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date: 21 July 2017

Parents as Agents for Change in Health and Risk Messaging

Summary and Keywords

Parents can be the target of health and risk messages about their children and can be a channel by which children hear health messages. This dual role can make parents powerful agents for change in children’s health. Parents receive health messages from a variety of sources including health care providers, schools, the media, the government, and family. Parents tend to be a more frequent target for health messages when their children are infants or young. They receive many messages related to keeping their children safe. Most of these messages are not developed as part of a rigorous data-driven and theory-based intervention and often lack sophisticated message development and design. Furthermore, instead of segmenting parents and tailoring messages, parents are frequently treated as a monolith, with no diversity related to behavior or communication.

As children age, parents can become the channel by which children can hear a health message. Parents of school-age children and adolescents are continually communicating messages to their children and are often targeted to communicate messages related to health or risk behaviors. Intentional efforts to encourage parents to talk to their children are often related to risk behaviors among older children. Specifically, parents are asked to convey messages about sexual health, alcohol and drug use, and driving. Evidence points to parent–child communication in general and communication about specific risk behaviors as protective for children. Research has also suggested that adolescents want to hear health messages from their parents. Parents are a natural choice to communicate about health and risk throughout childhood and adolescence due to the parent–child relationship and the influence parents can have over children. However, this special relationship does not automatically translate into parents having good communication skills. Messages designed to encourage parents to communicate with their children about a health topic have often been developed with the assumption that parents know what to communicate and how to effectively communicate with their children. Deficits in communication skills among parents have been recognized by some campaign developers, and an emphasis on developing those skills has been a significant part of some messages targeting parents. Health communication campaigns have been developed to inform parents about when and how to talk to their children about health issues such as alcohol, drugs, and sex. Unfortunately, not all parent–child communication is positive or effective and this can have potential unintended consequences. Treating parents as an audience in a more nuanced manner, with greater emphasis on evidence-based message development, could result in more effective messages and better health outcomes.

Keywords: health communication, parent–child communication, family communication, parenting styles, message development

Parents have the ability to influence children’s health behavior and are responsible for the well-being of their children. Because of this role, parents are often viewed as important agents of change for children’s health (Faith et al., 2012; Lau, Quardrel, & Hartman, 1990). It is not surprising that parents have been both the target of health communication messages and encouraged to send their children risk or health messages. Communicating with parents about how to keep their children healthy provides parents with information that they might not be aware of and exposes them to messages that are relevant to the development of the child. Messages designed to encourage parents to communicate with their children can provide important prompts to parents, convey knowledge parents do not have about health topics, and address behavioral antecedents, such as risk perceptions and attitudes, to parent-initiated conversations. Unfortunately, messaging does not account for the diversity of parents as an audience or agents of change.

In this article we outline the theoretical foundation for parents as agents of change and provide examples of health communication campaigns and strategies aimed at parents across stages of child development. Considerations for message development, including antecedents to behavior, age and developmental stage, family structure, parenting style, family communication, message processing, and framing, are discussed. Challenges for message development are also presented.

Theoretical Foundation

Message development commonly happens at the individual level (parents as target) and at the interpersonal level (parents communicating with their children), with the recognition that many factors influence health behaviors. Parents not only create environments that influence their children’s behaviors, they also serve as role models through their attitudes and behaviors associated with health (Faith et al., 2012). The social ecological model identifies four inter-related factors that impact health behaviors: individual, interpersonal or relationship, community, and societal (Stokols, 1992). Individual factors that influence behavior include biology and personal history, as well as attitudes, beliefs, and other behaviors. Interpersonal or relationship factors include a person’s social network, partners, and family members. Theoretical frameworks, addressing health behavior, and communication, addressing both of these levels, can be used to understand parent–child communication about health topics.

There are multiple theories that demonstrate that others, such as parents, have influence or act as an agent of change on someone’s behavior at the interpersonal level. This influence can happen via modeling such as in the Social Cognitive Theory (Bandura, 1986), where learning can happen via observation or via verbal communication. Social cognitive theory attempts to examine the relationship between learning and observation of others. Children have ample time to learn health and risk behaviors, both negative and positive, from their parents. Children can observe if their parents use seat belts, abuse alcohol, eat fruits and vegetables, or are physically active. Through these observations children are learning behaviors that may or may not be congruent with the health messages parents are sending to their children. The theory of normative social behavior (Rimal & Real, 2005) is based on the idea that what others are perceived to be doing influences individual behavior. This theory focuses specifically on the effects of one type of social norm—descriptive norms (the perceived prevalence of others’ behavior). Most children are exposed daily to their parents’ normative behavior. This influence on children cannot be underestimated. Social support is another mechanism parents can use to influence children’s behavior. Depending on the type of support parents provide and what activities they select to support, parents can send verbal and non-verbal messages to their children that can influence behavior.

The Theory of Reasoned Action argues that behavior is influenced by attitudes as well as subjective norms (Fishbein & Ajzen, 1975). Subjective norms refer to a person’s willingness to comply with an important referent group, specifically whether someone believes that others approve of the target behavior and if the person wants to comply with others. Parents can clearly be the important referent group for children. Intermedia theory or 2-Step Flow (Katz & Lazarsfeld, 1955) purports that messages may not reach individuals directly from the sender but instead are conveyed through others or opinion leaders. Parents can serve the role of opinion leader in their relationships with their children or in their families.

