Does Message Framing Help with Willingness to Pursue Behavioral Therapy: A Study in People with Migraine

Abstract

Objectives:

Behavioral treatments for migraine prevention are safe and effective but underutilized in migraine management. Health message framing might be helpful in guiding patients with treatment decisions. We sought to assess for associations between message framing and the willingness to seek migraine behavioral treatment in persons with migraine.

Methods:

We developed four message frames for Turk Prime participants who screened positive for migraine using the American Migraine Prevalence and Prevention (AMPP) screen: Specific Loss Framing (SLF), Specific Gain Framing (SGF), Nonspecific Loss Framing (NSLF), Nonspecific Gain Framing (NSGF). The message frames were initially piloted in 56 participants on Turk Prime, revised accordingly by headache specialist and with health communication specialist input, and then randomly distributed to the larger sample on Turk Prime.

Results:

There were 401 participants. Median age was 34 [IQR=12 years]. More than two thirds of participants (70.3%) were women. Median number of headache days/ month was 5 [IQR=5.3]. Some (12.5%) used evidence-based behavioral therapy for migraine. Out of the 401 participants, broken down as 101 SLF, 98 SGF, 100 NSLF and 102 NSGF, there were no significant differences in willingness to pursue behavioral treatment for migraine between the message framing groups; the median (IQR) were 4 (1) for all four types of message frames, Kruskal-Wallis p-value 0.41.

Conclusion:

Message framing was not associated with willingness to seek behavioral therapy for migraine.

Introduction

Per the Center for Disease Control and the National Institutes of Health, health communication is “the study and use of communication strategies to inform and influence individual decisions that enhance health.” {¹} A main point of health communication is to disseminate health information to influence personal health choices and to improve literacy. In the field of neurology and psychiatry, health communication is essential e.g. much of a neurologist’s time is spent taking a detailed history and counseling patients regarding diagnoses and treatment decision making. There has been some research on health communication in neurology. When eliciting a history, neurologists tend to use closed ended questions, not the “Ask-Tell-Ask” approach. {²}.While recent research has begun to investigate various methods for delivering information and for decision-making, to date, such research has examined recommending versus providing options {^3,4} and no data supports one method over the other. This is especially important in the field of neurology and psychiatry where adherence to treatment has been proven to be a challenge in a wide variety of neurologic and psychiatric conditions. {^5–7}However, little research has been done on how to frame neurologists’ and psychiatrists’ recommendations to improve adherence to therapies.

The term “health message frames” refers to how health messages can be written or “framed” to highlight the benefits of engaging in a behavior (a gain frame) or the costs of not engaging in a behavior (a loss frame). {^8,9} Although findings are mixed based on the behavioral goal, in general, gain-framed messages have been shown to be more effective than loss-framed messages in promoting prevention or health-promoting behaviors. {^8,9} Yet, this method of health communication study has not been studied in the field of neurology.

We sought to study how message framing might be useful in adhering to recommendations to initiate behavioral therapy. Behavioral therapy has many applications within the field of neurology. Unfortunately, despite the Level-A evidence for several treatments for neurologic conditions, patients fail to adhere to recommendations to pursue these treatments. This has been seen most recently in one study which showed that only about half of people with migraine who initiated scheduling a behavioral therapy appointment for migraine prevention {¹⁰} and in a recent study for Psychogenic Non Epileptic Seizures which showed that while 80% of subjects attended the first psychiatric visit appointment, only 42% attended the second, 24% attended the third, and only 14% remained adherent through the fourth visit. {¹¹} Thus, using migraine, the second most disabling condition worldwide, {¹²} we sought to examine whether positive or negative gain frames, and whether specific frames (more detailed amounts of data) were associated with peoples’ likelihood to pursue Level-A evidence based therapies for migraine prevention. We sought to use Turk Prime, a platform for participant recruitment in the behavioral sciences {^13,14} to explore the impact of message framing on migraine participants’ willingness to participate in behavioral therapy. We also sought to examine this accounting for patient demographics such as age, gender, ethnicity, education level, income. {^13,14}

We hypothesized that the gain-framed messages would be more effective than the loss-framed messages and that the more specific messages would be more effective than the less non-specific messages.

Methods

Study Design and Population

This was a cross-sectional study assessing migraine participants’ intention to pursue behavioral treatment based on the way in which behavioral therapy for migraine was framed to them in an online survey. Study participants were recruited online via Turk Prime. Turk Prime administered the survey to eligible participants. Inclusion criteria were: Turk Prime participants with migraine ages 18 to 89 years, proficient in English, and listing migraine as a medical condition. This was the inclusion criteria we set-up using the pre-qualifier panel set-up by Turk Prime. Exclusion criteria were: Fewer than 4 headache days a month. The exclusion criteria enabled us to study those Turk Prime participants who had migraine and would likely qualify for migraine preventive treatment. Turk Prime contacted its participant pool with information about the study [a study description, the monetary compensation, and the time required to complete the study]. If they were interested in participating, they were asked to complete a migraine screening initial questionnaire to ensure that they met migraine diagnosis. The predictors in the study were demographic variables, headache characteristics, and types of message frames. The primary outcome was likelihood to pursue behavioral therapy for migraine prevention. The goal of this study was to assess whether different message frames impact likelihood to pursue behavioral therapy for migraine prevention.

