OBJECTIVE: To examine the impact of different presentations of equivalent information (framing) on treatment decisions faced by patients.
DESIGN: A systematic review of the published literature was conducted. English language publications allocating participants to different frames were retrieved using electronic and bibliographic searches. Two reviewers examined each article for inclusion, and assessed methodological quality. Study characteristics were tabulated and where possible, relative risks (RR; 95% confidence intervals) were calculated to estimate intervention effects.
MEASUREMENTS AND MAIN RESULTS: Thirty-seven articles, yielding 40 experimental studies, were included. Studies examined treatment (N=24), immunization (N=5), or health behavior scenarios (N=11). Overall, active treatments were preferred when outcomes were described in terms of relative rather than absolute risk reductions or number needed to treat. Surgery was preferred to other treatments when treatment efficacy was presented in a positive frame (survival) rather than a negative frame (mortality) (relative risk [RR]=1.51, 95% confidence interval [CI], 1.39 to 1.64). Framing effects were less obvious for immunization and health behavior scenarios. Those with little interest in the behavior at baseline were influenced by framing, particularly when information was presented as gains. In studies judged to be of good methodological quality and/or examining actual decisions, the framing effect, although still evident, was less convincing compared to the results of all included studies.
CONCLUSIONS: Framing effects varied with the type of scenario, responder characteristics, scenario manipulations, and study quality. When describing treatment effects to patients, expressing the information in more than one way may present a balanced view to patients and enable them to make informed decisions.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Coulter A. Evidence based patient information. BMJ. 1998;317:225–6.
Coulter A, Entwistle V, Gilbert D. Sharing decisions with patients: is the information good enough? BMJ. 1999;318:318–22.
Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science. 1981;211:453–8.
Kahneman D, Tversky A. Choices, values, and frames. Am Psychol. 1984;39:341–50.
Wilson DK, Purdon SE, Wallston KA. Compliance to health recommendations: a theoretical overview of message framing. Health Educ Res. 1988;3:161–71.
McGettigan P, Sly K, O’Connell D, Hill S, Henry D. The effects of information framing on the practices of physicians. J Gen Intern Med. 1999;14:633–42.
Edwards A, Elwyn G, Covey J, Matthews E, Pill R. Presenting risk information—a review of the effects of ‘framing’ and other manipulations on patient outcomes. J Health Commun. 2001;6:61–82.
McNeil BJ, Pauker SG, Sox HCJ, Tversky A. On the elicitation of preferences for alternative therapies. N Eng J Med. 1982;306:1259–62.
Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17:1–12.
Moher D, Jadad AR, Nichol G, Penman M, Tugwell P, Walsh S. Assessing the quality of randomized controlled trials: an annotated bibliography of scales and checklists. Control Clin Trials. 1995;16:62–73.
Bernstein LM, Chapman GB, Elstein AS. Framing effects in choices between multioutcome life-expectancy lotteries. Med Decis Making. 1999;19:324–38.
Bier VM, Connell BL. Ambiguity seeking in multi-attribute decisions: effects of optimism and message framing. J Behav Decis Making. 1994;7:169–82.
Detweiler JB, Bedell BT, Salovey P, Pronin E, Rothman AJ. Message framing and sunscreen use: gain-framed messages motivate beachgoers. Health Psychol. 1999;18:189–96.
Donovan RJ, Jalleh G. Positive versus negative framing of a hypothetical infant immunization: the influence of involvement. Health Educ Behav. 2000;27:82–95.
Gurm HS, Litaker DG. Framing procedural risks to patients: is 99% safe the same as a risk of 1 in 100? Acad Med. 2000;75:840–2.
Hux JE, Naylor CD. Communicating the benefits of chronic preventive therapy: does the format of efficacy data determine patients’ acceptance of treatment? Med Decis Making. 1995;15:152–7.
Jacoby A, Baker G, Chadwick D, Johnson A. The impact of counselling with a practical statistical model on patients’ decision-making about treatment for epilepsy: findings from a pilot study. Epilepsy Res. 1993;16:207–14.
Kuhn KM. Communicating uncertainty: framing effects on responses to vague probabilities. Organ Behav Hum Decis Process. 1997;71:55–83.
Levin IP, Schnittjer SK, Thee SL. Information framing effects in social and personal decisions. J Exp Soc Psychol. 1988;24:520–9.
Linville PW, Fischer GW, Fischhoff B. AIDS risk perceptions and decision biases. In: Pryor JB, Reeder GD, eds. The Social Psychology of HIV Infection. Hillside, NJ: Lawrence Erlbaum Associates; 1993:5–38.
Malenka DJ, Baron JA, Johansen S, Wahrenberger JW, Ross JM. The framing effect of relative and absolute risk. J Gen Intern Med. 1993;8:543–8.
Marteau TM. Framing of information: its influence upon decisions of doctors and patients. Br J Soc Psychol. 1989;28:89–94.
Martinez TS. Message framing and college students’ HIV-preventive behavior. Dissertation Abstracts International: Section B. The Sciences & Engineering. 2000;60:4303.
McNeil BJ, Pauker SG, Tversky A. On the framing of medical decisions. In: Bell DE, Raiffa H, Tversky A, eds. Decision Making Descriptive Normative and Prescriptive Interactions. Cambridge, UK: Cambridge University Press; 1988:562–8.
