“To Reach the New Generation… TikTok:” Applying Behavioral Economics to Adolescent and Young Adult HIV Pre-exposure Prophylaxis Education.

Abstract

Objectives:

To investigate how adolescents and young adults (AYA) would respond to the framing of health messages for HIV pre-exposure prophylaxis (PrEP) using principles of psychology and economics (behavioral economics). Our hypothesis was that gain-frame messaging (focused on benefits) would be better received than loss-frame messaging (focused on risks).

Methods:

Focus groups were held to determine AYA preferences for messaging around PrEP to design a social media video. Two videos were developed using either gain-frame (emphasized positive effects of PrEP) or loss-frame messaging (emphasized negative consequences of non-use). Thirty AYA were shown the videos and interviewed about their impressions, message framing preferences, and impact.

Results:

Interviews were held May – October 2023. Participants ranged in age from 15–25 years (mean 21.5 years) and the majority identified as White (70.0%). Most (80.0%) identified as cisgender. A third (33.3%) had ever tested for HIV, none had an HIV diagnosis, and 36.7% did not feel that PrEP applied to them personally. Thematic findings included: generally positive views of PrEP, AYA would like to see the video in a doctor’s office as this would make it more trustworthy (20%), and the video would lead them to do additional research. Gain-framed messaging was preferred over the loss-framed video messaging (53.3%). PrEP efficacy was the most important medical fact presented. AYA disliked advertisement-like or “staged” video elements and favored genuineness and relatability.

Conclusion:

AYA preferred gain-framed over loss-frame PrEP messaging, and information on PrEP efficacy delivered by authentic messengers is likely to resonate. Our study generalizability may be limited due to a primarily cisgender and White sample. These findings offer novel insights into AYA perspectives around PrEP messaging for brief videos that could be disseminated through social media for PrEP education.

Practice implications:

Health care professionals should consider using social media and gain-framed messages for health education.

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) is a highly effective intervention for prevention of HIV and has been approved for adolescents and young adults (AYA) that weigh at least 35kg since 2018. Unfortunately, PrEP remains greatly underutilized among AYA in most age groups.[1,2] Many provider-related factors contribute to this, such as lack of comfort in prescribing, privacy concerns, and lack of understanding of eligibility.[2,3] One barrier to use is that AYA have limited knowledge and use of PrEP.[2,4] To end the HIV epidemic,[5,6] adolescents, who learn differently than adults,[7] need implementation strategies specifically tailored to their developmental stage. Other behavioral interventions to increase PrEP use have relied on peer support (with and without coaching) and automated texting have been found to increase PrEP use from 11% to 15%, although it did not affect PrEP adherence. [8] Despite existing interventions, PrEP use among AYA continues to be limited in the United States; of all age groups, AYA aged 13–24 years have the lowest utilization of PrEP despite need.[1]

Behavioral economics is a concept that incorporates principles from psychology and economics to understand human behaviors around decision-making. [9] Behavioral economics therefore utilizes cognitive biases that exist in order to affect behavior change. In addition, behavioral economics can overlap with many existing theoretical frameworks, as described elsewhere[9] Examples of behavioral economics principles include delay discounting (the tendency to think about the present rather than future), loss aversion (prioritizing avoiding loss rather than comparable gains), and financial incentives (as motivation for health behaviors). In the context of HIV prevention, behavioral economics offers strategies that can directly address the critical informational and decisional barriers that impede PrEP use for youth.[9,10] There is nascent research that behavioral economics shows promise in promoting health behaviors in adolescents.[9–12] Behavioral economics has been used to inform HIV prevention strategies for adults, mostly related to financial incentives,[13–19] and represents an untapped opportunity to improve PrEP uptake among vulnerable AYA. One promising behavioral economics technique that is often employed in educational interventions is called framing. The framing effect is a cognitive bias where individuals decide between options based on whether they are presented with positive or negative connotations, a gain- or loss-frame, respectively. [9] To this end, the way in which an educational message is framed can result in a “nudge” to encourage a behavior change without the individual realizing it. Gain frame messaging has been found to be effective for health messaging in other areas, such as smoking cessation.[20] The study of behavioral economics principles for PrEP is limited, often involving financial incentives.[21]

The use of behavioral economics principles among AYA for HIV prevention is limited. AYA need PrEP educational strategies that are tailored to their developmental stage and the use of framing of messaging is an opportunity in which to effectively provide educational messages. Research additionally shows that adolescents and young adults turn to social media for health information,[22–25] although social media can additionally provide misinformation and encourage harmful behaviors.[26] The use of social media, including Tik Tok, is crucial for engaging in health care with AYA given its ubiquity in this age group. In 2022, over 2/3 of teens aged 13–17 in the United States report using Tik tok,[27] Our team sought to investigate where AYA prefer to receive messaging for PrEP and how the framing of messaging using behavioral economics concepts would be received. This was done via focus groups, the results of which were used to develop an educational intervention that featured both loss and gain frame messaging, which we subsequently evaluated in a second round of qualitative interviews. Our hypothesis was that gain-frame messaging would be better received than loss-frame messaging.

