African American Parents’ Perceived Vaccine Efficacy Moderates the Effect of Message Framing on Psychological Reactance to HPV Vaccine Advocacy

Abstract

This experiment assessed how the frame of promotional vaccine messages elicited psychological reactance differently for African American parents according to their level of perceived vaccine efficacy. We found that those with low perceived HPV vaccine efficacy experienced more psychological reactance in response to loss-framed messages compared to gain-framed messages, whereas message framing made little difference for those with high perceived HPV vaccine efficacy. In addition, the interaction between frame and perceived HPV vaccine efficacy indirectly affected parents’ intentions to vaccinate their child for HPV via reactance. These results support current theorizing about framing effects under defensive message processing specifically as it applies to psychological reactance.

Vaccine hesitancy is a cause of low vaccination rates worldwide (Bednarczyk, 2018), posing a notable threat to global public health (World Health Organization, 2019). Such is the case for vaccines for the human papillomavirus (HPV) in the U.S. in particular. For example, two HPV vaccines approved by the U.S. Food and Drug Administration are recommended for protecting against several HPV types that are responsible for 70% to 90% of cervical cancers (Galbraith et al., 2016). Despite evidence for the efficacy and safety of these vaccines, the overall coverage of HPV vaccines in the U.S. has remained significantly below the goal of 80% in Healthy People 2020 (Nan et al., 2019; Newman et al., 2018). As of 2019, the Centers for Disease Control and Prevention (2020) report that approximately 71% of adolescents ages 13-17 had received a single dose of an HPV vaccine, but only 54% had completed the recommended 3-dose series.

HPV vaccination is controversial among African American parents in particular (Galbraith et al., 2016), with their vaccination acceptance and intentions tied closely to beliefs about the HPV vaccine, which include concerns about safety, side effects, and effectiveness (Galbraith-Gyan et al., 2019a, 2019b). African Americans report greater distrust of HPV vaccines and desire for more information about the safety and efficacy of HPV vaccines (Katz et al., 2016). Perceptions of distrust and lack of information is compounded by the fact that African Americans are less likely to receive HPV vaccine recommendations from health providers (Fenton et al., 2019). These issues likely contribute to HPV and cervical cancer disproportionately affecting African Americans, with African-American women 80% more likely to die from cervical cancer than white women (American Cancer Society, 2019). Thus, investigating how vaccine advocacy affects HPV vaccination among this group is particularly important.

For controversial health topics such as vaccination, people often hold preexisting beliefs that influence how they respond to persuasive health messages, which may explain why vaccine promotion sometimes fails to increase intention to vaccinate or even backfires by decreasing intention to vaccinate (Bednarczyk, 2018). One explanatory mechanism for counterproductive outcomes of health advocacy is psychological reactance (Brehm, 1966), which refers to the aversive motivational state brought about by perceptions of threatened freedoms that increases the propensity to engage in adverse behaviors. When health messages recommend a course of action, people can become reactant and reject recommendations (Reynolds-Tylus, 2019). Reactance is known to relate to anti-vaccination attitudes and behavior (Bednarczyk, 2018; Hornsey et al., 2018; Soveri et al., 2020).

There is reason to believe that acceptance, or rejection, of HPV vaccine recommendations is closely tied to reactance for African American parents due to targeted historical mistreatment and discrimination of African Americans by the medical community (Fu et al., 2017). When Washington, D.C., a city with a large African-American population, became one of the first jurisdictions to mandate HPV vaccination for public school entry, parents and members of the media were quick to condemn the mandate as paternalistic (Milloy, 2007; Washington Times, 2007). At the time, opponents argued that the mandate was imposed by white legislators who were not interested in hearing the concerns of African American parents (Milloy, 2007). Even today, African American parents voice concerns about the HPV vaccine’s safety and associated mistrust of medical authorities that are characterized by negative emotion and counterarguments, suggesting reactance-consistent responses to HPV vaccination campaigns (Lama et al., 2021). African-American mothers and daughters continue to hold similar concerns related to HPV vaccines, questioning whether public health officials consider racial differences when making recommendations (Galbraith-Gyan et al., 2019a). Similar vaccination mandates have shown to elicit psychological reactance, ultimately reducing vaccination uptake (Betsch & Böhm, 2016; Sprenholz & Betsch, 2020).

