The results of the study, published today (Dec. 7) in the Cochrane Database of Systematic Reviews, contradict the premise of the framing effect on making health decisions. The framing effect is supported by the Prospect theory, for which Princeton University psychologist Daniel Kahneman was awarded the 2002 Nobel Prize for economics and which describes decisions between alternatives that involve risk.
The systematic review synthesized data from 35 studies of 16,342 participants.
“We found that, in general, framing may have little, if any, effect on health consumers’ behavior,” says Elie A. Akl, MD, PhD, lead author and assistant professor of medicine, family medicine and social and preventive medicine at UB’s School of Medicine and Biomedical Sciences and School of Public Health and Health Professions. Akl also holds a part-time appointment in the Department of Clinical Epidemiology and Biostatistics at McMaster University.
The study was designed to systematically review all empirical evidence about how the framing effect influences health consumers.
“There is a widely held belief in the medical and public health communities that the framing of health messages can affect the behaviors of health-care consumers,” Akl explains. “If true, then clinical and public health practitioners could develop health messages that are framed in ways that would positively affect the health behaviors of consumers. Framing would provide clinical and public health practice with an easy to use, inexpensive tool that could actually improve public health.”
But the results didn’t show any such effect. The study found that such framing has “little if any consistent effect on behavior,” according to the paper; the authors also note that this finding is consistent with those of other systematic reviews on the framing effect.
“While framing may improve a patient’s perceptions of a specific screening test, or his or her intentions to undergo it, there are a multitude of other factors that come into play and end up affecting behavior,” Akl explains. They include other factors related to language, such as how much information was provided, how personalized the message was, and the use of visual and statistical information.
Other factors that may have a bearing on the behavior of health consumers include the availability and accessibility of health services.
The 35 studies included in this systematic review covered a very broad range of health behaviors. They included decisions regarding the use of sunscreen to combat skin cancer, taking antihypertensive medications for high blood pressure and the use of condoms to prevent sexually transmitted diseases. They also included studies of people who were making decisions about regular exercise, follow-up appointments after abnormal Pap tests, and screening for HIV, prostate cancer or mammography, among others.
So, what is the best way for clinicians to discuss such decisions with their patients?
“The current state of science doesn’t allow clear guidance on whether or how clinicians and public health workers should frame their health-care messages,” Akl concedes.
The paper says: “In the absence of evidence for the superiority of one frame over the other, a balanced presentation when producing patient information or decision aids is likely to be the safest approach.”
Akl notes that while language in general probably makes some difference, framing is only one part of the language equation. “There might be specific but yet undetermined conditions, for example, the type of health message or the specific health conditions being discussed, under which framing may have an impact,” he says. “Future research needs to investigate these conditions.”
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