Education and Message Framing Increase Willingness to Undergo Research Lumbar Puncture: A Randomized Controlled Trial

Abstract

Reluctance to undergo lumbar puncture (LP) is a barrier to neurological disease biomarker research. We assessed whether an educational intervention increased willingness to consider research LP and whether message framing modified intervention effectiveness. We randomly assigned 851 recruitment registry enrollees who had previously indicated they were unwilling to be contacted about studies requiring LP to gain or loss framed video educational interventions describing the procedure and the probability of experiencing adverse events. The gain framed intervention emphasized the proportion of individuals free of adverse events; the loss frame emphasized the proportion experiencing adverse events. The primary outcome for the study was the participant's post-intervention agreement to be contacted about studies requiring LP. Participants were mean (SD) age 60.1 years (15.7), 69% female (n = 591), and mostly college educated and white. Among the 699 participants who completed the study, 43% (95% CI: 0.39, 0.47; n = 301) changed their response to agree to be contacted about studies requiring LP. We estimated that participants randomized to the gain framed intervention had 67% higher odds of changing their response compared to those randomized to the loss frame (Odds Ratio = 1.67; 95% CI: 1.24, 2.26; p < 0.001). A classification and regression tree model identified participants' pre-intervention willingness as the strongest predictor of changing response. Education, in particular education that alerts participants to the probability of not experiencing adverse events, may be an effective tool to increase participation rates in research requiring LP.

Using Behavioral Nudges to Engage Pregnant Women in a Smoking Cessation Trial: An Online Field Quasi-Experiment

“…Consistent with our results, an RCT of screening of undiagnosed atrial fibrillation that used behavioral nudges under multiple forms, including personalization, managed to increase enrollment rates from 0.8% to 9.4% over 10 months [6]. Similarly, Witbracht et al [7] found that message framing was effective in changing subjects' initial negative response to undergo research lumbar puncture, with participants randomized to the gain framed intervention having 67% higher odds of agreeing to be contacted about studies requiring lumbar puncture compared to those randomized to the loss frame.…”

“…Recent evidence shows that behavioral nudges could be used to enhance RCT enrollment rates by addressing enrollment barriers [5]. For example, two studies that made use of behavioral nudges in the form of personalization [6] and message framing [7] found them effective in increasing enrollment rates in an RCT of screening of undiagnosed atrial fibrillation and in an RCT designed to test different strategies to increase willingness to undergo research lumbar puncture. Behavioral nudges have been defined as any "aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives" [8].…”

Neuroimmunological investigations of cerebrospinal fluid in patients with recent onset depression – a study protocol

“…We expect some eligible patients to decline participation solely due to the lumbar puncture. This is partly overcome by increasing knowledge of the procedure among patients and hospital staff, since lack of knowledge seems to contribute the most to unwillingness towards lumbar puncture [69].…”

State‐of‐the‐art of lumbar puncture and its place in the journey of patients with Alzheimer's disease

“…36 A recent study involving 851 individuals who had previously indicated unwillingness to be contacted for research involving LP reported that those who received gain-framed video education (i.e., emphasizing the proportion of individuals free of AEs) had 67% higher odds of changing their response compared to those who received loss-framed video education (i.e., emphasizing the portion experiencing AEs), indicating that message framing is important for developing optimal patient education. 109 Reimbursement is a critical "system readiness" barrier. While the expenses of performing LP procedures have been covered-to varying degrees-in the reimbursement frameworks in most countries, overall they tend to be low; the expense of CSF biomarker assays is largely not covered in reimbursement systems.…”

“…Informative videos could help improve the knowledge of patients and reduce their fears 36 . A recent study involving 851 individuals who had previously indicated unwillingness to be contacted for research involving LP reported that those who received gain‐framed video education (i.e., emphasizing the proportion of individuals free of AEs) had 67% higher odds of changing their response compared to those who received loss‐framed video education (i.e., emphasizing the portion experiencing AEs), indicating that message framing is important for developing optimal patient education 109 …”