Promoting healthy behaviors: How do we get the message across?

International Journal of Nursing Studies 47 (2010) 500–512

Promoting healthy behaviors: How do we get the message across?

Rachel E. Myers *

University of South Florida College of Nursing, 12901 Bruce B. Downs Boulevard, MDC 22, Tampa, FL 33612, United States

A R T I C L E I N F O

Article history:

Received 10 April 2009

Received in revised form 22 November 2009

Accepted 24 November 2009

Keywords:

Behavior change

Healthy behaviors

Message framing

Message tailoring

Nursing

A B S T R A C T

The world is experiencing a rapid rise in chronic health problems, which places an

enormous burden on health care services. Modifiable health behaviors are largely

responsible for this high prevalence and incidence of chronic diseases. This realization has

made initiatives that promote healthy behaviors an international and interdisciplinary

priority. How can nurses and other health care providers get the message across to their

patients in order to maximize likelihood of leading to desired outcomes? Message tailoring

is a well-established health communication approach shown to increase the persuasive-

ness of message effects in the promotion of healthy behaviors. Message framing is an

effective message tailoring strategy that has been well-studied in the psychology

literature over the past 20-plus years across a breadth of health behaviors while being

severely understudied in the nursing literature. Numerous variables, especially those

related to individual differences, have been shown to moderate message framing effects, a

finding of great utility for nursing. This article presents a detailed review of the current

state of the message framing literature, offers specific suggestions for advancing this

literature, and highlights implications for research, education, and practice, with

particular attention to nurses.

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What is already known about the topic?

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00

d

essage tailoring is a well-established health commu-nication approach shown to increase the persuasivenessof message effects in the promotion of healthy behaviors.

- M
essage framing is an effective message tailoringstrategy that has been well-studied in the psychologyliterature over the past 20-plus years across a breadth ofhealth behaviors.
- T
here is a paucity of message framing empirical studiesin the nursing literature.
What this paper adds

- T
his paper presents a detailed review of message framingas a behavior change strategy and highlights implicationsfor nursing research, education, and practice.
* Tel.: +1 813 974 7667.

E-mail address: [email protected].

20-7489/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.

oi:10.1016/j.ijnurstu.2009.11.017

- T
his paper provides a thorough review of the currentstate of the message framing literature and drawsspecific conclusions – where it has gone and where itsfuture lies – by summarizing findings from three meta-analytic reviews and other empirical studies.
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his paper offers suggestions for advancing the messageframing literature by presenting general and specificexamples for future studies that have not previouslybeen examined in clinical populations, including combi-nations of certain moderating variables and framingstrategies to help identify the most effective message‘‘ingredients’’ under a variety of circumstances.
The world is experiencing a rapid rise in chronic healthproblems, which places an enormous burden on healthcare services (World Health Organization [WHO], 2005a).In 2005, an estimated 60% (35 million) of all global deathswere due to chronic diseases, primarily diabetes mellitusand cardiovascular diseases (32%), cancers (13%), andchronic respiratory diseases (7%) (Abegunde et al., 2007).Chronic diseases also place a grave economic burden on

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R.E. Myers / International Journal of Nursing Studies 47 (2010) 500–512 501

nations (Centers for Disease Control and Prevention [CDC],2008; WHO, 2005b). The WHO (2005a) calls for the healthcare workforce to transition from a traditional provider-centered approach to a contemporary patient-centeredapproach in order to lessen the occurrence and detrimentalimpact of these worldwide burdens. For example, it isestimated that at least 80% of all type 2 diabetes andcardiovascular disease and over 40% of cancer can beprevented through changes in behavior (WHO, 2005b).Unhealthy diet, physical inactivity, and tobacco use arethree examples of modifiable behaviors that contribute tothe prevalence of chronic diseases. A patient-centeredapproach, where care is coordinated across time andcentered around patients’ needs, values, and preferences,strengthens patients’ role in managing their healthproblems by empowering them to become active decisionmakers rather than just passive recipients of care (WHO,2005a).

Health education and self-management/self-care train-ing, with an emphasis on promoting healthy behaviors toprevent future problems, are vital components of apatient-centered approach. This education and trainingmay be informal (e.g., unplanned and unstructured duringa clinic visit) or formal (e.g., structured group diabetesclass) and range from simple (e.g., distribute writtenmaterials) to complex (e.g., teach skill of self-monitoringblood glucose). Nurses play an essential part in deliveringthis education and training, both independently andalongside other health care providers. Nurses are wellplaced and have extensive opportunities to deliver patienteducation and training in a variety of settings (Coster andNorman, 2009). Studies have revealed that nurses areperceived as credible sources of health information. Forexample, Jones et al. (2003) conducted a pilot study andfound that Registered Nurses (RNs) were not onlyperceived as credible sources but that this credibility didnot differ from medical doctors (MDs). Research has alsoshown that patients find nurses easier to approach forhealth information than doctors. For example, Collins(2005) explored both nurse and doctor patient commu-nications and found that overall, patients more openly andfreely communicated with nurses.

Despite the fact that patient education and training arewell-established key features of nursing and that nursesrecognize these as important functions of their role, nursesoften report difficulty providing education and training(see Coster and Norman, 2009; Kim et al., 2008). Forinstance, lack of time is a common barrier to effectivenurse–patient communication. Nurses may only have afew minutes to deliver an important health educationmessage. How do nurses get their message across to theirpatients in order to maximize likelihood of their messageleading to the desired outcome—promotion of healthybehaviors? What well-established, empirically tested,effective strategies can nurses employ to help themsuccessfully achieve their goal? The field of healthpsychology offers a theoretical and conceptual frameworkfrom which nursing can draw upon as a guide to answeringthese questions.

Health psychology emphasizes health promotion anddisease prevention and focuses on the development of

theoretical constructs and empirically derived principles ofbehavior change (Matarazzo, 1980, 1982). Health psychol-ogy is also devoted to ‘‘understanding psychologicalinfluences on how people stay healthy, why they becomeill, and how they respond when they do get ill’’ (Taylor,2003, p. 17). Myers and Beckstead (unpublished manu-script) present an overview of the field of healthpsychology and highlight health psychology’s utility fornursing research, education, and practice by providingexamples of applications in nursing.

