William Mosley-Jensen and Edward Panetta
Health professionals and the public puzzle through new or controversial issues by deploying patterns of reasoning that are found in a variety of social contexts. While particular issues and vocabulary may require field specific training, the patterns of reasoning used by health advocates and authors reflect rhetorical forms found in society at large. The choices made by speakers often impact the types of evidence used in constructing an argument. For scholars interested in issues of policy, attending to the construction of arguments and the dominant cultural modes of reasoning can help expand the understanding of a persuasive argument in a health context. Argumentation scholars have been attentive to the patterns of reasoning for centuries. Deductive and inductive reasoning have been the most widely studied patterns in the disciplines of communication, philosophy, and psychology. The choice of reasoning, from generalization to specific case or from specific case to generalization, is often portrayed as an exclusive one. The classical pattern of deductive reasoning is the syllogism. Since its introduction to the field of communication in 1957, the Toulmin model has been the most impactful device used by critics to map inductive reasoning. Both deductive and inductive modes of argumentative reasoning draw upon implicit, explicit, and affective reasoning. While the traditional study of reasoning focused on the individual choice of a pattern of reasoning to represent a claim, in the last 40 years, there has been increasing attention to social deliberative reasoning in the field of communication. The study of social (public) deliberative reasoning allows argument scholars to trace patterns of argument that explain policy decisions that can, in some cases, exclude some rhetorical voices in public controversies, including matters of health and welfare.
Referred to as the “most consistent and reliable method for conferring resistance to persuasion” by Miller et al. in 2013, over the past 50 years inoculation has exerted significant influence in shaping theoretical and contextual resistance research and message design. Used as a message strategy, inoculation elicits threat, or realized attitudinal/behavioral vulnerability, which motivates individuals to shore up attitudinal/behavioral defenses by providing both material and guided practice aiding the process of effective counterarguing, which in turn increases individuals’ resistance to attitudinal/behavioral challenges. The motivation is responsible for sustaining the inoculation effect over an extended period of time. Inoculation messages, however, do much more than just inspire a robust defense. They motivate individuals to engage others regarding the attitudinal/behavioral topic in an attempt to reassure and advocate their positions, thus diffusing the inoculation message over social networks. The attitudinal/behavior protection elicited by inoculation messages is not limited to the message’s target attitude/behavior, but instead spreads over related attitudes/behaviors as well, thus increasing the pragmatic utility of this message strategy. Inoculation’s effectiveness extends beyond the realm of resistance, as inoculation messages are also effective in both shaping and changing attitudes/behaviors.
Because of its success, inoculation-based message strategies have been applied in numerous contexts and with numerous topics. Some of inoculation’s applied contexts include commercial, instruction/education, interpersonal, political, corporate, public relations, cross-cultural, health, and risk. More specifically, in the health and risk contexts, inoculation has been applied in promotion or prevention capacity on topics such as politically-motivated violent acts, smoking, drinking, unprotected sex, vaccination, and health-related policy, with current research exploring its efficacy in addiction interventions and indoor tanning-bed usage prevention. Inoculation may also be used as a strategy to reduce recidivism in criminal prison inmates and preventing verbal aggression in schools. Additional promising areas for application of inoculation-based strategies may include the promotion and protection of healthy eating habits as well as positive attitudes/behaviors toward mammograms, colonoscopies, breastfeeding, and regular exercise, just to name a few. As Ivanov suggested, the “application of the strategy [is] boundless.”
Amy E. Chadwick
Hope has been defined in primarily two ways, and both have implications for message design within health and risk communication. First, hope has been defined as a way of thinking, or disposition, that affects how people pursue goals. Dispositional hope manifests in beliefs about one’s capacity to initiate and sustain action toward goals (agency) and one’s ability to generate ways to reach those goals. Dispositional hope has been associated with positive physical and mental health outcomes. For example, high-hope women have greater intentions to engage in cancer prevention behaviors than do low-hope women. Numerous studies have associated higher hope with better pain management, and people who are higher in hope have a greater pain tolerance than people lower in hope. Hope is also related to better psychological adjustment.