Therefore, it is important to tailor vaccine advocacy in ways that are sensitive to a potential reactance response in order to increase HPV vaccination uptake among African Americans. Researchers have examined how message framing (i.e., gain vs. loss framing) influences reactance to health advocacy (e.g., Quick et al., 2015; Reinhart et al., 2007). However, research about reactance in relation to message framing in the context of vaccination is scant (Nan et al., 2018).

Additionally, meta-analytic reviews show that the relative effects of gain vs. loss frames on persuasive outcomes, in general (O’Keefe & Jensen, 2007, 2008, 2009) and in the context of vaccines (O’Keefe & Nan, 2012; Penţa & Băban, 2018), are either nonsignificant or consistently small, leading to calls for a “second generation” of framing research focusing on moderating variables that determine the relative effects of gain and loss frames (Covey, 2014). One variable that has received some attention in relation to framing effects in the context of vaccination is perceived vaccine efficacy. Research has primarily examined how message-based perceptions of vaccine efficacy mediate the effects of framing (Abhyankar et al., 2008; Ferguson & Gallagher, 2007). However, little has investigated the moderating role of prior perceptions of vaccine efficacy in the context of message framing, and scholars have yet to explore the relationship between prior perceptions of vaccine efficacy, framing, and reactance.

Nan et al.’s (2018) integrative model of message framing outlines how the interaction between framing and various individual differences influences persuasive outcomes. It specifically addresses framing effects under defensive motivation, which shares similarities with reactance, being characterized by negative emotion and counterargument. The model proposes that if defense-motivated people are presented with a message advocating a position incongruent with their prior beliefs, they are more likely to experience reactance and reject the message. Based on these arguments, loss frames (compared to gain frames) emphasizing efficacy of HPV vaccines might engender reactance and message rejection for African American parents who perceive HPV vaccines to be ineffective.

Through the lens of psychological reactance theory (Brehm, 1966) and the integrative framework of message framing (Nan et al., 2018), we seek to, first, test whether the effects of gain- and loss-framed messages on reactance are moderated by individual perceptions of HPV vaccine efficacy, and, second, whether that moderation indirectly influences African-American parents’ intentions to vaccinate their child against HPV via reactance.

Psychological Reactance Theory

Psychological reactance theory (PRT; Brehm & Brehm, 1981) explains how persuasive health messages sometimes cause audiences to reject health recommendations. PRT suggests that when people perceive threats to their behavioral autonomy (in the form of a message’s behavioral directives), they feel compelled to restore a sense of freedom by engaging in actions contrary to the advocacy. The state of reactance, operationalized as the combination of anger and negative thoughts in response to the message (Dillard & Shen, 2005; Rains, 2013), motivates people to reestablish freedom by enacting the prohibited behavior. Reactance also functions trait-like, wherein people are temperamentally inclined toward perceiving threats to freedom (Hong & Page, 1989).

Research related to reactance and vaccination has focused both on trait and state reactance. In the contexts of HPV vaccination (Finkelstein et al., 2020) and childhood vaccinations in general (Soveri et al., 2020), higher levels of trait reactance are associated with less trust in medical authorities and rejection of vaccination recommendations. Similarly, parents higher in trait reactance are less confident in HPV vaccines (Shah et al., 2019). The introduction of vaccine mandates is also met with outcomes indicative of state reactance (Betsch & Böhm, 2016; Sprenholz & Betsch, 2020). More directly, counterattitudinal vaccination messages increase reactance and decrease intentions to vaccinate, with reactance mediating the relationship between message-attitude incongruence and vaccination intention (Kim et al., 2020). These findings support Nan et al.’s (2018) proposition because participants presented with vaccine messages that were incongruent with prior beliefs expressed greater intentions to act against message recommendations via increases in reactance.

Psychological Reactance and Message Framing

One important aspect of reactance research concerns the examination of message-based antecedents of state reactance in order to mitigate its experience (Shen, 2015). Scholars have examined message features that arouse and diminish reactance, such as controlling vs. autonomy-supportive language (e.g., Crano et al., 2017; Dillard & Shen, 2005; Quick & Considine, 2008; Quick & Kim, 2009), scripts that contain reminders of freedom (e.g., Bessarabova et al., 2013, 2017; Miller et al., 2007; Richards & Banas, 2015, 2018; Richards et al., 2017, 2020; 2021), use of novel messages or narratives (e.g., Moyer-Guse & Nabi 2010; Quick, 2013), and gain vs. loss framing (Cho & Sands, 2011; Reinhart et al., 2007). This study focuses on the latter feature, which is a persuasive strategy that highlights either the positive consequences of performing a behavior (i.e., gain-frame) or the negative consequences of not performing a behavior (i.e., loss-frame). In context, Gerend and Shepherd (2007) showed that messages conveying outcomes of HPV vaccination adopt either gain frames (e.g., “There are many benefits you may experience if you get the genital HPV vaccine.”) or loss frames (e.g., “There are many risks you may experience if you don’t get the genital HPV vaccine.”). Churchill and Pavey (2013) proposed that the relative influence of gain- and loss-framed messages is contingent upon a person’s sense of freedom to act in accordance with their own beliefs and their acceptance of advice from others.

