1. Washington D.C., USA, 22-27 July 2012www.aids2012.org Framing HIV testing messages for urban and rural audiences: evidence from a field experiment in northwest Ethiopia Mesfin Awoke Bekalu 1,2 (MPhil) Steven Eggermont 1 (PhD) 1 KU Leuven, Belgium 2 Bahir Dar University, Ethiopia

2. Washington D.C., USA, 22-27 July 2012www.aids2012.org Framing health messages One of the various ways of matching messages with recipient characteristics. Different framing techniques such as temporal (e.g., Bonner & Newell, 2008), personal/relational (e.g., Ko & Kim, 2010) and gain- vs. loss (e.g., Rothman & Salovey, 1997; Schneider, 2006; Rothman et al., 2006

3. Washington D.C., USA, 22-27 July 2012www.aids2012.org Framing … Relatively better empirical evidence for gain- vs. loss-framed messages – messages that focus on the benefits of performing a recommended behavior and those that focus on the costs of failing to perform the behavior, respectively (Smith & Petty, 1996; Rothman & Salovey, 1997; Schneider, 2006; Rothman et al., 2006; Abhyankar, O’Connor, & Lawton, 2008). Framing research has identified differentials in effectiveness of gain- vs. loss-framing based on the type of health behavior promoted – prevention or detection (Rothman & Salovey, 1997)

4. Washington D.C., USA, 22-27 July 2012www.aids2012.org Framing … Prevention behaviors: preventing the onset of a health problem (e.g., condom use, sunscreen use, etc.) – better promoted by gain-framing. Detection behavior: detecting a health problem (e.g., HIV testing, mammography, etc.) – better promoted by loss-framing.

5. Washington D.C., USA, 22-27 July 2012www.aids2012.org Framing … The prevention-detection classification, although very important, does not always capture individuals’ construal of a given health-related behavior. Research focus shifted to specifying the optimum conditions in which gain- and loss- framed messages would be most effective (Devos-Comby & Salovey, 2002; Rothman et al., 2006; Latimer et al., 2007).

6. Washington D.C., USA, 22-27 July 2012www.aids2012.org Framing … Optimum conditions such as direct/personal experience and issue involvement. Direct/personal experience – the primary determinant of how people construe a given health behavior (Rothman et al., 2006). People with personal experience of testing for HIV are more likely to construe the behavior as a means of monitoring their health (whatever is the test result), whereas those without are more likely to perceive it as a means of detecting the presence of the virus

7. Washington D.C., USA, 22-27 July 2012www.aids2012.org Framing … Issue involvement: Prevention behaviors – gain-framed messages tend to be more effective among individuals with high issue involvement, while loss-framed messages are more likely to be effective among people with low issue involvement (Millar & Millar, 2000;Jung & Villegas, 2011). Detection behaviors: loss-framed messages are more likely to be effective among individuals with high issue involvement, while gain-framed messages are more effective among people with low issue involvement (Maheswaran & Meyers-Levy, 1990; Banks et al., 1995; Meyers-Levy & Maheswaran, 2004; Jung & Villegas, 2011).

8. Washington D.C., USA, 22-27 July 2012www.aids2012.org Framing … The prevention-detection classification becomes particularly difficult when it comes to HIV testing. While primarily a detection behavior, HIV testing is being promoted as a prevention behavor across prevention contexts for two main reasons:

9. Washington D.C., USA, 22-27 July 2012www.aids2012.org Framing … Biomedical: HIV testing  ART  viral load suppression (e.g., Wilson et al., 2008; Attia et al., 2009). Behavioral: knowing status  protect oneself and others (e.g., Valdiserri et al., 1999; Summers et al., 2000;Painter, 2001).

10. Washington D.C., USA, 22-27 July 2012www.aids2012.org Hypotheses: Anticipating that HIV testing could be construed as a prevention behavior, we hypothesized: H1 = A gain-framed HIV testing message will be more persuasive than a loss-framed message among individuals with high experience with HIV testing. H2 = A gain-framed HIV testing message will be more persuasive than a loss-framed message among individuals with high concern about and information needs on HIV/AIDS.

11. Washington D.C., USA, 22-27 July 2012www.aids2012.org Hypotheses... Moreover, we anticipated that urban residents will have much more direct experience and issue involvement with HIV/AIDS and HIV testing than rural residents. This assumption was made on two grounds: epidemiological and socio-ecological.

