Effect of Exposure to Visual Campaigns and Narrative Vignettes on Addiction Stigma Among Health Care Professionals

Key Points Question Are specific communication strategies effective in reducing stigma toward people with opioid use disorder (OUD) among health care professionals? Findings In this randomized clinical trial involving a national sample of 1842 health care professionals, exposure to visual campaigns combined with short narrative vignettes told from the perspective of a patient with OUD that emphasized the harm of stigmatizing language or the effectiveness of medications for treating OUD was associated with reduced levels of stigma. Meaning The findings of this randomized clinical trial suggest that carefully designed communication campaigns may reduce OUD-related stigma among health care professionals.


Introduction
Overdose mortality rates have worsened during the SARS-CoV-2 pandemic. 1,2[5] Defined through a sociological perspective, stigma occurs when the processes of labeling, stereotyping, status loss, and discrimination are enforced through power differentials. 6Stigma toward people with OUD and other substance use disorders is rooted in racism, classism, and other systems of oppression. 7,8In the health care system, stigma manifests at multiple levels. 9Expectation of stigma may reduce treatment seeking and engagement with care. 10,11Stigma enacted by clinicians may result in worse quality of care and exacerbate patient mistrust. 4,5,12,13On a structural level, stigma contributes to discriminatory policies and reduced investment in systems that support people with OUD. 5,14Although interest in stigma-related issues has grown, 3 the evidence base for stigmareduction strategies remains limited. 4,15evious studies have reported a connection between language and stigma.7][18] Clinician use of stigmatizing language may translate to worse quality of care. 13However, stigmatizing language remains common in clinical and public discourse. 19,204][25] Most health care professionals receive minimal training in addiction and its treatment. 26Health care professionals may be more aware that they are interacting with patients with OUD when these individuals display OUD symptoms and may be unaware that they are interacting with patients with OUD when these individuals are in recovery, 12 which could distort the practitioner's sense of the potential for recovery.
Despite the robust evidence base in favor of medication treatment, stigma has impeded broad availability of highly effective medications approved by the US Food and Drug Administration to treat OUD. 27Stigma toward the opioid agonists methadone and buprenorphine is related to the misperception that these medications replace 1 drug for another. 28,29Among clinicians, higher levels of stigma have been associated with less interest in prescribing medication for the treatment of OUD. 26,30,31Sympathetic narratives that highlight solutions such as effective treatment can help audiences empathize with a person with OUD. 4,15,23,25,32Communication strategies focusing on the effectiveness of medication in facilitating recovery may be particularly persuasive to an audience of health care professionals.
Health care professionals are frequently exposed to messages from patients, other clinicians, and health care system administrators.A health care professional may better relate to communication from a fellow health care professional but be more emotionally engaged when messages are delivered by patients.To our knowledge, no study has evaluated the effectiveness of

Data
The study sample included 1242 Ipsos KnowledgePanel members who self-reported their current employment in a health care profession.Ipsos uses probability-and address-based sampling to create an online panel comprising 60 000 members representative of the US population. 33Among 2703 KnowledgePanel members invited to participate in the study, 1484 completed the online survey, and 1242 qualified for study inclusion based on current employment in a health care profession (Figure).
To ensure greater representation of physicians and nurses, we supplemented the KnowledgePanel sample with 600 members of SurveyHealthcareGlobus, a health care market research firm with an opt-in online panel of physicians and nurses. 34Among the 111 105 SurveyHealthcareGlobus panelists invited to participate, 10 265 completed the online survey, and 600 qualified for study inclusion.Our sampling approach was informed by an effort to enroll a large diverse group of health care professionals from across the US.We did not focus on clinicians dedicated to treating OUD because stigma affects quality of care for patients with OUD across all health care settings.

Study Design
Ipsos used a probability proportional to size sampling approach to select random samples corresponding to 8 exposure groups and 1 nonexposure control group.the Words Matter message frame, the patient described interacting with clinicians using language such as addict and feeling as though the clinicians "didn't see me as a person" and "all they could see was my addiction."In the clinician vignette, the clinician described using terms such as addict and learning that this language made patients feel as though "I didn't see them as people" and "all I could see was their addiction."In each narrative vignette, the patient, clinician, and health care system administrator evolved in their understanding of the harm of stigmatizing language, and the vignettes ended by noting that "health care professionals can be role models."The Medication Treatment Works vignettes included similar content and language across the 3 different messenger narratives and shared themes with the Words Matter message frames, including an emphasis on health care professionals as role models.The Medication Treatment Works patient vignette featured a person recovering from OUD with the help of medication; the clinician and administrator vignettes described positive experiences with providing medication for the treatment of patients with OUD.

