Framing Effects on Decision-Making for Diagnostic Genetic Testing: Results from a Randomized Trial

Andrew A Dwyer, Hongjie Shen, Ziwei Zeng, Matt Gregas, Min Zhao, Andrew A Dwyer, Hongjie Shen, Ziwei Zeng, Matt Gregas, Min Zhao

Abstract

Genetic testing is increasingly part of routine clinical care. However, testing decisions may be characterized by regret as findings also implicate blood relatives. It is not known if genetic testing decisions are affected by the way information is presented (i.e., framing effects). We employed a randomized factorial design to examine framing effects on hypothetical genetic testing scenarios (common, life-threatening disease and rare, life-altering disease). Participants (n = 1012) received one of six decision frames: choice, default (n = 2; opt-in, opt-out), or enhanced choice (n = 3, based on the Theory of Planned Behavior). We compared testing decision, satisfaction, regret, and decision cognitions across decision frames and between scenarios. Participants randomized to 'choice' were least likely to opt for genetic testing compared with default and enhanced choice frames (78% vs. 83-91%, p < 0.05). Neither satisfaction nor regret differed across frames. Perceived autonomy (behavioral control) predicted satisfaction (B = 0.085, p < 0.001) while lack of control predicted regret (B = 0.346, p < 0.001). Opting for genetic testing did not differ between disease scenarios (p = 0.23). Results suggest framing can nudge individuals towards opting for genetic testing. These findings have important implications for individual self-determination in the genomic era. Similarities between scenarios with disparate disease trajectories point to possible modular approaches for web-based decisional support.

Trial registration: ClinicalTrials.gov NCT04372888.

Keywords: choice architecture; congenital hypogonadotropic hypogonadism; decision-making; genetic counselling; genetic testing; hereditary breast and ovarian cancer; theory of planned behavior.

Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Figures

Figure 1
Figure 1
Study schematic. (A) Participants were randomized to one of two scenarios then reviewed information about the respective condition. (B) Participants were then randomized to one of six frames and made a genetic testing decision.
Figure 2
Figure 2
Framing effects on hypothetical genetic testing decision-making (n = 1012). Participants randomized to the choice frame (white) were significantly less likely to opt for testing (135/171 [78.9%], p < 0.05) compared with default (opt-in: 139/167 [83.2%], opt out: 148/170 [87.1%]), or enhanced choice frames (context/consequences: 144/167 [86.2%], affect/commitment: 151/169 [89.9%], norms: 154/169 [91.1%]). The gray dotted line depicts ‘choice’ as a reference point for default (gray bars) and enhanced choice frames (black bars). * p < 0.05.
Figure 3
Figure 3
Satisfaction with decision and decision regret according to framing (n = 1012). Satisfaction with decision (SWD) and decision regret (DRS). (a) SWD scores did not differ across frames (F = 1.353, p = 0.24). (b) DRS scores did not differ across decision frames (F = 0.875, p = 0.49). Boxes show mean scores ± one standard deviation (error bars). White = choice, gray = default frames (opt-in, opt-out), and black = enhanced choice (context/consequence, affect/commitments, norms).

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