Parents should be charged with being agents of change because children, even adolescents and emerging adults, want to hear health messages from their parents. While parents may not perceive their children to be willing to listen to health messages from them, the evidence points to adolescents and college students preferring to hear from their parents on many heath topics, including sexual health. Adolescents report wanting their parents to talk to them about sexual health topics (Kirby, 2002), and college students report wanting to have parents talk with them about a variety of health messages (Baxter, Egbert, & Ho, 2008). Establishing that parents are viewed as an important resource for health information is a compelling reason to continue to encourage parents to communicate with their children about risk and health topics but not enough to justify extensive interventions designed to increase parent–child health and risk communication. This communication must also be associated with better health outcomes for children. There is some evidence that parent–child communication about health topics is related to positive health outcomes. Specifically when examining parent–child communication about sex, scholars have found positive associations with less risky sexual behavior (Miller, Levin, Whitaker, & Xu, 1998), and adolescents who report higher levels of parent communication and connectedness have a lower risk of experiencing suicidal ideation (Kuramoto-Crawford, Ali, & Wilcox, 2016).

There are advantages to encouraging parents to be more involved agents of change in their children’s health. Parents are able to have influence over their children for extended periods of time, which can be advantageous for complicated behaviors that must be repeated, such as healthy eating. Involving parents in communication about sensitive topics avoids the challenges of having the government, organizations, or schools communicating about sensitive topics with minors. Programs that provide sexual health education have become controversial in schools, and refocusing pregnancy and sexually transmitted infection prevention programs to target parents to educate children is much less controversial. To date, no evaluation studies have examined the effectiveness of parent–child communication about sex versus a proven-effective, school-based program.

There is a rich history of targeting parents with messages designed to provide them with information about how to keep their children healthy and safe (World Health Organization, 2009). Public health and risk messaging have targeted parents with children of all ages and across infectious and chronic diseases and injury prevention. Most health messages directed at parents have not benefited from intentional and extensive formative research and development (Noar, Palmgreen, Chabot, Dobransky, & Zimmerman, 2009; Sixsmith, Fox, Doyle, & Barry, 2014). Even fewer of these messages have been subjected to rigorous evaluation (Noar, 2006; Sixsmith et al., 2014). Without solid message development it is not clear that most messages directed at parents have the potential to be effective at changing parent behavior. Without rigorous evaluation, there is no evidence of the effectiveness of the messages.

Messages Across Stages of Child Development

Expectant Parents

Messages targeting parents begin even before parenthood officially starts. For example, prior to folic acid–fortified foods, messages were designed to encourage women who are not yet pregnant and may not even be intending to get pregnant to take folic acid supplements (Centers for Disease Control and Prevention, 1997). These messages were part of a groundbreaking campaign that worked to heighten women’s awareness about the importance of preconception care and folic acid, even before women were considering a pregnancy. Warning labels on alcohol and cigarettes are intended to deter pregnant women from consuming these items, which are harmful to the fetus, although there is some debate about the effectiveness of these messages (Hankin et al., 1993; Levis et al., 2014). One of the reasons these labels may not be effective is the label was designed to address awareness and knowledge, not the more influential factors associated with the behaviors, such as addiction. For example, the labels have not affected the alcohol use of risky or heavy alcohol users, probably because the messages are only awareness raising and do not address the factors that influence alcohol use among pregnant women who are risky or heavy alcohol users.

Text4baby (Whittaker et al., 2012) is an intervention that bridges the transition between pregnancy and parenthood, using text messaging to provide women with messages tailored to the development of the fetus and infant. This extensive intervention was innovative when it was first unveiled. It was one of the first campaigns to use text messaging and navigate the early challenges of sending texts that cost the receiver and automated scheduled texts. These messages are on a range of topics. Women opt into the program and receive preprogrammed messages to their cell phones based on the due date or infant’s birth date. This channel allows for significant tailoring of messages to the current week of pregnancy or age of infant. Highly tailored messages should be more relevant to mothers and may increase their willingness to comply compared with other less tailored, more generic messages.

Parents of Infants and Young Children

Messages for parents of infants and very young children are common. For example, parents of young infants are targeted with messages designed to inform and motivate them to follow recommendations for infant sleeping positions and to breastfeed their infants or support breastfeeding mothers. Messages target parents to properly care for their children’s teeth and instruct their children on oral hygiene. Over the past few decades, considerable efforts has been expended to communicate with parents about the importance of immunizations. Recently messages have focused on encouraging vaccination in response to the anti-vaccination movement. Much of this communication has taken place via social media, which has allowed for two-way communication between the public health community and anti-vaccination activists (Leask, 2015). This type of almost simultaneous bi-directional communication was not possible before social media. While some public health messages about vaccines directly address the messages from the anti-vaccination groups, there is debate about this approach. Vaccination hesitators, parents who are on the fence about vaccination, may be repelled by this confrontational pro-vaccine messaging and more effectively persuaded by strong recommendations by trusted health care providers. “I immunize” is an Australian campaign designed to address vaccine hesitation (Attwell & Freeman, 2015). Using a value-based approach that addressed the non-traditional lifestyle of parents in areas with low vaccination rates, the messaging was associated with more positive attitudes about vaccines.

