Improving Communication During a Pandemic Flu Outbreak
Condition: Healthy
Study type: Interventional

Summary: 
      During the last pandemic influenza antivirals were prescribed both as prophylaxis and
      treatment. However, adherence rates were suboptimal. This study assessed the effect of
      theory-based and evidence-based health messages, which promoted the use of antivirals as
      prophylaxis for pandemic influenza, on intentions to use antivirals. Using hypothetical
      scenarios, the investigators tested whether written health communications about pandemic flu
      and recommended preventative medication (i.e. a prophylactic treatment with antivirals) had
      an effect on study participants' beliefs about the pandemic flu and the advice received, and
      their intention to adhere to the recommendation. In particular, the investigators assessed
      the behavioural impact of health messages presented in four different linguistic formats,
      defined by a 2×2 (agency assignment × attribute framing) factorial design. The originality of
      this study relies on the attempt to maximise the behavioural impact of written health
      messages by combining the agency assignment and attribute framings, which have never been
      tested together, and by systematically targeting specific predictors of adherence intentions
      through these messages. The findings of this study may be used to improve the behavioural
      impact of health communications to the general public in case of a pandemic flu outbreak in
      the UK.
    

Detailed description: 
      Background: In 2009, a new strain of influenza virus, called pandemic influenza A(H1N1)pdm09,
      was detected in humans. During the pandemic in 2009/2010, antiviral medications were
      prescribed both as prophylaxis and treatment for influenza. However, many people, including
      those with chronic health conditions, did not used the antivirals as prescribed. This study
      focused on adherence to antivirals used as prophylaxis, as this is a key preventative stage
      before any vaccine can be available to the public. To ensure protection of public health
      during public health emergencies, such as pandemic flu, it is essential that the general
      public follow the health advice received. Therefore, future risk communications about the use
      of antivirals for pandemic influenza will need to address the barriers and facilitators of
      adherence.

      This study investigated the effect of theory-based and evidence-based health messages, which
      promoted the use of antivirals as prophylaxis for pandemic influenza, on intentions to use
      antivirals. In particular, using hypothetical scenarios, the investigators tested whether
      written health communications about pandemic flu and recommended preventative medication
      (i.e. a prophylactic treatment with antivirals) had an effect on study participants' beliefs
      about the pandemic flu and the advice received, and their intention to adhere to the
      recommendation.

      The linguistic manipulation used in the present study was based on an adaptation of a
      successful manipulation carried out by McGlone et al. (2013), who found that using the virus
      agency assignment in medical factsheets increased students' perception of susceptibility to
      and worry about the virus A/H1N1, perception of the severity of the consequences of catching
      the virus, perception of efficacy of the vaccine and reported intention to get the vaccine
      compared to the human agency assignment. The investigators wanted to test whether these
      results could be replicated in the context of taking antivirals for pandemic flu, using a
      more representative sample of the general population and controlling for baseline intentions.

      For what concerns the framing of the side effects, research shows that the way information on
      medication side-effects is presented affects people's intentions to accept the recommended
      medications. The same side-effect likelihood can be expressed in a positively framed message
      (i.e. 90% of people will not develop side-effects) or in negatively framed message (i.e. 10%
      of people will develop side-effects). Although a previous meta-analysis (Moxey et al. 2003)
      found no significant framing effect on either actual immunization or behavioural intention,
      it found that positively framed information increased positive attitudes toward immunization
      and perception of the benefits of immunization, decreased expectation of side-effects and led
      to a more realistic understanding of the side-effects of influenza vaccines.

      In addition, the health messages used in this study targeted specific variables, which have
      been in the past associated with higher adherence to antivirals for pandemic influenza. In
      particular, a recently published systematic review (Smith et al. 2016) investigated the
      factors affecting adherence to antivirals for influenza, including pandemic flu. They
      included 26 studies, of which 23 assessed pandemic influenza. Although many of the reviewed
      studies had serious methodological flaws, the review identified several psychosocial factors
      associated with adherence to antivirals prescribed as prophylaxis for pandemic flu. In
      particular, 11 studies investigated actual adherence to prophylactic antivirals. These
      studies showed that actual adherence was associated with previous adherence to other
      preventative measures for pandemic flu, beliefs that the recommended prophylactic measures
      were necessary and having discussed taking oseltamivir, a commonly used antiviral, with
      someone who had not experienced side effects. Although only one study found that the presence
      of side-effects was a significant predictor of non-adherence, the occurrence of side-effects
      was the most commonly self-reported reason for the discontinuation of oseltamivir. The review
      also included 8 studies investigating psychosocial predictors of intention to adhere: for
      instance, higher perceived susceptibility to the pandemic flu, higher perceived severity of
      pandemic flu, knowledge of pandemic flu, higher self-efficacy and response efficacy, and
      having previously accepted the flu vaccine were all associated with higher adherence
      intentions.

      Methods: In May/June 2016 the investigated conducted an online experiment. After reading a
      hypothetical pandemic flu scenario, 349 adult UK residents were randomly allocated to one of
      four conditions, defined by a 2x2 (agency assignment × attribute framing of side effects)
      factorial design. Each condition presented messages describing the pandemic flu using
      linguistic expressions that assigned agency to either the humans (HA: human agency) or the
      virus itself (VA: virus agency), whilst describing the antivirals side effects in terms of
      the chances of either experiencing (NF: negative framing) or not experiencing side effects
      (PF: positive framing). Although presented with different framings the health messages
      provided equivalent information that targeted specific predictors of adherence. Participants
      were blinded to group assignment. Intentions to use the antivirals and potential mediating
      factors were measured. The aim was to understand the potential behavioural impact of the four
      health messages developed and to better understand the factors influencing adherence
      intentions.
    

Intervention name(s): Agency Assignment framing; Attribute framing
Intervention type(s): Other; Other
Intervention description(s): Linguistic framing used in written health messages. Each version of the messages described the pandemic flu and the efficacy of the antivirals using linguistic expressions that assigned transmission to either humans (HA: 'You can contract the virus when you touch…') or the pandemic flu virus itself (VA: 'It can infect you when you touch…'); Linguistic framing used in written health messages. Each message described the side effects of the antivirals in terms of chances of either experiencing (negative framing: 'Uncommon side effects (10% of people will be affected)') or not experiencing side effects (positive framing: 'Uncommon side effects (90% of people will not be affected)') after using them.
Other intervention name(s): Framing effect on behavioural intentions; Framing effect on behavioural intentions
Allocation: Randomized
Intervention model: Factorial Assignment
Intervention model description: This study was a vignette-based randomised controlled trial, with a 2 (human vs virus agency assignment) x 2 (negative vs positive frame of antivirals side effects) between-participants factorial design. All participants were presented with a hypothetical pandemic flu scenario describing moderate health consequences (i.e. about 1 in 1000 infected people dying). The scenario: 1) in the initial scenario participants were told to imagine that their GP (although not confirming whether it was a pandemic case) had advised them to take antivirals as a precaution; 2) after measuring baseline intentions, participants were introduced to the second part of the scenario where they were asked to imagine being at their local pharmacy where a pharmacist provided them with some health messages and information about the antivirals. Participants were randomised to one of the four health messages described below. After reading the health messages their intentions to use antivirals were re-measured.
Masking: Single (Participant)
Primary purpose: Prevention
Keywords: Adherence, medication; Pandemic Influenza