The role of usability, usefulness and frame in persuasive health communication

Background: A large proportion of ill-health is preventable (Signorelli 1993). A goal for health promoters is to provide information about health risks with the aim of persuading individuals to modify their behaviour. Previous research suggests that the readability of many health promotion materials is too low for effective comprehension. Evidence suggests that much of the health information available is written at a level that is too difficult for the target populations (e.g. Dollahite et al. 1996, Meade & Byrd 1989, Greenfield et al. 2005). Whilst this work is useful in identifying barriers to accessibility to health information, there has been little research that systematically explores the concept of usability within the context of health information. Objectives: The first objective of the thesis was to examine whether the concepts of usability and usefulness as outlined in the Technology Acceptance Model (Davis 1993) can be applied to the domain of health promotion and used to predict intentions to follow the advice given in health promotion leaflets. Second, the studies sought to make distinctions between subjective and objective usability and to explore the factors underlying subjective ratings of the usability of health information. Further, the thesis sought to demonstrate that both objective and subjective usability would influence the persuasive effect of health promotion materials. Finally, using theory from dual-processing models of persuasion (e.g. Elaboration Likelihood Model. Petty and Cacioppo 1986) it was predicted that when usability of leaflets was high, participants would be more likely to make judgements about their intentions to follow the advice given in the leaflets based on peripheral clues such as frame (Tversky and Kahneman 1981, Rothman and Salovey 1997, Levin et al. 1998). Methodology: 5 empirical studies examined the research questions. The first study consisted of two samples from working populations (n=441), and explored manual handling and use of hearing protection. Participants evaluated existing health and safety leaflets in relations to their usability and usefulness, and rated their intentions to follow the advice in the leaflets. The second study, also conducted on a working population (n=97), used experimentally manipulated leaflets on safe manual handling to test the hypothesis that framing effects would be found when usability of leaflets was high. The third study used a student sample (n=127) to explore factors that influence subjective usability. The study used experimentally manipulated leaflets about safe alcohol consumption to examine whether the concept of subjective usability is a function of reader characteristics (psychological constructs, mood, past exposure to the health problem) and leaflet characteristics (frame, objective reading ease). The fourth study used a student sample (n=238) to test the effect of objective reading ease on recall, in order to test for differences in processing of two experimentally manipulated leaflets about safe alcohol consumption. It was predicted that easy leaflets would be processed at a more shallow level than difficult leaflets. The fifth study, also conducted on a student sample using experimentally manipulated safe alcohol leaflets (n= 135), used pre and post testing to further explore the effects of usability on framing effects, and to test for a moderating role of prior knowledge on the effect of usability on intentions. Results: The studies showed that readers distinguish two separate components to health information leaflets: usability and usefulness. Subjective perceptions of usability and perceived usefulness predicted intentions to follow the advice given in the leaflets. Objective usability (reading ease) influenced the persuasive effect of the leaflets, with easy leaflets being more persuasive than difficult leaflets. Perceived usefulness partially mediated the relationship between subjective usability and intentions. Objective reading ease affected recall, with easy leaflets resulting in higher levels of both accurate and false recall of the information in the leaflets. Prior knowledge moderated the relationship between usability and intentions. Those with low prior knowledge were more persuaded when usability was high. Usability influenced the effect of frame on intentions. Framing effects were only found where usability was high. Where framing effects were found, negative frame was more persuasive than positive frame, offering support for Levin et al.'s (1998) typology of framing effects. Conclusions: Results from the studies show that the concepts of usability and usefulness, formalised in models of technology acceptance (TAM), can be applied to health information and used to predict intentions to follow health promotion recommendations. A distinction can be made between subjective and objective usability, and both of these can influence persuasion. Using theory from dual-processing models of persuasion, usability of health information leaflets can influence the effect of frame on intentions to follow the health promotion advice.

[1]  Wayne T. Steward,et al.  Need for Cognition Moderates Responses to Framed Smoking-Cessation Messages 1 , 2003 .

[2]  Tina M. Lowrey.  The Effects of Syntactic Complexity on Advertising Persuasiveness , 1998 .

[3]  J. Walsh,et al.  Exploring attitude and belief correlates of adhering to the new guidelines for low-risk single-occasion drinking: an application of the theory of planned behaviour. , 2001, Alcohol and alcoholism.

[4]  J. Geer,et al.  Creating impressions: An experimental investigation of political advertising on television , 1994 .

[5]  Mark P. Zanna,et al.  Differential weighting of favorable and unfavorable attributes in impressions of personality. , 1972 .

[6]  N. Schwarz.  Heuristics and Biases: Feelings as Information: Moods Influence Judgments and Processing Strategies , 2002 .

