. All studies analyzed were intervention or case studies that manipulated vending machines and analyzed sales or revenue data. This literature review is limited to studies conducted in the United States within the past 2 decades (ie, 1994 to 2015), regardless of study population or setting. Ten articles met these criteria based on a search conducted using PubMed. Study manipulations included price changes, increase in healthier items, changes to the advertisements wrapped around vending machines, and promotional signs such as a stoplight system to indicate healthfulness of items and to remind consumers to make healthy choices. Overall, seven studies had manipulations that resulted in statistically significant positive changes in purchasing behavior. Two studies used manipulations that did not influence consumer behavior, and one study was equivocal. Although there was no intervention pattern that ensured changes in purchasing, price reductions were most effective overall. Revenue from vending sales did not change substantially regardless of intervention, which will be important to foster initiation and sustainability of healthier vending. Future research should identify price changes that would balance healthier choices and revenue as well as better marketing to promote purchase of healthier items.

Temporal Consequences, Message Framing, and Consideration of Future Consequences: Persuasion Effects on Adult Fruit Intake Intention and Resolve

Message framing is a persuasive strategy that has seen mixed evidence for promoting fruit intake intentions, potentially because framed messages for fruit intake have not (a) explicitly compared short-term consequences versus long-term consequences, (b) considered individual-level differences in time perspective, and (c) used alternative measures of fruit intake intentions. In the present online study, the effects of persuasive messages created from temporal context (short term vs. long term) and message frame (gain framed vs. loss framed) were investigated on fruit intake intentions and resolve among a sample of Dutch adults who were categorized as either present oriented or future oriented. For intention and resolve, results showed a significant Type of Frame × Type of Temporal Context interaction, such that gain-framed messages were more persuasive when combined with long-term consequences and loss-framed messages were more persuasive when combined with short-term consequences. The effect sizes for these differences were similar for resolve and intention, but only differences for intentions were significant. No other effects were found. These results demonstrate that message framing theory may usefully consider the inclusion of temporal context of outcomes and alternative motivation measures to maximize their persuasive effects.

When do gain-framed health messages work better than fear appeals?

Past literature reviews of gain-framed versus loss-based health messages have been inconsistent and inconclusive. To resolve this and provide a clearer pattern, this review focuses on the individual or person-specific characteristics of target audiences. The results indicate that by answering the following four questions about a target audience, one can predict whether a gain-framed or a loss-based health message will be more effective. 1) Is there a low (versus high) level of involvement in the issue? 2) Is there a high (versus low) certainty of the outcome? 3) Is there a low (versus high) preference for risk? 4) Is there a heuristic (versus piecemeal) processing style? The profiling of audiences on these factors has two distinct benefits; it resolves many of the seeming inconsistencies in past positive-negative and gain-loss message research (such as fear appeals working better with experts than nonexperts) and it helps predict which type of message will be most effective with a given audience.

Emphasizing the losses or the gains: Comparing situational and individual moderators of framed messages to promote fruit and vegetable intake

Health messages are a commonly used way to promote changes in dietary habits but their efficacy could be enhanced by strategies such as the way in which the presented arguments are framed. This study aimed to test the effectiveness of framed messages (gain vs. loss) on behavioural intention and fruit and vegetable (FV) intake, comparing predictions based on prominent theoretical perspectives on message framing (function of the health behaviour and recipients' motivational orientation) and by further exploring the role of baseline intentions as a potential moderator of the framing effects. Undergraduate students (N = 180) completed the three assessment points in time. At baseline, individual moderators (motivational orientation and intentions) and fruit and vegetable intake were assessed. One week later, participants were randomly assigned to the loss or gain-framed message and indicated their intentions for FV intake the following week. A week later, FV intake over the previous week was assessed. The gain-frame was not conducive, per se, to higher intentions or behaviour. Having intention as the outcome, only baseline intentions moderated the effects of message frame. When considering FV intake as the outcome, both motivational orientation and baseline intentions moderated the effects of message frame, with the loss-frame promoting higher FV intake among individuals who were prevention-oriented and had higher baseline intentions. Findings suggest that the success of framed messages for FV intake depends upon the recipient's characteristics, such as motivational orientation, baseline intentions, and cultural background, with implications for health communication interventions.