Loss framing should induce more reactance for a couple reasons. First, the language used in loss framing tends to be more forceful and controlling compared to gain framing (Cho & Sands, 2011). As a result, loss framing might be perceived as more manipulative and higher in persuasive intent, which triggers reactance (Shen, 2015). Second, the effect of loss framing on reactance could also be understood from the perspective of fear appeals. By highlighting the negative consequences of noncompliance, loss framing aligns with the threat component of fear appeals. Indeed, studies suggest that loss framing results in stronger fear arousal (e.g., Schneider et al., 2001; Seo et al., 2013; Shen & Dillard, 2007), and fear appeals lead to reactance (Shen & Coles, 2015). Simply put, there is theoretical reason to believe that loss, versus gain, frames induce more reactance.

Several studies across a variety of health contexts show that loss frames elicit more reactance than gain frames. Reinhart et al. (2007), in the context of organ donation, found that loss-framed messages were not only more reactance inducing, but also seen as having greater manipulative intent. Shen (2015) found that loss frames elicited higher levels of reactance in the context of skin cancer prevention. Shen and Dillard (2007) found that loss-framed messages led to stronger anger arousal (although negative cognitions went unmeasured) in several health-related contexts. Cho and Sands (2011) found greater perceived threats to freedom among adolescents who read loss-framed messages about sun safety.

However, not all studies conclude that loss frames cause more reactance compared to gain frames. Some find no difference between gain and loss frames on reactance (Lee & Cameron, 2017; Quick & Bates, 2010). Others find that gain frames elicit more reactance than loss frames (Quick et al., 2015; Ratcliff et al., 2019).

These contradictory findings highlight the importance of considering additional contextual features in order to better understand how framing brings about reactance. One factor that has received some attention is the discrepancy between preexisting beliefs or expectations and the position advocated in a message. For example, Kim et al. (2020) found that messages that were counter to people’s prior beliefs elicited greater reactance. Ratcliff et al. (2019) suggested the relationship between framing and reactance is a function of expectancy violations caused by differences between one’s beliefs about appropriate health advocacy and the reasoning advanced in a message. Taking into consideration discrepancies between preexisting beliefs and message recommendations might help clarify the relationship between framing and reactance.

The Moderating Role of Preexisting Efficacy Beliefs

Similar to the inconsistencies in results about the relationship between framing and reactance in general, framing research about a variety of vaccine-related health topics—including HPV (Nan, 2012), influenza (e.g., Yu & Shen, 2013), and H1N1 (Nan et al., 2012) vaccines—demonstrates inconsistencies about the relative effect of gain vs. loss frames. Meta-analyses show no difference in the main effect of gain- and loss-framed appeals for encouraging vaccination (O’Keefe & Nan, 2012; Penţa & Băban; 2018). Rather, numerous moderators influence framing effects, including characteristics of the message recipient like their motivational orientation (Nan, 2012a) and time orientation (Nan, 2012b) as well as situational factors like the presence of threat cues like the color red (Gerend & Sias, 2009) and behavioral frequency (Gerend et al., 2008).

One plausible reason for inconsistencies in framing effects is individual differences in preexisting beliefs about a certain health topic (Covey, 2014). Specific to HPV vaccination, parents’ vaccination beliefs (e.g., beliefs about vaccine risk and efficacy) correlate with vaccine acceptability, vaccination attitudes, and intentions (Nan et al., 2019; Newman et al., 2018; Reiter et al., 2009). For African American parents, efficacy beliefs are usually low whereas concerns about safety, cost, and distrust in health information from medical authorities are high (Galbraith-Gyan et al., 2019a, 2019b; Nan et al., 2019). When parents encounter persuasive health messages that do not align with their preexisting beliefs, they tend to defend their own positions, otherwise known as defense-motivation (Jonas et al., 2005).