METHODS

Development of Educational Video Content

AYA were recruited from several settings: Boston Children’s Hospital, Fenway Health in Boston, University of Michigan and the University of California Los Angeles (UCLA) via flyers and online postings. Interested individuals clicked on a link or scanned a QR code to open a self-administered screening survey in Research Electronic Data Capture (REDCap).[28] Eligible participants were 13–25 years old, English speaking, and able to attend an interview with BCH research staff in on a secure videoconferencing platform (Zoom).

Our investigation involved two stages. In the first stage, we interviewed AYA participants to ascertain general preferences around PrEP-focused message campaigns that could be used to inform the development of a novel, brief video intervention, specifically tailored to AYA. In the second stage, we presented two version of the novel intervention, one with a gain-framed messaging approach and one with a loss-framed approach, to AYA and ascertained their specific preferences regarding the two videos and any additional need for modification to ensure that the videos were optimally tailored to AYA. This study was approved by the Boston Children’s Hospital Institutional Review Board.

Participants who screened as eligible were asked to complete a brief demographic survey in REDCap prior to participating in an approximately one-hour-long focus group. Each of the six focus groups was run by two members of the study team and included anywhere from three to six participants. Prior to each session, participants were reminded that they had the option of using a pseudonym and keeping their videos off while in the Zoom room to protect their privacy.

The first stage interview questions asked about where participants typically get their health information from and how they determine whether a health resource is trustworthy. Additional questions queried participants’ knowledge about HIV and PrEP and how they would prefer to receive education about these topics (e.g., from a doctor or on social media), as well as ways that they would not want to learn about them. Next, study staff shared a slide set with different examples of existing adult PrEP educational campaign ads from the Centers for Disease Control and Prevention and departments of public health. For each slide, participants were asked for their interpretation of what the ad was trying to say, what they liked and disliked about the ad (e.g., images, wording, formatting), whether they felt anything was missing from the ad, and what actions they might choose to take after viewing the ad. Participants were also asked to share their thoughts on slides that featured sample gain- and loss-framed messaging without any images. Examples of these messages included: “Waiting to have sex until you are older is the safest and most effective way to avoid getting a sexually transmitted infection (like chlamydia or HIV)” and “Sex at a young age can lead to a sexually transmitted infection (like chlamydia or HIV).”[12] At the end of each focus group, participants were asked if they had additional thoughts or suggestions for how educators and healthcare providers could best share information about HIV and PrEP with teens and young adults. Participants received a $40 e-gift card after completion of the group interview as remuneration. Interviews were transcribed verbatim and analyzed via rapid qualitative analysis.[29]

Creating and Piloting the Educational Video

Themes identified during the Aim 1 analysis were used to inform the development of loss- and gain-framed educational tools around HIV and PrEP. The study team employed a video production company experienced with creating media related to PrEP, Rocketship Creative, Inc., to film two PrEP education videos. Design of the video was based off of feedback received in Aim 1 from this study. An actor was selected with assistance of the production company based on a video audition. Screenshots of the video featuring the actor are in Figure 1. Scripts for the videos were written by the research team to incorporate the behavior economics principles of framing. One video featured gain-framed messaging (“using PrEP puts me in control of my sex life and my sexual health”) and the other video featured loss-framed messaging (“without PrEP, you can be at high risk for getting HIV, leaving control of your sexual health up to chance”). Each video was approximately one-minute long and featured the same actor, setting, and graphics, with the message framing being the only substantial difference. This was by design in order to test the gain-frame versus loss-frame messaging. To gather feedback on the videos (second stage), AYA participants were again recruited via flyers and online postings (see Aim 1). Eligibility criteria were the same as for Aim 1, although participation in Aim 1 was exclusionary. We sought to recruit 30 participants, or until thematic saturation was reached.