Parents of School-Aged Children

Some campaigns do not overtly instruct parents on a specific behavior but include parents in the messaging that primarily targets children. This is a result of children’s growing independence but lack of control or access to resources, which still makes parents in important part of the health communication process. Children cannot drive, they are not able to access health care without a parent, and they have limited financial resources. The Centers for Disease Control and Prevention (CDC)–developed VERB campaign, which focused mainly on tweens (ages 9 to 13), had a parent component because the children in this age group have little autonomy and are dependent on parents for transportation and planning their day. This campaign was a monumental and seminal effort by CDC to address physical activity in a well-funded campaign, which benefited from extensive formative research, rigorous use of theory, and adherence to message development processes and social marketing practices. Parent messages were intended to change parents’ knowledge, beliefs, and expectations related to physical activity and their tween children. Conscious of the developmental stage of tweens, where parental action can create reactance (i.e., tweens feeling parents are taking away their ability to choose), the campaign did not ask parents to do more than provide a supportive environment in which tweens could be active (Huhman, Heitzler, & Wong, 2004). Parents of school-aged children are included in nutrition education interventions because children in this age group are dependent on their parents for purchasing and preparing foods. Pick a better snackTM is a classroom-based intervention with a social marketing component that targets parents at point-of-purchase in grocery stores (Blitstein et al., 2016). Children are exposed to new fruits and vegetables in the classroom while parents receive supporting messages in the store to encourage fruit and vegetable purchases. Prompts such as stickers and newsletters are designed to remind parents to ask their children about the nutrition education and specifically the fruits and vegetables they tried. This provides the child with an opportunity to tell parents about the items they like and let parents know that if they purchase and prepare these fruits and vegetables the child will eat them. This tactic has also been used to encourage parents to pack more nutritious lunches for their children (Goldberg et al., 2015).

Most recently parents have been targeted with messages promoting the cancer prevention vaccine that prevents human papillomavirus (HPV). Despite marketing of the vaccine by pharmaceutical companies and public health messaging from CDC and the American Cancer Society, HPV vaccine coverage rates are significantly below the rates of other vaccines recommended for this age group. Increasing efforts are directed to health care provider recommendations because messages directed at parents from HPV vaccine–promoting organizations do not appear to be influencing the HPV vaccine coverage rates.

Parents of Adolescents

The popular wisdom around teens is that they have stopped paying attention to their parents and have turned to their peers. People frequently refer to peer pressure as being a major concern, but there is a substantial body of evidence that parents are still an agent of change with influence on adolescents. Adolescents want to get information and talk to their parents about important health topics, and adolescents are listening to parents’ messages, even if it appears that they are not. Parents have been the targets of several health campaigns targeting adolescent health behaviors. Parents are routinely asked to communicate about risk behaviors, such as alcohol and drug use, sexual activity, and risky driving.

Parents of adolescents have been encouraged to talk with their children about alcohol and drugs. Using messages, for example, that remind parents that they want to be the first one to talk to their children about alcohol or drugs, implying the other person might be offering them alcohol or drugs. Other messages address parents’ concerns that their children are not listening to them (Surkan, Dejong, Herr-Zaya, Rodriguez-Howard, & Fay, 2003). Well-funded, highly anticipated national campaigns to address drug use in youth directed at youth and parents have reached many parents in the United States (Hornik et al., 2002) and Australia (Australian Government Department of Health, 2015). The United States–based National Youth Anti-Drug Media Campaign drew significant attention because of the amount of funding for campaign development and paid media as well as the evaluation that indicated many parents recalled the messages. High rates of recall of campaign messages may have contributed to changes in parenting behavior, including communication with children, but there was not a clear connection between parent–child communication or other behaviors and youth-related health outcomes.

Driving is another area of adolescent health that has experienced efforts to engage parents (Carney, McGehee, Lee, Reyes, & Raby, 2010). Parents play several key roles in keeping their adolescent children safe on the road including supervising practice driving and providing coaching and instruction, setting driving privileges, monitoring unsupervised driving, and emphasizing the need to follow traffic laws. Programs like the Checkpoints Program have successfully advocated for written driving agreements signed by parents and teens (Simons-Morton, Hartos, Leaf, & Preusser, 2006). These limit driving behavior in higher-risk situations, such as at night, in bad weather, or with other teens in the car and have shown to be related to significantly fewer traffic violations (Zakrajsek et al., 2013).

Parents Speak Up National Campaign (Davis, Blitstein, Evans, & Kamyab, 2010) is based on parent–child communication as a protective factor for adolescents engaging in sexual activity (Guzman et al., 2003; Huebner & Howell, 2003; Karoksky, Zeng, & Kosorok, 2000) and evidence that little or no parent–child communication about sex may be filled by peer communication and peer influence (Whitaker & Miller, 2000), which can be detrimental and is not a protective factor (Holtzman & Rubinson, 1995). There is no published evaluation data to understand how this type of campaign is related to adolescent health outcomes.