Much of the research on dispositional hope focuses on correlating hope with a variety of positive health and non-health outcomes; however, psychotherapeutic interventions have also been designed to increase dispositional hope. These interventions have shown improvements in health-related outcomes. Although their potential is not yet realized, interventions for developing dispositional hope could improve compliance with medical recommendations, increase adoption of health behaviors, and decrease risk behaviors.
The second way that hope has been defined is as a discrete emotion. Discrete emotions are brief, intense, psychological, and evaluative reactions directed at external stimuli (e.g., people, events, or objects). In response to these external stimuli, emotions help individuals adapt to their environment by activating a unique pattern of thoughts (cognitions), physiological changes, subjective feelings, motor expressions, and action (or behavioral) tendencies.
Lazarus’s cognitive-mediational theory has been one of the most influential theories of discrete emotions that includes a definition of hope. Lazarus identifies the core relational theme of hope as “fearing the worst but yearning for better.” Lazarus deems hope to be a problematic emotion because he believes hope contains both positive and negative elements. Despite uncertainty about the exact nature of hope, Lazarus believes that hope is vital to coping with stress. Hope enables people to believe in the possibility of better circumstances and therefore is critical as a coping mechanism against despair. Lazarus does not provide guidance for what a message might need to include to evoke hope.
Drawing on Lazarus and appraisal theories in general, MacInnis and de Mello suggest tactics that consumer marketing advertisements could use to induce hope. Specifically, the authors focus on turning “impossibility into possibility” and enhancing “yearning.” De Mello and MacInnis also theorize that hope can lead to motivated processing of information resulting in both positive (e.g., coping, well-being, and goal achievement) and negative (e.g., risky behavior, self-deception) outcomes. Unfortunately, the theorizing of de Mello and MacInnis was never empirically tested.
To further explore how feelings of hope are created, Prestin examined underdog narratives in entertainment media. Underdog narratives show characters who are attempting to meet a goal despite unfavorable circumstances and odds. These narratives evoke hope and make people more motivated to meet their own personal goals. Although their potential has not been fully explored, underdog narratives may assist individuals in overcoming challenging circumstances, such as battling addiction or developing new health habits. There are numerous mechanisms still to be examined that may explain the effects of underdog narratives beyond their ability to evoke hope.
Recently, Chadwick defined hope as a future-oriented, discrete emotion that focuses on an opportunity to achieve a desired future outcome. Her definition builds on the work of Lazarus and Roseman and has implications for the design of messages that evoke hope. According to Chadwick, hope is evoked by appraisals of a future outcome as (a) consistent with goals (goal congruence), (b) possible but not certain (possibility), (c) important (importance), and (d) leading to a better future (future expectation). All four of these appraisals combine to create a perception of opportunity and the discrete emotion hope. Hope motivates behavior by focusing one’s thoughts on capitalizing on an opportunity. Chadwick states that hope also involves (a) an approach action tendency that motivates individuals to take, or continue, action to achieve the desired outcome, (b) increased heart rate and skin conductance, (c) an open facial expression, heightened focus, and alert body posture, and (d) a feeling of eager attention.
Chadwick’s definition has clear implications for developing messages that evoke hope. Messages designed to create appraisals of the importance, goal congruence, positive future expectation, and possibility of a future event evoke hope and are called hope appeals. Like other theoretical explications of emotional appeals, a hope appeal has two components: (a) the inducement of hope through the presentation of an opportunity and (b) the presentation of recommended actions to achieve the desired outcome. The recommended actions component includes information designed to (a) increase the receiver’s perception of his or her ability to perform the recommended action (i.e., self-efficacy) and (b) demonstrate the ability of the recommended actions to achieve the desired outcome (i.e., response efficacy).