Figure 1:

Screenshots of videos

a. Same introduction of video

b. Gain frame messaging example

c. Loss frame messaging example

Video by Rocketship Creative Inc (rocketshipcreative.com), featuring Josephine Chiang (they)

Participants meeting Aim 2 eligibility criteria completed a demographic survey prior to attending an interview over Zoom with a member of the study staff (DD or BG). After reviewing the study background and interview guidelines, study staff requested participants’ consent to record the interview audio for later transcription. The second stage interview questions inquired about where participants generally receive their health information from and whether they use social media to gather health information, as well as current knowledge about HIV and PrEP. Participants were then shown one of the two PrEP educational videos developed for the study. The order in which the videos were shown (gain-framed followed by loss-framed or vice versa) was alternated across participants. After watching the video, participants were asked for their overall impression, as well as their interpretation of the video’s message, and how they felt about the language, tone, actor, aesthetics, and clarity of the medical information provided. Participants were also asked where they would prefer to view the video (e.g., on social media, at school, or in a doctor’s office), whether the video impacted their knowledge about or interest in using PrEP and what action steps they might take after viewing the video, and whether they would make any changes to the video. Additionally, they were asked if they would have wanted the video to discuss whether parents need to know or give permission for their child to use PrEP.

After discussing their impressions of the first video, participants viewed the second video and were asked the same set of questions, as well as whether they preferred one video over the other. The interview guide was revised iteratively during this process. After interviewing the first 7 participants to add a question that highlighted the different message framing between the videos and ask which language they preferred. After the 9^th participant, questions were added to include several more examples of gain- versus loss-framed language and asked which framing participants liked better. At the conclusion of each interview, study staff asked if participants had any additional suggestions for how social media could be used to teach teens and young adults about PrEP. Following the interview, participants received a $40 e-gift card.

Interviews were transcribed verbatim. Study staff (DD and BG) reviewed transcripts and identified common themes that were organized into a codebook. The interview transcripts and codebook were entered into Dedoose[30] for subsequent qualitative analysis. The codebook was reviewed and adjusted until there was agreement on codes within the research team. After finalizing the codebook, DD and BG independently applied codes to the interview transcripts. Discrepancies in coding were reviewed and discussed until consensus was attained. Once coding was completed, two members of the team reviewed the coded transcripts for emerging themes.

RESULTS

Stage 1: Development of Video

To develop the educational video, six focus groups were held from September 2022-November 2022 with a total of 24 participants. The mean age was 22 years (range 17–25 years). The majority of participants identified as white (58.3%) and not Hispanic/Latinx (95.8%); over half identified as women (58.3%) and half as straight/heterosexual (50.5%). Many participants (79.2%) had heard of PrEP and 12.5% had taken PrEP. Full demographics are in Table 1. Five major emergent themes emerged from the date. First, AYA had limited knowledge about HIV, much of which was learned in school settings: ““My experience learning about HIV and AIDS was from very bad high school, public school sex education where they pretty much just told us, if you have unprotected sex, you can get HIV“ (Cisgender female, 22 years old). Additionally, despite AYA being familiar with PrEP, their knowledge was basic (e.g., it prevents HIV) and lacking in details around efficacy and practical issues in accessing PrEP (e.g. coverage by insurance). One participant stated: “I would love to learn more about it [PrEP]. But I don’t think I’ve ever actually looked into how I can access it.” (Transgender male, 22 years old). AYA preferred to learn about PrEP through social media platforms, and several had learned about PrEP through dating apps. A 24-year-old non-binary participant said: “It’s important to meet people where they are, and people are widely on social media.” Additionally, one focus group participant said: “…if you want to reach the new generation, like the younger generation, then you know, TikTok or another up and coming app would probably be a really good place to promote that. But you know, a barrier to that would be definitely fighting against all of the false news, and you know, all the other click-baits, or anything else, just to kind of compete for that attention.”

Table 1.