12. Washington D.C., USA, 22-27 July 2012www.aids2012.org Hypotheses... Epidemiological – in most sub-Saharan African countries, urban prevalence tends to be higher than rural prevalence, except Senegal (UNAIDS, 2009). Ethiopia, according to UNAIDS (2009), the urban-rural ratio was 8:1 Socio-ecological – in most sub-Saharan African countries urban and rural contexts differ in social/cultural norms, life style, infrastructure, etc.

13. Washington D.C., USA, 22-27 July 2012www.aids2012.org Hypotheses... So, if urban residents have higher direct experience and issue involvement, H3 = A gain-framed HIV testing message will be more persuasive than a loss-framed message among urbanites rather than ruralites.

14. Washington D.C., USA, 22-27 July 2012www.aids2012.org Methods Gain- vs. loss-framed brochures were prepared. The messages in each version were organized around four parallel topics – Gain Version: early actions, longer & healthier life, protecting loved ones from the virus, and peace of mind; Loss Version: delayed actions, shorter & unhealthier life, exposing loved ones to the virus, and worry (format adapted from Van‘t Riet et al., 2010). Brochures distributed to 394 participants (199 Urban: 46.2% male, 53.8% female; 195 Rural: 79% male, 21% female). Through pretest-posttest measures of intention to test for HIV, the relative persuasiveness of gain- and loss-framed messages was determined.

15. Washington D.C., USA, 22-27 July 2012www.aids2012.org Methods... Univariate General Linear Model (GLM) was employed to determine the main and interaction effects of the independent variables on the outcome variable. One covariate (Baseline Intention to Test for HIV), four independent variables (Gain- vs. Loss-framing, Experience with HIV Testing, Concern about and Information Needs on HIV/AIDS, and Urbanity vs. Rurality) and three interaction terms (Gain vs. Loss X Experience with HIV Testing, Gain vs. Loss X Concern about and Information Needs on HIV/AIDS, and Gain vs. Loss X Urbanity vs. Rurality) were entered into the model.

16. Washington D.C., USA, 22-27 July 2012www.aids2012.org Results Urbanity vs. rurality, F(1, 385) = 9.28, p < 0.01, η2 =.02; Experience with HIV testing F(1, 385) = 17.20, p < 0.001, η2 =.04; Concern about and information needs on HIV/AIDS, F(1, 385) = 18.97, p < 0.001, η2 =.05, significantly moderated the effects of gain- vs. loss-framing on Intention to Test for HIV.

17. Washington D.C., USA, 22-27 July 2012www.aids2012.org Results... While urbanites, participants with more experience with HIV testing and those with higher concern about and information needs on HIV/AIDS were motivated by gain-framing, ruralites and those with lower concern about and information needs on HIV/AIDS were motivated by loss-framing. Both gain-framing and loss-framing led to similar outcomes among individuals with low levels of experience with HIV testing, with a slight advantage for the loss-framed message.

18. Washington D.C., USA, 22-27 July 2012www.aids2012.org Results... Figure 1: Interaction effect of Gain- vs. Loss-framing with Experience with HIV Testing on Intention to Test for HIV 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 Low HIV testing experienceHigh HIV testing experience Gain Loss

19. Washington D.C., USA, 22-27 July 2012www.aids2012.org Results... Figure 2:Interaction effect of Gain vs. Loss framing with Urbanity vs. Rurality on Intention to Test for HIV 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18 RuralUrban Intention to test for HIV Gain Loss

20. Washington D.C., USA, 22-27 July 2012www.aids2012.org Conclusion Urbanites and ruralites are motivated by differently framed prevention messages. It was also noted that to the extent recipients are concerned about HIV/AIDS and are familiar with HIV testing, gain-framing is more advantageous, suggesting a possible construal of HIV testing as more of a prevention than a detection behavior in such situations.

21. Washington D.C., USA, 22-27 July 2012www.aids2012.org Implication for intervention If the findings of this study can be replicated in other contexts, urban and rural contexts may need differently designed (framed) messages.

22. Washington D.C., USA, 22-27 July 2012www.aids2012.org Limitation The experiment used brochures and thus only literate participants were eligible.

23. Washington D.C., USA, 22-27 July 2012www.aids2012.org Acknowledgements: KU Leuven HIV Research Trust (funding the fieldwork part of this study)

24. Washington D.C., USA, 22-27 July 2012www.aids2012.org Thank you!