Parents of College Students and Adult Children

Parents continue to have a strong influence on the behavior of college-aged and adult children, and this has been exploited in messages about alcohol and sexual health. Especially during the first year of college, parents are able to exert influence on their children related to alcohol use (Turrisis, Jaccard, Taki, Dunnam, & Grimes, 2001), and this influence has been harnessed by interventions encouraging communication. In the past, it has been argued that the more young adults become involved in dating, the less influence their parents have on their sexual behavior and the more influence their peers and partners have on their behavior. However, even among college students, parents have influence on young adults’ sexual behavior (Booth-Butterfield & Sidelinger, 1998).

While traditionally we have thought about parents as communicators of health messages to children and adolescents, there is some evidence that parents can continue to be an agent of change influencing the health behavior of the their adult children (Lowe, Baxter, Hirokawa, Pearce, & Peterson, 2010). In some health-related matters such as pregnancy, adult women may turn to their mothers for advice. When adult women were asked whom they would turn to for information on how to care for themselves if they were pregnant, adult women identified their mothers as a trusted information source. Interventions have used mothers of adult women to start conversations about preventing fetal alcohol syndrome by encouraging contraceptive use or abstinence from alcohol.

Considerations for Message Development

While messages targeting parents are common, many of these messages have not been intentionally created using basic principles of message development including the use of theories or models of behavior change, being informed by data, audience segments, and tailoring (Noar 2006; Noar et al., 2009; Sixsmith et al., 2014). Following are factors that need to be considered when developing messages for parents that extend beyond the basic considerations for effective message development (see Noar, 2012, and Noar, Harrington, & Aldrich, 2009, for more information about message development). Audience segmentation, which ensures that the message is relevant to the specific audience is rarely applied to parents. The VERB campaign offers a few examples of messages targeting parents and segmented by cultural group. Effective segmentation needs to move beyond socio-demographic variables and include other factors related to the target behavior (Slater, 1996).

Antecedents to the Desired Behavior

Messages that target relevant theoretical constructs related to health behaviors will be more likely to resonate with the target audience. Theories and models can be used to segment the target audience. For example, some parents might perceive that their health care provider (an important referent person) wants them to vaccinate their children against HPV, and parents report a high willingness to comply with this request (Brewer et al., 2011). This subjective norm may not be important to some groups of parents because they have little desire to comply with the request of a health care provider. Admittedly, while tailoring messages to a segment of parents is possible and desirable, attempting to target a segment of parents may be difficult based on our current strategies for targeting, such as place-based communication channels like radio. Text messaging or other social media may increase the ability of campaign developers to tailor and target messages (Price et al., 2015).

Message development must include the use of a theory or theoretical framework that identifies the antecedents to the desired behavior (Noar, 2012). Messages that only increase awareness or provide knowledge are not effective at creating behavior change. By using behavioral theories or frameworks, the modifiable factors related to a behavior can be identified and messages can be developed to target those factors. For example, messages that encourage parent–child communication may not be effective unless self-efficacy (parents’ belief in their ability to communicate) and response efficacy (parents’ belief that communicating with their child will be effective) are present in the message. Typically, messages aimed at parents provide information to raise parents’ perception of threat or risk to their children in order to motivate parents to act. According to the Extended Parallel Process Model (Witte, 1992), messages that do not also contain self-efficacy (build confidence in ability to perform promoted behavior) and response efficacy (perception that promoted behavior will have desired outcome) while increasing threat are less likely to succeed compared to messages that provide parents with easy concrete steps to take and clear messages about the effectiveness of communicating with their children. Response efficacy, the idea that action being supported actually leads to a positive outcome, is key for parents. Parent have low response efficacy about their communication with their children. This may be a result of the total experience parents have communicating with their children. Parents who have had little success with requests for their children to pick up their dirty clothes may have very low response efficacy because previous experience has indicated to them that their communication with their children is not effective at persuading their children to act. Succinctly said, parents must believe that what is being asked of them will result in positive outcomes. Messages to encourage low-income mothers of preschool-aged children to seek preventive dental care need to be segmented by mothers’ efficacy (Askelson et al., 2015). Mothers’ beliefs about their ability to ensure their child has a preventive oral health exam and mothers’ beliefs about how effective preventive exams are at protecting their children against negative oral health outcomes are related to the receipt of preventive oral exams.

Age and Developmental Stage

The needs of children and their parents change radically from infancy to adolescence and emerging adulthood. Parents are likely to be focused on their children’s current stage of development, and therefore messages to parents of infants about the importance of adolescent health issues will be irrelevant to these parents. Messages must be designed to address parents at their child’s developmental stage and be tailored to the salient concerns of parents at that stage. Even messages about child car safety seat use, which only impact parents of children younger than age eight, need to be crafted to account for the specific age and size of a child. It is difficult to design a message that is generic enough to cover parents of infants to parents of school-aged children yet specific enough that it provides them the information they need to protect their child in a vehicle.

Family Structure

Messages may need to take into account family structure. While the composition of the “typical” American family has changed over the last century, family policies and family communication research have not kept pace (Baxter & Braithwaite, 2006; Segrin & Flora, 2005). Many family policies and the majority of the family communication research substantiate the traditional, nuclear family in the United States, particularly related to health. However, family forms and functions continue to evolve. Family communication scholars have paid little attention to family relationships and family members outside the marital and parent–child dyads, such as grandparents, aunts and uncles, cousins, stepparents, and other kin (Floyd & Morman, 2006). Therefore, more research is needed to understand how different family forms and the extended family system impact health communication. Galvin (2006) points out that families are becoming increasingly diverse, which requires them to be more discourse dependent. Scholars in the field recognize that family communication does not happen in a vacuum; family relationships have shared heritage, similar values, and social rituals that impact communication. Based on context, family members adjust their communication behaviors to interact appropriately and effectively among others. To better understand relational and cultural contexts, family communication scholars can recognize the cultural differences by utilizing such theoretical perspectives as relational dialectics or communication accommodation theory. For example, relational dialectics can be used by family communication scholars to describe how systems of meaning vary across cultures (Baxter, 2006).