[7]  Wolfgang Schneiderandjoachim K Rkel.  The Knowledge Base and Text Recall: Evidence from a Short-Term Longitudinal Study , 1989 .

[8]  J. P. Wanous,et al.  Overall job satisfaction: how good are single-item measures? , 1997, The Journal of applied psychology.

[9]  Qing Zeng-Treitler,et al.  Readability of patient and health care professional targeted dietary supplement leaflets used for diabetes and chronic fatigue syndrome. , 2010, Journal of alternative and complementary medicine.

[10]  H. Rao Unnava,et al.  Self-Referencing , 1989 .

[11]  D. Marlowe,et al.  A new scale of social desirability independent of psychopathology. , 1960, Journal of consulting psychology.

[12]  D. G. Gardner,et al.  Single-Item Versus Multiple-Item Measurement Scales: An Empirical Comparison , 1998 .

[13]  J Tyndall,et al.  Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home. , 2003, The Cochrane database of systematic reviews.

[14]  Cindy D. Kam,et al.  Beyond the “Narrow Data Base”: Another Convenience Sample for Experimental Research , 2007 .

[15]  Wolfgang Stroebe,et al.  Social Psychology and Health , 1995 .

[16]  Yong Zhang,et al.  Moderating Effects of Need for Cognition on Responses to Positively versus Negatively Framed Advertising Messages , 1999 .

[17]  John R. Rossiter,et al.  The C-OAR-SE procedure for scale development in marketing , 2002 .

[18]  R. Lutz.  Changing Brand Attitudes through Modification of Cognitive Structure , 1975 .

[19]  H. Simon,et al.  The functional equivalence of problem solving skills , 1975, Cognitive Psychology.

[20]  A. Lupia.  New Ideas in Experimental Political Science , 2002, Political Analysis.

[21]  Fred D. Davis.  User Acceptance of Information Technology: System Characteristics, User Perceptions and Behavioral Impacts , 1993, Int. J. Man Mach. Stud..

[22]  Jean-Charles Chebat,et al.  Limits of the Effects of Advertisement Framing: the Moderating Effects of Prior Knowledge and Involvement , 1998 .

[23]  R. Flesch.  The Art of Readable Writing , 1974 .

[24]  Christian Homburg,et al.  Applications of structural equation modeling in marketing and consumer research: A review , 1996 .

[25]  Rapson Gomez,et al.  Neuroticism and extraversion as predictors of negative and positive emotional information processing: comparing Eysenck's, Gray's, and Newman's theories , 2002 .

[26]  D. Machin,et al.  Randomised trial of compliance with screening for colorectal cancer. , 1986, British medical journal.

[27]  A. Tversky,et al.  Choices, Values, and Frames , 2000 .

[28]  Gerjo Kok,et al.  Pictures and text in instructions for medical devices: effects on recall and actual performance. , 2006, Patient education and counseling.

[29]  M. Becker,et al.  Scales for Measuring Health Belief Model Dimensions: A Test of Predictive Value, Internal Consistency, and Relationships among Beliefs* , 1977, Health education monographs.

[30]  B. Svarstad,et al.  Using alternative methodologies for evaluating patient medication leaflets. , 2002, Patient education and counseling.

[31]  D. Black,et al.  Evaluation of a "loss-framed" minimal intervention to increase mammography utilization among medically un- and under-insured women. , 2002, Cancer detection and prevention.

[32]  J. Dollahite,et al.  Readability of printed sources of diet and health information. , 1996, Patient education and counseling.

[33]  Emily White,et al.  Reliability and Validity of 2 Single-Item Measures of Psychosocial Stress , 2006, Epidemiology.

[34]  Thomas Deroche,et al.  Social cognitive determinants of the intention to wear safety gear among adult in-line skaters. , 2009, Accident; analysis and prevention.

[35]  Pauline A. Smith.  Towards a Practical Measure of Hypertext Usability , 1996, Interact. Comput..

[36]  Robert Meeds,et al.  Surface-structure transformations and advertising slogans: The case for moderate syntactic complexity , 2002 .

[37]  M. Willig,et al.  FLUCTUATING ASYMMETRY IN THE CHEETAH: METHODOLOGICAL AND INTERPRETIVE CONCERNS , 1987, Evolution; international journal of organic evolution.

[38]  Ken Eason,et al.  Towards the experimental study of usability , 1984 .

[39]  P. Keller.  Converting the unconverted: the effect of inclination and opportunity to discount health-related fear appeals. , 1999, The Journal of applied psychology.

[40]  R. H. Ettinger,et al.  Approval Seeking, Social Cost, and Aggression: A Scale and Some Dynamics , 1976 .