Nan et al. (2018) proposed a framework that integrates several theoretical perspectives often used to guide message framing research and delineates crucial factors determining the relative persuasiveness of gain vs. loss frames. Specifically, it addresses the relative effect of gain vs. loss frames when defense-motivation is activated. According to this integrative framework, gain-framed messages are more effective than loss-framed messages under defense-motivated processing when the advocacy is counterattitudinal, whereas gain and loss frames are equally persuasive when the advocacy is proattitudinal (Proposition 3, Nan et al., 2018). For those who believe HPV vaccines are ineffective, promotional arguments for the efficacy of vaccines do not align with their preexisting beliefs. In other words, vaccine advocacy is counterattitudinal for those who perceive vaccine efficacy to be low. When these individuals encounter persuasive health messages, they engage in defense-motivated processing, characterized by counterarguments and negative affect, aiming to maintain the stability of their own cognitive systems (Bailey et al., 2018; de Hoog et al., 2008; Jonas et al., 2005).

According to this perspective, after encountering vaccine promotion messages, people who are low in perceived vaccine efficacy engage in defense-motivated processing that results in counterarguments and negative affect. Such responses are similar to current understandings of reactance as the combination negative cognitions and anger (Dillard & Shen, 2005). Indeed, defensive message processing can manifest as reactance (Clayton et al., 2019).

Thus, we expect that the effect of loss-framed (vs. gain-framed) messages on reactance should be more pronounced when individuals believe a vaccine to be increasingly ineffective. Conversely, when individuals believe a vaccine to be effective, we expect little difference between gain and loss frames on reactance. Accordingly, we propose the following hypothesis of moderation regarding the interplay between framing, preexisting beliefs about vaccine efficacy, and reactance.

H1: Loss-framed messages, compared to the gain-frame messages, elicit more reactance particularly for those who are low in perceived HPV vaccine efficacy.

The Mediating Role of Reactance

Although the state of reactance is the focal mechanism of the PRT (Shen & Dillard, 2013), the theory is processual. Scholars note that the phenomenon should be modeled as a sequence by which freedom-threatening stimuli precede reactance, which, in turn, prompts efforts to restore the threatened freedom (Quick et al., 2013). Dillard and Shen (2005) showed that reactance, as the combination of anger and negative cognition, mediated the effect of message features (i.e., freedom threatening language) and preexisting cognitive inclinations (e.g., reactance proneness) on attitude and behavioral intention. Meta-analysis supports this mediation (Rains, 2013). In relation to message framing, studies show that reactance mediates the effect of framing on relevant attitudinal outcomes (e.g., Quick et al., 2015; Reinhardt et al., 2007; Shen, 2015; cf. Ratcliff et al., 2019).

We base our mediation model on Dillard and Shen’s (2005), which conceptualized both people’s preexisting cognitive inclinations and a message’s features to be antecedents of reactance, which then predicted behavioral intention. Here, perceived HPV vaccine efficacy and message framing (and their interaction) function as antecedents of reactance, which mediates their effects on intention to vaccinates one’s child against HPV. Thus, we propose the following hypothesis:

• H2: Loss-framed messages, compared to the gain-frame messages, indirectly elicit less vaccination intention via reactance particularly for those who are low in perceived HPV vaccine efficacy.

Method

Participants and Procedures

All procedures received IRB approval. The experiment consisted of people answering a pretest questionnaire, viewing an experimental stimulus in the form of a pamphlet about HPV, and answering a posttest questionnaire. Participants were recruited from community outlets (e.g., laundromats and shopping malls) in the surrounding Washington DC area. To qualify, participants had to identify as African American, be at least 18 years of age, and be a custodial parent of at least one child eligible for HPV vaccination (i.e., between 9-17 years of age and had not completed the full series of the HPV vaccine). Parents were told the purpose of the study was to evaluate educational materials about HPV vaccination. They first completed the pretest, then were randomly assigned to review a pamphlet that presented arguments for vaccination in either a gain-frame or loss-frame, and then completed the posttest. Upon completion of the study, participants were thanked and given a $25 gift card.

Of 211 initial respondents, 184 completed the measures used in this study, and these comprised the final sample. Most were mothers (73%). The average age was 36.13 (SD = 9.07). Most reported having some college education (38%) or college degree (32%), with fewer having advanced degrees (12%) or high school degrees (16%), and with 2% reporting not having graduated high school.