Empirically, scholars have tested the effects of hope and messages that evoke hope. Hope appeals increase attention to messages about climate change and increase mitigation behavioral intention and mitigation behavior. In addition, feelings of hope increase interest in climate change protection and are positively correlated with pro-environmental behaviors and support for climate change policies. Feelings of hope significantly predict interest in climate protection, self-efficacy, interpersonal communication intention, information seeking intention, and behavioral intention. Hope and hopeful narratives have also been associated with greater perceived message effectiveness and more agreement with the message content. After a stressful experience that accelerates heart rate, evoking hope decelerates heart rate and decreases state anxiety. This research provides evidence that messages that evoke hope can counter the psychological and physiological effects of stressful events. In addition, researchers have examined the effects of hope on a variety of health, persuasion, political communication, and marketing outcomes. Preliminary evidence indicates that hope appeals are equally as or more effective than guilt and fear appeals at increasing interpersonal communication intention, self-efficacy, information seeking intention, and behavioral intention. In addition, hope appeals create less reactance (anger) than fear appeals. Together these results indicate that hope and hope appeals have substantial potential to influence health and risk behavior.
Hye-Jin Paek and Thomas Hove
Risk perception refers to people’s subjective judgments about the likelihood of negative occurrences such as injury, illness, disease, and death. Risk perception is important in health and risk communication because it determines which hazards people care about and how they deal with them. Risk perception has two main dimensions: the cognitive dimension, which relates to how much people know about and understand risks, and the emotional dimension, which relates to how they feel about them.
Several theoretical models have been developed to explain how people perceive risks, how they process risk information, and how they make decisions about them: the psychometric paradigm, the risk perception model, the mental noise model, the negative dominance model, the trust determination model, and the social amplification of risk framework. Laypeople have been found to evaluate risks mostly according to subjective perceptions, intuitive judgments, and inferences made from media coverage and limited information. Experts try to base their risk perceptions more on research findings and statistical evidence.
Risk perceptions are important precursors to health-related behaviors and other behaviors that experts recommend for either dealing with or preventing risks. Models of behavior change that incorporate the concept of risk perception include the Health Belief Model, Protection Motivation Theory, the Extended Parallel Process Model, and the Risk Perception Attitude framework.
Public awareness and perceptions of a risk can be influenced by how the media cover it. A variety of media factors have been found to affect the public’s risk perceptions, including the following: (1) amount of media coverage; (2) frames used for describing risks; (3) valence and tone of media coverage; (4) media sources and their perceived trustworthiness; (5) formats in which risks are presented; and (6) media channels and types. For all of these media factors, albeit to varying degrees, there is theoretical and empirical support for their relevance to risk perceptions.
Particularly related to media channels and genres, two hypotheses have emerged that specify different kinds of media influences. The impersonal impact hypothesis predicts that news media mainly influence how people see risks as affecting other individuals, groups, nations, or the world population in general (societal-level risk perceptions). By contrast, the differential impact hypothesis predicts that, while news media influence people’s societal-level risk perceptions, entertainment media have stronger effects on how people see risks as affecting themselves (personal-level risk perceptions).
As the media environment become increasingly diverse and fragmented, future research on risk perception needs to examine more of the influences that various media, including social media, have on risk perception. Also, the accounts of how those influences work need to be further refined. Finally, since people’s risk perceptions lead them to either adopt or reject recommended health behaviors, more research needs to examine how risk perceptions are jointly affected by media, audience characteristics, and risk characteristics.
Arvind Singhal and Lucia Dura
The Positive Deviance (PD) approach is based on the premise that every community has individuals or groups whose uncommon behaviors and strategies enable them to find better solutions to problems than their peers although everyone has access to the same resources and challenges. In contrast to traditional problem-solving approaches that begin with an expert-driven analysis of “what is not working” with people—their explicit needs, deficits, problems, and risks—followed by attempts to plug those gaps, the PD approach focuses on identifying “what is working.” PD offers a systematic framework to identify assets, indigenous knowledge, and home-grown solutions, and to amplify them for wider adoption.
The PD approach was operationalized and systematized in the early 1990s in Vietnam to address malnutrition. At the time, 65% of children under five were malnourished. Instead of looking for the causes and applying best practices, PD pioneers looked for children from very poor families who were well-nourished. Through community-led efforts, they determined the existence of positive deviants, identified their behaviors and strategies, and amplified them. The process was replicated across 14 villages—each identifying its own batch of local practices—and malnutrition decreased by 85%. These actions led to PD as we know it today in the form of the “6 Ds”: Define, Determine, Discover, Design, Discern, and Disseminate.