Measures
After exposure to the visual campaign with or without an accompanying narrative vignette, all participants answered questions designed to measure stigma toward people with OUD (domain A), the primary set of outcomes.Participants in the control group answered the questions with no preceding exposure to either message frame.After completing questions for domain A, participants randomized to 1 of the 4 Words Matter groups answered questions about the appropriateness of various terms (domain B).Participants randomized to 1 of the 4 Medication Treatment Works groups answered questions about OUD medication treatment (domain C).Participants randomized to the control group answered questions in all 3 domains.For all participants, domain A questions appeared first; for the control group, the order of domains B and C was randomized.The order of questions within each domain was randomized for all groups to reduce risk of bias due to priming.
Domain A included items adapted from the General Social Survey stigma module 35,36 and from published scales measuring stigma. 14,30These items assessed preferences for social distance (such as unwillingness to have a person with OUD marry into their family or be a neighbor), 14,30,36,37 perspectives on the causes of OUD, 14,30,36 support for increased governmental spending on OUD programs, and level of warmth felt toward people with OUD. 38Dimensions of stigma were measured using 5-point Likert scales, and levels of warmth were measured by a feeling thermometer (range, 0-100 points).
Domain B questions asked participants to rate on a 5-point Likert scale the extent to which they agreed or disagreed that language was appropriate to use in clinical settings.The language included 5 stigmatizing terms (addict, substance abuse, dirty and clean [in reference to drug test results], and addicted baby) and 5 alternative nonstigmatizing terms (person with substance use disorder, substance use, negative and positive [in reference to drug test results], and baby born with neonatal opioid withdrawal syndrome).7][18] We created a stigmatizing terms scale (Cronbach α = .74)by summing the Likert scale responses to the stigmatizing terms and dividing by the total number of items.We used the same procedure for the alternative terms to create a nonstigmatizing terms scale (Cronbach α = .72).Participants in the Words Matter and control groups reported whether they would sign a Words Matter pledge committing to the use of nonstigmatizing language.
Domain C began by asking participants whether a treatment for OUD existed that was effective over a long period. 39This question was followed by a short explanation of the Food and Drug Administration-approved medications for the treatment of OUD.Participants then responded to adapted versions of several questions from domain A (substituting "a person taking medication to treat OUD" for "a person with OUD") and questions about perceived effectiveness of OUD medication treatment 26,30,31 (all survey questions are available in eTable 3 in Supplement 2).

Statistical Analysis
We used unpaired 2-sided t tests and χ 2 tests to assess differences in observed characteristics across study groups.We dichotomized Likert scale responses (eg, agree and strongly agree were coded as 1, and other responses were coded as 0) and estimated logistic and linear regression models (for the feeling thermometer item and scales) to assess differences in responses between the exposure groups and the control group.In the models, we controlled for participant age, sex, prescriber status (physician, nurse practitioner, or physician assistant), and race and ethnicity (non-Hispanic White or non-Hispanic other race).We calculated predicted margins and marginal effects to display results for binary outcomes as predicted probabilities and changes in predicted probabilities.To correct for multiple hypothesis testing, we generated sharpened false discovery rate q values and identified estimates with q values less than .05as statistically significant (with 2-sided P values reported to aid interpretation of significance). 40To estimate the marginal effect of the narrative vignettes on outcomes, we also assessed differences between groups exposed to both the visual campaign and a narrative vignette vs those exposed to the visual campaign only.In a sensitivity analysis, we estimated ordered logistic regression models using the nondichotomized Likert scale responses.
Data were analyzed using Stata software, version 14 (StataCorp LLC).

Attitudes Toward People With Opioid Use Disorder
In the control group, 142 participants (70.6%) reported unwillingness to have a person with OUD marry into their family, and 90 participants (44.8%) reported unwillingness to have a person with OUD as a neighbor ( Exposure to the combined Words Matter visual campaign and administrator vignette was associated with a 5.6-point (95% CI, 1.6-9.6;P = .006)higher warmth rating than nonexposure.
Exposure to the combined Medication Treatment Works visual campaign and administrator vignette was associated with a 5.9-point (95% CI, 2.0-9.7;P = .003)higher warmth rating than nonexposure.
For both message frames, exposure to the combined visual campaign and clinician vignette was not associated with significantly different levels of stigma compared with nonexposure.
Relative to exposure to the visual campaign alone, exposure to the combined visual campaign and patient vignette was associated with lower levels of stigma in both the Words Matter and Medication Treatment Works groups (eg, unwilling to have a person with OUD as a neighbor: difference, -12.1 percentage points [95% CI, -21.5 to -2.8; P = .01]in the Words Matter group and -9.9 percentage points [95% CI, -19.0 to -0.7; P = .04]in the Medication Treatment Works group) (eTable 5 in Supplement 2).