Experimental Messages

The pamphlet was a bifold brochure consisting of information about HPV and the vaccine in four numbered sections (i.e., “1. What is HPV?,” “2. Who should get this HPV vaccine and when?,” “3. HPV vaccine: Why get vaccinated?,” and “4. How can I learn more?”). The third section was surrounded by a border and shaded to draw attention to the text box, which uniquely included bolded text. Within the box, four bullet points provided arguments for vaccinating one’s child for HPV. This material was used to manipulate message frame with each bulleted sentence being presented in gain frames or loss frames. For example, the gain-framed version stated “By having your child receive the HPV vaccine, you make it much less likely for him/her to get genital HPV,” whereas the loss-framed version stated that “By not having your child receive the HPV vaccine, you make it much more likely for him/her to get genital HPV.” Aside from the frame of these four sentences, the pamphlets were identical.

Measures

HPV vaccine efficacy.

In the pretest, three items adapted from Nan and Madden (2012) assessed the degree to which parents perceived that the HPV vaccine was effective in preventing HPV (e.g., “If my child gets the HPV vaccine, he or she will be less likely to get HPV;” 1 = Strongly disagree, 5 = Strongly agree). The scale was reliable (M = 3.57, SD = 0.72, α = .74).

Reactance.

Consistent with the intertwined model (Dillard & Shen, 2005; Rains, 2013), reactance was operationalized as the combination of felt anger and negative cognitions. In the posttest, anger was assessed with a single item that asked how angry parents felt in response to the message’s advocacy of vaccinating children against HPV (1 = none of this feeling, 4 = a great deal of this feeling; M = 1.43, SD = 0.85). Negative cognitions were assessed by asking parents to write down all the thoughts they had while reading the pamphlet, with space to record up to ten separate thoughts. They then self-coded each thought as either positive or negative toward the HPV vaccine as well as related or not related to the HPV vaccine (see Reynolds-Tylus et al., 2020). Thoughts that were negative toward and related to the HPV vaccine were summed (M = 0.62, SD = 1.11). Anger and negative cognitions were then standardized and averaged to form the combined measure, which is consistent with previous treatments of the variable (e.g., Ratcliff et al., 2019; Richards et al., 2020).

HPV vaccination intentions.

In the posttest, three items adapted from Nan et al. (2015) assessed intentions toward vaccinating one’s child for HPV (e.g., “How likely would you be to have your child vaccinated in the future?;” 1 = Extremely unlikely, 5 = Extremely likely) under conditions of the vaccine being free (M = 3.80, SD = 1.13, , α = .88) or the vaccine costing $375 (M = 3.31, SD = 1.15, , α = .89).

Control variables.

In addition to parents’ income, age, education, and sex, variables were assessed as statistical controls due to unique aspects of the HPV context. All were measured in the pretest. HPV awareness and knowledge of the HPV vaccine correlate with vaccination uptake (Chan et al., 2015; Cohen & Head, 2013), so to control for awareness of the disease, parents were asked whether they had heard of HPV prior to their participation in the study (18% indicated no, 2% indicated not sure, and 80% indicated yes), and to control for knowledge of the HPV vaccine’s function, parents were asked whether they had heard that the HPV vaccine could prevent cervical cancer (27% indicated no, 4% indicated not sure, and 69% indicated yes). To control for child-gender differences in provider recommendation of HPV vaccination (Lindley et al., 2016) as well as differences in parents’ intentions toward vaccinating sons and daughters for HPV (Berenson & Rahman, 2012), parents’ number of sons (range = 0-4, M = 0.69, SD = 0.75) and daughters (range = 0-3, M = 0.67, SD = 0.68) between the ages of 9 and 17 were covaried. Because trust in medical authorities affects willingness to vaccinate children against HPV (Nan et al., 2014) and mistrust in doctors cooccurs with reactance to predict parents’ vaccination of their children more generally (Soveri et a., 2020), a covariate of trust in information from healthcare professionals was assessed with a single item (i.e., “In general, how much would you trust information about health or medical topics from a doctor or other health care professional?;” 1 = A lot, 4 = Not at all; M = 1.76, SD = 0.91).

Results

Two custom moderated mediation models were tested using PROCESS 3.5 (Hayes, 2018) with 95% confidence intervals (CIs) and 5000 bootstrap samples. The models assessed full mediation of reactance as intervening between the independent variables (i.e., the experimental framing variable [coded so 0 = gain-frame and 1 = loss-frame], perceived HPV vaccine efficacy, and their interaction) and intention to vaccinate one’s child for HPV. The models were identical save for the outcome variable being intention when free or at cost. Thus, the regression results predicting the mediator of reactance were identical in both models.