Sample Demographics

	Aim 1 (n=24)		Aim 2 (n=30)
	n	%	n	%
Race
White	14	58.3%	21	70.0%
More than one race	3	12.5%	2	6.7%
Black or African American	-	-	4	13.3%
Asian	5	20.8%	1	3.3%
Native American or Alaskan Native	1	4.2%	-	-
Native Hawaiian or other Pacific Islander	1	4.2%	-	-
No Response	-	-	2	6.7%
Ethnicity
Not Hispanic and/or Latino/a/x	23	95.8%	26	86.7%
Hispanic and/or Latino/a/x	1	4.2%	2	6.7%
No Response	-	-	2	6.7%
Gender Identity
Woman	14	58.3%	13	43.3%
Man	7	29.2%	12	40.0%
Non-Binary, Gender Queer, Gender Non-Conforming	2	8.3%	2	6.7%
More Than One Gender	1	4.2%	-	-
Prefer Not To Answer	-	-	1	3.3%
No Response	-	-	2	6.7%
Identify as Transgender or Current Gender is different than Sex Assigned on Birth Certificate
No	18	75.0%	24	80.0%
Yes	6	25.0%	5	16.7%
No Response	-	-	1	3.3%%
Sexual Orientation
Straight/Heterosexual	12	50.0%	16	53.3%
Bisexual	5	20.8%	5	16.7%
Gay or Lesbian	4	16.7%	2	6.7%
Queer	3	12.5%	4	13.3%
Pansexual	-	-	1	3.3%
Asexual	-	-	1	3.3%
No Response	-	-	1	3.3%
Highest Level of Education Completed
8th Grade	-	-	2	6.7%
9th Grade	-	-	2	6.7%
10th Grade	-	-	3	10.0%
11th Grade	1	4.2%	4	13.3%
Some College	8	33.3%	4	13.3%
Bachelor’s Degree	8	33.3%	13	43.3%
Master’s Degree	5	20.8%	1	3.3%
No Response	2	8.3%	1	3.3%
Have Had Penetrative Sex
Yes	17	70.8%	20	66.7%
No	7	29.2%	10	33.3%
Used Condom During Last Penetrative Sex Activity^1
Yes	5	20.8%	9	30.0%
No	12	50.0%	11	36.7%
Told by Doctor or Nurse That They Had Sexually Transmitted Disease
Yes	9	37.5%	3	10.0%
No	15	62.5%	26	86.7%
No Response	-	-	1	3.3%
Told by Doctor or Nurse That They Had Sexually Transmitted Disease in Past 6 Months
Yes	1	4.2%	1	3.3%
No	23	95.8%	28	93.3%
No Response	-	-	1	3.3%
Ever Tested for HIV
Yes	10	41.7%	10	33.3%
No	14	58.3%	19	63.3%
No Response	-	-	1	3.3%
Has Diagnosis of HIV
Yes	1	4.2%	-	-
No	23	95.8%	30	100.0%
Ever Heard of PrEP
Yes	19	79.2%	17	56.7%
No	5	20.8%	13	43.3%
Ever Talked to Healthcare Provider About PrEP
Yes	6	25.0%	3	10.0%
No	18	75.0%	26	86.7%
No Response	-	-	1	3.3%
Healthcare Provider Said to Consider Taking PrEP
Yes	1	4.2%	-	-
No	5	20.8%	2	6.7%
No Response	-	-	1	3.3%
Ever Taken PrEP
Yes, Currently Taking	2	8.3%	1	3.3%
Yes, Taken in the Past	1	4.2%	1	3.3%
No	21	87.5%	27	90.0%
No Response	-	-	1	3.3%
Interest in Taking PrEP
Extremely Interested	5	20.8%	-	-
Very Interested	1	4.2%	1	3.3%
Somewhat Interested	2	8.3%	3	10.0%
A Little Interested	5	20.8%	5	16.7%
Not At All Interested	11	45.8%	20	66.7%
No Response	-	-	1	3.3%
Reasons for Not Taking PrEP^2
I don’t think I need it	16	66.7%	20	66.7%
I had not heard about PrEP until today	4	16.7%	11	36.7%
My work/school schedule could get in the way	3	12.5%	2	6.7%
I would forget to take the PrEP pills each day	3	12.5%	3	10.0%
I would have difficulty getting the medication	1	4.2%	-	-
I don’t know how to get the costs of PrEP covered	2	8.3%	2	6.7%
I do not know where to go to get PrEP	1	4.2%	4	13.3%
I am worried about talking to a doctor about my sex life	4	16.7%	-	-
I am not able to return for PrEP check-ups every 3 months	2	8.3%	1	3.3%
Concerned PrEP might not provide complete HIV protection	1	4.2%	1	3.3%
I am nervous about side effects that might make me sick	2	8.3%	2	6.7%
I’m worried about the long-term effects of PrEP on my health	2	8.3%	4	13.3%
My friends or family would not support me taking PrEP	3	12.5%	1	3.3%
I’m worried that my friends would find out that I was on PrEP	2	8.3%	1	3.3%
I am worried that my family would find out that I was on PrEP	6	25.0%	2	6.7%
I am worries sexual partners would find out that I was on PrEP	-	-	1	3.3%
I’m worried that people would judge me for taking PrEP	6	25.0%	1	3.3%
I’m worried that people may think I’m HIV-positive if they see that I’m taking HIV medications as PrEP	1	4.2%	1	3.3%
I worry about getting permission from a parent or guardian	-	-	1	3.3%
I don’t know how or do not like taking pills	-	-	1	3.3%
I do not like needles or getting injections	3	12.5%	3	10.0%
I am worried that it may interact with my other medications^3	1	4.2%	2	6.7%
Other^4	3	12.5%	1	3.3%