Study Questionnaire

The initial screening questionnaire to identify participants with migraine used the American Migraine Prevalence and Prevention (AMPP) {¹⁵} screening questions for migraine diagnosis. Using branching logic, the participants who screened positive for migraine were randomized by Turk Prime to one of the four hypothetical messages to assess the impact of health message framing on participants’ willingness to engage in behavioral therapy for migraine. The messages were gain-framed or loss-framed, and either specific or non-specific. The survey and the initial messages were developed by a headache specialist and health psychologist. Eight message frames about behavioral treatment for migraine were initially developed: six specific messages and two nonspecific messages, with half being gain-framed and the other half loss-framed. These initial message frames were randomly distributed to 56 participants meeting study criteria (seven participants/frame). Based on the initial feedback from participants and feedback from two health communication experts (AF and AL), four final messages frames were used in the full study with a goal of N=400 (100 participants/frame). The message provided to the participants was as follows:

“Behavioral therapy for migraine helps people with migraine change their lifestyle and day-to-day approach to migraine attacks to better manage migraine. Examples of behavioral therapy include cognitive behavioral therapy, biofeedback and/or relaxation therapy. Cognitive behavioral therapy helps people with migraine change how they think about and respond to migraine attacks. It also teaches them lifestyle changes to help reduce migraine frequency. Relaxation training teaches people with migraine how to control their bodies’ reaction to stress, which can reduce migraine frequency. Biofeedback gives people with migraine insight into how their bodies react to stress, and how they can use relaxation training, by giving them literal feedback (e.g., computer printout, audible tone, etc.) into their bodies’ stress responses.”

We then provided the participants with one of four messages:

1. “Not participating in behavioral therapy for migraine is a lost opportunity to improve both (1) the number of headache days per month and (2) the severity of your pain. This could lead to more days with headache in the long term.” (Non-specific loss frame)

2. “Participating in behavioral therapy for migraine may reduce both 1) the number of headache days per month and 2) the severity of your pain. This could lead to fewer days with headache in the long-term” (Non-specific gain frame)

3. “Not participating in behavioral therapy for migraine is a lost opportunity to improve both 1) the number of headache days per month by at least half and 2) the severity of your pain. This could lead to more days with headache in the long-term.” (Specific loss frame)

4. “Participating in behavioral therapy for migraine may reduce both (1) the number of headache days per month by half and (2) the severity of your pain. This could lead to fewer days with headache in the long term.” (Specific gain frame)

Study participants were then asked, “Given what you know about behavioral treatment for migraine, how likely are you to do behavioral treatment?” Responses were captured using a Likert Scale (1=Not at all likely to 5=Strongly Likely).

Statistical Analyses

The distribution of the data was assessed for normality with Kolmogorov-Smirnov test. Nonparametric data was presented as median, interquartile range, and analyzed with Kruskal Wallis. Chi square and linear regressions were also performed. The statistical analyses were performed with IBM SPSS Statistics V25.0.0.

The study was approved by the New York University Langone Health Institutional Review Board (IRB). Subjects were paid $0.75 for each completed survey.

Results

Demographic Variables

There were 401 participants. The median age was 34 (IQR 12) years old. The majority N=282 (70.3%) were women. Caucasian was the predominant ethnicity (75.3%). In terms of employment, N=252 (62.8%) work full time. (table 2)

Table 2:

Headache Characteristics and Treatment History

	Total n=401		SGFa n=98		NSGFb n=100		SLFc n=101		NSLFd n=102
	Median	IQR	Median	IQR	Median	IQR	Median	IQR	Median	IQR	Kruskal-Wallis H 0.56
Number of headache days per month:	5	5.3	4.2	6.25	4.8	7	5	4	5	4.7
Headache intensity:	7	2	7	2.8	7	2	7	2	8	3	Kruskal-Wallis H 0.46
MIDAS score	28	29	26.5	32	29	29.8	28	24	31.5	28.75	Kruskal-Wallis H 0.94
	N	%	N	%	N	%	N	%	N	%
Prior preventive medications	117	29.2	30	30.6	24	24	30	29.7	33	2.4	Kruskal-Wallis H 0.58
Prior evidence-based behavioral treatment for migraine	50	13.0	11	11.2	15	15	11	10.9	13	12.7	Chi square 0.98
Participants with at least 2 moderate to severe HA per week	181	45.1	38	38.8	40	40	53	52.5	50	49.0	Chi square 0.053
Participants with at least 15 HA days per month	45	11.2	7	7.14	17	17	14	13.9	7	6.9	Chi square 0.74

Headache characteristics

The median, IQR number of headache days per month was 5, 5.8. Nearly half (181 participants or 45% of participants) reported at least two headaches of moderate to severe intensity per week. About 11 % (45 participants) reported having more headache days than not. The median headache intensity was 7 out of 10 (IQR 2). The median MIDAS score was 28 (IQR 29). Nearly a third (29.2% or 117 participants) of participants reported taking at least one migraine preventive medication. One in eight (50 participants or 12.5%) participants have previously tried at least one evidence-based cognitive behavioral treatment for migraine prevention.