[41]  Byron Reeves,et al.  MESSAGE COMPLEXITY AND ATTENTION TO TELEVISION , 1985 .

[42]  D. Pothier,et al.  Readability statistics of patient information leaflets in a Speech and Language Therapy Department. , 2008, International journal of language & communication disorders.

[43]  P. Knapp,et al.  A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines. , 2007, Health technology assessment.

[44]  Wang.  Framing Effects: Dynamics and Task Domains , 1996, Organizational behavior and human decision processes.

[45]  L. Sigelman,et al.  Reconsidering pocketbook voting: An experimental approach , 1991 .

[46]  P. Salovey,et al.  Influence of mood on health-relevant cognitions. , 1989, Journal of personality and social psychology.

[47]  T. Baranowski,et al.  Beliefs as Motivational Influences at Stages in Behavior Change , 1992, International quarterly of community health education.

[48]  A. Bechara.  Decision making, impulse control and loss of willpower to resist drugs: a neurocognitive perspective , 2005, Nature Neuroscience.

[49]  Sabine A. Einwiller,et al.  Accuracy Motivation, Consensus Information, and the Law of Large Numbers: Effects on Attitude Judgment in the Absence of Argumentation , 1998 .

[50]  Hans Lind,et al.  A note on the robustness of a classical framing result , 1992 .

[51]  S. Chaiken,et al.  Communication modality as a determinant of message persuasiveness and message comprehensibility. , 1976 .

[52]  B. Sternthal,et al.  Detecting and Explaining Vividness Effects in Attitudinal Judgments , 1984 .

[53]  A. O’Cathain,et al.  Use of evidence based leaflets to promote informed choice in maternity care: randomised controlled trial in everyday practice , 2002, BMJ : British Medical Journal.

[54]  F. Craik,et al.  Levels of Pro-cessing: A Framework for Memory Research , 1975 .

[55]  Christopher Leone,et al.  Some Effects of the Need for Cognition on Course Grades , 1988 .

[56]  M. Conner,et al.  Efficacy of the Theory of Planned Behaviour: a meta-analytic review. , 2001, The British journal of social psychology.

[57]  Rolph E. Anderson,et al.  Technical Wording in Advertising: Implications for Market Segmentation , 1980 .

[58]  A. Olshan,et al.  Multiple comparisons and related issues in the interpretation of epidemiologic data. , 1995, American journal of epidemiology.

[59]  D. Pothier,et al.  Readability of out-patient letters copied to patients: can patients understand what is written about them? , 2009, The Journal of Laryngology & Otology.

[60]  F. Craik,et al.  The effects of elaboration on recognition memory , 1980, Memory & cognition.

[61]  Paul W. Paese.  Effects of Framing on Actual Time Allocation Decisions , 1995 .

[62]  Cathy D. Meade,et al.  Readability Formulas: Cautions and Criteria , 1991 .

[63]  G. Bower,et al.  Mood effects on person-perception judgments. , 1987, Journal of personality and social psychology.

[64]  James N. Druckman,et al.  Political Preference Formation: Competition, Deliberation, and the (Ir)relevance of Framing Effects , 2004, American Political Science Review.

[65]  D. Mick,et al.  Levels of Subjective Comprehension in Advertising Processing and Their Relations to Ad Perceptions, Attitudes, and Memory , 1992 .

[66]  J. Druckman,et al.  Framing and Deliberation: How Citizens' , 2003 .

[67]  Duane T. Wegener,et al.  Not all stereotyping is created equal: differential consequences of thoughtful versus non-thoughtful stereotyping. , 2006, Journal of personality and social psychology.

[68]  Matthew G. Rhodes,et al.  The effects of a levels-of-processing manipulation on false recall , 2000, Psychonomic bulletin & review.

[69]  L. Berkowitz,et al.  Feelings, direction of attention, and expressed evaluations of others , 1990 .

[70]  Rapson Gomez,et al.  Susceptibility to positive and negative mood states: test of Eysenck’s, Gray’s and Newman’s theories , 2000 .

[71]  Alexander J. Rothman,et al.  Shaping perceptions to motivate healthy behavior: the role of message framing. , 1997, Psychological bulletin.

[72]  Chris Baber,et al.  Subjective evaluation of usability , 2002, Ergonomics.

[73]  Kazuhisa Takemura,et al.  Influence of Elaboration on the Framing of Decision , 1994 .

[74]  Sandra J. Milberg,et al.  The differential processing of price in gains and losses: the effects of frame and need for cognition , 2000 .