Effective health communication is one example of ahealth behavior modification approach and uses theore-tical-based principles to inform and influence individualand community decisions that enhance health (U.S.Department of Health and Human Services [DHHS],2000). Health behaviors and habits are complex, aredetermined by the interplay of multiple factors, and areresistant to change (see Rodin and Salovey, 1989; Taylor,2003). Message tailoring is a health communicationstrategy that involves the customization of informationand interventions to best fit the characteristics and needsof specific target populations or individuals (Kreuter andWray, 2003; Salovey, 2005). There is empirical evidencethat tailored health messages, compared to general, non-tailored health messages, are more persuasive andeffective in promoting behavior change through variousmechanisms such as enhanced salience and stimulation ofgreater cognitive activity or elaboration (e.g., Kreuter et al.,1999; Kreuter and Wray, 2003; Latimer et al., 2005).Nurses have long recognized the value of enhancing nurse–patient communication and of utilizing approaches such asmessage tailoring (although not always labeled as such) innursing interventions (e.g., Coster and Norman, 2009; Kimet al., 2008; Shin et al., 2006). Message framing is onemethod of message tailoring that involves manipulatinghow information is framed in order to affect people’sbehavioral decisions (Rothman and Salovey, 1997). Myersand Beckstead (unpublished manuscript) briefly describemessage framing theory and provide examples of howmessage framing has been applied in health-relateddecision problems. However, they stop short of discussingthe current state of message framing theories and research.

The purpose of this article is to more comprehensivelydescribe developments in message framing as a behavioralchange strategy and to discuss its utility for guidingnursing research, education, and practice. In the nextsection I examine the origins of message framing theory. Ithen discuss its definitions and typologies. Next, Isummarize related theories and conceptual modelsfollowed by a review of empirical studies. Finally, I discussimplications for research, education, and practice with aspecific focus on applications in nursing.

1. Origins of message framing

Decision making under risk involves a choice betweenprospects or gambles. Historically, expected utility theoryhas dominated the analysis of decision making under risk(Kahneman and Tversky, 1979) and involves assigningexpected values to final assets of prospects (choiceoptions). The utilities of outcomes are weighted by their

R.E. Myers / International Journal of Nursing Studies 47 (2010) 500–512502

probabilities of occurrence and are used to determine theoverall utility of each choice option (see Keeney and Raiffa,1976; von Neumann and Morgenstern, 1944, for moredetails about expected utility theory). Kahneman andTversky (1979) demonstrated several phenomena thatsystematically violate the basic tenets of expected utilitytheory and thus concluded that the expected utility theorywas an inadequate descriptive model of decision makingunder risk. As a result, they proposed an alternative modelof risky choice – prospect theory – to better understandpreference and decision making under conditions ofuncertainty.

In comparison to expected utility theory, prospecttheory examines the subjective values and subjectiveprobabilities of choice options rather than the finaloutcomes of wealth and welfare. Kahneman and Tversky(1979) describe the risky choice process as consisting oftwo phases: editing and evaluation. The editing phaseinvolves a preliminary analysis of all possible choiceswhere options are organized and reformulated and out-comes are coded in terms of gains or losses, relative to aneutral reference point or asset position. The subsequentevaluation phase involves evaluating each edited optionfor overall value and choosing the option of highest value.Prospect theory proposes that when potential losses of asituation are made salient and behavioral choices involverisk or uncertainty, people are generally risk-seeking andwill more likely assume these risks. Conversely, whenpotential gains of a situation are made salient andbehavioral choices pose minimal risk or minimal uncer-tainty, people are generally risk-averse and will morelikely act to avoid the risks.

Tversky and Kahneman (1981) introduced and testedhow prospect theory could be applied to the framing ofdecisions. They describe a ‘‘decision problem’’ as one thatcan be defined by the options or acts people must choosefrom, the possible consequences or outcomes of these acts,and the conditional probabilities (contingencies) of out-comes occurring given a particular act. They use the term‘‘decision frame’’ to refer to one’s conception of the acts,outcomes, and contingencies related to a specific choiceand propose several factors that influence which frame adecision-maker will adopt, including one’s cultural norms,habits, and personal characteristics and the formulation ofthe problem. Tversky and Kahneman’s (1981) overallfindings supported basic tenets of prospect theory. Peopletended to be sensitive to whether alternatives were framedin terms of their associated costs or benefits when thesituations were objectively equivalent. The prototypicalexample of risky choice framing effects comes fromTversky and Kahneman’s (1981) ‘‘Asian disease problem’’,in which a hypothetical disease is expected to kill people.Different pairs of alternative options for responding to theoutbreak were presented to research participants,expressed as outcomes of either the number of lives lostor saved. Consistent with prospect theory, the majority ofrespondents chose the risk averse option when gains werecertain (i.e., lives saved) and the risk seeking option whenlosses were certain (i.e., lives lost). Prospect theory andthese early empirical findings laid the foundation for thefuture of message framing research.

2. Message framing: definitions and typologies

Message framing involves manipulating how informa-tion in a message is framed. The ultimate goal of messageframing is usually to promote a particular behavior(Rothman and Salovey, 1997). Message framing effectsare complex, and the empirical literature lacks consistency,as later described. These discrepant findings can partiallybe attributed to the absence of a universal operationaldefinition of message framing. Instead, a variety ofinconsistent operational definitions exist (Wilson et al.,1988), ranging from ‘‘loose’’ to ‘‘strict’’ interpretations(Kuhberger, 1998). Researchers have developed typolo-gies/classification schemes of message framing in anattempt to operationally define message framing anddemonstrate various ways to frame messages (e.g., Fagley,1993; Levin et al., 1998; Rothman and Salovey, 1997;Rothman et al., 1993; Tversky and Kahneman, 1981;Wilson et al., 1988). These various definitions andtypologies reveal that messages can be framed in morethan one way, but most commonly, they are framed interms of gains (benefits) or in terms of losses (costs). Gain-framed messages typically present benefits achieved byadopting a target behavior whereas loss-framed messagesusually convey costs of not adopting the target behavior(Rothman and Salovey, 1997; Salovey, 2005). Nearly allhealth-related information can be framed in terms of gainsand/or losses. This discussion paper primarily focuses onthe gain/loss definition of message framing and how thiscommunication strategy can be utilized by nurses andother health care providers to help get their messageacross with regard to promoting healthy behaviors.

3. Theories and conceptual models of message framingin health research

Historically, prospect theory has been a primaryframework for understanding preference and decisionmaking under conditions of uncertainty and the dominantunderlying theoretical perspective for message framing(Kahneman and Tversky, 1979, 1984; Tversky and Kahne-man, 1981). Empirical evidence suggests, however, thatprospect theory does not solely explain the effects ofmessage framing on all behavior types under all circum-stances, specifically those regarding health-related beha-viors (Levin et al., 1998; Rothman and Salovey, 1997;Wilson et al., 1988). The theory inadequately addressesthe mechanisms and conditions under which messageframing alters people’s attitudes, beliefs, and behaviors.Some researchers have found that prospect theory alone isinsufficient and have offered alternative theoreticalperspectives to help explain why people vary in theirresponses when presented with different but objectivelyequivalent descriptions of the same decision problem. Afew of these alternative perspectives are described next.