H1 predicted that the loss-frame, compared to the gain-frame, would elicit more reactance particularly for those who were low in perceived HPV vaccine efficacy. Results in Table 1 show a significant main effect for message frame (B = 1.42)—overall, the loss frame caused more reactance—as well as a significant interaction between frame and perceived HPV vaccination efficacy (B = −0.33). This interaction was decomposed to assess the effect of frame at various levels of perceived HPV vaccine efficacy. As the visual decomposition of the interaction in Figure 1 demonstrates, the loss-frame resulted in significantly more reactance compared to the gain-frame when perceived HPV vaccine efficacy was low (i.e., 16th percentile; B = 0.42, SE = 0.15, t = 2.82, 95% CI [0. 13, 0.72]) but not when moderate (i.e., 50th percentile; B = 0.20, SE = 0.12, t = 1.72, 95% CI [−0.03, 0.43]) or high (i.e., 84th percentile; B = −0.02, SE = 0.17, t = −0.14, 95% CI [−0.35, 0.30]). Table 2 further depicts the nature of the interaction according to the Johnson-Neyman technique, which identified the point along the continuous spectrum of perceived HPV vaccine efficacy that framing effects ceased to affect reactance significantly. Among roughly the lower half of parents who perceived the HPV vaccine as less efficacious (47.28%, below the value of 3.58), the loss (vs. gain) frame elicited increasingly more reactance as perceived efficacy decreased. For the upper half of parents who perceived the HPV as more efficacious (52.72%), frame did not significantly affect reactance according to perceived efficacy. H1 was supported.

Table 1.

Predictors of Psychological Reactance

				95% CI
	B	SE	t	LL	UL
Frame	1.42	0.58	2.43*	0.27	2.57
Perceived vaccine efficacy	0.36	0.26	1.37	−0.16	0.87
Frame × Perc. vaccine eff.	−0.33	0.16	−2.08*	−0.65	−0.02
Income	−0.00	0.06	−0.05	−0.13	0.12
Education	−0.01	0.07	−0.11	−0.14	0.12
Age	−0.00	0.01	0.20	−0.02	0.01
Sex	−0.14	0.14	−1.02	−0.41	0.13
Awareness of HPV	−0.19	0.09	−2.05*	−0.37	−0.01
Knowledge of HPV vaccine	0.21	0.08	2.54*	0.05	0.38
Number of sons	0.05	0.09	0.49	−0.14	0.23
Number of daughters	0.16	0.09	1.81	−0.01	0.33
Trust in health professionals	0.11	0.07	1.61	−0.02	0.24

Note.

^*p < .05

^†p < .10. Message frame was coded so 0 = gain, 1 = loss. Sex was coded so 1 = male, 2 = female. Education was coded so 1 = some levels of high school, 2 = completed high school, 3 = some college, 4 = completed college, 5 = postgraduate education. Awareness of HPV and Knowledge of HPV vaccine were coded so 1 = no, 2 = not sure, 3= yes. Income was coded so 1 = under $15k, 2 = $15k-34k, 3 = $35k-75k, 4 = $75k-99k, 5 = $100k-200l, 6 = over $200k.

Figure 1.

Effect of framing on reactance at low (16th percentile), moderate (50th percentile), and high (84th percentile) levels of perceived HPV vaccine efficacy.

Table 2.

Conditional Effect of Focal Predictor (Message Frame) at Values of the Moderator (Perceived HPV Vaccine Efficacy) on the Criterion Variable (Psychological Reactance)

HPV vaccine					95% CI
efficacy	B	SE	t	p	LLCI	ULCI
1.33	0.98	0.38	2.58	.011	0.23	1.72
1.52	0.91	0.35	2.61	.010	0.22	1.61
1.70	0.85	0.32	2.64	.009	0.22	1.49
1.88	0.79	0.30	2.68	.008	0.21	1.38
2.07	0.73	0.27	2.72	.007	0.20	1.26
2.25	0.67	0.24	2.76	.007	0.19	1.15
2.43	0.61	0.22	2.80	.006	0.18	1.04
2.62	0.55	0.19	2.83	.005	0.17	0.93
2.80	0.49	0.17	2.85	.005	0.15	0.83
2.98	0.43	0.15	2.83	.005	0.13	0.72
3.17	0.37	0.13	2.73	.007	0.10	0.63
3.35	0.30	0.12	2.50	.013	0.06	0.54
3.53	0.24	0.12	2.10	.037	0.02	0.47
3.58	0.23	0.12	1.97	.050	0.00	0.46
3.72	0.18	0.12	1.56	.121	−0.05	0.41
3.90	0.12	0.13	0.97	.334	−0.13	0.37
4.08	0.06	0.14	0.44	.664	−0.21	0.34
4.27	−0.00	0.16	−0.00	.999	−0.31	0.31
4.45	−0.06	0.18	−0.34	.733	−0.41	0.29
4.63	−0.12	0.20	−0.60	.547	−0.52	0.28
4.82	−0.18	0.23	−0.81	.421	−0.63	0.27
5.00	−0.24	0.25	−0.97	.335	−0.74	0.25