When considering message development there is significant evidence that mothers and fathers may interpret messages differently, which can lead to mothers and fathers taking different courses of action based on the message. We know, for instance, that fathers communicate about sex differently than mothers (Wright, 2009). There is also evidence that mothers and fathers communicate with sons and daughters differently, especially about sexual health topics, and this difference might be a result of differences in antecedents to communicating such self-efficacy (Wilson & Koo, 2010). Treating mothers and fathers generically as parents may lead to some messages being unappealing. For example, when framing of a message is considered, mothers and fathers have reacted to empowerment and hope frames differently (Jordan et al. 2015). Single parents also reacted differently to frames when compared to two-parent households (Bacon, 2015). Topic avoidance related to sex is also dependent on the makeup of the parent–child dyad (Golish & Caughlin, 2002), for example, adolescents have the most topic avoidance with fathers and stepparents.

Parenting Style

Parenting style refers not only to how parents communicate but to how they parent children, how they relate to their children, and how they perceive their children (Baumrind, 1991). Four types of parenting styles have been identified based on demandingness or control (how much obedience a parent requires) and responsiveness or support (how attentive a parent is to the child’s needs). Authoritative parenting is demanding and responsive to the child. Authoritarian parenting is not responsive to the child but is demanding. Permissive parents are not demanding but responsive. Neglectful parenting neither places demands on nor responds to the child. Parenting style is an important factor to consider when developing messages. Authoritative parenting style has been associated with multiple positive outcomes for children and is purported to be a protective factor for adolescents, including decreased adolescent drug use (Stephenson, Quick, Atkinson, & Tschida, 2005) and high psychosocial competence and low behavioral dysfunction in adolescents (Lamborn, Mounts, Steinberg, & Dornbusch, 1991). Authoritative parenting has been linked to positive outcomes for college students, including higher grade point averages and better adjustment to college life (Strage, 2000). Research on drug prevention revealed that authoritative parenting was associated with parent–child communication about strategies to avoid drugs, parents monitoring daily activities, and parents knowing children’s plans well (Stephenson, Quick, Atkinson, & Tschida, 2005).

While parenting style’s associations with risk behavior and communication about risk behaviors has been documented, little research has been conducted on how parenting style is related to other health behaviors. In the context of fruit and vegetable consumption, authoritative parents would most likely interpret a message to increase fruit and vegetable consumption in their children by behaviors such as including the children in menu planning, shopping, and food preparation. These parents may also implement strategies such as a “try bite,” which requires a child to take a bite of every food. Authoritarian parents might translate the message to encourage fruit and vegetable consumption by requiring the children to “clean their plates” before they are allowed to leave the table or punish children for not eating their fruits and vegetables. Neglectful parents may not offer healthy food, and permissive parents would be persuaded to serve whatever the child prefers. The evidence that some parenting styles might be more beneficial to children leads to questions about communicating messages to parents with a parenting style that appears not to be as beneficial. There have not been studies examining how to craft messages that would persuade parents to behavior in a manner that is not consist with the parenting style.

Family Communication

Most messaging for parents ignores the variation within family communication. Family communication happens within the context of the family system (Segrin & Flora, 2005). Using a life-course perspective of the family system posits that communication in the family will vary depending on the characteristic traits of the family or the state of the relationships related to particular stages of development (Vangelisti, 2006). Therefore, family communication scholars take into account how broad stages of family development (such as infancy or adolescence) and transitions (such as parenthood) affect family interactions.

There are multiple family communication frameworks to consider during message development. Family Communication Patterns (FCP; Ritchie & Fitzpatrick, 1990) as an important message development consideration will be examined below. A main tenant of this theory is that children’s perceptions of reality and socialization reflect how parents communicate with them. FCP theory is unique because it emphasizes bi-directional communication influences of the family (Koerner & Fitzpatrick, 2006). Ritchie (1991) argues that all families can be categorized into one of two communication types based on the family communication patterns: conversation-oriented and conformity-oriented. Families with communication patterns that are conversation-oriented are more likely to have discussions of ideas, while families with conformity orientation are more likely to have parents asserting control and making decisions. Children in conversation-oriented households are more likely to be free thinkers, and children in conformity-oriented households tend to strive for conformity. Understanding how parents interpret and enact health messages based on the family communication patterns is important to message development.

Family communication patterns are also related to the reasons parents choose to communicate with their children (Barbato, Graham, & Perse, 2003). Conformity-oriented parents used communication to influence their children, whereas conversation-oriented parents were more likely using conversation to achieve relational goals, such as affection, pleasure, and relaxation. Differing motivations for communication based on FCP may need to be considered during message development, as parents’ motivation may be related to their FCP.