Stigmatizing Language and Alternative Terms
In the control group, 93 participants (46.3%) agreed that addict was an appropriate term to use in a clinical setting, and 163 participants (81.1%) agreed that substance abuse was an appropriate term (eTable 6 in Supplement 2).A total of 148 participants in the control group (73.6%) were willing to sign a pledge to use nonstigmatizing language.
Compared with nonexposure, exposure to the Words Matter visual campaign combined with the patient vignette was associated with lower probabilities of endorsing addict (difference, −23.1 percentage points; 95% CI, −32.1 to −14.

Attitudes About Medications for Opioid Use Disorder
The Medication Treatment Works visual campaign combined with the patient vignette was associated with a 4.6-point (95% CI, 0.3-9.0;P = .04)higher warmth rating toward people receiving medication to treat OUD, with a similarly higher warmth rating (difference, 4.4 points; 95% CI, 0.

Discussion
This randomized clinical trial assessed the effects of 2 message frames delivered through visual campaigns and written narrative vignettes from the perspectives of a patient with OUD, a clinician, or a health care system administrator among a large national sample of health care professionals.Our findings suggested that visual campaigns alone may have limited impact on stigma toward people with OUD.A potentially more effective communication strategy may combine these visual campaigns with narrative vignettes featuring the voices of people with OUD.
Findings were consistent with other research suggesting that messages emphasizing nonstigmatizing language [16][17][18] and highlighting effective treatment 23,25 through sympathetic stories 23,25,32 can reduce stigma among the public and that narrative-based messaging can be an effective means of communicating important information to clinicians. 41Both the Words Matter and Medication Treatment Works message frames were associated with lower levels of stigma when they incorporated vignettes, particularly vignettes featuring narratives from the perspective of a patient with OUD.Exposure to narrative vignettes from all messengers (patients, clinicians, and administrators) was associated with greater recognition of stigmatizing language.Health care systems seeking to reduce stigma may consider highlighting these voices in their communication efforts.Hiring and integrating people with lived experience into the health care professional workforce is a contact-based approach that may also be an effective stigma-reduction strategy.
Several high-profile communication campaigns have used images and stories of real individuals with OUD who received treatment with medication. 42,43Notably, our Medication Treatment Works vignettes were not associated with lower levels of medication-related stigma.Other strategies are likely needed to reduce stigma toward these highly effective medications, including structural and policy reforms to improve access. 44Several health care systems have implemented campaigns to discourage use of stigmatizing language and encouraged staff to sign language pledges. 21,22Although the results of the present study suggest that these pledges have the potential to improve recognition of stigmatizing terms that are inappropriate for use in clinical settings, we did not find that the Words Matter message frame was associated with greater willingness to sign a language pledge.
Communication campaigns likely need to be implemented together with other interventions to change behavior rather than knowledge and attitudes only.
Stigma toward people with OUD and other substance use disorders has been constraining our ability to resolve the persistent drug overdose problem. 5

Conclusions
In this randomized clinical trial, messages about nonstigmatizing language and effective medication for the treatment of OUD were associated with reductions in stigma toward people with OUD among health care professionals.Stigma-reduction efforts targeting health care professionals may improve health care system capacity to serve people with OUD.

JAMA Network Open | Substance Use and Addiction Effect
of Visual and Narrative Campaigns on Addiction Stigma in Health Care Professionals Understanding the ways in which different messages and messengers affect stigma and related attitudes among health care professionals is important to informing the design of effective stigma-reduction communication campaigns in health care settings.In this study, we enrolled a large national sample of health care professionals to assess the impact of 2 message framing strategies communicated through a visual campaign with and without an accompanying written narrative vignette from the perspective of a patient with OUD, a clinician, or a health care system administrator.The study was approved by the institutional review board of Johns Hopkins Bloomberg School of Public Health.All participants were members of 1 of the 2 online panels and provided consent to participate in surveys at the time of panel enrollment (with incentives for participation provided by the panel administrators).Therefore, this study was JAMA Network Open.2022;5(2):e2146971.doi:10.1001/jamanetworkopen.2021.46971(Reprinted) February 4, 2022 2/14 Downloaded From: https://jamanetwork.com/ on 09/28/2023 different stigma-reduction messages or messengers among health care professionals.deemed exempt from the need for additional informed consent.The trial protocol was registered retrospectively because the original conception was a survey experiment (Supplement 1).This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline for randomized clinical trials.