Effects of Previous Fruit Intake, Descriptive Majority Norms, and Message Framing on Fruit Intake Intentions and Behaviors in Dutch Adults Across a 1-Week Period

OBJECTIVE

To test the effects of descriptive norm and message framing on fruit intake (intentions) in Dutch adults.

DESIGN

Randomized pretest-posttest study using a 2 × 2 design.

SETTING

Internet-based.

PARTICIPANTS

Dutch adults recruited via leaflets and announcements on intranet and Internet and who provided immediate intention (n = 294) and 1-week follow-up intention and fruit intake data (n = 177).

INTERVENTION

Messages combining information on intake of others (low vs high intake) with information about positive or negative outcomes of (in)sufficient fruit intake.

MAIN OUTCOME MEASURES

Fruit intake intentions and fruit intake.

ANALYSIS

Analyses of covariance.

RESULTS

Those already consuming sufficient fruit and receiving negative information about insufficient fruit intake increased their motivation to consume sufficient fruit immediately (P = .03), but not at 1-week follow-up. Those who read positive information about sufficient fruit intake reported higher fruit consumption than those who read negative information about insufficient fruit intake (P = .03). This was stronger in those already consuming sufficient fruit. There were no effects of descriptive norm information (P > .19).

CONCLUSIONS AND IMPLICATIONS

Information about outcomes was more persuasive than descriptive majority norm information. Effects were generally stronger in those already consuming sufficient fruit.

Nutrition Information In Community Newspapers: Goal Framing, Story Origins, and Topics

Obesity rates are high in the rural United States. Because small communities often have few health care practitioners, nutrition news in community newspapers may be a useful source of information. This content analysis of a random sample of 164 nutrition stories from 10 community newspapers in the rural West North Central Midwest was guided by concepts from goal-framing theory. Locally generated stories comprised nearly half of the sample, suggesting that nutrition is a salient topic in many rural communities. Hedonic frames related to food enjoyment were twice as frequent as health improvement frames. Results suggest food promotion was the most common topic of nutrition stories, with guidelines for a healthy diet appearing about half as often. Stories about a healthy diet and food promotion were most often written locally. Findings are discussed with recommendations for improvement of community news coverage of nutrition.

The effects of narrative and message framing on engagement and eating intention among a sample of adult Hispanics

OBJECTIVE

To test the effect of narrative messages and gain- and loss-framed messages on persuasive outcomes with a sample of Hispanic adults.

METHODS

A 2 (message type: narrative, non-narrative) × 2 (message frame: gain-framed, loss-framed) between subjects posttest only. Data were collected at 2 outdoor festivals in West Texas. Participants were a convenience sample of 72 Hispanic adults (mean age, 40.6 years). Main outcome measures were message engagement, message relevance, attitude toward message, healthy eating intention, and physical activity intention. Data analysis included analysis of variance and multivariate analysis of variance.

RESULTS

There was no significant difference between narrative and non-narrative messages. Gain-framed messages were rated more positively, whereas loss-framed messages were considered more engaging and also produced higher intentions to eat healthy and to become physically active. The interaction between message type and message framing was not significant.

CONCLUSIONS AND IMPLICATIONS

Loss-framed messages produced the unanticipated effect of higher message engagement and higher intention. This finding suggests that messages emphasizing losses associated with unhealthy eating and lack of physical activity may be more effective when targeting Hispanic adults than messages emphasizing potential gains. The lack of difference between narrative and non-narrative messages suggests there is no disadvantage to using narratives, but also no advantage.

Health message framing effects on attitudes, intentions, and behavior: a meta-analytic review

BACKGROUND

Message framing has been an important focus in health communication research, yet prior meta-analyses found limited support for using framing to increase persuasiveness of health messages.

PURPOSE

This meta-analysis distinguished the outcomes used to assess the persuasive impact of framed messages (attitudes, intentions, or behavior).