Notes to add:

^{^1}Participants only responded to this question if they answered ‘yes’ to the question prior

^{^2}Participants were able to select more than one options and percentages here represent what percent of each group (Aim 1 participants, Aim 2 participants) selected each option

^{^3}Medication information specified by participants included ‘Testosterone’ (Aim 1 participant), ‘Colchicine and Metoprolol Succinate’ (Aim 2 participant), and ‘Multiple’ (Aim 2 Participant)

^{^4}Three of the participants (Aim 1) who selected ‘Other’ did not specify their reason and one participant (Aim 2) wrote in ‘I am currently not having penetrative sex with a partner with a penis- at minimal risk for HIV’

Participants preferred to receive messages about PrEP from specific sources, including age-appropriate peers, social media influencers, and health professionals. “I personally would be most likely to listen to a peer, someone my age.” (Cisgender female, 22 years old). Lastly, loss-framed messaging was poorly received with a preference for gain-framed messaging. “The [gain frame “Like, why would I ask, what are the risks of not taking PrEP [referring to loss-frame messaging example]? That’s not a question that I would ask. I would ask, what are the benefits of taking PrEP?” (11/3/22 group interview participant) Additionally, loss-frame messaging was perceived as a “threat.” (9/22/22 group interview participant)

Stage 2: Testing of the Video

Interviews were held May – October 2023 and 30 participants were recruited. Participants ranged in age from 15–25 years (mean 21.5 years, IQR 17–23.8 years) and predominantly identified as White (70%) or Black/African American (13.2%). Most (80%) identified as Cisgender and 16.7% as Transgender. Full demographics are in Table 1. A third (33.3%) had ever been tested for HIV and none had an HIV diagnosis. Despite a generally positive view of PrEP amongst participants, 36.7% did not feel that PrEP applied to them personally (i.e., viewed themselves as low risk for HIV.) Half of participants identified the efficacy of PrEP as the standout medical fact presented. Several participants disliked advertisement-like or “staged” video elements (20%) and favored genuineness and relatability: “I think it’s a nice introduction to PrEP. It’s certainly really easy to understand, very approachable. They’re trying to make it casual and conversational… I think [the actor] is generally like a young relatable person in that she’s walking to brunch and she’s kind of wearing things that like 18 to 24 year olds wear. And I also think that the fact that she’s talking about sexual health so openly is very positive. I think that’s good.” (23-year-old cisgender female).

Most (53.3%) preferred the gain-framed over the loss-framed video messaging although 30% did prefer the loss-framed video messaging. The remaining 16.6% felt the videos were too similar to have a preference. Seven participants accurately noticed the differences between the videos was due to language and tone difference in the loss frame versus gain frame video. The gain-frame video tone was described as “casual,” ‘friendly’, and “positive.” The loss frame tone was described similarly, but a few participants mentioning a “fear factor” tone to the messaging (“[the loss frame video] had a little bit of a fear factor… versus the [gain frame video] you’d feel more, like, confident in my decisions.” (24-year-old cisgender gay or lesbian woman). One participant stated: “I mean, honestly, the videos are pretty similar already. I guess the first one [the gain framed] still seemed better; I don’t know, the first one still caught my attention more. Because this one [the loss framed] was, it doesn’t apply to me because I’m not worried about getting HIV. So I was like, okay. She was like, Are you worried about it? And I’m like, No. But as in the first one, everyone can kind of watch it.” (19 year old Asian straight/heterosexual woman with some college education). Most participants did not feel that the video was applicable to them: “I don’t think PrEP is necessarily something I would need” (22 year old straight/heterosexual White man with a Bachelor’s degree).

With regards to the design of the videos, participants did not like ad-like or staged elements. Over half of participants referred to our video as an “ad.” Bright colors were positively received (eg influencer was walking outside on a nice day and had a light green shirt on with a rainbow pin, Table 2). The length of the video was approximately one minute, which was favorably received: “Honestly, I feel the length was perfect. It wasn’t too long. It got everything down in a minute, but it got it down where it was explained clearly to me, where I actually understood everything.” (18 year old White straight/heterosexual woman with an 11^th grade education). Twenty-two participants noted that they felt that the length of the video was a good length, one said that it was too short to address all of the information necessary to educate about HIV. The video was found to be easy to understand. Participants were also asked what they might change, such as number of people in the video. With regards to how many people should be featured in the video (one actor versus multiple people), the majority of participants preferred one person or were indifferent (n=26).