Wilson et al. (1988) emphasize consequences as acentral feature in theoretical frameworks of health-behavior change and identify two recurring dimensionsassociated with behavior change research that involveconsequences: perceived value and perceived threat.Besides prospect theory, numerous theories emphasize


perceptions of the value or threat of an outcome containedin a recommendation, such as the health belief model(Hochbaum, 1958; Rosenstock, 1960), health promotionmodel (Pender, 1982), theory of reasoned action (Ajzenand Fishbein, 1980; Fishbein and Ajzen, 1975), theory ofplanned behavior (Ajzen, 1985, 1988, 1991), and protec-tion motivation theory (Rogers, 1975). Several researchershave integrated tenets from prospect theory with one ormore of these other theories to study message framingeffects on health behaviors (e.g., Jones et al., 2004; McCalland Martin Ginis, 2004).

Nearly all health-related information can be framed interms of either benefits (gains) or costs (losses). However,the literature is replete with inconsistent findings, as laterdescribed. Rothman and Salovey (1997) offer potentialexplanations of how and why prospect theory maycontribute to these inconsistent predictions. One plausiblepossibility is the unique differences between health-related decision problems and decision problems initiallytested in prospect theory. First, health decision problemsare often real, dealing with personal issues rather thanhypothetical public health issues. Second, health decisionoptions are sometimes non-discrete and compound (i.e.,may consist of more than two options) instead of discreteand simple. Third, perceived risk for health behaviordecisions is more subjective because formal probabilitiesof outcomes occurring as a result of these decisions areoften unknown. Fourth, in health behavior messageframing research, experimenters often have less controlover the situations in which framed messages arepredicted to exert influence than initial researchers inthis area. This factor could undermine any systematic testof prospect theory’s predictions and result in inconsistentpatterns of findings in health behavior research. Rothmanand Salovey conclude that despite limitations of prospecttheory, its basic assumptions can be operationalized andtested in health behavior research if careful attention ispaid to the context in which a health message is received.

Rothman and Salovey (1997) propose three stages inthe decision-making process during which the relativeinfluence of gain- and loss-framed messages may beexamined. The likelihood that people respond to messageframing in a manner consistent with prospect theory variesover these three stages. First, the amount of attention orcognitive processing people direct to the message canimpact the degree to which they integrate the messageinto a mental representation of the health issue. Second,people’s receptivity to, or acceptance of, a particular framethat a message advocates can also impact framing effects,and people’s past and current experiences influence thisreceptivity. Third, people’s perceived function of theadvocated health behavior (i.e., prevention, detection, orrecuperative) can influence message framing effects.

Rothman et al. (1993) and Rothman and Salovey (1997)describe health behaviors as serving one of three func-tions: to ‘‘prevent’’ onset of a health problem (e.g., regularphysical activity will help prevent high blood glucose), to‘‘detect’’ the development of a health problem (e.g., self-monitoring of blood glucose will detect abnormal bloodglucose levels), or to ‘‘cure or treat’’ an ongoing healthproblem (e.g., insulin administration will help keep blood

glucose levels within the desired range). The effect ofmessage framing is partly based on whether taking actionis perceived to involve risk or uncertainty. For example,people tend to perceive performance of a detectionbehavior as risky (e.g., it may identify an illness) andperformance of a prevention behavior as relatively safe(e.g., it maintains one’s health status). Based on theoreticalprinciples and the empirical literature, Rothman andSalovey (1997) draw the following conclusions: loss-framed messages are predicted to be most effective inpromoting detection behaviors and gain-framed messagesare predicted to be most effective in promoting preventionbehaviors. Many behaviors are typically construed ashaving just one function (i.e., prevention, detection, orcuring), but some behaviors may be perceived as servingmultiple functions. For example, some women mayperceive undergoing a Pap test as serving a detectionfunction because it detects the presence or absence ofcervical problems. However, some women may alsoperceive undergoing a Pap test as serving a preventionfunction because if it reveals mild cervical abnormalities,early interventions can be done to try and prevent further,more severe abnormalities (e.g., cervical cancer). It isplausible that such dual perceptions have contributed tothe inconsistent findings in the literature.

Studies are emerging that integrate persuasion theorieswith prospect theory to examine message framing effectson health behaviors. One example is Petty and Cacioppo’s(1986) elaboration likelihood model (ELM) of persuasioneffects. The basic premise of ELM is that a message’spersuasive ability to influence a person’s change in attitudeabout a particular issue or argument depends on how likelythe person will elaborate upon (i.e., think about) this issueor argument. Several variables drawn from ELM have beenshown to produce moderating effects on message framing.For example, Jones et al. (2003) found that sourcecredibility moderates the effect of message framing onexercise intentions, exercise behaviors, and cognitiveresponse/elaboration measures. People who received again-framed message from a credible source elaboratedthe message the most and reported the greatest amount ofexercise intentions and behaviors.

Studies are also emerging that integrate motivationtheories with prospect theory to examine message framingeffects on health behaviors. According to several theoriesof motivation (see Carver et al., 2000, for a review),behavior is regulated by two distinct, orthogonal systems:an approach system and an avoidance system. Bothsystems represent chronic dispositional motivation styles,where one system (approach) regulates ‘‘appetitive’’behavior toward potential rewards and the other system(avoidance) regulates ‘‘aversive’’ behavior away frompotential threats or punishments (Carver and White,1994; Gray, 1982, 1990). Therefore, people with apredominant approach-orientation respond more to cuesof reward or incentive, whereas people with a predomi-nant avoidance-orientation respond more to cues ofpunishment or threat (Carver et al., 2000). Mann et al.(2004) propose that motivational style (approach/avoid-ance orientation) interacts with message frame. Theydeveloped a congruency hypothesis, which predicts that


health messages framed to be aligned with motivationalstyle will be the most effective in promoting healthbehaviors. Early empirical findings offer support for thishypothesis (e.g., Mann et al., 2004; Sherman et al., 2006).

Regulatory focus theory (Higgins, 1997, 1998, 1999)predicts that regulatory focus (or goal orientation) is thedominant motivation system that guides decision-makingand behavior. This theory distinguishes between two typesof goal orientation: promotion-focus and prevention-focus. People with a promotion-focus (‘‘promoters’’) aremotivated by advancement and accomplishment andeagerly pursue goals that ensure the presence of positiveoutcomes (e.g., they regularly exercise to achieve optimalblood glucose control). People with a prevention-focus(‘‘preventers’’) are motivated by security needs andvigilantly pursue goals that ensure the absence of negativeoutcomes (e.g., they regularly exercise to avoid high bloodglucose). The regulatory focus motivation system reflectsspecific types of desired end states (final outcomes) ratherthan broad dispositions as emphasized in the approach/avoidance system (Mann et al., 2004). Similar to thecongruency hypothesis in the approach/avoidance system,the ‘‘value from fit’’ hypothesis states that when peoplepursue goals in a manner consistent with their regulatoryfocus, they experience a sense of ‘‘fit’’ which increases thevalue of their behavior (Higgins, 2000). Several studiessupport this hypothesis and have found that a messageframed to fit people’s regulatory focus in their goalorientation is more persuasive. Examples in health careinclude: smoking cessation (e.g., Zhao and Pechmann,2007), dieting (e.g., Fuglestad et al., 2008), physical activity(Latimer et al., 2008a), sunscreen use (Keller, 2006), dentalflossing (Uskul et al., 2009), and fruit and vegetable intake(e.g., Latimer et al., 2008b).