Note. Message frame was coded such that 0 = gain and 1 = loss. The bolded line represents the 47.28 percentile of perceived vaccine efficacy, below which the loss-frame (vs gain-frame) increasingly elicited more reactance.

H2 predicted that the moderation between message frame and perceived HPV vaccine efficacy would indirectly influence intentions via reactance. Results in Table 3 show a significant negative relationship between reactance and intentions, both when free (B = −0.50) and at cost (B = −0.32). As reported in Table 4, loss-frame (compared to gain-frame) significantly diminished intention to vaccinate, both when free and at cost, for parents who were relatively low in perceived HPV vaccine efficacy (i.e., 16th percentile), but not when perceived efficacy was moderate (i.e., 50th percentile) or high (i.e., 84th percentile). H2 was supported.

Table 3.

Predictors of Intentions to Vaccinate One’s Child Against HPV

	Intention when Free					Intention at Cost
				95% CI					95% CI
	B	SE	t	LL	UL	B	SE	t	LL	UL
Reactance	−0.50	0.10	−4.81***	−0.70	−0.29	−0.32	0.11	−2.92**	−0.54	−0.10
Income	−0.06	0.09	−0.69	−0.23	0.11	0.06	0.09	0.68	−0.12	0.25
Education	0.07	0.09	0.79	−0.11	0.25	0.11	0.10	1.18	−0.08	0.31
Age	−0.02	0.01	−2.11*	−0.04	−0.00	−0.01	0.01	−1.07	−0.03	0.01
Sex	0.03	0.19	0.19	−0.33	0.40	0.26	0.20	1.35	−0.12	0.65
Awareness of HPV	0.02	0.13	0.17	−0.23	0.28	−0.26	0.14	−1.86	−0.53	0.02
Knowledge of HPV vaccine	0.18	0.12	1.54	−0.05	0.41	0.10	0.12	0.84	−0.14	0.35
Number of sons	0.11	0.13	0.82	−0.15	0.36	0.19	0.14	1.37	−0.08	0.46
Number of daughters	0.25	0.12	2.06*	0.01	0.48	0.23	0.13	1.83	−0.02	0.48
Trust in health professionals	−0.13	0.09	−1.43	−0.31	0.05	−0.10	0.10	−1.03	−0.29	0.09

Note.

^***p < .001

^**p < .01

^*p < .05. Message frame was coded so 0 = gain, 1 = loss. Sex was coded so 1 = male, 2 = female. Education was coded so 1 = some levels of high school, 2 = completed high school, 3 = some college, 4 = completed college, 5 = postgraduate education. Awareness of HPV and Knowledge of HPV vaccine were coded so 1 = no, 2 = not sure, 3= yes. Income was coded so 1 = under $15k, 2 = $15k-34k, 3 = $35k-75k, 4 = $75k-99k, 5 = $100k-200l, 6 = over $200k.

Table 4.

Conditional Indirect Effects of Framing on Intentions via Reactance

	Intention when Free				Intention at Cost
			95% CI				95% CI
Perceived HPV vaccination efficacy	B	SE bootstrap	LLbootsrap	ULbootsrap	B	SE bootstrap	LLbootsrap	ULbootsrap
Low (16th%)	−0.21	0.11	−0.448	−0.002	−0.13	0.08	−0.316	−0.003
Moderate (50th%)	−0.10	0.06	−0.224	0.017	−0.06	0.04	−0.162	0.006
High (84th%)	0.01	0.08	−0.144	0.191	0.01	0.05	−0.100	0.126

Note. Message frame was coded such that 0 = gain and 1 = loss.