O’Connor AM, Boyd NF, Tritchler DL, Kriukov Y, Sutherland H, Till JE. Eliciting preferences for alternative cancer drug treatments. The influence of framing, medium, and rater variables. Med Decis Making. 1985;5:453–63.
O’Connor AM. Effects of framing and level of probability on patients’ preferences for cancer chemotherapy. J Clin Epidemiol. 1989;42:119–26.
O’Connor AM, Pennie RA, Dales RE. Framing effects on expectations, decisions, and side effects experienced: the case of influenza immunization [published erratum appears in J Clin Epidemiol. 1997;50:747–8]. J Clin Epidemiol. 1996;49:1271–6.
Robberson MR, Rogers RW. Beyond fear appeals: negative and positive persuasive appeals to health and self-esteem. J Appl Soc Psychol. 1988;18:277–87.
Rothman AJ, Salovey P, Antone C, Keough K, Drake Martin C. The influence of message framing on intentions to perform health behaviors. J Exp Soc Psychol. 1993;29:408–33.
Rothman AJ, Martino SC, Bedell BT, Detweiler JB, Salovey P. The systematic influence of gain- and loss-framed messages on interest in and use of different types of health behavior. Personal Soc Psychol Bull. 1999;25:1355–69.
Rybash JM, Roodin PA. The framing heuristic influences judgements about younger and older adults’ decision to refuse medical treatment. Appl Cognit Psychol. 1989;3:171–80.
Siegrist M. Communicating low risk magnitudes: incidence rates expressed as frequency versus rates expressed as probability. Risk Anal. 1997;17:507–10.
Smith SM, Levin IP. Need for cognition and choice framing effects. J Behav Decis Making. 1996;9:283–90.
Wilson DK, Wallston KA, King JE. Effects of contract framing, motivation to quit, and self-efficacy on smoking reduction. J Appl Soc Psychol. 1990;20:531–47.
Wilson DK, Kaplan RM, Schneiderman LJ. Framing of decisions and selections of alternatives in health care. Soc Behav. 1987;2:51–9.
Zimmermann C, Baldo C, Molino A. Framing of outcome and probability of recurrence: breast cancer patients’ choice of adjuvant chemotherapy (ACT) in hypothetical patient scenarios. Breast Cancer Res Treat. 2000;60:9–14.
Wong CO, McMurray NE. Framing communication: communicating the antismoking message effectively to all smokers. J Comm Psychol. 2002;30:433–48.
Morris J, Hammitt JK. Using life expectancy to communicate benefits of health care programs in contingent valuation studies. Med Decis Making. 2001;21:468–78.
Schneider TR, Salovey P, Pallonen U, Mundorf N, Smith NF, Steward WT. Visual and auditory message framing effects on tobacco smoking. J Appl Soc Psychol. 2001;31:667–82.
van Assema P, Martens M, Ruiter RA, Brug J. Framing of nutrition education messages in persuading consumers of the advantages of a healthy diet. J Hum Nutr Diet. 2001;14:435–42.
Misselbrook D, Armstrong D. Patients’ responses to risk information about the benefits of treating hypertension. Br J Gen Pract. 2001;51:276–9.
Straus SE. Individualizing treatment decisions. The likelihood of being helped or harmed. Eval Health Prof. 2002;25:210–24.
Blumenschein K, Johannesson M. An experimental test of question framing in health state utility assessment. Health Policy. 1998;45:187–93.
Krishnamurthy P, Carter P, Blair E. Attribute framing and goal framing effects in health decisions. Organ Behav Human Decis Process. 2001;85:382–99.
Farrell K, Ferguson E, James V, Lowe KC. Confidence in the safety of blood for transfusion: the effect of message framing. Transfusion. 2001;41:1335–40.
Jasper JD, Goel R, Einarson A, Gallo M, Koren G. Effects of framing on teratogenic risk perception in pregnant women [published erratum appears in Lancet. 2002;359:1702]. Lancet. 2001;358:1237–8.
Maheswaran D, Meyers-Levy J. The influence of message framing and issue involvement. J Marketing Res. 1990;27:361–7.
Blumenschein K, Johannesson M, Yokoyama KK, Freeman PR. Hypothetical versus real willingness to pay in the health care sector: results from a field experiment. J Health Econ. 2001;20:441–57.
Kuhberger A, Schulte-Mecklenbeck M, Perner J. Framing decisions: hypothetical and real. Organ Behav Human Decis Process. 2002;89:1162–75.
Rothman AJ, Salovey P. Shaping perceptions to motivate healthy behavior: the role of message framing. Psychol Bull. 1997;121:3–19.
“The effects of information framing on patients’ treatment decisions” was a poster presentation at the Ninth Cochrane Colloquium, October 9–13, 2001, Lyon, France.
This research was supported by a project grant from the National Health and Medical Research Council (NHMRC) of Australia. Annette Moxey is also a recipient of an Australian Postgraduate Award (APA) Scholarship funded by The University of Newcastle, Australia.
Rights and permissions
About this article
Cite this article
Moxey, A., O’Connell, D., McGettigan, P. et al. Describing treatment effects to patients. J GEN INTERN MED 18, 948–959 (2003). https://doi.org/10.1046/j.1525-1497.2003.20928.x
- information framing
- informed decision making
- systematic review