Different sets of speech acts are also associated with these types of family communication (Koerner & Cvancara, 2002). Messages designed to prompt parent–child communication need to account for these differences. Conversation orientation describes families who seek discussion and input from members. Conformity orientation describes families who prefer that all members share similar attitudes, values, and beliefs. The family communication patterns are associated with children’s perceptions about the frequency of discussions about sexual health (Booth-Butterfield & Sidelinger, 1998). Adolescents who described family communication patterns as conversation-oriented and supportive of divergent attitudes and beliefs (low conformity orientation) were associated with more frequent discussion about sex (Booth-Butterfield & Sidelinger, 1998). Children from high conversation-oriented families also reported more initiation of communication about sex (Huebner & Howell, 2003). Other research has found that parents have communication patterns high in conformity orientation have less communication with their adolescents about sex (Taris & Semin, 1997).

Most research has been conducted on the person seeking information (the child), not the person providing information (the parent). The Theory of Motivated Information Management (TMIM) explicitly recognizes the information provider in the uncertainly management process (Afifi & Matsunaga, 2008). This theory hypothesizes that parents go through similar evaluation and decision phases before they decide whether or not to disclose information or communicate with their children. Once asked for information by a parent, the child must determine whether or not he or she has the ability to respond to the information requested, has the ability to cope with the result of providing the information, and believes the information seeker is able to manage the information received (Afifi & Matsunagam, 2008). For that reason, children should also be treated as providers of information, not just the seekers of information. Research questions should investigate how much information parents want to provide to their children. More specifically, this research and future health campaigns should assess parents’ and children’s ability to discuss/disclose information to each other (communication efficacy), their ability to handle the repercussions of discussing/disclosing information (coping efficacy), and perceptions of how they will receive the information (target efficacy).

Message Processing

Communication and message processing theories and models provide insight into how parents process and understand messages. Little is known about how parents specifically process messages, but the variation in message processing that exists in the general population most certainly exists in parents, and therefore the assumption that not all parents will process the same message in the same manner is appropriate. For example, the Elaboration Likelihood Model (ELM) posits that when an individual is motivated by a message (the message is relevant) and has the ability to think about and scrutinize a persuasive message (the person is intellectually capable), attitude change will occur via the central route. This central path of processing involves more cognition compared to the peripheral route. Attitude change via the central route requires considerable cognitive effort or “elaboration” (i.e., scrutiny of issue relevant arguments within the message) (Petty & Cacioppo, 1986). Under such high elaboration conditions, the individual critically examines all pertinent information (i.e., message quality and/or credibility of the source) to evaluate the merit of the position advocated. According to the ELM, variables (i.e., credibility and/or attractiveness) that add merit to the persuasive message will have a greater impact on attitudes under high-elaboration than low-elaboration conditions. Alternatively, attitudes formed or changed via peripheral route processing are less persistent, predictive of behavior, and resistant to change than those formed through central route processing.

Framing of Messages

Just as behavioral theories help identify what determinants need to be changed and targeted by campaign messages, persuasion theories explain how to change those determinants (Noar, 2012). As part of message development, framing must be considered. Scheufele defines frames as “patterns of interpretation through which people classify information in order to handle it efficiently” (2004, p. 402). A number of types of frames have been described. Gain and loss framing are frequently cited types of frames used for health communication messages. A gain message would highlight how HPV-related cancers such as cervical or oropharynx could be prevented if a parent vaccinated their child against HPV, while a loss frame message would focus on how HPV-related cancers will happen without a vaccination. This type of framing is important, as there is evidence that in some situations a gain message will perform better (Rothman, Bartels, Wlaschin, & Salovey, 2006). Because there is not definitive evidence to point to whether a gain frame or loss frame is generally better, these types of frames need to be considered and tested in message development for parents. For example, Prospect Theory (Kahneman & Tverskey, 1979) suggests that persons avoid risks when they focus on gains and seek risk when they are focused on losses. As a result, it is important to present positive outcomes of performing a behavior (gain frame).

Message framing should be specific to the behavior. In the example of the HPV vaccine, there are two possible health frames, a sexually transmitted disease prevention frame or a cancer prevention frame, and not surprising when considering communication with parents of children eligible for the HPV vaccine (ages 9–26), a cancer prevention frame appears to be more appealing to parents (Blasi, King, & Henrikson, 2015). Other framing considerations for parents are related to the emotional appeals. For example, framing a message from a nurturance perspective as opposed to fear or humor can impact appeal and acceptance of messages for parents (Birch, Fisher, & Davison, 2003).

Challenges for Message Development

While communicating health and risk messages to parents can be effective and expedient, there are some challenges to be aware of. The failure of health and risk messages to influence parents may be related to the message development topics outlined above but could also be a result of assumptions and unreasonable expectations on the part of public health and health communication practitioners and scholars.

Health behaviors are complicated, and behaviors are often more nuanced than can be communicated in a message or public service announcement (PSA) and may have many caveats. For example, in the VERB campaign, prompting physical activity required broad definitions of what the behavior was, multiple messages, and many channels. There are some behaviors that are easier to change with a health communication strategy (Snyder, 2007). Asking people to start a new behavior is in general easier than trying to encourage people to cease an existing behavior. It might be easier to convince parents to add a fruit or vegetable to a meal than to ask the parent to eliminate sugar-sweetened beverages from a child’s diet. Therefore, message developers should consider whether the target behavior is the most appropriate. Perhaps the same health outcome (decrease in obesity rates among children) could be obtained by encouraging fruit and vegetable consumption as opposed asking parents to ban soda. Behaviors that are recurring are harder to modify compared to behaviors that only happen once. Messages encouraging vaccination might be more successful than messages encouraging parents to put sunscreen on their children every time they leave the house.