Discussion

Developing strategies for communicating with those who are wary of vaccines is key to increasing vaccine uptake. This study explored the relationships between exposure to gain- or loss-framed messaging, perceptions of vaccine efficacy, and psychological reactance in order to assess the counterproductive outcomes of messaging on vaccine acceptance. Specifically, this study examined the effects of message framing on African American parents’ reactance and associated willingness to vaccinate their children against HPV depending on their levels of perceived HPV vaccine efficacy. Relying on arguments put forth in the integrative model of message framing (Nan et al., 2018) and the tenets of PRT (Brehm, 1966), we expected that parents exposed to loss frames (vs. gain frames) would exhibit higher levels of reactance and subsequently be more likely to reject message recommendations if their perceptions of vaccine efficacy were low.

Results supported these predictions. First, we found a significant interaction between frame and perceived HPV vaccine efficacy, such that people exposed to loss frames reported significantly higher levels of reactance compared to people exposed to gain frames when perceived vaccine efficacy was low, but not when perceived vaccine efficacy was moderate or high. Second, exposure to loss frames (vs. gain frames) significantly diminished intention to vaccinate via reactance for parents who were low in vaccine efficacy, but not for parents who were moderate or high in vaccine efficacy.

The results of this study support theoretical notions put forth by the integrative model of message framing (Nan et al., 2018) and add to the body of literature exploring the relationships between individual’s preexisting beliefs, gain and loss frames, and reactance in health communication. The model’s third proposition states that when people engage in defense-motivated processing, loss frames are less persuasive than gain frames. In our study, we were able to pinpoint an application in which this proposition functions in relation to vaccine advocacy. Our findings support the notion that reactance occurs when people low in perceived vaccine efficacy engage in defense-motivated processing following exposure to a loss-framed message advocating for vaccination. This research also contributes to understandings about whether gain- or loss-framed messages lead to reactance by offering evidence of moderation due to preexisting beliefs, specifically beliefs about vaccine efficacy.

This study has practical implications as well, especially relating to messaging for African Americans, who are disproportionately affected by HPV and hesitant toward the HPV vaccine. For African-American parents with low perceptions of HPV vaccine efficacy, loss-framed messages (compared to gain-framed messages) may lead to greater reactance and message rejection. It follows that health communicators should consider avoiding loss-framed messaging for African-American parents with low perceptions of vaccine efficacy, or work to increase perceptions of vaccine efficacy to moderate levels prior to exposure to loss-framed messages. Studies also connect increased levels of reactance to anti-vaccination attitudes and higher likelihood of vaccine rejection (Finkelstein et al., 2020; Hornsey et al., 2018). Future research might investigate whether interventions designed to increase perceptions of vaccine efficacy prior to exposure to loss-framed messages temper reactance and increase vaccination. Others note the possibility that efficacy information might enhance the persuasiveness of loss-framed health appeals (Quick & Bates, 2010). Future research might also explore the relationship between framing, vaccine hesitancy, and reactance in the context of other vaccines as well as in contexts of other behaviors for which perceived efficacy is low.

Limitations

While this research contributes to the body of work related to gain- and loss-frame messaging, it has limitations. First, because there was no measurement of perceived freedom threat, we cannot be certain that the aversive psychoemotive reaction to the loss-framed message was due to perceptions of threatened autonomy (see Quick et al., 2013). However, these results are theoretically and empirically consistent with a reactance response. Second, we only measured short-term message effects. It is not clear whether the pattern of results can be replicated for measures taken following message exposure after a delay. We also measured behavioral intention but not measure actual behavior. Future studies should assess long-term message effects as well as the effects of framing and efficacy perceptions on behavior in addition to intention. Finally, participants in our study were African-American parents, and while it is important to understand HPV vaccination messaging effects among this group, additional studies might need to be conducted to generalize our findings about HPV vaccine messaging to other populations.

Conclusion

This research demonstrates how message framing exacerbates or mitigates the potential negative consequences of beliefs about vaccine efficacy. We found that, via reactance, loss-framed (compared to gain-framed) HPV vaccination advocacy reduced intentions to vaccinate one’s child particularly among parents who believed the HPV vaccine to be inefficacious. An implication of this work is to assess people’s perceptions of vaccine efficacy prior to message exposure in order to strategically tailor the framing of the message to prevent reactance and message rejection. Namely, these results suggest that loss-framed vaccine advocacy should be avoided for audiences with low vaccine efficacy beliefs. Understanding the relationships between individual perceptions, message framing, and reactance in the context of HPV vaccination is particularly important among African Americans, who are disproportionately affected by HPV and report desiring more information about the safety and efficacy of the HPV vaccine prior to vaccinating their children.