[75]  K. Ashing-Giwa.  Quality of Life and Psychosocial Outcomes in Long-Term Survivors of Breast Cancer , 2000 .

[76]  J. Haidt.  The emotional dog and its rational tail: a social intuitionist approach to moral judgment. , 2001, Psychological review.

[77]  W. Kintsch.  Text comprehension, memory, and learning. , 1994, The American psychologist.

[78]  Alice H. Eagly,et al.  Comprehensibility of persuasive arguments as a determinant of opinion change. , 1974 .

[79]  P. Fagan,et al.  Cultural sensitivity and readability of breast and prostate printed cancer education materials targeting African Americans. , 1998, Journal of the National Medical Association.

[80]  K. Mccaul,et al.  Breast cancer worry and screening: some prospective data. , 1996, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[81]  Marcia K. Johnson,et al.  Contextual prerequisites for understanding: Some investigations of comprehension and recall , 1972 .

[82]  Pr Peres-Neto,et al.  How many statistical tests are too many? The problem of conducting multiple ecological inferences revisited , 1999 .

[83]  H D Harvey,et al.  The health promotion implications of the knowledge and attitude of employees in relation to health and safety leaflets , 2000, International journal of environmental health research.

[84]  R. Batra,et al.  The Role of Mood in Advertising Effectiveness , 1990 .

[85]  S. Biddle,et al.  Predicting Physical Activity Promotion in Health Care Settings , 2001, American journal of health promotion : AJHP.

[86]  J Siemiatycki,et al.  The problem of multiple inference in studies designed to generate hypotheses. , 1985, American journal of epidemiology.

[87]  Joseph R. Spiegel,et al.  Readability analysis of patient information on the American Academy of Otolaryngology–Head and Neck Surgery website , 2009, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[88]  J. Forgas.  On mood and peculiar people : affect and person typicality in impression formation , 1992 .

[89]  D. Voaklander,et al.  Depression following Traumatic Spinal Cord Injury , 2005, Neuroepidemiology.

[90]  Duane T. Wegener,et al.  The elaboration likelihood model: Current status and controversies. , 1999 .

[91]  A. V. Ciardullo,et al.  Assessment of Readability and Learning of Easy-to-Read Educational Health Materials Designed and Written with the Help of Citizens by Means of Two Non-Alternative Methods , 2006, Advances in health sciences education : theory and practice.

[92]  J. Cacioppo,et al.  The need for cognition. , 1982 .

[93]  K. Fiedler,et al.  Mood and memory for tightly organized social information , 1986 .

[94]  D. Lauver,et al.  Message framing, dispositional optimism, and follow-up for abnormal Papanicolaou tests. , 1990, Research in nursing & health.

[95]  K. Sanders-Phillips.  Correlates of health promotion behaviors in low-income Black women and Latinas. , 1996, American journal of preventive medicine.

[96]  Stella W. Y. Chan,et al.  Highly neurotic never-depressed students have negative biases in information processing , 2007, Psychological Medicine.

[97]  Michael Friedman,et al.  Developing brief scales for use in clinical practice: the reliability and validity of single-item self-report measures of depression symptom severity, psychosocial impairment due to depression, and quality of life. , 2006, The Journal of clinical psychiatry.

[98]  R. Sanson-Fisher,et al.  A cost-effective approach to the development of printed materials: a randomized controlled trial of three strategies. , 2004, Health education research.

[99]  J. Henrich.  Does culture matter in economic behavior? Ultimatum game bargaining among the machiguenga , 2000 .

[100]  R. Robinette.  The relationship between the Marlowe-Crowne Form C and the validity scales of the MMPI. , 1991, Journal of clinical psychology.

[101]  K. Blick,et al.  Levels of Processing and the Retention of Paired-Associates , 1989 .

[102]  R. W. Rogers,et al.  A Protection Motivation Theory of Fear Appeals and Attitude Change1. , 1975, The Journal of psychology.

[103]  Alexander J. Rothman,et al.  The effects of framing and action instructions on whether older adults obtain flu shots. , 2002, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[104]  N. Frijda.  The laws of emotion. , 1988, The American psychologist.

[105]  I. Rosenstock.  Why people use health services. , 1966, The Milbank Memorial Fund quarterly.

[106]  S. Chaiken.  The heuristic model of persuasion. , 1987 .

[107]  P Norman,et al.  Understanding binge drinking among young people: an application of the Theory of Planned Behaviour. , 1998, Health education research.

[108]  Baruch Fischhoff,et al.  AIDS risk perceptions and decision biases. , 1993 .

[109]  Paul Slovic,et al.  Comparison of Bayesian and Regression Approaches to the Study of Information Processing in Judgment. , 1971 .