JAMA Network Open | Substance Use and Addiction Effect
of Visual and Narrative Campaigns on Addiction Stigma in Health Care Professionals

113 808 Individuals assessed for eligibility 111 105 From SurveyHealthcareGlobus 2703 From Ipsos KnowledgePanel 819 Randomized to receive words matter message 819 Received words matter message as randomized 1842 Included in the final analysis 822 Randomized to receive medication treatment works message 822 Received medication treatment works message as randomized 201 Randomized to receive no message 201 Received no message as randomized 111 966
Excluded 110 505 From SurveyHealthcareGlobus a 100 840 Did not complete screening questions or survey 9665 Did not meet health care profession inclusion criteria 1461 From Ipsos KnowledgePanel b 1219 Did not complete screening questions or survey 242 Did not meet health care profession inclusion criteria a Excluded if not working in health care profession at time of study.Nurses, physicians categorized as general practitioners or family doctors, and physicians categorized as specialists were included to achieve 600 participants, with approximately one-third represented from each category.b Excluded if not working in health care profession at time of study or if working in a nonqualifying health care profession, such as dentist, dental hygienist, dental assistant, optometrist, veterinarian, veterinary assistant, or massage therapist.c Ipsos KnowledgePanel used a probability proportional to size sampling approach to select 9 random samples.JAMA Network Open | Substance Use and Addiction Effect of Visual and Narrative Campaigns on Addiction Stigma in Health Care Professionals JAMA Network Open.2022;5(2):e2146971.doi:10.1001/jamanetworkopen.2021.46971(Reprinted) February 4, 2022 4/14 Downloaded From: https://jamanetwork.com/ on 09/28/2023

Table 2 )
. Most participants in the control group disagreed that people with OUD Effect of Visual and Narrative Campaigns on Addiction Stigma in Health Care Professionals vignette was associated with a lower probability of unwillingness to have a person with OUD marry into the family (difference, −16.8 percentage points; 95% CI, −26.1 to −7.4; P < .001)and a 7.2-point (95% CI, 3.2-11.1;P < .001)higher warmth rating than nonexposure.Exposure to the combined Medication Treatment Works visual campaign and patient vignette was associated with lower probabilities of unwillingness to have a person with OUD marry into the family (difference, −14.5 percentage points; 95% CI, −23.8 to −5.3; P = .002)and to have a person with OUD Exposure to the Words Matter and Medication Treatment Works visual campaigns alone was not associated with statistically significant differences from the control group (eg, unwilling to have a person with OUD marry into the family: difference, 0.3 percentage points [95% CI, −8.5 to 9.1; P = .94]in the Words Matter group and −5.3 percentage points [95% CI, −14.3 to 3.7; P = .25]in the Medication Treatment Works group).However, exposure to the combined Words Matter visual JAMA Network Open | Substance Use and Addiction JAMA Network Open.2022;5(2):e2146971.doi:10.1001/jamanetworkopen.2021.46971(Reprinted) February 4, 2022 6/14 Downloaded From: https://jamanetwork.com/ on 09/28/2023 campaign and patient

Table 2 .
Effect of Exposure vs Nonexposure to Words Matter and Medication Treatment Works Message Frames on Stigma Toward People With Opioid Use Disorder a Effect of Visual and Narrative Campaigns on Addiction Stigma in Health Care Professionals a Analysis included all 1842 participants.Logit regression models were used to estimate differences between exposure groups and nonexposure control group.Percentage point differences and mean differences in warmth level were calculated using postestimation marginal effects.Model estimates were adjusted for age (continuous), female sex, prescriber status (physician, nurse practitioner, or physician assistant), and race and ethnicity (non-Hispanic White or non-Hispanic other race).bEstimatereachedthreshold of statistical significance as defined by a sharpened false discovery rate q value of <.05.Sharpened q values rather than P values were used to correct for multiple hypothesis testing.cScorerange, 0-100 points.JAMA Network Open | Substance Use and AddictionJAMA Network Open.2022;5(2):e2146971.doi:10.1001/jamanetworkopen.2021.46971(Reprinted) February 4, 2022 8/14 Downloaded From: https://jamanetwork.com/ on 09/28/2023

on 09/28/2023 analyses
Effect of Visual and Narrative Campaigns on Addiction Stigma in Health Care Professionals estimating ordered logistic regression models with nondichotomized Likert scale response options produced qualitatively similar results (eTable 9 to eTable 11 in Supplement 2).