The construct of promotion and prevention focusappears related to the construct of approach and avoidanceorientation. An approach strategy is usually taken forpromotion, and an avoidance strategy is usually taken forprevention (Higgins, 1997). Similar behavioral predictionsabout message framing effects are sometimes made forapproach-oriented and promotion-focused people, as wellas for avoidance-oriented and prevention-focused people(Lee and Aaker, 2004; Mann et al., 2004; Rothman et al.,2008). However, no study in health behavior research todate has examined both constructs in the same sample.Studies are emerging that test the hypothesis that peoplewho have an approach orientation or a promotion focusrespond more favorably to gain-framed message appeals,whereas people who have an avoidance orientation orprevention focus respond more favorably to loss-framedmessage appeals. Several of these studies have providedempirical support for this hypothesis (e.g., Lee and Aaker,2004; Mann et al., 2004; Sherman et al., 2006; Uskul et al.,2009). Research on the interaction of dispositional factorswith message frame needs to be both replicated andextended to include potential moderators of this interac-tion effect on health behaviors.

Rothman et al. (2006, 2008) provide a new conceptua-lization of framing effects on health behaviors. Theyacknowledge two dominant perspectives that to date haveguided researchers in understanding the conditions under

which gain- and loss-framed messages should be maxi-mally persuasive: situational factors (i.e., differences inhealth behavior function) and dispositional factors (i.e.,individual differences in sensitivity to favorable orunfavorable outcomes). Both factor types have been testedseparately as potential moderators in regulating persua-siveness of gain- and loss-framed messages in thepromotion of health behaviors. Rothman et al. (2006,2008) suggest that both sets of moderating factors mayrest on a single set of underlying cognitive and affectiveprocesses, based on tenets of the regulatory focus theory,and thus propose the two factors should be measuredsimultaneously when testing message framing effects.They hypothesize that health behaviors can evoke either apromotion- or prevention-focus mindset, and this effect isinfluenced by both features of the behavioral domain andcharacteristics of the individual. More specifically, theypredict when people consider performing a behaviorintended to promote health (e.g., physical activity), peoplewill experience thoughts and feelings consistent with apromotion-focus mindset, whereas when people considerdoing a behavior intended to detect the presence of ahealth problem (e.g., exercise stress test), people willexperience thoughts and feelings consistent with aprevention-focus mindset. The variability in how peopleinterpret a given behavior (as either promotion ordetection) will moderate relative influence of the framedmessage. Consideration of this integrated approach ofsituational and dispositional factors has only recentlyappeared in the literature.

In summary, many theories and conceptual frameworkshave been proposed to explain message framing effects onhealth behaviors. Early studies of message framingtypically involved just one theoretical approach, namelyprospect theory. More recently, studies have involved theintegration of two or more theories. Strong evidencesupports that no one theory or model can solely explainmessage framing effects. Multi-theoretical integratedapproaches are necessary to better understand thecomplexity of these effects. Examples of these approachesare described in the next section.

4. Empirical studies

Prospect theory was initially tested in laboratorysettings using discrete choice decisions involving mone-tary outcomes (e.g., gambling and purchasing) andhypothetical situations. Since Tversky and Kahneman’s(1981) original ‘‘Asian disease problem’’, many studieshave used message framing to test the preference reversalprediction of prospect theory across a broader range ofdecision problems (Rothman et al., 1993). In particular,there has been a recent increase in the study of messageframing effects on health behaviors.

I conducted a review of the literature to assess thecurrent state of message framing research in healthbehaviors. I used three methods to locate relevantempirical studies: computerized database searches ofCINAHL, PsycINFO, and PubMed, using ‘‘message framing’’as a search term; examination of previous reviews andtextbooks; and inspection of reference lists in previously


located studies. My overall impressions of findings andconclusions from these reviews and studies are presentedhere.

This literature review revealed that over the past 20years, 25-plus health related behaviors have been studiedin message framing research, such as smoking (e.g.,Moorman and van den Putte, 2008), drinking (e.g., Gerendand Cullen, 2008), exercise/physical activity (e.g., Jones etal., 2003), eating habits/behaviors (e.g., Tykocinski et al.,1994), dental hygiene (e.g., Sherman et al., 2006), prostateexams (e.g., Cherubini et al., 2005), mammograms/breastscreenings (e.g., Finney and Iannotti, 2002), Papanicolaou(Pap) tests (e.g., Lauver and Rubin, 1990), skin cancerprevention (e.g., Rothman et al., 1993), heart disease (e.g.,Meyers-Levy and Maheswaran, 2004), vaccinations (e.g.,Gerend and Shepherd, 2007), and hand hygiene (e.g.,Jenner et al., 2005). These papers were primarily found inthe psychology literature with only a few in the nursingliterature (e.g., Jenner et al., 2005; Lauver and Rubin,1990). Several studies involved hypothetical health-related situations such as a new viral disease (e.g.,Rothman et al., 1999, Experiment 1) rather than actualhealth problems such as breast cancer risk (e.g., Finneyand Iannotti, 2002). Also of note, many studies involvedcollege students (often undergraduate psychology stu-dents) (e.g., Sherman et al., 2006) rather than represen-tative samples of persons with or at high risk fordeveloping various diseases such as skin cancer (e.g.,Detweiler et al., 1999).