Table 2:

Themes and representative quotes after participants viewed videos

Theme	Sub-Themes	Participant Quotes
Views on PrEP	General Opinion on PrEP	“My one friend who– I don’t know that many people that take it. My one friend who I know well who takes it, I know she has a lot of anxiety around STIs and just stuff like that in general. So I think it’s beneficial for her in terms of– I mean, it keeps her safe physically, but also it just like– yeah, I think it benefits her mentally, too.” – A 24 year old White straight/heterosexual woman, with Bachelor’s degree “I haven’t looked into the—like super hard into the medication itself. I know, like the idea of it is definitely great, because I mean, anybody who’s at risk for HIV should definitely be taking precautions to try to lower that risk as much as they can for themselves. But I know every medication also has a drawback. So I’m not sure what those are for this specific type of medication. But I’m sure that there’s information out there.” – 23 year old White straight/heterosexual man with a Bachelor’s degree
	Information in Video Did not Always Seem Applicable to Participant	“I don’t really know who would use PrEP. But if I knew, like, specifically, like everyone should use it, or everyone who’s sexually active should use it, then maybe—Or like if it—Because my previous notion was like it’s for men who are Gay. That’s all I – So maybe I’d send it to a friend like that, maybe not. But maybe.” – 19 year old White straight/heterosexual woman with some college education “I think by just kind of knowing what HIV is, in the first place, and understanding that, if you actually practice, like, safe sexual practices, and have a good understanding of what other things not to do, not sharing a needle, I don’t think PrEP is necessarily something I would need.” – 22 year old straight/heterosexual White man with a Bachelor’s degree
Gain vs. Loss Frame Feedback	Minimal to No Differences Noted Between Videos	“If you didn’t say it was a different video, I wouldn’t have thought it was a different video. I thought it was the same video. It was the same.” – 15 year old queer participant (no gender provided) with 11th grade education level “I mean, honestly, the videos are pretty similar already. I guess the first one [the gain framed] still seemed better; I don’t know, the first one still caught my attention more. Because this one [the loss framed] was, it doesn’t apply to me because I’m not worried about getting HIV. So I was like, okay. She was like, Are you worried about it? And I’m like, No. But as in the first one, everyone can kind of watch it.” – 19 year old Asian straight/heterosexual woman with some college education
	Gain Frame Messaging More Favorable than Loss Language	“I feel like when people hear that it’s 99% effective, that makes them more comfortable than being like, if you don’t use this right, it’s not going to be effective. I feel like that wording makes people more comfortable with it.” 16 year old White asexual transgender man with a 10th grade education “[Gain frame messaging is] just more empowering … instead of using a fear-mongering mindset, it’s more of using an empowerment mindset.” 24-year-old White queer non-binary person with a bachelor’s degree “I think that ‘take control’ is more empowering than ‘don’t leave it up to chance,’ which there are many other actions you can do that don’t leave your chances of HIV up in the air besides being on this medication. There’s other things, other stuff that you can take that don’t involve taking a prescription.” −23-year-old White straight/heterosexual woman.
Video Feedback and Impact	General video feedback	Ad-like “It [PrEP video] seems like an odd combination of something that’s clearly an advertisement and something that’s trying to not really seem like it; like the mentioning the “last post,” and things like that.”- 15 year old White transgender queer female with a 9th grade level of formal education “It’s still kind of long for an ad. I would want to say, I’m kind of conflicted about the way it starts. Because I feel like you want to have like a hook, if you’re going to grab people’s attention. Like people will click off in the first three seconds. So you want to have something that’s really eye-catching, like in the first three seconds. And to start it with, like, “Oh, I’m going to go meet a friend, blah, blah, blah,” it’s nice, and it’s fun, and it’s kind of like a vlog. But it’s also like boring. It’s like, it’s not hooking me. I’m probably going to skip it.” – 16 year old White straight/heterosexual man with a 10th grade level of formal education Colors “Colors are good. And the lime green [shirt] sure brings some pop out to it.” 22 year old White straight/heterosexual man with a Bachelor’s degree, discussing the gain framed video “I liked that there was like the [rainbow Pride] pin, that really showed inclusivity.” 