PD has been used widely to address a large number of intractable social problems—many of them dealing with health and risk: reducing endemic malnutrition, decreasing neonatal and maternal mortality, reducing goiter and diseases of micronutrient deficiency, boosting organ transplantation rates and cancer screenings, increasing mental well-being and psychological resilience, preventing and controlling malaria and Chagas, and reducing hospital-acquired infections in healthcare.
From 2004 to 2008, six U.S. hospitals pioneered the use of PD to address the growing incidence of infections caused by the antibiotic resistant bacteria Methicillin-resistant Staphylococcus aureus (MRSA). PD was used to identify and amplify evidence-based infection prevention practices. Pilot outcomes included a 73% average reduction in healthcare-associated MRSA infections units and a subsequent decrease of between 33 and 84% at the different hospitals.
The PD approach to problem-solving holds important implications for public health scholars and practitioners, risk communicators, and message designers. The cases of Vietnam and one of the pilot hospitals are used to illustrate the ways that through language- and action-based strategies PD challenges traditional risk and health messaging, proposing instead an asset-based, participatory, and sustainable framework.
Simon Zebregs and Gert-Jan de Bruijn
Meta-analyses are becoming increasingly popular in the field of health and risk communication—meta-analyses allow for more precise estimations of the magnitude of effects and the robustness of those effects across empirical studies in a particular domain. Despite its popularity, most scholars are not trained in the basic methods involved with meta-analyses. There are advantages to meta-analysis in comparison to other forms of research synthesis. An overview of the methods involved in conducting and reporting meta-analytical research is helpful.
However, the methods involved with meta-analyses are not as clear-cut as they may first appear. Numerous issues must be considered and various arbitrary decisions are required during the process. These issues and decisions relate to various topics such as inclusion criteria, the selection of sources, quality assessments for eligible studies, and publication bias. Basic knowledge of these issues and decisions is important for interpreting the outcomes of a meta-analysis correctly.
Ashley Kennard, Courtney Anderegg, and David Ewoldsen
Knowledge and comprehension are essential components of an individual’s understanding of a health text. Whether reading a health pamphlet or watching a health campaign in the form of a public service announcement (PSA), or watching edutainment programming, individuals gain knowledge about the health topic being discussed. Knowledge, however, can only be retained if the individual can also comprehend the text or video. Often comprehension in a health context focuses on health literacy or the degree to which individuals can process and understand health information in order to make informed health decisions. Health literacy is commonly viewed in terms of the readability (e.g., reading level, complexity) of the health text or script. However, in order for individuals to gain knowledge and use that knowledge appropriately and effectively in making health decisions, individuals need to comprehend or understand what the text is conveying.
Because comprehension is such an important component of gaining and using health knowledge, we must understand how we store health knowledge in memory. A schema is a mental representation that stores knowledge as interrelated pieces of information. Schemas tend to be a fairly static representation of knowledge. A mental model is a more dynamic mental representation in that we use mental models to process, organize, and comprehend incoming information. In a mental model, there is a correspondence between an external entity and the constructed mental model of that entity that allows people to counterfactually manipulate information and engage in problem solving. A situation model is the most contextualized mental representation because it encompasses a specific event or set of interrelated events. There are several ways in which to examine comprehension processes. One way is to examine the most basic level of comprehension by investigating the importance of language and semantic representation of a text. A more complex way to examine comprehension is to view the activation levels of various words or concepts important in creating a representation of the story structure in memory. One model that specifically examines concept activation is the landscape model. The model posits that greater frequency of activation and the strength of activation of a concept determine the concept’s overall activation level. The higher the activation level of a concept in a text or video, the more likely the concept will be included in the mental representation for the text or video and stored in memory. A third way to study comprehension is to examine how concepts change throughout a text and how the concepts relate to one another. The event-indexing model describes how individuals create situation models based on five dimensions of information: time, space, protagonist, causality, and intentionality. Throughout the process of gaining information, the individual updates the situation models for a text on each of the five dimensions. When events have similar dimensions in common, the events are connected in memory; thus, describing health information with similar dimensions in common (e.g., a protagonist the entire way through the text, events happening in the same amount of time) will be better recalled later. Empirical work on comprehension of both text and video messages has demonstrated the landscape model and event-indexing model’s ability to examine comprehension processes based on the format, language, and organization of the information. Health message design can benefit from utilizing these comprehension models to ensure that knowledge is received by the intended audience and comprehended, and thus able to be used in future experiences.