Whereas several early studies tested only main effectsof framing on health behaviors, more recent research onmessage framing has focused on identifying and examin-ing variables that moderate framing effects. Over 20moderators of this relationship have been studied. Some ofthese variables are situational such as health behavior typeor function (e.g., Hsiao, 2003), framing method (e.g.,Ferguson and Gallagher, 2007), temporal context (e.g.,Gerend and Cullen, 2008), and type of value appeal (e.g.,Robberson and Rogers, 1988). Other variables are disposi-tional and represent individual differences such ascognitive processing style (e.g., Meyers-Levy and Mahes-waran, 2004), issue involvement (e.g., Rothman et al.,1993), personal relevance (e.g., McElroy and Seta, 2003),stages of readiness to change (e.g., Hsiao, 2003), need forcognition (e.g., Rothman et al., 1999), perceptions ofbenefits, risks/threats, susceptibility, and/or disease sever-ity (e.g., Toll et al., 2008), behavioral norms (e.g., Blantonet al., 2001), perceived source credibility (e.g., Arora et al.,2006; Jones et al., 2003), motivational style (e.g., Gerendand Shepherd, 2007; Mann et al., 2004), regulatory focus(e.g., Uskul et al., 2009), and consideration of futureconsequences (e.g., O’Connor et al., 2009). One moderatorthat emerges from this extensive list which seemsintuitively appealing to nurses is consideration of futureconsequences (CFC). Nurse researchers recognize thatmany, if not most, behaviors result in short and long-termhealth consequences and have examined constructssimilar to CFC such as subjective time experience (e.g.,Sanders, 1986; Strumpf, 1987), future time perspective(e.g., Rew et al., 2002), and health temporal orientation(e.g., Russell et al., 2003, 2006).

Strathman et al. (1994) proposed the CFC construct.They describe it as a cognitive mindset that refers to theextent to which people consider the potential distantoutcomes of their current behaviors and the extent towhich they are influenced by these potential outcomes.They hypothesize that people low in CFC focus more ontheir immediate needs and concerns and will therefore actto satisfy these immediate needs. Conversely, people highin CFC consider the future implications of their behaviorand act in accordance with their distant goals. Severalstudies of a variety of health behaviors support Strathmanet al.’s (1994) CFC hypothesis such as colorectal screening(e.g., Orbell et al., 2004), diabetes screening (Orbell andHagger, 2006), sunscreen use (Orbell and Kyriakaki, 2008),exercise (e.g., Ouellette et al., 2009), and smoking (Adamsand Nettle, 2009). Although CFC is a relatively stableconstruct over time, it may be changeable under certaincircumstances such as when individuals experience asignificant event or dramatic change in their life. Inaddition, messages can be manipulated in various ways tomatch individuals’ CFC and thus increase effectiveness ofthe message. CFC has been shown to impact messageframing, regulatory focus framing, and temporal framing.O’Connor et al. (2009) found that people high in CFC aremore responsive to loss-framed messages related to healthinformation-seeking behaviors, and people low in CFC aremore responsive to gain-framed messages (an example ofmessage framing effects). Kees (2007) found people high inCFC reported greater levels of persuasion than people lowin CFC when a message related to consuming unhealthyfoods was prevention-framed; however, when the mes-sage was promotion-framed, people low and high in CFCresponded similarly (an example of regulatory focusframing effects). Orbell and Kyriakaki (2008) found thatpeople high in CFC reported greater intentions to usesunscreen when positive outcomes were presented asdistal and negative outcomes were presented as immedi-ate; the opposite was true for people low in CFC (anexample of temporal framing effects).

Regardless of whether examining main effects ormoderating effects, the overall pattern of results formessage framing’s influence on health behavior decisionsis inconsistent. Several studies revealed findings in linewith Rothman and Salovey’s (1997) predictions, whereloss-framed appeals were more effective for detectionbehaviors (e.g., Kalichman and Coley, 1995; Meyerowitzand Chaiken, 1987; Rothman et al., 1999) and gain-framedappeals were more effective for prevention behaviors (e.g.,Detweiler et al., 1999; Jones et al., 2003; Rothman et al.,1999). However, several studies failed to find an advantagefor either frame (e.g., Lalor and Hailey, 1990; Lauver andRubin, 1990) or found the message framing effect to belimited to a specific subset of individuals (e.g., Apanovitchet al., 2003; Finney and Iannotti, 2002).

Several researchers have offered possible explanationsfor these and other discordant results, including thelimitations of prospect theory (e.g., Rothman and Salovey,1997), ambiguous theoretical terms such as ‘‘risk’’ (O’Keefeand Jensen, 2006, 2007), inconsistent applications ofprospect theory (e.g., O’Keefe and Jensen, 2006, 2007),the influence of other theories/conceptual models (e.g.,


Wilson et al., 1988), the lack of a universal operationaldefinition of message framing (e.g., Levin et al., 1998), thevariability in taxonomies/classification schemes of mes-sage framing (e.g., Levin et al., 1998), the diversity ofbehaviors studied (e.g., Wilson et al., 1988), and theexistence of omitted moderating variables (e.g., Rothmanand Salovey, 1997).

Three meta-analysis papers on message framingresearch have been published in an attempt to system-atically organize, analyze, and summarize the effects ofmessage framing on health behaviors. The earliest meta-analysis was by Kuhberger (1998). He examined 136empirical papers that reported framing experiments. Basedon studies described within these papers, he calculated 230single effect sizes. His analysis encompassed a broad scopeof domains (health, business, gambling, and social), studydesigns, and framing types. He defined and coded studycharacteristics in the following areas and examined each as apotential moderating variable: risk characteristics (includ-ing risk manipulation, quality of risk, and number of riskyevents); task characteristics (including framing manipula-tion, response mode, comparison, unit of analysis, andproblem domain); participant characteristics (includingwhether the sample was students or the target audience);and year of publication. His findings revealed that overallmessage framing produced small to moderate effects. Inaddition, he found that taken as a whole, most of the studycharacteristics were significant moderators except partici-pant characteristics (student vs. target population) and unitof analysis (individual vs. group).

More recently, O’Keefe and Jensen (2006) conducted ameta-analytic review of the relative persuasiveness ofgain- and loss-framed messages based on 165 studies.They classified the studies into one of six distinct broadtopical categories: disease detection behaviors, diseaseprevention behaviors, other health-related behaviors,sociopolitical subjects, advertising of consumer productsand services, and other (otherwise unclassified). They alsocoded each appeal as containing one of four types of kernelstate phrasing (which refers to linguistic representations ofthe consequence/outcome): exclusively desirable, exclu-sively undesirable, combination of desirable and undesir-able, or indeterminate (related to unavailability ofsufficient message detail). They examined both messagetopic and kernel state phrasing as potential moderatingvariables. For each distinguishable message pair, theycalculated an effect size to summarize the comparisonbetween a gain-framed message and its loss-framedcounterpart. Across all 165 studies, they did not find asignificant persuasive advantage for one framing form overthe other. However, they did find that message topic had asignificant moderating effect. Of the five substantivebehavior categories examined, only disease preventionshowed a significant difference in persuasiveness. Formessages advocating disease prevention behaviors, therewas a significant persuasive advantage of gain-framedmessages over loss-framed messages (consistent withtheoretical predictions). Contrary to expectation, however,for messages advocating disease detection behaviors, gain-and loss-framed messages did not significantly differ. Inaddition, they did not find any significant moderating

effects of kernel state phrasing. O’Keefe and Jensen (2006)offer several possible explanations of their findings. Themost plausible explanation is presented next.