25 year old White straight/heterosexual woman with a Bachelor’s degree, discussing the loss framed video Length “I liked that they were like one minute-ish. Like just quick-to-the-point videos.” – 15 year old Black Hispanic bisexual woman with an 8th grade education, discussing the gain-framed video “Honestly, I feel the length was perfect. It wasn’t too long. It got everything down in a minute, but it got it down where it was explained clearly to me, where I actually understood everything. So, I feel like when it was worded in a minute, I feel like it actually got a lot of knowledge in me.” – 18 year old White straight/heterosexual woman with an 11th grade education, discussing the loss framed video Actor/Influencer Approachable and Understandable in video “I mean, she came off as friendly, and very clear about what she was talking about.” – 23 year old Asian non-binary queer participant with a Bachelor’s degree discussing the gain framed video “The actor just seems a very normal everyday person. I know a lot of the ones I’ve seen on TV for Truvada, a lot of the time it’s gay men. But it can also be like, I don’t describe this well, but kind of very stereotypical gay men. And for me, I don’t really identify as much with the stereotypes. So seeing someone who looks like a pretty regular person not really being stereotyped, it it’s a little more relatable to me.” – 21 year old White gay man with some college education discussing the loss framed video Language was easy to understand “I think it’s a nice introduction to PrEP. It’s certainly really easy to understand, very approachable. They’re trying to make it casual and conversational.” – 23 year old White straight/heterosexual woman with a Bachelor’s degree discussing the gain frame video “I thought it was definitely clear and made sense and I understood everything that she said.” −16 year old White queer participant (gender not provided) with an 11th grade education discussing the loss frame video Presentation of Facts Effective “I did notice that she said it was 99% effective twice, but I feel like that was good to repeat because that’s good information that I would be asking if it hadn’t already been explained, I think.” – A 24 year old White straight/heterosexual woman, with Bachelor’s degree discussing the gain frame video “I thought they [the video actor] did, it was a good job giving visuals for the facts; so they were like, it’s 99% effective, and they showed a visual. I thought that that helped me remember that fact or whatever.” 14 year old White straight/heterosexual man with an 8th grade education, discussing the loss framed video
	Number of people in video	“I did like that it was one person talking to you, rather than, you know, sometimes ads have so many people. So it felt less like an ad for PrEP, and more like an information little thing.” – 19-year-old White straight/heterosexual woman with some college “I think multiple people make it seem a little bit more like more like an educational video, rather than something that could come across as just like something casual, and thought of on the spot. So I liked it with one person.” 22 year old White bisexual woman with a Bachelor’s degree
	Video Should Share information about Parent Involvement	“I think that [discussing if parents need to know or give permission] could be helpful to put in. I actually don’t think that’s something that’s very well addressed anywhere. I think, yeah, throwing in a line, if you’re over this age, you don’t have to ask your parents to get it. I don’t know how you’d phrase it, but your parents don’t have to know. I think that’d be an easy line to throw in.” – 21 year old White gay man with some college education “Yes, I think that would be important to mention. Even if its just a little brief something, or even at the end when she’s putting the phone away from her, and the PrEP [typed word] comes up, even if there’s something at the end that says something about parents.” 24-year-old gay or lesbian white woman with Bachelor’s degree
	Video Appropriate for Social Media and Doctor Offices	“It might be good on social media, specifically like– because a doctor’s office especially or a school can tell you those things in other ways. But social media gets it out to people who aren’t necessarily seeking out that information. It can be a good way of informing people who aren’t necessarily looking for that information.” 17 year old White transgender bisexual man, education level not provided “I mean if it’s at a doctor’s office, I would probably think it was like pretty trustworthy, versus if I saw it on TikTok, I’m like, you know, anyone can make a video and say whatever they want, and put it on TikTok. And especially if it’s an ad, I’m like, you know, not sure if I can really trust that information. So that would definitely make a difference, like how it’s presented.” 16 year old White straight/heterosexual man with a 10th grade education level
	Video Impacted on Interest in PrEP	“I would probably do my own little research and then talk to a parent or a healthcare provider about it.” – 15 year old Black bisexual woman with an 8th grade education “I would probably look it up online first and do a little bit of research on my own. And if I had– I’m obviously over 18, so I would talk to– if I saw it online and stuff, then I would talk to my doctor about it.” 23 year old Hispanic bisexual woman with a Bachelor’s degree “I liked that she said “if you want to take control of your sex life, you should ask about it….It’s kind of like, why wouldn’t you want to know more about it? I think that’s a good approach that makes me want to learn more about it.” 24-year-old White straight/heterosexual woman with Bachelor’s degree