Risk Estimation

Parent communication with a child about a risk behavior is often prompted by a parent believing the child is at risk for engaging in the behavior. Unfortunately, parents are not able to estimate risk and have consistently underestimated the behaviors children are involved in. Parents of junior high school–aged children underestimated the risk behaviors of their children, such as carrying a weapon to school, using LSD or cocaine, suicide attempts, sexual intercourse, alcohol use, and tobacco and marijuana use (Young & Zimmerman, 1998). When it comes to HPV (Askelson et al., 2010) or hepatitis B (Moore-Caldwell, Werner, Powell, & Greene, 1997), many parents do not believe their child is at risk for these diseases. Underestimation of risk can lead parents to draw conclusions about what actions they should take that can be false or have negative consequences to their children’s health. Parents may decide not to vaccinate their children against HPV or wait to vaccinate, missing the important early immune response that is key to protection against HPV. Messages must take into account parents’ misestimation and not rely solely on the faulty perceptions of risk.

Parents’ Skills and Readiness

Sometimes parents are willing to take the steps a message encourages them to take, but they lack the skills or knowledge needed to be accurate and effective. Specifically related to parent–child communication about sex, parents have shown interest in communicating but frequently lack the knowledge they need to confer on their children (Boone & Lefkowitz, 2007). Parents may have had little exposure to sexual health information, or it may have been many years since they had formal sexual health education and have either forgotten or medicine has advanced.

Research (Afifi, Joseph, & Aldeis, 2008) also suggests that parents do not know the best way to disclose information about sex to their children. Many are uncomfortable talking about sex-related topics and may be confused in their role in communicating and providing information about sex to their children (Miller, Norton, Fan, & Christopherson, 1998). Communication competence has also been found to play a role in how parents and adolescents talk to each other about sex (Afifi et al, 2008).

Developers crafting messages for parents need to keep in mind that some behaviors maybe too difficult for some parents. Parents have a finite amount of financial resources, time, and patience. Asking parents to do one more thing may be asking too much from already-stressed parents. Often health and risk messages are directed at the most vulnerable and disadvantaged groups, who may not have the resources to perform the behavior a message supports. For example, messages about increasing fruit and vegetable consumption are often targeted to low-income families receiving food assistance from program such as the Supplement Nutrition Assistance Program (food stamps). Fresh fruit and vegetables are costly and can require time to prepare. Asking families with limited income and time to purchase fruits and vegetables may not be effective, even if parents are willing, because the barriers of cost and time are too significant for the parents to overcome. Messages and communication materials also need to reflect the literacy level of the targeted parents (Suleiman, Lin, & Constantine, 2016). Additionally, the messages all assume that parents have a positive relationship with their children. The messages do not take into account the already strained parent–child relationships.

Parents might struggle with appropriate and effective communication (Glowacki, 2016), especially when parents’ actions are not concurrent with the messages they are trying to send to their children. Families with strained or harmful relationships may interpret messages in ways that create more negative outcomes than positive behavior change.

Other considerations are the interventions and messages that encourage children to engage with their parents in conversations hoping that the will parent convey important messages. The children act as a prompt for the parent, who might have neglected to communicate with the child about sexual health or nutrition. Pick a better snackTM coaches children to ask their parents for fruits and vegetables for snacks based on the fruits and vegetable the child has learned about and tasted. These prompts may assist parents in fulfilling their role as an agent of change.

Competing Messages

Parents and children receive competing messages for many health behaviors. For example, fast food restaurants compete with nutrition-promoting messages on TV. Commercial marketing also promotes products and behaviors that can have negative impacts on health. Smaller budgets of health communication interventions struggle to compete with these persuasive commercial messages. Non-scientific sources may promote anti-vaccine rhetoric on social media. Addressing these competing and inaccurate messages is a challenge. There is evidence that refuting inaccurate claims may change knowledge or perception but does not actually impact behavioral intentions (Nyhan, Reifler, Richey, & Freed, 2014). We have limited knowledge as to how to persuade individuals in these situations. Prior to implementing a campaign, it is imperative that the public health practitioners and campaign designers try to identify potential competing messages to be able to understand the possible impact on messaging (Rothman, Decker, & Silverman, 2006).

The Role of Policy

One challenge that is not specific to parents but applies to many audiences is the effectiveness of environmental or policy changes, as opposed to individual messages designed to persuade one person to change behavior. For example, seat belt use only became widespread after laws were passed requiring people to use them (Williams, Wells, & Lund, 1987). Similarly, laws requiring the use of car seats for children created significant behavior change (Sauber-Schatz, West, & Bergen, 2014). Booster seats, which are required in some states, also experienced increased use due to policy changes (Bingham, Eby, Hockanson, & Greenspan, 2006). Graduated drivers licensing laws have the ability to require parents to limit their teen’s driving, which might be more effective than individual parents trying to enforce limitations on their teen driver (Foss & Goodwin, 2003). Asking parents to attend to public health concerns with their children may be addressing public health challenges too far downstream. It is not effective to simply putting a bandage or individual level focus on a challenge, which might best be solved by a policy, environment and systems change. Clearly there are some behaviors that can most effectively be addressed through policy, systems, and environmental change and messages directed at individuals are less effective.