METHODS

One hundred eighty-nine effect sizes were identified from 94 peer-reviewed, published studies which compared the persuasive impact of gain- and loss-framed messages.

RESULTS

Gain-framed messages were more likely than loss-framed messages to encourage prevention behaviors (r = 0.083, p = 0.002), particularly for skin cancer prevention, smoking cessation, and physical activity. No effect of framing was found when persuasion was assessed by attitudes/intentions or among studies encouraging detection.

CONCLUSIONS

Gain-framed messages appear to be more effective than loss-framed messages in promoting prevention behaviors. Research should examine the contexts in which loss-framed messages are most effective, and the processes that mediate the effects of framing on behavior.

A pragmatic trial in the Rio de Janeiro subway to capture smokers for a quitline: methodological challenges and opportunities

According to the World Health Organization, smoking is an important cause of death worldwide. To encourage smoking cessation, persuasive messages can be used to raise smokers' risk perception. This article discusses challenges and solutions in designing a study to evaluate the effect of two different communication strategies ("gains from quitting" vs. "losses from continuing smoking") in encouraging calls to a quitline. The authors conducted an intervention study in two subway stations for 4 weeks, considering only 1 strategy per station. Large posters containing non-age-specific images and texts, on the basis of the theme"shortness of breath," were displayed on central dividing columns on the boarding platforms. Call rates from the selected stations, and respective rate ratios, overall and per study week, were calculated. Passengers who were smokers, exposed to the positive-content message, called on average 1.7 times more often than did those exposed to the negative-content message (p = .01). Moreover, call rate ratios did not decline over the 4 weeks of the study (p = .40). The effectiveness findings suggest that antismoking campaigns could use positive-content messages in order to recruit a larger smoker population. The proposed methodology can also be used to evaluate effectiveness of messages for "capturing" individuals with other health problems (e.g., alcohol abuse), thereby increasing its potential impact.

Usability of a web-based personal nutrition management tool

'Personal Nutrition Management Tool' (PENUMAT) is an interactive web-based application which aims to help individuals seeking nutrition information on the Internet. However, little is known about the usability of such applications. The purpose of this study was to evaluate the usability of PENUMAT using multi-method approach. For an in-depth usability analysis, using a multi-method approach involving protocol analysis, interviews and a system usability scale (SUS) was adopted. The sample consisted of 10 healthy (five males and five females) volunteers between the ages of 22 and 60. The overall usability score was calculated; usability problems and users' opinions were obtained. All usability problems were classified according to the heuristics and listed with their frequencies. Overall, the usability score ranged from 77.5 to 100, with a median of 88.7. In-depth usability analysis exposed several usability problems mostly related to content, navigation and interactivity. Interview results showed that 'being personal and private' (70%) and 'providing personal feedbacks' (60%) were the most appreciated characteristics of the tool. Although the tool has an acceptable overall usability score, several unnoticed usability problems of the interface design were realised with the in-depth analysis. Therefore, the importance of using a multi-method analysis of usability was pointed out.

Steps in the design, development and formative evaluation of obesity prevention-related behavior change trials

Obesity prevention interventions through dietary and physical activity change have generally not been effective. Limitations on possible program effectiveness are herein identified at every step in the mediating variable model, a generic conceptual framework for understanding how interventions may promote behavior change. To minimize these problems, and thereby enhance likely intervention effectiveness, four sequential types of formative studies are proposed: targeted behavior validation, targeted mediator validation, intervention procedure validation, and pilot feasibility intervention. Implementing these studies would establish the relationships at each step in the mediating variable model, thereby maximizing the likelihood that an intervention would work and its effects would be detected. Building consensus among researchers, funding agencies, and journal editors on distinct intervention development studies should avoid identified limitations and move the field forward.