When asked for feedback about the impact of the video, participants most often said after seeing both gain-frame and loss-frame videos that they would seek more information. Moreover, the efficacy of PrEP was a stand-out fact: “[the video did] a good job giving visuals for the facts; so they were like, it’s 99% effective, and they showed a visual. I thought that that helped me remember that fact.” 14-year-old White straight/heterosexual man with an 8^th grade education, discussing the loss framed video. Participants said that viewing the video at a doctor’s office would increase how “trustworthy” the video was; 33% specifically mentioned a doctor’s office as a location where they thought the video could be shown and 23.3% said that it could be shown in a health class or other school setting. Additionally, they would do their own research and talk to a healthcare provider following seeing the video. When asked if they would share this video with a friend, 17 (56.7%) said yes.

DISCUSSION AND CONCLUSION

1. DISCUSSION

This study used input from AYA to create two social-media style videos on PrEP incorporating behavioral health economics principles. These videos were then tested with AYA to receive feedback on their content and their impression on how it might influence their use of PrEP in the future. We found that AYA Adolescents use social media to educate themselves about health care topics. AYA participants in the development phase of our study wanted to learn more about PrEP through social media as a primary option. Moreover, they preferred messaging with succinct information, follow-up resources (e.g., a website), contained diverse identities, and had additional information about who is eligible for PrEP.

In reviewing statements about PrEP, participants received gain-framed messaging more favorably than loss-framed messaging. Prior research on use of TikTok to educate found that audiences do engage on videos related to sexual health, but videos may lack evidence-based content to influence behavior change.[31] Most sexual health videos on Tik Tok are created by users themselves, not educational entities or health care providers.[32] This can lead to information that conflicts accurate health education provided in school and health care settings. Prior research found that sexual minorities who have sex with men who heard about PrEP from the internet had stronger intentions to use PrEP, although those who heard about it through sexual partners and public health campaigns were more likely to discuss it with a provider.

Notably, our videos were designed intentionally to be visually similar but differ only on the messaging of the educational statement in order to test the gain-frame versus loss-frame messaging. This led to videos that participants found to be very similar, and for some, difficult to discern the difference between the two. Future research is necessary in order to better understand how to leverage and test behavioral economic principles in social media messaging.

Limitations to this study is that participants required Internet access and English proficiency to participate. An additional limitation is that participants were primarily White and cisgender, which limits generalizability, especially as this sample did not include populations that may benefit most from PrEP. In both parts of our study, participants had limited experience taking PrEP. Prior work on PrEP messaging campaigns primarily focuses on men who have sex with men[33] and we took a more general approach to recruitment and testing to ensure that the video would be acceptable to a wider array of AYA who may potentially benefit from PrEP. As men who have sex with men are still the predominate recipients of PrEP among AYA,[2] not focusing on this subgroup is a strength for how educational interventions may be viewed among populations who are not optimally prescribed PrEP. Strengths also included that we used AYA perspectives to develop our video and we were able to include participants with diverse gender identities and we recruited from 3 distinct geographic areas.

2. CONCLUSION

AYA have only basic knowledge about PrEP, even when familiar with the medication. For participants in our study, social media is a place where they want to see more educational outreach. Information on PrEP efficacy delivered by authentic messengers is likely to resonate. Peer influencers could improve knowledge and access to PrEP for youth, in particular if messaging is tailored for AYA and uses gain-frame as opposed to loss-frame messaging.

3. PRACTICE IMPLICATIONS

To ensure that health care education is reaching adolescents and young adults, the modern online space should not be ignored. Departments of public health and health care centers should consider expanding educational outreach beyond print and websites to include social media platforms. Tiktok campaigns posted on an official account and also shown in waiting rooms should be considered. This may also include working with social media influencers or production studios in order to create videos that are authentic, trustworthy, and relevant to AYA. The way in which health information messaging is framed should be taken into account when crafting messaging. Our recommendation is to use gain-frame messaging and if possible solicit feedback from AYA during development to ensure that the video will resonate as intended with the goal audience.

Implications and Contributions statement:

HIV pre-exposure prophylaxis (PrEP) is underutilized by adolescents and young adults (AYA). This study demonstrates that behavioral economic framing of educational messaging is a strategy to address barriers that impede PrEP use for AYA on social media, a place where AYA want to see more educational outreach.

Abbreviations:

PrEP

Pre-exposure prophylaxis

AYA

adolescents and young adults