As previously discussed, health prevention and detec-tion behaviors are commonly described in terms of theirrisk, with prevention behaviors typically perceived as lessrisky than detection behaviors. It is this distinguishingcharacteristic that has guided several theoretical predic-tions of message framing effects on these behaviors.O’Keefe and Jensen (2006) suggest that the word ‘‘risk’’ andits variants (e.g., ‘‘risky’’) are ambiguous and have variousinterpretations. In the original prospect theory (Kahnemanand Tversky, 1979, 1984; Tversky and Kahneman, 1981),‘‘risk’’ refers to the association between action andoutcome; an action is perceived as ‘‘risky’’ if its outcomesare perceived as probabilistic or not certain. In the morefamiliar application of prospect theory to gain-lossmessage variation (e.g., Rothman and Salovey, 1997),‘‘risk’’ refers to the perceived desirability or dangerousnessof an outcome; an action is perceived as ‘‘risky’’ if theoutcome is undesirable or dangerous. These differentinterpretations of prospect theory make some theoreticalassumptions problematic. For example, some people mayperceive exercise (a prevention behavior) as ‘‘not risky’’because it is typically safe; others may perceive exercise as‘‘risky’’ because the outcomes are not certain. If people uselevel of uncertainty to classify a behavior’s level of risk, thismay result in no difference of perceived risk betweendisease detection and disease prevention behaviors andthus no effect of message framing.

In an extension of this meta-analysis, O’Keefe andJensen (2007) published another review, with a specificfocus on only disease prevention behaviors. They analyzed93 studies that examined the use of gain-framed and loss-framed messages in advocating disease prevention beha-viors. Unlike their previous analysis, they classified theseprevention behaviors into eight broad categories: diet/nutrition behaviors, safer-sex behaviors, skin cancerprevention behaviors, dental hygiene behaviors, exercisebehaviors, smoking cessation or non-initiation, inoculation(vaccination), and other (or multiple different) preventionbehaviors. They also coded each appeal as containing oneof four types of kernel state phrasing. They examined bothspecific behavior type and kernel state phrasing as designvariables potentially moderating framing effects. For eachdistinguishable message pair, they calculated an effect sizeto summarize the comparison between a gain-framedmessage and its loss-framed counterpart. They found asignificant advantage of gain-framed appeals, but theeffect size was extremely small and limited to oneprevention behavior (dental hygiene). For messagesadvocating dental hygiene behaviors, the analysis revealedexpected results: gain-framed appeals were more persua-sive than loss-framed appeals. However, the analysis foundno differences in persuasiveness between framed mes-sages concerning any of the other seven preventionbehavior categories. For kernel state phrasing, they foundmessage framing effects do not dependably vary as aconsequence of kernel state phrasing in gain-framedappeals but that they do dependably vary in loss-framedappeals.


O’Keefe and Jensen (2007) go on to discuss possibleexplanations for their findings, including unique character-istics of dental hygiene behaviors. The most plausibleexplanation they offer relates to the varying ambiguousinterpretations of ‘‘risk’’, as previously described in their2006 meta-analysis. They suggest that it cannot be assumedthat all health prevention and health detection behaviors areconsidered risk-averse and risk-seeking, respectively. Con-sequently, it cannot be predicted that matching gain- andloss-framed messages with prevention and detectionbehaviors, respectively, will always be more effective. Theyalso suggest the perceived protective outcomes of perform-ing dental hygiene behaviors may be more certain (and thusless risky) than the protective outcomes of performing theother seven prevention behaviors, which would potentiallymake the dental hygiene behaviors more sensitive to theexpected effects of gain-framed messages.

As with any meta-analytic study, each of the threereviews on message framing research had limitations thatneed to be considered, such as the exclusion of potentiallyrelevant studies, the lack of sufficient message details toexamine interesting variables such as ‘‘dose’’ of framingmanipulation, the methods for calculating certain effectsizes (as noted in O’Keefe and Jensen, 2007), andinsufficient power to detect differences in all conditions(e.g., as noted in O’Keefe and Jensen, 2007, for both exerciseand skin cancer prevention behaviors). In addition, O’Keefeand Jensen (2006, 2007) did not examine study character-istics as moderators in either of their meta-analyticreviews, a variable that produced several significantmoderating effects in the Kuhberger (1998) review. Ofeven greater concern is that none of the reviews examinedindividual differences or other more general cognitivedimensions as potential moderators of the messageframing effect on health behavior decisions. Latimer etal. (2007) suggest the effectiveness of framed messageshinges on how the individual thinks and feels about thebehavior and not just the function or nature of the behaviorper se. Failure to consider the influence of individualdifferences on message framing effects may suppress thetrue framing effects and underestimate the utility of gain-and loss-framed appeals.

5. State of the literature conclusions

Based on my review of the message framing literature, Inow present my conclusions regarding the current state ofthe literature and a few suggestions for advancing thisliterature. Additional, more specific recommendations areoffered in the next section. First, I conclude that althoughthree meta-analysis papers on message framing researchhave been published, all three fall short of providing anadequate, comprehensive summary. For example, thesepapers do not consistently report and compare studycharacteristics such as research design, sample description,research setting, nature of the health problem (hypotheticalor real), dependent variables (e.g., attitudes, beliefs, inten-tions, and behavior changes), moderating variables, andmeasures used. Inclusion of these and other factors such asunderlying theoretical/conceptual frameworks in futuremeta-analyses will provide a richer understanding of the

literature and better equip researchers to propose mean-ingful recommendations based on their synthesis.

Next, I conclude that although message framing studieshave been conducted on a breadth of prevention anddetection behaviors, fewer studies have examined pre-vention (Rothman et al., 2008). This is of concern giventhat three modifiable prevention behaviors – unhealthydiet, physical inactivity, and tobacco use – are largelyresponsible for the high prevalence and incidence ofchronic diseases (WHO, 2005b). For example, only seven ofthe studies I reviewed examined the effect of messageframing on physical activity intentions and/or behaviors(Arora et al., 2006; Hsiao, 2003; Jones et al., 2003, 2004;Kroll, 2005; McCall and Martin Ginis, 2004; Robberson andRogers, 1988). All but two of these seven (Kroll, 2005;McCall and Martin Ginis, 2004) were basic studiesconducted on either high school or college students ratherthan more salient, target populations such as people withtype 2 diabetes or cardiovascular disease. This finding issimilar to the overall trend noted in message framingstudies across many health behaviors.

Furthermore, I conclude that although numerous mod-erators of message framing effects have been studied, acomprehensive analysis and synthesis of these effects hasnot been published. Systematic reviews are needed tothoroughly summarize these relationships, which will yielda fuller understanding of message framing’s boundaries. Inaddition, other types of message tailoring such as temporalframing (immediate vs. distal consequences) should beexamined simultaneously with message framing (gains vs.losses) to test for interactions that may yield even morepersuasive health promotion messages than either manip-ulation alone. Studies such as these have only recentlystarted to evolve.

