Examining the Effects of Message Framing on Medication Beliefs, Intentions to Take Medication, Medication Adherence, and Asthma Control among College Students
Type of DegreePhD Dissertation
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Background: Asthma remains a burden to society with approximately $80 billion per year spent on asthma-related medical expenses in the United States. Inhaled corticosteroids (ICS), a mainstay medication for managing persistent asthma, have the potential to reduce the morbidity and frequent exacerbations associated with persistent asthma. However, young adults, in particular, are less likely to take their ICS as prescribed given their transition from adolescence to adulthood and decreased parental supervision. Message framing, a psychological approach which emphasizes losses or gains in message presentation and capitalizes on an individual’s risk perceptions to influence his or her decision-making, may help. Objectives: This study aims to: 1) develop gain- and loss-framed messages for medication adherence targeted at young adults with asthma; 2) examine the effects of gain- and loss-framed messages on Beliefs, Intentions to take medications, Medication Adherence, and Asthma Control; and 3) examine an hypothesized relationship between Message Frame, Beliefs, Intentions, Medication Adherence, and Asthma Control. The overall goal is to improve asthma control among young adults enrolled in college by utilizing message framing to address nonadherence. Methods: First, a qualitative meta-synthesis of studies examining the experience of living with asthma among young adults was undertaken. Literature searches were conducted in PubMed, CINAHL, and PsycINFO, from inception through March 2019. A high sensitivity search of Google Scholar through March 2019 was also performed to identify additional articles. Qualitative and mixed study designs (studies using quantitative and qualitative methods) exploring the experiences of young adults with asthma were included. The rigor of included studies was assessed using the Mixed Methods Appraisal Tool (MMAT). Grounded theory approach was used in synthesizing the data. Themes from the review were used in developing gain- and loss-framed messages for the promotion of medication adherence among young adults in college. Second, college students were recruited and randomized to receive either gain- or loss-framed messages three times per week for eight weeks. Data collection was performed at baseline, week four, and week eight. Measures included Beliefs, Intentions, Medication Adherence, and Asthma Control. Path analysis was used to assess the relationship between Message Frame, Beliefs, Intentions, Medication Adherence, and Asthma Control. Mixed-design ANOVA was used to assess whether Beliefs, Intentions, Medication Adherence or Asthma Control improved differentially from baseline across gain- and loss-frame groups. Results: Seven high-quality studies with MMAT scores between 75-100% were identified for inclusion in the qualitative meta-synthesis. Five categories related to “living with asthma as a young adult” emerged: 1) needs (e.g., information on weather); 2) barriers (e.g., decreased parental support); 3) enablers (e.g., knowledge of asthma management); 4) behaviors (positive e.g., taking medication as prescribed; negative behaviors e.g., stopping medications when better); and 5) outcomes (disease, interpersonal, and personal outcomes). The emerging theory on the experience of living with asthma as a young adult posits that when needs are met, enablers are present, and barriers are removed, young adults are more likely to exhibit positive behaviors with desired outcomes. A total of 26 gain- and loss-framed messages were created from the themes, addressing the outcomes of living with asthma as a young adult. Results from the framing intervention indicate that there was a significant difference in participants’ Intentions to take medication as well as Asthma Control from baseline irrespective of the message frame. However, there was no difference between changes in Beliefs, Intentions, Medication Adherence, and Asthma Control of participants receiving gain- versus loss-framed messages. Additionally, the intervention had no effects on Beliefs and Medication Adherence from baseline. Findings from the path analysis reveal that Beliefs exert a large direct effect on Intentions (0.571), a medium direct effect on Medication Adherence (0.439), and a medium indirect effect on Medication Adherence, mediated by Intentions (0.222). These effects were all significant. Non-significant paths include the path from framing to Beliefs and Medication Adherence to Asthma control. Conclusions: Young adults have several needs, barriers, enablers, behaviors, and outcomes as a result of living with asthma. In this study, framed mobile messages delivered via SMS improved young adults’ intentions to take their medication as prescribed as well as their asthma control. Further studies with a control group are needed to support causality. A 100% retention rate and over 85% engagement rate suggests that young adults are comfortable receiving text messages promoting adherence to ICS. Beliefs about the necessity of ICS may lead to greater intentions to take the medications as well as consistent medication-taking behavior.