The influence of message framing, intention to quit smoking, and nicotine dependence on the persuasiveness of smoking cessation messages

This study explores the combined effect of message framing, intention to quit smoking, and nicotine dependence on the persuasiveness of smoking cessation messages. Pre- and post-message measures of quit intention, attitude toward smoking cessation, and perceived behavioral control were taken in two separate waves from current cigarette smokers with varying levels of nicotine dependence (N=151). In the second wave, participants were randomly assigned to one of two groups. In the first group, participants read a smoking cessation message which emphasized the benefits of quitting (positive frame). In the second group participants read a message which emphasized the costs of not quitting (negative frame). Results show that smokers' intentions to quit smoking and their level of nicotine dependence jointly influence the persuasiveness of positive and negative message frames. When nicotine dependence and quitting intention are both high, a negative frame works best. Conversely, a positive frame is preferable when nicotine dependence or quitting intention is low. Smokers' level of processing is proposed as the underlying mechanism explaining the different effects of message frames.

The relative persuasiveness of gain-framed and loss-framed messages for encouraging disease prevention behaviors: a meta-analytic review

A meta-analytic review of 93 studies (N = 21,656) finds that in disease prevention messages, gain-framed appeals, which emphasize the advantages of compliance with the communicator's recommendation, are statistically significantly more persuasive than loss-framed appeals, which emphasize the disadvantages of noncompliance. This difference is quite small (corresponding to r = .03), however, and appears attributable to a relatively large (and statistically significant) effect for messages advocating dental hygiene behaviors. Despite very good statistical power, the analysis finds no statistically significant differences in persuasiveness between gain- and loss-framed messages concerning other preventive actions such as safer-sex behaviors, skin cancer prevention behaviors, or diet and nutrition behaviors.

Effecting dietary change

A world epidemic of diet-related chronic disease is currently being faced. In the UK incidence of obesity alone has tripled in the last 20 years and this trend is predicted to continue. Consensus exists for the urgent need for a change in diet and other lifestyle factors and for the direction and targets for this change. The evidence for how this change can be achieved is less certain. It has been established that disease processes begin in childhood. Recent evidence indicates that dietary habits too are established in childhood but that these habits are amenable to change. While establishing a healthy lifestyle in childhood is paramount, interventions have the potential to promote positive change throughout the life course. Success in reversing current trends in diet-related disease will depend on commitment from legislators, health professionals, industry and individuals, and this collaboration must seek to address not only the food choices of the individual but also the environment that influences such choices. Recent public health policy development in England, if fully supported and implemented, is a positive move towards this goal. Evidence for effective strategies to promote dietary change at the individual level is emerging and three reviews of this evidence are discussed. In addition, three recent dietary intervention studies, in three different settings and with different methods and aims, are presented to illustrate methods of effecting dietary change. Further work is required on what factors influence the eating behaviour and physical activity of individuals. There is a need for further theory-based research on which to develop more effective strategies to enable individuals to adopt healthier lifestyles.

Increasing daily fruit and vegetable consumption: what changes do cardiac patients make?

BACKGROUND

Interventions targeting fruit and vegetable consumption report significant increases in consumption but do not detail how increases are achieved. This prospective study explored (i) the changes in daily fruit and daily vegetable consumption of cardiac patients participating in an intervention study and (ii) how participants made these changes.

METHODS

A total of 120 cardiac patients were asked to increase their daily fruit and vegetable consumption by two portions and to maintain this over 3 months. They were telephoned at 7-, 28- and 90-day follow-up to record daily consumption using a dietary questionnaire; 94 participants completed all parts of the study.

RESULTS

Mean reported daily fruit and daily vegetable consumption increased by 1.07 (SD = 1.26) and 0.34 (SD = 0.96) portions, respectively, over 3 months. These increases were statistically significant (P < 0.001) and greatest for participants who reported eating low levels of fruit and vegetables at recruitment. Eating fresh fruit as a snack and at mealtimes were preferred choices for participants.

CONCLUSIONS

Providing information and telephone follow-up could be used by busy healthcare professionals instead of face-to-face contact. Interventions to increase total fruit and vegetable consumption could usefully focus on eating fruit. Interventions to increase vegetable consumption need further investigation.

Impact of diet-related cancer prevention messages written with cognitive and affective arguments on message characteristics, stage of change, and self-efficacy

OBJECTIVE

To determine if participants reading messages matched to a preferred style of message argument respond more favorably than participants reading unmatched messages.

DESIGN

Randomized trial using telephone and in-person surveys and cognitive response interviews.