Finally, I conclude that message framing is severelylacking in the nursing literature and is underutilized bynurses and other health care providers. Message framingoffers promising research, education, and practice impli-cations for providers, as presented in the next section.

6. Research, education, and practice implications

Nations are calling for an increase in health commu-nication research as one strategy to address the globalepidemic of chronic diseases. For example, health com-munication is 1 of 28 focus areas in the U.S. Healthy 2010initiative (DHHS, 2000). The initiative calls for an increasein health communication evaluation and research aimed atenhancing health care providers’ communication skills sothat providers may design and deliver more effectivemessages intended to promote behavior changes. There isa paucity of published empirical studies that adequatelyexamine health care provider educational interventionsand the effectiveness of these interventions in contributingto desired outcomes. Coster and Norman (2009) report onfindings of a review of 30 Cochrane systematic reviews ofeducational interventions designed to improve patients’knowledge and skills to manage chronic disease, withparticular reference to nursing contribution and practice.The majority of reviews (60%) were judged to provideinadequate evidence of the effectiveness of the interven-


tions. This insufficient evidence, coupled with lackingquality of several trials that were evaluated, limitedCochrane reviewers’ ability to draw firm conclusions onthe effectiveness of educational interventions and to makespecific clinical practice recommendations. Future experi-mental studies are needed to help identify the ‘‘ingredi-ents’’ of successful messages (e.g., gain- vs. loss-framed)that health care providers deliver to their patients, with anemphasis on how to tailor these ‘‘ingredients’’ based onindividual differences among their learners.

Message framing is an effective health communicationstrategy that has been well-studied in the psychologyliterature over the past 20-plus years across a breadth ofhealth behaviors. However, most of these studies wereconducted in a laboratory setting with college students(sometimes using hypothetical health problems) ratherthan in a patient setting with a more salient targetpopulation, using actual health problems. Nurses are wellplaced in various clinical settings and thus have a powerfulopportunity to help fill this gap in the literature byextending previous findings of message framing effects tohealth care provider educational interventions research.For example, when delivering diabetes self-managementeducation to adults with type 2 diabetes, is a gain-framedor loss-framed message more effective in promotinghealthy behaviors such as regular physical activity? Whatindividual differences among these learners, such as CFC,motivational style, or perception of risk, moderatemessage framing effects? What other types of messagetailoring such as temporal framing (immediate vs. distalconsequences) may interact with message framing? Howshould providers customize their message based ondifferences in dispositional and situational factors in orderto maximize persuasiveness of the message? Studies suchas this example which involve other highly prevalentchronic diseases (e.g., cardiovascular disease and cancer)and associated modifiable health behaviors (e.g.,unhealthy diet and tobacco use) will provide empiricalanswers to these questions and strengthen researchers’ability to ascertain what educational interventions willwork for whom and in what situations. These studies willalso respond to the international call for increased healthcommunication research. Nurses have a prime opportunityto be on the cutting edge of message framing research inclinical settings involving target populations that will helpguide the practice of health care providers in variousdisciplines in delivering influential messages to theirpatients. Research alone, however, is insufficient toachieve this desired goal. The valuable role of educationmust also be considered.

Nurses and other health care providers require ade-quate knowledge and skills to successfully apply andincorporate research findings into their communicationand education practices. However, providers vary in theircommunication abilities, and there is a scarce amount ofsuitable training opportunities to enhance these skills(Astin and Closs, 2007; Kim et al., 2008; WHO, 2005a). TheWHO (2005a) reports that training of the internationalhealth care workforce has generally not kept pace with therapid escalation of chronic health problems and that theworkforce demonstrates a lack of training, education, and

skill set to effectively manage patients with chronicconditions. This is largely related to challenges encoun-tered during the recent transformation from the traditionalprovider-centered approach (which emphasized treatingacute, episodic illnesses) to the contemporary patient-centered approach (which emphasizes promoting healthand preventing chronic conditions and associated compli-cations). The WHO (2005a) presents a new and expandedtraining model that consists of five core competencieswhich augment rather than replace existing competenciesand can be implemented in a variety of training contexts.This model is designed to help expand the skills of allhealth care providers to meet the new complexitiesassociated with the chronic disease epidemic. The firstcompetency in this model – patient-centered care – isparticularly relevant to the health communication litera-ture as it includes the following main components:interviewing and communicating effectively, assistingchanges in health-related behaviors, supporting self-management, and using a proactive approach. Astin andCloss (2007) comment on how the WHO report (2005a) canbe specifically applied to nursing, particularly the patient-centered care competency. They suggest that little hasbeen done to equip nurses with the adequate knowledgeand skills required to deliver self-management educationand thus call for greater training opportunities.

Health care providers in general need to be competentin designing and delivering educational messages based ontheoretically sound and empirically tested health com-munication strategies such as message framing. Presentingmultiple training opportunities in various settings andcontexts will enhance the ability of providers to effectivelyeducate and motivate their patients to better care forthemselves. For example, in nursing academic programs,therapeutic nurse–patient communication and educationis a learning objective that cuts across a broad spectrum ofhealth behaviors associated with chronic disease manage-ment and prevention. Therefore, components of healthcommunication research and well-established educationalinterventions should be woven throughout the curricula ofall relevant courses in the program. In clinical settings, on-site workshops might be offered or off-site education couldbe made available to staff. Interactive exercises mayespecially be useful when teaching communication skills,such as audio-/videotaping learners during role-playscenarios and playing back these tapes for learners andpeers to critique their own performance. Less formaleducational opportunities such as independent learning(e.g., handbooks and online literature reviews) and real-time, ‘‘on-the-job’’ mentoring may also be valuable andpromote reinforcement and enhancement of these learnedskills. In addition to health communication approaches,providers also need to be familiar with situational anddispositional factors that have been shown to impactpersuasiveness of approaches like message framing.

As with any training, initial and ongoing competenceneeds to be assessed, which is consistent with the WHO’s(2005a) model. For example, ability to execute effectivecommunication strategies might be evaluated via methodssuch as requiring learners to develop tailored written orverbal health behavior messages (e.g., gain- vs. loss-


framed; immediate vs. distal framed) and then deliverthese messages in various contexts such as simulation, roleplaying, or demonstration with the target audience. Abilityto assess for potential moderating variables and to applythe results could be evaluated by having learners completewell-known, validated measures (e.g., CFC scale for CFC(Strathman et al., 1994) and BIS/BAS scale for motivationalstyle (Carver and White, 1994)) and to then select whichversion of the framed message they designed should bemost persuasive in promoting the healthy behavior (basedon theory and research). Health care providers’ compe-tence in skills such as these is necessary to help maximizethe potential practice implications of well-establishedhealth communication strategies.