Network Open | Substance Use and Addiction Effect
Clinical settings are meant to be welcoming and safe environments in which people with substance use disorders can seek care and connect to services.Given that stigma among health care professionals can have serious consequences for patients with OUD, stigma-reduction communication campaigns are needed to target this population.Encouraging changes in language and improving understanding of the effectiveness of medication treatment may reduce stigma toward people with OUD. of Visual and Narrative Campaigns on Addiction Stigma in Health Care Professionals systems, the inclusion of real people in communication materials could increase the authenticity of the campaign; whether this inclusion changes the effects of these messages is unknown.Third, participants answered questions directly after viewing the visual campaign and/or vignettes a single time.The durability of effects and the impact of repeat exposure (during an extended campaign) are uncertain.Fourth, we conducted the study during the SARS-CoV-2 pandemic, which strained the health care workforce, potentially affecting responses.Fifth, we could not translate estimated changes in attitudes into measures of clinical impact; future work is warranted to explore these connections.
percentage is consistent with the composition of the broader health care professional workforce.45Second,we did not use vignettes from real individuals, although message design was informed by input from health care professionals and people with lived experience.We constructed the exposures to minimize confounding and enhance our ability to isolate the impact of the most important elements of the messages and messengers.When designing campaigns for health care JAMA JAMA Network Open.2022;5(2):e2146971.doi:10.1001/jamanetworkopen.2021.46971(Reprinted) February 4, 2022 10/14 Downloaded From: https://jamanetwork.com/ on 09/28/2023 Allen B, Nolan ML, Paone D. Underutilization of medications to treat opioid use disorder: what role does stigma play?Subst Abus.2019;40(4):459-465.doi:10.1080/08897077.2019.164083345.Day JC, Christnacht C. Women hold 76% of all health care jobs, gaining in higher-paying occupations.United States Census Bureau.August 14, 2019.Accessed December 11, 2021.https://www.census.gov/library/stories/2019/08/your-health-care-in-womens-hands.htmlStructure of Randomized Clinical Trial eTable 2. Narrative Vignettes Communicating Words Matter and Medication Treatment Works Message Frames eTable 3. Questions Included in Each Domain eTable 4. Comparison of Characteristics of Survey Participants Across Study Arms eTable 5. Effects of Exposure to the Words Matter and Medication Treatment Works Narrative Vignette and Visual Campaign Combination on Stigma Toward People With Opioid Use Disorder Relative to the Visual Campaign-Only Groups eTable 6.Effects of Exposure to the "Words Matter" Visual Campaign and Vignette Frames on Perceptions of Clinically Appropriate Language Related to Substance Use Relative to the No-Exposure Control Group eTable 7. Effects of Exposure to the Words Matter Narrative Vignette and Visual Campaign Combination on Perceptions of Clinically Appropriate Language Related to Substance Use Relative to the Visual Campaign-Only Group eTable 8. Effects of Exposure to the "Medication Treatment Works" Visual Campaign and Vignettes on Stigma toward People with Opioid Use Disorder Receiving Medication Treatment Relative to the No-Exposure Control Group eTable 9. Effects of Exposure to the Words Matter and Medication Treatment Works Message Frames on Stigma Toward People With Opioid Use Disorder Relative to the Nonexposed Control Group Estimated With Ordinal Logistic Regression Models eTable 10.Effects of Exposure to the Words Matter Narrative Vignette and Visual Campaign Combination on Perceptions of Clinically Appropriate Language Related to Substance Use Relative to the Visual Campaign-Only Group Estimated With Ordinal Logistic Regression Models eTable 11.Effects of Exposure to the Medication Treatment Works Visual Campaign and Narrative Vignettes on Stigma Toward People With Opioid Use Disorder Receiving Medication Treatment Relative to the Nonexposed Control Group Estimated With Ordinal Logistic Regression Models eFigure.Words Matter and Medication Treatment Works Visual Campaigns 44.