Paul Sebastian Ruppel and Günter Mey
Grounded theory methodology is one of the most widely used approaches to collect and analyze data within qualitative research. It can be characterized as a framework for study design, data collection, and analysis, which aims at the development of middle-range theories. The final result of such a study is called a “grounded theory,” and it consists of categories that are related to each other.
Health and risk message design researchers working with grounded theory methodology are explicitly invited to use any kind of data they consider suitable for a particular project. Grounded theory methodology studies were originally based on intense fieldwork data, but in the meantime, interviews have become the most widely used type of data. In addition, there is a growing interest in using visual data such as pictures or film. Grounded theory methodology originated from sociology, but has since been applied in many different disciplines. This widened application went along with modifications, new developments, and innovations, and led to several current variants of grounded theory methodology.
Basic features of grounded theory methodology include theoretical sampling, specific coding procedures with a comparative approach to analysis, and memo writing. The strategy of theoretical sampling requires that theoretical insights gained from the analysis of initially collected data guide subsequent data collection. Hence, during the research process data collection and analysis alternate and interact. For data analysis, different ways of coding enable the researcher to develop increasingly abstract conceptual ideas and reflections, first embodied in codes, later in categories. This analytical process allows for a step-by-step development of categories that are grounded in data. Category development entails comparisons at all stages, for example, of different cases during sampling, of different data pieces, and of different codes and categories during analysis. As a result, grounded theory methodology is also known as the constant comparative method. Throughout the research process the researcher writes memos and keeps track of the development of conceptual ideas, methodological reflections, and practical to-dos. Today, many researchers use software specifically developed to assist the process of qualitative data analysis.
Irina Iles and Xiaoli Nan
Counterfactual thinking is the process of mentally undoing the outcome of an event by imagining alternate antecedent states. For example, one might think that if they had given up smoking earlier, their health would be better. Counterfactuals are more frequent following negative events than positive events. Counterfactuals have both aversive and beneficial consequences for the individual. On the one hand, individuals who engage in counterfactual thinking experience negative affect and are prone to biased judgment and decision making. On the other hand, counterfactuals serve a preparative function, and they help people reach their goals in the future by suggesting effective behavioral alternatives.
Counterfactual thoughts have been found to influence an array of cognitive processes. Engaging in counterfactual thinking motivates careful, in-depth information processing, increases perceptions of self-efficacy and control, influences attitudes toward social matters, with consequences for behavioral intentions and subsequent behaviors. Although it is a heavily studied matter in some domains of the social sciences (e.g., psychology, political sciences, decision making), counterfactual thinking has received less attention in the communication discipline. Findings from the few studies conducted in communication suggest that counterfactual thinking is a promising message design strategy in risk and health contexts. Still, research in this area is critically needed, and it represents an opportunity to expand our knowledge.
Rachel A. Smith
A premise in health promotion and disease prevention is that exposure to and consequences of illness and injury can be minimized through people’s actions. Health campaigns, broadly defined as communication strategies intentionally designed to encourage people to engage in the actions that prevent illness and injury and promote wellbeing, typically try to inspire more than one person to change. No two people are exactly alike with respect to their risk for illness and injury or their reactions to a campaign attempting to lower their risk. These variations between people are important for health messaging. Effective campaigns provide a target audience with the right persuasive strategy to inspire change based on their initial state and psychosocial predictors for change. It is often financially and logistically unreasonable to create campaigns for each individual within a population; it is even unnecessary to the extent to which people exist in similar states and share psychosocial predictors for change. A challenging problem for health campaigns is to define those who need to be reached, and then intelligently group people based on a complex set of variables in order to identify groups with similar needs who will respond similarly to a particular persuasive strategy. The premise of this chapter is that segmentation at its best is a systematic and explicit process of research to make informed decisions about how many audiences to consider, why the audience is doing what they are doing, and how to reach that audience effectively.