Researchers have found that health care providereducational interventions for patients with chronic con-ditions such as asthma, diabetes, and epilepsy cancontribute to desired patient outcomes like increasedknowledge, adoption of healthy self-management beha-viors, and improved health status (see Barlow et al., 2002;Coster and Norman, 2009). Most importantly, thesebenefits help patients experience better overall healthand quality of life. Furthermore, these desired outcomesare also valuable to providers themselves. For example,reimbursement for services to clinicians such as nursepractitioners and physicians is often tied to how successfultheir patients are at achieving targeted clinical goals suchas normal hemoglobin A1C, blood pressure, and blood lipidlevels. Clinicians are well aware of these goals but struggleto obtain them, largely related to patient education issues.

As part of a patient-centered approach, a vast amount ofteaching aimed at promoting healthy behaviors is requiredfor patients with chronic conditions and related co-morbidities. Well-established health communication stra-tegies such as message framing are needed to acceleratethe speed in which patients adopt these behaviors in orderto expedite attainment of targeted goals and healthbenefits. Health care providers report several barriers toproviding effective educational interventions such as lackof knowledge of well-established strategies, lack ofconfidence in ability to implement these strategies, lackof time to personally deliver health education, and lack ofcommunication aids to reinforce and support this educa-tion (see Coster and Norman, 2009; Kim et al., 2008).Message framing is an approach that offers excitingpromise in its potential to help lessen these barriers, aspreviously described with regard to research and educa-tion implications and as further described next.

Health care providers often use printed materials todeliver patient education. It is usually preferable to use thesematerials in conjunction with personally delivered educa-tion to help reinforce and support the messages. In reality,however, printed materials are often used as the primarymeans to educate patients, largely due to insufficient timefor personal delivery of the messages. Thus, it is essential tohave adequate materials that either alone or coupled withpersonal education are highly persuasive in promotinghealthy behaviors. Most printed materials utilized are fromthe health care industry (e.g., pharmaceutical and medicalsupply companies) and are not always readily available toproviders. In addition, these materials often contain biased,

branded, inadequate information, are written at unaccep-table reading and readability levels, and are not modifiableto account for individual differences in learners. Theselimitations weaken the persuasive power of these materialsand may even render them ineffective and meaningless topatients. As a result, providers may be required to designtheir own printed materials. Principles of message framingand other message tailoring strategies can help guide nursesand other providers in developing customized materials toenhance overall effectiveness of educational interventions.

In addition to written materials, message framing haspotential for high utility by health care providers indelivering less formal, verbal health messages. As part ofthe initial assessment, where providers should routinelyassess patient characteristics like readiness to learn andpreferred learning styles prior to providing education,providers could also evaluate individual characteristicsthat moderate message framing effects on health beha-viors (e.g., motivational orientation and CFC). Many ofthese characteristics can quickly be assessed using short,well-established instruments. Based on theory andresearch, providers could then use these assessmentfindings to customize framing of the verbal message(e.g., gain vs. loss or immediate vs. distal) to be mostcongruent with their patient’s characteristics (e.g.,approach- vs. avoidance-oriented or low vs. high CFC).This strategy can be used to deliver education in a varietyof clinical settings such as informally at the bedside orformally during a structured teaching session.

All messages, regardless of the medium through whichthey are delivered, need to be appropriately customized.Knowing the right combination of ‘‘ingredients’’ that aremost effective with specific populations under a variety ofcircumstances will assist providers and the health careindustry to formulate ‘‘optimally’’ tailored messages tohelp maximize their persuasiveness in promoting behaviorchange and hastening attainment of targeted goals.

7. Conclusion

This article has provided a detailed review of messageframing and its utility for nursing. The evolution ofmessage framing, its definitions and typologies, prominenttheories and conceptual models, a review of empiricalstudies, and implications for research, education, andpractice with specific applications for nursing werediscussed. As the paragraphs above illustrate, messageframing has been widely studied over the past 20-plusyears as a behavior change strategy in the health behaviordomain. Over 150 studies have examined message framingeffects on the promotion of self-care behaviors (seeKuhberger, 1998; O’Keefe and Jensen, 2006, 2007). Earlystudies tested only main effects of framing on healthbehaviors, but this approach was overly simplistic andcontributed to discordant findings. More recently researchhas focused on testing potential moderating variables thatinfluence message framing effects. Numerous moderatorshave been identified, particularly variables involvingindividual differences.

Historically nurses have acknowledged and valuedindividual differences in patient characteristics and have


recognized the advantages of tailoring message content tobe congruent with patient characteristics, thus enhancingthe effectiveness of nurse–patient communication (e.g.,Coster and Norman, 2009; Shin et al., 2006). It is well-established that a message tailored to fit a person’s needsand characteristics enhances the message’s persuasiveness(Kreuter and Wray, 2003). The challenge lies in knowinghow to precisely customize messages to help optimize theirdesired effects (i.e., promoting healthy behaviors). Messageframing is one example of a message tailoring approach thathas been shown to increase the effectiveness of messages.However, this approach has been largely understudied innursing. Clearly a multi-theoretical, integrated, interdisci-plinary approach is necessary to provide a richer under-standing of message framing effects on health behaviors.Nurses should embrace the opportunity to apply principlesfrom the health psychology literature to the nursingliterature.

Although health psychology has generated manyinteresting approaches for improving people’s healththrough promoting behavioral change, much of the workin this field may be described as basic research aimed atclarifying constructs and establishing principles. In con-trast, much of nursing research may be described asapplied research aimed at solving challenging problemsusing practical means in ‘‘real world’’ settings. Psychologytheory coupled with nursing practice is an untappedpartnership that has exciting possibilities for increasingthe effectiveness of health communication approaches.Myers and Beckstead (unpublished manuscript) illustratehow collaboration between health psychology and nursingin general can produce scientific progress in health care byfacilitating a cohesive progression of empirical validationand extension from basic research to practical application.Nurses can benefit from this partnership by a heightenedawareness of the vast theoretical and empirical healthpsychology literature. Health psychologists may alsobenefit from this partnership by collaborating with suchnurses who can provide valuable insight into how best toadapt and apply established scientific knowledge to thepromotion, improvement, and maintenance of humanhealth and well-being. Collectively, this collaboration willbring about a richer understanding of how to employ apatient-centered approach to effectively get health mes-sages across to target populations. This enhanced under-standing will better equip nurses and other health careproviders to design and deliver appropriately tailoredhealth messages in order to optimize promotion of healthyself-management behaviors and ultimately contribute to areduction in the burdensome impact of chronic diseasesthroughout the world.

Conflict of interest

None.

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Promoting healthy behaviors: How do we get the message across?