Motivating Influenza Vaccination Among Young Adults: The Effects of Public Service Advertising Message Framing and Text Versus Image Support

In the United States (US), the Centers for Disease Control and Prevention (CDC) uses health communication to foster an accurate understanding of influenza, to convey the benefits of flu vaccination, and to increase acceptance of flu vaccination. The organisation also uses social marketing, which integrates commercial marketing concepts with strategic communication to increase the effectiveness of behaviour change and health recommendation promotion efforts, to motivate influenza vaccination. Given that public service advertisements (PSAs) and "brand promises" (what the user of a product or service can expect) are often core components of health communication and social marketing efforts, this study examined whether, and how, framing and the use of text or image support to convey influenza vaccination brand promises affected college-attending young adults' beliefs and intentions regarding influenza vaccination.

To introduce the investigation, the researchers look at previously published research on PSAs and flu vaccination acceptance, message factors and persuasion, health message framing, support for core messages (text vs. images or a combination), vaccine confidence, positive and negative affect toward flu vaccine PSAs, and attitude toward flu vaccine. In doing so, they articulate the following research questions:

• Research Question (RQ) 1: Do the framing strategy and message support approaches used in a flu vaccination PSA affect young adults' confidence in the flu vaccine?
• RQ2: Do flu vaccine PSAs that use different framing strategies and message support approaches produce different affective responses in young adults?
• RQ3: Do flu vaccine PSAs that use different framing strategies and message support approaches differentially impact young adults' attitude toward flu vaccination?
• RQ4: Do flu vaccine PSAs that use different framing strategies and message support approaches differentially influence young adults' intention to receive a flu vaccine?
• RQ5: What associations may exist between affect toward the PSAs, attitude toward flu vaccine, vaccine confidence, and vaccine intention among young adults?

A total of 122 participants, whose average age was 21, participated in an online study in April 2015 at a large Southeastern (US) public university. Participants were randomly assigned to view one of four influenza vaccination-related print PSAs from the CDC (see Appendix A): a loss frame with image support, a gain frame with image support, a loss frame with text support, and a gain frame with text support. After viewing, participants completed a questionnaire that contained the measures (dependent variables): participants' self-reported confidence in influenza vaccination, affect related to the PSAs, attitude toward flu vaccine, and flu vaccination intention.

Findings, in brief:

• With regard to RQ1: The loss-framed text-supported PSA had the strongest influence on vaccine confidence, while the gain-framed, text-supported PSA had the smallest impact on participants' confidence in flu vaccine.
• With regard to RQ2: The loss-framed, text-supported PSA had the strongest impact on "interested affect" toward the flu vaccine PSA. (The observable manifestations of affect are typically captured through the measures ofemotion-driven responses (e.g., afraid, scared, happy, or interested) that people have toward health messages and campaigns.)
• With regard to RQ3: The loss-framed, text-supported PSA had the strongest effect on attitude toward flu vaccine.
• With regard to RQ4: The gain-framed, image-supported PSA and loss-framed, text-supported PSA produced similarly positive effects on flu vaccination intention.
• With regard to RQ5: Given the non-significant effects of the flu vaccine PSAs on "worried affect", this variable was not included in the analyses.

Overall, the findings highlight the importance of assessing both the framing used in social marketing or health communication materials and the approach used to support the framing. It is likely that the effectiveness of framing is affected by the visuals and text used to reinforce the brand promise conveyed by the framing, irrespective of whether it is positive or negative.

The results suggest that not only should social marketers and health communicators consider pretesting the approach used to support or reinforce the framing used in a PSA, it is also helpful to use a range of communication outcome measures to gauge potential effectiveness. This study, for example, used cognitive, affective, and behaviour intention measures, and by doing so, was able to look for consistency across those measures. Here, it was found that the two pairings that performed the best did so across all measures: The gain-framed image-supported PSA and loss-framed text-supported PSA were both associated with the highest levels of positive affect toward the PSA, positive attitude toward flu vaccination, flu vaccination confidence, and flu vaccination intention.

The researchers assert that the findings provide direction for future research involving message framing. The needs include research that looks more deeply at the types of images used to support positive and negative framing, variations in the text or type of content used with different framing approaches, and what happens in contexts other than print (e.g., short videos, including video PSAs). Furthermore, this study only encompassed one domain of integrated social marketing communications (ISMC): the promotional domain. A next step is to systematically integrate communication and educational materials and messages with elements from the product, price, or place domains. For instance, the researchers propose examining whether the effects or effectiveness of framing and message support approach varies based on where a flu vaccine is made available (e.g., doctor's office, pharmacy, or retail location) or price (e.g., free or in concert with a promotional incentive). Finally, future studies could build off this effort by using the approaches examined here with different population groups, different vaccines, and different executions of gain- and loss-framed messages and supporting approaches. They could also examine whether timing (e.g., prior to flu season) produces similar or different findings.