For Better or for Worse? An Integrative Perspective of Message Framing Moderators’ Effects on Vaccination Sustainable Health Behavior Change

Round 1

Reviewer 1 Report

This paper reviews the conceptual framework and reports the results of an empirical qualitative study looking at the influence of message framing on health decisions and behaviors.

The case study is looking at decision to accept COVID-19 immunization.  The research participants are 67 students aged 19-23.  The qualitative methodology involves two well-defined research questions pursued using semi-structured interview techniques during 8 focus groups. 

The background section invoking the various theories of health behavior is appropriate and well-done. The thematic analysis of transcripts involving codes and sub-codes is appropriate and reasonably well-described.  The findings described in the text and portrayed in Figures 2 – 5 (generated by the ATLAS.ti qualitative analysis program) are interesting and generally appropriate.

The authors argue that a gain-framed vs. loss-framed messaging structure aimed at supporting positive health behaviors is inadequate, and that other factors such as stage-of-change should be considered.  They also argue that the impact of gain- vs. loss framing may depend on factors other than purpose (e.g. detection, prevention), and that these other factors should be evaluated as potential moderators or mediators of the degree of influence of the input (message, intervention) on the output (health decision, health behavior). 

The authors focus on Prochaska and Diclemente’s stages-of-change theory (transtheoretical model).  While interesting and even novel for this setting, I am not convinced this is completely appropriate.  Certainly, the vaccine-hesitant population could be considered to be in a pre-contemplative state, with contemplation and action (receiving vaccine) as subsequent stages.  However, there may not be much of a preparation stage for those deciding to get immunized, and the stages of maintenance and potential relapse really don’t make much sense in the vaccination context.  Nevertheless, this is a novel approach, perhaps worthwhile, and clearly a central focus for these authors.  Their main finding/assertion makes good sense and is potentially important: “Specifically, we found that people that are in contemplation and in preparatory stage of change need different narratives to be convinced to implement a new health behavior.”

Suggestion #1:  Enhance discussion of how vaccine acceptance might be considered a positive health behavior that should be maintained over time (not just one shot or vaccine series, but a life-long sets of choices that might or might not be sustained).

While the two Research Questions are well-defined and appropriate, and the authors’ opinions/conclusions regarding gain- and loss-framed messaging are well-articulated, it is not clear how the empirical research helped lead to these opinions/conclusions.  As written it seems that these researchers went into this study with their opinions, which were supported.  Because this is a hypothesis-generating rather than hypothesis-testing study, readers need to know exactly how the observation findings led to novel insights or deeper understanding.

Suggestion #2:  Clarify which parts of the authors’ conceptual framework existed before the data were collected, which ones emerged as new elements or insights, and which ones developed or transformed significantly.

It is unclear exactly who analyzed the transcripts, and how they were analyzed.  This type of research is generally considered to be stronger if the analytic team is multi-disciplinary, and if the transcripts are analyzed independently, with iterative discussion leading to consensus. 

Suggestion #3:  Explain: 1) who read the transcripts, 2) what the disciplinary background(s) was/were, 3) how the transcription analysis proceeded, and 4) what specific directions the readers/analysts received prior to reading the transcripts.  If instead the analysis was done by only one person using the ATLAS program, that person’s background and analytic stance should be clarified, and this should be explained both in the methods section and then as a limitation.

Suggestion #4: Explain in more substantive detail exactly how the Codes and Sub-codes were derived.  How much of this framework existed before the data were collected?  Were the Code categories specified before the data were collected, or did they emerge newly?

Suggestion #5:  Reduce the length of Sections 1, 2, and 3, and consider moving some of this material to Section #4.  This could help with the criticism that these authors came into this study with a particular viewpoint, and simply found what they were looking for.  The description of how existing conceptual frameworks are wrong or incomplete, and how this study helps to expand or correct those theories, should especially be moved from the background sections into the final discussion and interpretation section.

The title is long and does not reference the focus of the empirical study.

Suggestion #6:  Consider shortening article title and including reference to the COVID-19 vaccine decision.  Readers potentially interested in this study include those interested in vaccine hesitancy and not only those focused on theories of health behavior change.

Errata:  1)  In Abstract, “stages of chance” should be “stages of change” ;  2) In 4. Results and Discussion, “the more grounded it is in the date” should be “the more grounded it is in the data”.

Finally, I question whether this is the most appropriate journal for this work.  Individual-level decision-making and behaviors are extremely important for the field of environmental sustainability.  Readers of Sustainability will be interested in theories and data relating to choices, decisions, and behavior change, and this paper does a very nice job of describing current theory and proposing improvements.  However, the study portrayed here is focused on vaccine uptake, a health behavior which has minimal connection with environmental sustainability.   The use of the word “sustainable” in the title actually seems mis-placed, as the focus is not on sustaining vaccine acceptance, but rather on the initial decision to receive the shot.  

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Review of “For better or for worse? An integrative perspective of message

framing moderators and gain-loss-framed narratives’ effects on

sustainable health behavior change”

 

The authors test a series of hypotheses derived from modifying prospect theory in regards to the stages of change model and the theory of planned behavior, allowing for perceived risk and control and vulnerability as modifiers to decision making in light of message framing.

 

1.      The paragraph in lines 38-44 seem to be a direct quotation from the abstract of Van’t Riet, J., Cox, A.D., Cox, D., Zimet, G.D., De Bruijn, G.J., Van den Putte, B., De Vries, H., Werrij, M.Q. and Ruiter, R.A., 2016. Does perceived risk influence the effects of message framing? Revisiting the link between prospect theory and message framing. Health psychology review, 10(4), pp.447-459. This should either be quoted and referenced or the authors should rewrite.

2.      Regarding the scope of the journal, it is not clear to me where this article fits. Maybe health related aspects of sustainability? The authors need to make clear how their work relates to sustainable development.

3.      It is generally a well-written article on its subject and interesting.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

1. Please supplement the statistical information of the studied person, such as age, occupation, physical condition, etc.

2. The author should further excavate the correlation between the individual status of the studied person and the survey results.

3. Please improve the references.

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Thank you for responding to my previous critique.  Very interesting work.

Reviewer 2 Report

Thanks for addressing concerns.