[110]  F. Craik,et al.  Interaction between encoding and retrieval operations in cued recall. , 1977 .

[111]  Irwin P. Levin,et al.  Risk taking, frame of reference, and characterization of victim groups in AIDS treatment decisions , 1990 .

[112]  Lauren G. Block,et al.  Increasing the Persuasiveness of Fear Appeals : The Effect of Arousal and Elaboration Author ( s ) : , 2007 .

[113]  H Wechsler,et al.  'Binge' drinkers at Massachusetts colleges. Prevalence, drinking style, time trends, and associated problems. , 1992, JAMA.

[114]  Peter Salovey,et al.  The Systematic Influence of Gain-and Loss-Framed Messages on Interest in and Use of Different Types of Health Behavior , 1999 .

[115]  A. Isen,et al.  Positive affect and decision making. , 1993 .

[116]  D. Stolle,et al.  Why Can’t a Student Be More Like an Average Person?: Sampling and Attrition Effects in Social Science Field and Laboratory Experiments , 2010 .

[117]  R. Baron,et al.  Negative Emotion and Message Processing , 1994 .

[118]  J. Cacioppo,et al.  Beyond Bipolar Conceptualizations and Measures: The Case of Attitudes and Evaluative Space , 1997, Personality and social psychology review : an official journal of the Society for Personality and Social Psychology, Inc.

[119]  Icek Ajzen,et al.  Explaining the Discrepancy between Intentions and Actions: The Case of Hypothetical Bias in Contingent Valuation , 2004, Personality & social psychology bulletin.

[120]  A. Paivio.  Images in mind: The evolution of a theory , 1993 .

[121]  I. Ajzen,et al.  From Intentions to Behavior: Implementation Intention, Commitment, and Conscientiousness , 2009 .

[122]  R. Parrott,et al.  Readability of skin cancer prevention brochures targeting parents of young children. , 1999, Journal of the American Academy of Dermatology.

[123]  H. de Vries,et al.  Investigating message-framing effects in the context of a tailored intervention promoting physical activity. , 2010, Health education research.

[124]  P. Sheeran,et al.  Temporal stability as a moderator of relationships in the Theory of Planned Behaviour. , 2000, The British journal of social psychology.

[125]  Clinton L. Johns,et al.  The importance of knowledge in vivid text memory: An individual-differences investigation of recollection and familiarity , 2008, Psychonomic bulletin & review.

[126]  Patricia A. Alexander,et al.  The influence of topic knowledge, domain knowledge, and interest on the comprehension of scientific exposition , 1994 .

[127]  Tamera R. Schneider,et al.  Visual and Auditory Message Framing Effects on Tobacco Smoking1 , 2001 .

[128]  R. McDermott.  Experimental Methodology in Political Science , 2002, Political Analysis.

[129]  Patricia Johnson,et al.  Effects on Reading Comprehension of Language Complexity and Cultural Background of a Text. , 1981 .

[130]  A. Tversky,et al.  The framing of decisions and the psychology of choice. , 1981, Science.

[131]  R. Dixon,et al.  Text recall in adulthood: The roles of text imagery and orienting tasks , 1989, Psychological research.

[132]  M. Conner,et al.  The theory of planned behavior and healthy eating. , 2002, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[133]  M. Becker,et al.  The Health Belief Model: A Decade Later , 1984, Health education quarterly.

[134]  J. Hill,et al.  The development and evaluation of a drug information leaflet for patients with rheumatoid arthritis. , 2003, Rheumatology.

[135]  I. Levin,et al.  Measuring the Effects of Framing Country-Of-Origin Information: a Process Tracing Approach , 1996 .

[136]  Robert S. Billings,et al.  The effects of response mode and importance on decision-making strategies: Judgment versus choice , 1988 .

[137]  R. Larsen,et al.  EXTRAVERSION, NEUROTICISM AND SUSCEPTIBILITY TO POSITIVE AND NEGATIVE MOOD INDUCTION PROCEDURES , 1989 .

[138]  J. Mayer.  How mood influences cognition , 1986 .

[139]  D. Scammon.  "Information Load" and Consumers , 1977 .

[140]  J. Sinacore.  Multiple regression: Testing and interpreting interactions , 1993 .

[141]  M. A. Gerend,et al.  Behavioral Frequency Moderates the Effects of Message Framing on HPV Vaccine Acceptability , 2008, Annals of behavioral medicine : a publication of the Society of Behavioral Medicine.

[142]  Phil A. Silva,et al.  A comparison of methods for increasing compliance within a general practitioner based screening project for colorectal cancer and the effect on practitioner workload. , 1988, Journal of epidemiology and community health.