Using message framing to achieve long-term behavioral changes in
persons with diabetes
Janet L. Grady, DrPH, RN
, Eileen B. Entin, PhD
, Elliot E. Entin, PhD
, Tad T. Brunyé, PhD
University of Pittsburgh at Johnstown, Johnstown, PA, 15904, USA
Aptima, Inc., Woburn, MA 01801, USA
U.S. Army NSRDEC, Natick, MA 01760, USA
Received 7 November 2008; revised 4 March 2009; accepted 24 March 2009
Abstract This study examines how the framing of educational information affects changes in health-related
knowledge, attitudes, and behavior. Patients with diabetes viewed either a gain- or a loss-framed
informational video about proper foot care and its importance for the prevention of health-
threatening problems. The gain-framed messages sustained long-term positive behavioral change.
Regression analyses showed that changes in attitudes were predicted by changes in knowledge and
that both framing and attitudes were predictors of long-term behavior. This study is important for
nurses and certified diabetes educators in that it demonstrates that gain-framed messages are effective
in sustaining health-promoting behavior.
© 2011 Elsevier Inc. All rights reserved.
1.1. Background and significance
Diabetes prevalence has reached epidemic proportions in
this country. The health and economic consequences for
Americans with this disease are overwhelming and expected
to grow as our population continues to age. Approximately
23.6 million people in the United States have diabetes and,
despite the disease being underreported as a cause of death,
diabetes was listed as the seventh leading cause of death in
the United States in 2006 (Centers for Disease Control and
Prevention, 2008). The direct medical costs of diabetes care
and complications of $116 billion, together with indirect
costs of $58 billion related to disability and reduced
productivity, resulted in an estimated economic cost of
diabetes totaling $174 billion in 2007 (American Diabetes
Diabetes puts individuals at risk for serious complications
resulting from chronic hyperglycemia, such as retinopathy
(potentially leading to blindness), nephropathy (which can
progress to renal failure), heart disease, stroke, infections,
and neuropathy (potentially causing severe pain and loss of
limbs). These complications contribute to a risk of death
among individuals with diabetes that is about 2 times higher
than that of individuals without diabetes (Centers for Disease
Control and Prevention, 2008).
Amputations and foot ulceration are the most common
consequences of diabetic neuropathy and major causes of
morbidity and disability in people with diabetes. Approxi-
mately 2% to 3% of individuals with diabetes develop one or
more foot ulcers each year, and an estimated 15% will
develop a foot ulcer during their lifetime (Singh, Armstrong, &
Lipsky, 2005). Over 60% of nontraumatic lower limb
amputationsoccur in people with diabetes (American Diabetes
Association, 2009; Ramsey, Newton, Blough, et al., 1999).
Current scientific evidence indicates that much of the
morbidity and mortality associated with diabetes can be
eliminated by prevention, early detection, improved delivery
Available online at www.sciencedirect.com
Applied Nursing Research 24 (2011) 22 – 28
This study was funded as part of Office of Naval Research Award No.
N00014-04-1-0825 and administered by the Henry M. Jackson Foundation,
Rockville, MD. The authors gratefully acknowledge the support of (a) Carol
Harding, RN, manager; Antoinette Frank, RN, CDE; and the Conemaugh
Diabetes Institute, Johnstown, PA; (b) J. Brad Ummer, Flipside Media, Inc.,
Glenshaw, PA; and the (c) Telehealth Department, Mount Aloysius College,
Cresson, PA. The opinions expressed in this article represent the opinions of
the authors and in no way reflect the endorsement or official positions of the
Office of Naval Research or the Department of Defense.
Corresponding author. Tel.: +1 781 496 2427.
E-mail address: firstname.lastname@example.org (E.B. Entin).
0897-1897/$ – see front matter © 2011 Elsevier Inc. All rights reserved.