There was no difference in age, gender, ethnicity, education, or employment by message frame (Table 2). Of note, there was are no difference in message frame perceived clarity between the groups.

There was no difference between the message frame groups in terms of headache frequency, headache intensity, MIDAS score, number of participants taking preventive medications, prior use of evidence-based cognitive behavioral treatments for migraine prevention (Table 2).

Message frame type and likelihood to pursue behavioral treatment

There was no association between the type of message frame and likelihood to pursue in person behavioral treatment, the median (IQR) were 4 (1) for all four types of message frames, Kruskal-Wallis p-value 0.41, η²_Hof 0.00030. Of note, the effect size was trivial.

Discussion

We did not find any significant change in the use of positive versus negative message framing or specific versus nonspecific message framing in peoples’ willingness to initiate behavioral therapy for migraine. Evidence-based behavioral treatments for migraine are underutilized despite the fact that they are effective in migraine prevention, are fairly safe and free of many of the adverse side effects that may occur with migraine preventive medications. {^16,17} Previous research has found that a lack of belief in efficacy or importance of behavioral treatment has been shown to be a barrier in patients pursuing behavioral treatment for migraine prevention. However, our results do not support that message frames with dissemination of knowledge about behavioral treatment efficacy is superior to those without efficacy. A better understanding of what facilitates migraine patients’ willingness to participate in behavioral therapy is needed.

Research has shown that the impact of a health message also depends on the patient’s involvement in the issue {¹⁸}, the efficacy of the proposed intervention, the ease of uptake of the intervention, and other individual differences (risk perception, tendency toward behavioral activation). {⁹} For example, experiences with prior interventions is particularly salient for message framing: previous research suggests patients who had negative experiences with prior interventions are more likely to respond to loss-frame messages. {¹⁸} Further, there is a large disconnect between people’s intentions to change behavior and the actual likelihood that they will change their behavior. {⁹} Other types of message-based health interventions include message tailoring and our results indicate that message framing is not adequate, at least in our given examples, in even increasing people’s intention of likelihood to pursue behavioral therapy. Perhaps a more tailored health message frame approach instead of the generic “one size fits all” messages such as the Self-Administered Behavioral Intervention using Tailored messages (SEABIT) for migraine is more useful. {¹⁹}

There were limitations in this study. (1) The quantitative study design may have limited our findings. Future work might include qualitative research to understand what additional information people might want before deciding whether to pursue behavioral therapy. (2) There may have been selection bias as the participants were paid volunteers. (3) The study does not account for any influence a healthcare provider may have on encouraging a patient to pursue behavioral therapy. (4) We did not study whether neural mechanisms involved in decision-making might affect decision making to pursue behavioral therapy, or whether migraine as a chronic pain disorder may bias brain-based decision making. In addition, we did not assess whether the use of migraine preventive medications (and which class of medications) might affect neural mechanisms and thus might be associated with the decision making to pursue behavioral therapy. However, these might be interesting areas of future study.

Conclusion

To our knowledge, no research has evaluated message framing to promote uptake of behavioral treatment. Our study did not reveal an association between health message framing and willingness to initiate behavioral therapy for migraine prevention. More research is needed on the most impactful ways to convey information to patients in Neurology clinics.

Table 1:

Participant Demographics

	Total n=401		SGF n=98		NSGF n=100		SLF n=101		NSLF n=102		Test, p value
Age:	Median	IQR	median	IQR	median	IQR	median	IQR	Median	IQR	Kruskal-Wallis H 0.094
	34	12	34	12.8	32	10	32	13	34	13
	N	%	N	%	N	%	N	%	N	%
Women	282	70.3	68	69.4	67	68.4	72	73.5	75	76.5	Chi square 0.267
Ethnicity (White/ Black/ Hispanic/ Asian, Native American and Other	302/50/26/23		70/13/5/10		73/13/9/5		80/11/7/3		79/13/5/5		Chi Square 0.573
Education (High school/some college and vocational/ Bachelor and associate/mast ers and Doctorate)	55/112/185/49		10/26/47/15		15/31/42/12		11/30/50/10		19/25/46/12		Chi square 0.33
Employment: Fulltime vs. not	252/149		69/29		57/43		56/45		70/32		Chi Square 0.48