Unintended Consequences

Message developers must also be careful to avoid messages that can stigmatize parents or children. Parents may be less receptive to messages that implicitly or explicitly indicate that there is a problem with their child. Parents may be less attentive to a message or less likely to heed a message that makes them feel like there is something wrong with their child. For example, messages about sexual health and adolescents might be off-putting to parents if the message indicates that their child is doing something wrong or has a problem (Schuster et al., 2001). There could also be blaming involved—for example, if adolescents are involved in alcohol use, parents might feel blamed for this behavior because they did not do what the health message encouraged or they did what the message encouraged and still their child participated in underage alcohol use. Other prevention messages might also contribute to stigma and victim blaming. Parents of children with spina bifida would be sensitive to messages that hold mothers accountable for the lack of folic acid in their diets before a fetus is conceived. Additionally, messages implying that a child with spina bifida is less desirable or not the type of child a parent would want can perpetuate stigma around disabilities.

Encouraging parent–child communication or encouraging parents to take a specific health behavior action might have unintended consequences that have yet to be explored. We do not know if some of the communication is unhelpful, hurtful, or even detrimental to children or the parent–child relationship. The parent–child relationship is not a relationship of equals. The power distribution lies mostly with the parent. This unequal distribution could play a role in parents punishing or shunning children for not doing a particular behavior that is being promoted. Related to communication about sensitive topics, research in parenting styles and family communication patterns indicates that parents will approach the task of talking with their child about a sensitive issue differently based on parenting style and communication patterns. There is not enough research to know if communication about a topic such as underage alcohol approached by a neglectful or permissive parent could be harmful or have the opposite effect. More needs to be understood about how parenting style and communication patterns may impact what parents say, how they say it, and how the child responds. This speaks to the unpredictability of the communication between parents and children when prompted by a health message. Unlike other messages, such as messages promoting people to have their yearly influenza immunization, asking parents to talk to their child has many uncontrolled and unknown variables. Message designers can be fairly certain that people asking their health care provider for the influenza vaccine will receive a similar response and be immunized. This certainty does not exist with asking parents to talk to their children about a health topic.

Additionally, when we ask parents to talk with their children about a topic, we must be aware of parents’ other role as someone who models behavior to their children. Parents can be negative role models for their children. How are messages received when parents’ actions are not aligned with their words? The old adage, “Do as I say, not as I do” is certainly relevant. For example, in the field of nutrition, parents are encouraged to talk to their children about eating more fruits and vegetables yet probably are not modeling the behavior. Parental communication with college students about drinking alcohol is not consistent with parents’ behaviors such as drinking with their children (Glowacki, 2016). There is not clear evidence on how children react when parental behavior is not congruent with the verbal message the parent is conveying to the child.

Parents receive many messages about their children, but we do not know how parents prioritize the messages they embrace and those that they do not. More needs to be understood about the hierarchy of needs that parents use to prioritize which messages are acted on.

Concluding Remarks

While much of what has been presented is related to messages developed as part of a solid, evidence-based message development process, there are parent- and family-specific considerations. Parenting styles are important to message development because parents’ behavioral decisions related to their children are understood and enacted through the lens of their parenting style. Family communication patterns explain more broadly how families communicate as a unit and are critical for predicting how parent–child communication might occur. Unfortunately, many of the concepts presented are not integrated into message development. It is not clear if this does not happen because people are not aware of these frameworks or do not think it is relevant to message development. Perhaps there are not enough resources to conduct the formative research, segment the audience, develop messages specific to the parenting style and/or family communication, and target parents with specific styles or patterns with the appropriate message.

Sadly, the field of health communication and parent–child communication does not have a long history of rigorously evaluated interventions, nor is there significant evidence on the connection between messages to parents and child health outcomes. More resources and academic attention should be engaged to evaluate these interventions. Parent-focused communication interventions should be tested against other interventions to understand the value of including parents. Without a larger body of evidence to demonstrate how these interventions are related to health outcomes, it is questionable whether these interventions should be funded. Health- and risk-related parent–child communication research has been focused on sexual health, alcohol and drug use, and driving. More attention needs to be directed toward understanding how parent–child communication can be used to influence children’s behavior related to non-risk behaviors, such as physical activity or preventive health care utilization.

This article included some examples of messaging that have used parents as the primary audience to impact the health and health behavior of their children across all stages of development. The importance of using parents as agents of change was highlighted. Factors related to message development and some challenges were presented, with overarching awareness that parents are a varied group in many dimensions. Parents are not homogeneous but represent all the diversity of a population in addition to specific factors such as family communication patterns and parenting styles. Parents are also multi-dimensional, meaning all the factors explored in this essay, including parenting styles, ability to process messages, and relevance of message frames, are present in a parent. There is limited research on how these factor may intersect to influence the receptivity of parents to certain messages or how parents interpret the messages. Not understanding the synergy or intersection of factors such as parenting style, framing, or life course is detrimental to the creation of effective messages.

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