SETTING

University campus.

PARTICIPANTS

Of 125 initially interested, a convenience sample of 100 university employees completed the study (female: 88%, white: 94%, mean age: 43.7).

INTERVENTION(S)

Participants read 2 print messages written with cognitive (COG) (fact based) or affective (AFF) (story based) arguments.

MAIN OUTCOME MEASURE(S)

7-point Likert scale ratings of message appeal, understandability, persuasiveness, and relevance according to classification into 1 of 4 message groups: COG-AFF (mismatched to affective), AFF-COG (mismatched to cognitive), COG-COG (matched cognitive), and AFF-AFF (matched affective).

ANALYSIS

1-way analysis of variance (P < or = .05) and systematic review of qualitative interviews.

RESULTS

The COG-AFF group consistently gave the lowest ratings to the affective messages and the AFF-COG group generally gave high scores compared with other message groups. Participants also expressed a desire for more factual information.

CONCLUSIONS AND IMPLICATIONS

A combination of cognitive and affective arguments may be appealing to subjects with an affective preference but disliked by individuals who prefer only a fact-based approach. Argument format may be an important message design consideration.

Describing treatment effects to patients

OBJECTIVE

To examine the impact of different presentations of equivalent information (framing) on treatment decisions faced by patients.

DESIGN

A systematic review of the published literature was conducted. English language publications allocating participants to different frames were retrieved using electronic and bibliographic searches. Two reviewers examined each article for inclusion, and assessed methodological quality. Study characteristics were tabulated and where possible, relative risks (RR; 95% confidence intervals) were calculated to estimate intervention effects.

MEASUREMENTS AND MAIN RESULTS

Thirty-seven articles, yielding 40 experimental studies, were included. Studies examined treatment (N = 24), immunization (N = 5), or health behavior scenarios (N = 11). Overall, active treatments were preferred when outcomes were described in terms of relative rather than absolute risk reductions or number needed to treat. Surgery was preferred to other treatments when treatment efficacy was presented in a positive frame (survival) rather than a negative frame (mortality) (relative risk [RR] = 1.51, 95% confidence interval [CI], 1.39 to 1.64). Framing effects were less obvious for immunization and health behavior scenarios. Those with little interest in the behavior at baseline were influenced by framing, particularly when information was presented as gains. In studies judged to be of good methodological quality and/or examining actual decisions, the framing effect, although still evident, was less convincing compared to the results of all included studies.

CONCLUSIONS

Framing effects varied with the type of scenario, responder characteristics, scenario manipulations, and study quality. When describing treatment effects to patients, expressing the information in more than one way may present a balanced view to patients and enable them to make informed decisions.

The (ir)relevance of framing nutrition education messages

Persuasive health education messages can either stress the positive consequences of performing a healthy behaviour (gain-frame) or the negative consequences of not performing a healthy behaviour (loss-frame). Based on studies on topics such as sun protection and breast self-examination there is evidence that messages in different action frames may differ in persuasive effects. Three randomised controlled trials were conducted to test framing effects in nutrition education on specific nutrition-related attitudes and intentions. In study 1, effects of gain-framed and loss-framed messages were studied among 152 adult education students on attitudes and intentions related to fat, fruit and vegetable consumption. In study 2 we confronted 149 regular students with differently framed messages related to a (more or less fictive) preventive dietary behaviour that was expected to be unknown to the study population, intake of flavonoids and risk for chronic disease. The impact on attitudes and intentions to use flavonoid-enriched spreads was studied. In study 3 we studied the effects of differently framed messages on attitudes and intentions related to more immediate and more personally relevant diet nutrition behaviour: folic acid supplement use before and during pregnancy among 100 female students. No significant differences in attitudes or intentions to perform the preventive nutrition behaviours were found between the gain-frame conditions and the loss-frame conditions in all three studies. The (lack of) effects were not moderated by factors such as perceived personal relevance, credibility or novelty of the information, or the perceived importance of the topic addressed. The results of the present studies suggest that action-frame choice has a very limited impact on the effectiveness of nutrition education in changing precautionary motivation.